Words With Arrows The Benefits of Mapping Whilst Talking

Potter, S., 2010. Words With Arrows The Benefits of Mapping Whilst Talking. Reformulation, Summer, pp.37-45.


This article is about that part of CAT which involves moments of mapping whilst talking. It covers the shared activity of sketching out CAT patterns of interaction whether these are internal to the person, interactive with others or engagements with culture and society. Its focus is the art of doing bits of descriptive writing and building diagrams, in the room, side by side, at a table with a client at the beginning of therapy as an aid to reformulation.

It is Jo’s first CAT session. With her permission, as she talks, I have been tracking her main words and phrases by marking them out on a big piece of paper. We are sitting side by side at a table. Like all of us she talks not just through words but with her face, hands and eyes. When I speak to clarify, or connect with, what she is saying, I turn and look to her and I point my pen at the paper. The link I make by speaking is paralleled by a link I make by pointing to the words on the paper. Our dialogue, which has been working at many implicit levels, is now working at two acknowledged levels. Let’s call them mapping and talking simultaneously, side by side. At this early stage the pointing at words on the paper is not much more than a gesture towards a richer level of communication. It is showing how meanings might be made between us. It seems to help the conversation flow and deepen.

As Jo continues talking I add to the sketching of links to key words but now both of us are looking at the patterns which are emerging on the paper. Momentarily she rests her hand on one of the words as if to lift it off the page and get the measure of it.

To explain the idea of moving between the poles of a reciprocal role I cup my hands above and below each other and swap them around as if I am slowly miming the shuffling of a pack of playing-cards. In seconds I have communicated a concept through mime that is very difficult to communicate in words alone. We are playing with the links between two ways of making meaning: mapping and telling. Jo describes the drawing we have made as words with arrows.

Our focus of attention shifts to-and-fro between her talking and my sketching. The sketching is becoming part of the art of our conversation. We reach that point where sketches of incidents and moments in her recent life seem to be also mapping lines in the narratives of the whole of her life. The flow diagram of one story is discovered to be the scaffolding for many stories. Finding this out together made us working partners. We are creating a paradigm for Jo’s subjective realities that is uniquely her own. There is an ancient intimacy between us, like parent and child learning the rules of language together. Soon we will make the step of using the sketches of her patterns of interaction in the present to make links with her early learning stories and wonder about her primary interactions with the world before she had language.

When we actively sketch out patterns of interaction together both client and therapist gain a ‘hands on’ understanding of the versatility of reciprocal role procedures as they map and make secure the telling of one story after another. In this way stories more easily resonate with each other. Feelings shimmer between one perspective and another. The sketching of maps helps the therapist and client to hover above the detail and to see the bigger picture.

Introduction

This article is about that part of CAT which involves moments of mapping whilst talking. It covers the shared activity of sketching out CAT patterns of interaction whether these are internal to the person, interactive with others or engagements with culture and society. Its focus is the art of doing bits of descriptive writing and building diagrams, in the room, side by side, at a table with a client at the beginning of therapy as an aid to reformulation (or at times of crisis or change during the therapy). It summarises the steps and features of such radically open, active and collaborative work. Active mapping whilst talking can help: gather material for the therapy reformulation, chart moments in the therapy relationship in the room, and give a ‘hands-on’ tutorial in the ideas and methods of CAT therapy. It can help prepare the client for the drama of the reformulation letter, demystify and open up the therapeutic relationship and bring out the combined resources of therapist and client. In this way it can serve as a brake on the therapist’s rush to expert positions or rein in the client who hurries to disclose too deeply. Most importantly it can remind both the therapist and the client that it is the activity of the relationship that is therapeutic. Accordingly this article highlights the rich, multi-modal communication of the therapeutic and educational relationship that can be enabled, contained and made visible through moments of mapping whilst talking.

Shared sketching highlights the side of CAT which is more like a personal tutorial in how to become your own therapist. There is a childlike, attitude of compassion, curiosity and self-discovery which can be more directly learnt in this way. It shows how such joint activity helps therapist and client negotiate the all-too-human, adult struggle with moments of creativity, engagement, influence, confusion, anxiety, loss, avoidance and conflict. Sometimes it feels like we as therapists don’t know what to do with the feelings that the richness of the therapeutic relationship engenders. This article supports a view that such complex therapeutic moments are more likely to arise and resolve safely, freely and productively by learning to map together what we talk about.

Such an approach does not neglect the conventional CAT practice which focuses reformulatory activity around the use of the psychotherapy file and similar psycho-educational questionnaires such as the PSQ (Ryle and Kerr 2002). Nor does it neglect the reading out of the prose reformulation letter. The preparation and use of the reformulation letter remain the most powerful opportunities for collaboration in therapy. Active sketching can help shape and prepare for this pivotal moment in therapy when the draft of the prose reformulation is read out, discussed and adapted to become the shared framework for therapy.

I will describe how the changing interactions between talking and mapping in the early sessions of therapy progresses from simple sketches to life maps, therapy maps and system maps. These different types of drawing are doing different types of collaborative work and can lead to a small portfolio of drawings during the therapy. Without such distinctions between types and purposes of diagrams a client and therapist can easily be overwhelmed by overly complex diagrams that try to do too many things and put too much on one sheet of paper at once.

I will mention some of the applications of mapping actively together. In particular it is an engaging and accessible way of teaching the relational imagination at the heart of CAT. I have found this to be the case when teaching people at all levels of expertise whether they are part of in-patient teams completely new to psychological therapies, health care assistants, senior medical staff or experienced psychotherapists. If I could teach my favourite football team, musicians or international negotiators to learn to think relationally in this way then I would.

This article ends by describing ‘speed’ supervision. This is a dialogic approach to developing instant sketches and maps as a way of developing psychological and relational understanding through one- to-one or small-group supervision and coaching. It involves making a map in a ten minute supervision session in pairs or in a small-group and sounding it out in another pair or small-group before returning to the first person or group. This to-and-fro of quickly talking through perspectives, aided by collaborative map making, is surprisingly powerful in its accumulative and dialogic effect.

‘Words with arrows’

Jo and I are sitting, side by side, at a table, with a sheet of drawing paper (A3) in front of us. The paper is covered, here and there, with words in black ink, some circled, some in bold and in capitals, others in tiny scribble, some highlighted. All are linked by lines and arrows. We have struggled with the choice of words, the meanings they carry and the way they connect or not. Out of nothing, in our initial meetings since agreeing to do CAT, we have simultaneously talked and sketched our way into this relational map of Jo’s patterns of interaction with herself and the world. I have been an active participant, suggesting, pinpointing, clarifying and reacting. Jo and I have done this work together. Admittedly I have been the one with the pen so far but the map is hers as much as mine. Her hands are on it. Her words and stories are traced by it.

There have been changing patterns and rhythms to our interactions. I think of Colwyn Trevarthen’s (2010) work on musicality of the early interactions between parent and infant. There is something similar going on in our joint activity. We are communicating through a web of relational activity with multiple intelligences coming from our bodies, minds and the languages and codes of the culture around us. Sketching is useful if it helps this richness become more apparent. It can allow me to share in the ebb and flow of her talk without taking over or intruding. It helps her sustain her voice and her reflections. My participation through sketching is sympathetic to our different modes of communicating. It helps me, as much as her, attune and orchestrate my responses. It is a subtle and democratic art which I have needed to practice and learn from experience. I am looking to hand over shared activity and authority over the emerging diagrams as soon as possible. Such joint activity makes the push and pull of the relationship more visible. It is an open and negotiable enactment magnet. This early sketching together is giving birth to something other than a CAT diagram. It is cultivating a therapeutic attitude.

In the very first session, after our introductions and before she began talking, I had initially explained how I might, with her permission, track some of her key words on paper and look for links. She was willing to try it and see if it helped. We started by sketching out the main elements of the first accounts she gave of her problems. This joint mapping brings CAT alive as an educational therapy. The palms of our hands and our fingers have been all over the emerging map as they do the work of touching, pointing and tracing the links between roles and feelings and action. The sketch of a pattern that first told one story does the work of giving shape and emotional meaning to another story. With the aid of the map we can discuss and track how the pattern that came from the interactions between her mum and dad now seems to resonate in the interaction between us.

During our second session, Jo and I were on our third sheet of paper and before us now is the beginnings of what we call a life-map. It is a ‘whole person’ map that links up the main narratives of childhood, adolescence and adulthood. Earlier sketches lie between us on the floor for back reference to see what words we first used and how we have changed the arrows around. These earlier sketches were instant ‘map and track’ reflections on the emotional contours of a story she was telling. They introduced her to the relational thinking behind the CAT model and its particular form of notation. She is beginning to get the hang of it because it helps her make deeper links between with her experience.
In sketching as we go, I have literally and symbolically shown Jo my ‘hands’. I have no cards up my sleeve, I have no hidden analysis. I have an expertise but it is to be discovered empirically and collaboratively alongside her expertise. At the forefront of my thinking is that I am helping her become her own therapist by teaching her the elements of a therapeutic attitude. The map acts as a vehicle for the expression of feelings in the deepening conversation between us. We can say things through the map that would otherwise be too direct or too loaded to communicate without embarrassment or confusion. We have had one or two important moments together of insight, confusion, distress and humour. Such moments are common to all therapies. Our main aim is the accurate description of how things are done. My pen is poised above the paper. So how do you do that, how do you get from here (feeling hurt) to over there (feeling angry)? Mapping helps us to work things out. Not knowing is shown to be okay. Gaps, blanks and question marks are shown to be okay. Without the mapping activity such gaps can be a source of powerful fantasies about the knowledge and authority of the therapist.

Mapping not only helps keep track of what is being shared but also it keeps track of how the therapy is developing. I point to one part of our map and say perhaps that is something to come back to. I ask her, with reference to another part of the map, whether the kind of interaction her mother and grandfather had was also like the one she was expecting to have with me. The map facilitates our tentative explorations of difficult topics.

Map and Talk

The relationship between talking, mapping and telling stories is richly interwoven. In the shared activity of mapping (and writing) out patterns of interaction and talking about the positions in life which they establish and maintain, the mapping helps the talking and the talking helps the mapping. It is a dialogic relationship. According to the Vygotskian inspired educationalist Jerome Bruner these are two fundamental ways of entering into meaning with the world. Bruner, as cited by Ryle (2004) calls these two ways the paradigmatic and the narrative (Bruner 1986). Or to put it more simply: map and talk. The joint activity of sketching helps us explore the relations between paradigmatic and narrative ways of shaping experience.

In all therapies, regardless of models, as a client speaks of their experiences they tell stories as offers of explanation. Sometimes these stories are naturally eloquent and seem to be given a voice for the first time. Other times they are too polished, saturated by repeated telling and closed. Most times our stories are searching for meaning and invite completion, correction or judgement from the therapist. Stories can be the bare bones of something that invites elaboration such as: “I was supposedly a happy child and then when I was seven my parents got divorced and my mother became ill. I became anxious.” Bit by bit we weave together with a client feeling, meaning and connections to such bare-bones beginnings of a story.

When someone tells a story there are many layers of richness. At one level there is a narrative shape to it. This is one way of giving experience meaning. The story might have a raw and simplified plot to it. You are born, you learn to live by fighting, you grow old and eventually you die. The plot when presented in that way is open to reaction, discussion and analysis. The person telling the story is unfolding a mental map or theory-about-life (paradigmatic understanding) that has been woven into the narrative shape of the story.

At the same time both speaker and listener are creating another kind of map according to how the story is told and used for explaining something. The judgements about, and the meaning of, the story is wrapped up in the style of telling. Early sketching with a client helps therapist and client to disentangle different layers of meaning-making through seeing more clearly the patterns that shape the story and its telling through talking. In these ways the accounting of any story is not just a telling of the story but an attempt to map its meaning cognitively, relationally and emotionally. The challenge in CAT is to weave together the various narratives with their plots and paradigms and each with their different claims on the truth such that the client’s ability to give voice to their understanding is enhanced and not overwhelmed.

All CAT tools try to help this process. The psychotherapy file (with its traps, dilemmas, snags and states) offers a paradigmatic way of scaffolding the patterns of interaction common to life experience. It works well if it enables the unique language and patterns of the client to find their distinctive voice and expression. It fails if the paradigmatic language of traps, snags and dilemmas get copied verbatim over into the prose of the reformulation letter and come to shape the client’s understanding in a determining way. CAT has evolved to work the client’s narratives through two forms of paradigmatic activity: prose description and maps. Sometimes the prose reformulation is too much a linear restatement of the client’s narratives without offering an overall, higher level understanding (paradigmatic). For me the process of working back and forth between mapping, writing and talking is the key to such therapy. The writing and the mapping should grow out of the therapy and then be presented in a way that doesn’t come as a surprise to the client but builds their own therapeutic capacity.

Although Ryle and Kerr in their glossary at the back of the Introduction to CAT book (2002) encourage the work of reformulation to be done, as much as possible, with the active participation of the client, I worry about a drift towards doing CAT reformulation to the client by taking notes away and returning to a later session with a relatively polished prose description. Subsequently a carefully planned diagram is presented somewhat as a done deal (often on power point these days). This is a process which can leave the client in awe and deskilled and outside the co-constructive activity of therapy. In working jointly at mapping in the session from the start, Bruner’s two methods of making meaning are in an immediate dialogue with each other. They nurse each other into finding a shared meaning for the client’s account of his or her experiences.

Some critics of a more active CAT approach may argue that subtler and more covert processes of transference and enactment may be bypassed. My own experience is that such active work is a safe and open net or scaffolding for the enactment of the client’s patterns and roles and they can thereby more visibly be named and discussed together. More particularly both poles of the reciprocal role patterns are likely to be more visible and more mildly expressed through such joint activity. Also such joint work doesn’t have to dominate the therapeutic relationship. It may be an activity which is in the foreground some of the time at the beginning of therapy but once the key patterns can be held in mind, the fact that they are held on paper becomes less and less relevant.

Teaching the client CAT’s methods for making maps

As I mapped out patterns of interaction in Jo’s accounts of her life, I explained along the way the key CAT concepts of reciprocal roles and procedures and shifts of response within and between states of being. My minimum sketch will have one or two contrasting procedures and at least two reciprocal role positions divided into more desired, more dreaded and more endured positions. I have in my mind one of the earliest and richest papers by Tony Ryle (Self-to-self and self-to-other 1975) where one end of a reciprocal role always implies not just the other end but the contrasting or absent pair. A reciprocal role of neglecting in relation to feeling neglected implies knowledge of caring to cared-for. In this spirit the minimum necessary data on a CAT map is two reciprocal roles and the key elements of the procedures (or dialogic sequences) which animate them in relation to each other. Like all CAT therapists, by actively making the map together, I am looking for the moment where the client, pointing at our emerging diagram, says. “What others did to me, I now do to myself. Oh, and sometimes, I do that bit of it to others? Or get others to play a version of that part for me?” As the client shares their developing understanding from the map the emotional connection follows. Sometimes the client doesn’t fully realise the emotion at the first moment of mapping. One client recognised a pattern and only made the emotional contact when subsequently describing it to a close friend.

I always end up with multiple states diagrams. They are useful and accurate not just for people with borderline or fragmented experience. They are great descriptive maps for all of us in our wobbly and less formulated states. We all shift and shake between states. We identify ourselves, creatively or defensively, with different states at different times and in different situations. What varies between borderline and more composed shifts between states is our ability to conduct the orchestra of states with appropriateness, fluency and awareness of movement and its impact on others and the world around us. Multiple self state maps can help describe the development of great orchestrations as well as mitigate dissonant and destructive absences of orchestration.

As indicated above I have a preferred layout in making life maps. It helps organise the diagram without dictating its content. It is adapted from Mardi Horowitz and his work on multiple states (Horowitz, 1998). I explain how I put the ‘desired-but-fragile-if-achieved’ states such as love, care, power, safety, admiration, achievement, inclusion, perfect control etc., at the top of the page and the ‘dreadfully-avoided-and-cut off’ states such as abandonment, shame, denial at the bottom of the page. In the middle of the page I put the ‘core pain’ or routinely endured states. Just above them go the more adaptive survival states and their procedures. If the desired or ideal states don’t get a mention I ask about them. It is surprising how often we overlook the things that are desired. Equally as a therapy progresses I know that we may add another layer to the reformulation as warded-off or disavowed states of shame and abandonment become safer to name, share and treat as a more normal and unavoidable part of the human condition.

Three kinds of drawing: sketches, life-maps and therapy diagrams assisted by bits of descriptive writing.

I have supervised and taught a great many ‘CAT’ people in recent years and it seems to me there is a great deal of variety and versatility in the way diagrams are made. Diagrams seem to be doing different kinds of drawing for different therapeutic or educational purposes. Often these different purposes get lumped together into one cumbersome therapy diagram that is trying to do too much. I encourage people to distinguish between the following types or stages of diagrams:

  • Sketches: firstly there are early and impromptu sketches of patterns of interaction that can be drawn from the client’s initial accounts of interacting with self, others and the world. These might be captured as procedural sequences or as shifts between positions, states or roles.
  • Life-maps: secondly arising from the links between these sketches and the emerging bigger picture are the life-maps of multiple roles and responses over a lifetime of development. Life-maps capture the bigger picture and key positions of someone’s life experience as a whole
  • Therapy maps: thirdly as the refined therapeutic tool for the middle phase of therapy there is the therapy map (if you’re a therapist working in mental health) or a personal problem solving map (if you’re a counsellor or coach helping with personal development). Therapy maps are the more therapeutically formulated and trimmed down diagrams to focus the personal problem solving work of the therapy.

All of these feature as sketching steps in a single therapy. Subsequent to this there might be contextual, system, team or management maps if you’re a consultant.

To accompany these varied ways of drawing out patterns of interaction at different levels of the person’s experience I have found it useful to co-write with the client bits of descriptive writing to bring out the flow and detail of a particular pattern more clearly.
These different types of mapping and the way they join up are now described in more detail. One the whole I fight shy of the general use of the acronym SDR as it points to a secret language and knowledge beyond the client’s reach. Instead I like the word sketches because it points up the provisional, outline nature of what we are drawing out.

Sketches

At the beginning of therapy we need simple sequential sketches or drawings of the emotional and relational roles played in a key story. These sketches initiate the client and the therapist’s educational relationship through discussing patterns of interaction involved in the story as they are being highlighted by the sketching. They begin to teach a therapeutic attitude and relational thinking.

The therapist is thinking to him or herself with CAT’s procedural and sequential language or the shifting images of dialogic movement between role positions and responses. This won’t necessarily be the same as what initially gets put down on paper. Fragments of feelings may be linked to behaviours but with relational gaps and question marks. Links between words and arrows which are not yet full formulated will have arrows pointing into a blank space with a question mark. These half-formulated sequences are as important as the clearly formulated sequences. Such provisional sketching can help with the processes of trust and containment in talking about difficult feelings. They will invite their own enactments. The client or therapist who likes to sort things out or keep things tidy will push for clarity and closure. The client or therapist who finds it hard to take a line and hold to it will invite lots of crossing out and fresh starts. Incidentally supervision can often tell a lot about the qualities of the therapeutic relationship from the sketching that is developing.

The process of shared sketching is as important as the product which at this stage may be no more than a temporary clarification or aid to emotional connection.

Life-maps

At some point in the early sessions, these sketches will morph into something more like a whole, life-story map. The transition is an important moment of perspective taking for the therapy. The client often sees the map now telling both ‘local’ stories about problems and incidents and general stories about their wider sense of self. With the shift to a life-map the client’s history and identity emerge from combination of sketches of specific patterns of interaction. This transition will be often repeated when gaps in awareness, memory and emotion are struggled with or bypassed. This emerging life-map is a crowded piece of paper that wouldn’t work as a therapeutic tool in the longer run. It is seeking to capture the resonance between early learning of reciprocal roles and procedures and their modification in adolescence and subsequent adult life. It may tell of relational patterns going back over generations. One client swept his hand across the life map we had created saying that one half was his mum’s side of the family and the other half his dad’s side of the family.

The life-map is a very different way of getting to know the person’s life story than the concept of ‘taking a history’ implies. Perhaps it is more like marking out an archaeological site within which the various positions the client has experienced in their life. The origins of some feelings and behaviours and roles are very clearly marked but others can only be guessed at or reconstructed by way of current interactions. The life-map in session five of therapy may be very different to one towards the end of therapy when we revisit the bigger picture of their life story free of detailed therapy concerns and problems.

The biggest gains may come from the way we experience this reworking of personal history rather than the history itself. In other words it is the reformulation that counts rather than the gathering of existing formulations. The other advantage of a life-map is that it hovers over more detailed incidents and procedures. One of my clients described going around the life map in many different ways telling many different stories. It wasn’t based on tracking the detail of patterns but more as a device for giving permission to voice different memories and associations.

A life-map can help tell the wider social stories of me in the world by making links to class, culture and national identities.
I take a bit longer than four sessions to get to complete a reformulation stage of therapy because the life-map helps us think more widely about the target problems and procedures which will soon emerge as the focus of the therapeutic work. A Genogram (McGoldrick 1985) in combination with a life-map offers a rich historical social and psychological perspective though the later captures the repetition of patterns across the generations more simply and fluidly. The life-map using CAT’s dialogic approach is a useful personal development, coaching or oral history research tool. It can help people outside of therapy developing a psychological understanding of their social history.

Therapy maps

In CAT therapy however the life-map is the history gathering step to the more typical diagram we call the ‘SDR’ or sequential diagrammatic reformulation or the ‘MSSD’ or multiple self states diagram. I think these are more ordinarily and clearly described as the therapy diagram. It is extracted from the early sketches and the life-map. In many cases it may greatly resemble a simplified life-map. It is the diagram that is going to guide the work of the therapy. It is best if it is tidy, clear and simple enough for the client to take home and routinely refer to as a way of monitoring the enactment of problems patterns of interaction. Its language and structure has been refined for the business of practical therapy whereas the sketches and life-maps that preceded it were opening something up.

As one client with an eating disorder, said of the life map and the therapy map. “At first I thought we were going round the houses to get to the point of eventually trying to tackle my problem. Now I realise that we needed to go round the houses to see my problems in the context of my life.” The therapy map describes the target problems and associated procedures and locates them in relation to symptoms and problems and the wider functioning and valuing of self. It offers a carefully considered and calibrated therapeutic focus. The therapist may well have taken time between sessions to draft out the therapy map in a neat form and as a process of self supervision to check his or her understanding. Sometimes this falls into shape in the room. Sometimes the client is most willing and best suited to do this tidying up between sessions and bring it back. It helps the client take ownership of the diagram.

Therapy maps do what CAT does best by linking the solving of problems, and management of symptoms, to the bigger story of self-functioning and self identity. I find it easiest to compose the more formal prose reformulation letter from this diagram with some reference back to the life-map for historical details and to the sketches for a sense of how our working relationship is developing. It is a short step from shared therapy diagram to shared writing of elements of the prose description. Indeed the shared mapping approach invites the writing out together of very short, single paragraph, prose descriptions of patterns. There is an emotional immediacy in co-writing and then reading them aloud to get the procedural, sequential and dialogic feel of them with the client. Writing in the room proceeds at a different pace and with a different rhythm to mapping together. The choice of who does the writing and the reading out and the choice of who is being addressed and naming and sharing the emotions involved is all part of the continuous process of helping the client become their own good therapist.

All these processes of sketching, mapping and writing add up to an important rehearsal of the more staged experience of the therapist going away and preparing a more considered prose reformulation and the powerful and important therapeutic drama of reading it out in full.

Creative and appropriate intimacy

These processes of mapping and talking are an appeal to forgo the detachment of power-point and word processing and get back to the rawness and vitality of sketching and writing patterns out long hand. There is something tender and nurturing about finding the words and making the links that thread together a life-shaping experience parts of which have never been formulated before. It is important the therapist doesn’t try to be clever, show off, or try to do perfect work. An unfinished sentence is one that the client is invited to complete or change. Words and the lines and arrows that connect them need to be puzzled over together.

In many approaches to therapy the therapist stays relatively uninvolved with the client. His or her role is more that of an adviser watching on. In other approaches, or with more emotionally unstable or vulnerable clients, the risk is of getting in too deep, of having to jump in to provide emotional first aid, or being so easy-going that the client gets into deep water without a line of negotiated meaning to get back up to the surface. Active, early map-making offers a scaffolding which is jointly owned and understood. It can work as a ‘perspective ladder’ taking the therapist and the client up and down between a big picture perspective and the small detail. Such a perspective ladder can help cool difficult moments down or warm detached behaviours up. Regardless of approach or setting there’s a special kind of appropriate intimacy to a good therapy session which for want of a better name I would call a working playfulness. It is willing to face and formulate the darkest and blankest of experience but always is ready to offer a hopefulness of meaning and connection. Sketching in all its varieties helps me and most clients engage in this way more than I or they otherwise would be able to.

Words live for the moment

Both mapping and talking in therapy have an eye for the specialness of certain words. As therapists we know how powerful words can be. They can be magical, misleading, deadening or confusing. Words are always alive in a unique way in the moment of their use. Words are inert most of the time in libraries, in books, archived at the back of our minds, relatively harmless as opinions and clichés in our daily chatter. We take for granted their instrumental power. Words in therapy have extra duties and they come alive with feeling and movement. In the Vygotskian sense they become tools. The word that goes on the paper in the initial sketch is a word that resonates and shapes the client’s account. They are suddenly going somewhere and they are for something. Children know that words are tools that you make things with. Words make pictures, stories or feelings and truths. Some children can do this with a spontaneity and playfulness that adults tend to have buried long since in procedural coping strategies. Listen to a child meaning what she or he says. The words are like mouthfuls and children at least before the verbal ironing out of schooling, speak with their whole bodies. In therapy we sometimes speak with the fearful, seductive, wounded, deceitful or robotic language of adulthood but try to contact with the more spontaneous language of childhood. I tend to think of therapy as an exercise in learning to speak again. In the case of childhood trauma or restriction we may be learning to speak with our own voice for the first time. We try to recreate this immediacy and honesty with words in therapy but we also have to live with our deceptions and language games. All our patterns of talking are evidence of how we interact with the world. My own sense is that the active and collaborative mapping of words onto paper helps our struggle in search of meaningful personal communication within different language games. In CAT we tend to forget, in our efforts to write impressive reformulation letters (the burden of the perfectionist therapist in an over-controlling profession) that diagrams are also words being written albeit linked by arrows rather than sentences.

Shared writing and reading

I think there is great value in the prose reformulation letter which the CAT therapist writes for and reads to the client in session’s four to seven towards the end of the reformulation process. By definition it is rarely something that can or should be polished and definitive but as professionals we seem to feel an undue pressure to get it right. Too much effort in getting everything into the letter and getting it all fixed can produce a letter which is beyond the client’s zone of proximal development. It can be unhelpful and even overwhelming for the client and exhausting and exposing for the therapist. The reformulation letter cannot suddenly give voice and shape to a therapy without preparation. Just as I have found a step by step approach useful for developing a diagrammatic understanding with the client, I also find it useful to introduce the use of shared writing step by step as a lead in to the reformulation letter.

To help the process of making and sharing the prose reformulation, I encourage trainees to practice writing bits of procedural description in the room. Even in the first session, if a pattern has been sketched out it can be a powerful containing and enabling experience to say. “Look let’s just write out this pattern in long hand. I will be the secretary! Let’s see now, how does it go?” This tends to slow the therapy down and commit therapist and client to naming a problematic pattern in full detail. For five minutes a client and I both write out, on our own, a letter to the other person which is only a few sentences long and which describes what we are beginning to understand about a particular target problem and associated procedures and positions. We take turns to read them out. A fuller understanding has developed and a new procedure is identified.

I tend not to read out a reformulation letter without having had these earlier rehearsals of small paragraphs jointly written in the session which give a sense of what is possible and what is useful and safe in the use of writing with a particular client. Reformulation is a continuous process not a product. One of its therapeutic high points is the reading out of the reformulation letter and the sharing of the more considered therapy map. From teaching and supervising lots of people I can see how sometimes the prose reformulation letter, often top heavy with history comes too much as a surprise for the client who has not had rehearsals in the use of it. Every sketch or bit of writing and mapping is a process of reaching out and engaging the client (and the therapist for that matter) in a reformulatory journey.

Applications of ‘map and talk’ outside of individual therapy: Early learning stories

In teaching how to do CAT nothing brings the method home more than getting people to work in pairs sketching out the patterns of interaction of an early-learning-story from their own life experience which they are willing to share and explore with each other.

Typical stories are to do with high expectations, the humiliations of school life or over-protection in relation to learning new skills such riding a bike, multiplication, performing a song in front of others and so on. The sketch is of the main reciprocal roles and coping procedures. Working with their own experience in turns brings out the resonance between one story and another as well as past and present experience. The direct experience of mapping and telling shows them how patterns behind one event in their lives shape other events. The ‘early-learning-stories’ approach works well with more social accounts of learning to be a boy or a girl, or learning the differences of culture and social class such as awareness of accent, ethnicity, wealth and poverty. Such stories are safe enough but powerful stepping stones to thinking about mapping and encountering more personal and intimate early experience. I have used group discussion of mapping early learning stories in very many training sessions. Often they cite it as one of the best bits of the training and the moment when the CAT model came alive and made some sense. I also use it with clients and in CAT groups such as a binge eating group.

‘Mini-therapy – the personal bridge between teaching and coaching

For various individuals and groups (therapists, medics, musicians, clinical psychology trainees) I have been using the format of a two and half hour single ‘map-and-go’ mini therapy session (with follow up meeting a month later) to develop a life map. The client has the overall interest in rapidly and provisionally over-viewing how they do what they do with themselves in the world. The context is usually professional training or preparatory to a coaching group. They have usually had some teaching in CAT and will subsequently have some coaching in groups to sustain the work of the mini therapy. In all, their total exposure to a CAT approach can be quite substantial but combines teaching, skills practice, intensive therapy and group coaching. At the heart of the whole experience is learning to actively make relational sketches, maps and diagrams. In the “map-and-go” mini therapy, the client is looking for a fuller personal understanding rather than relief from a particular distress. The sketches and life map, made in a couple of hours, can be taken away by the client. If it feels safe and timely and if they know something of CAT methods they can redo the map themselves in their own hand. Sometimes it can be helpful to encourage the person to write short descriptions or letters from one state to another, from the detail of the map. Sometimes more sessions of individual therapy may be advised. Respect for the pace at which both client and therapist are willing and able to go is all important. In the subsequent coaching groups peer supervision can be a good format for developing mapping skills further and at the same relational understanding and personal development takes place. The pioneer for offering a brief formulatory experience as part of training was Ian Kerr in his skills training for community mental health teams.

Training in relational skills for in-patient and community teams

A quite distinctive application of CAT’s mapping approach is to teach all the staff of a ward or a team a relationally enhanced approach to routine care and treatment. In a two day training programme with six or seven follow-up reflective practice sessions CAT can make a difference to ward or team culture. In training teams the aim is not to teach skills in doing therapy but to develop psychological understanding and relational intelligence through learning CAT’s active map making approach for self supervision.
With in-patient teams learning to map the patterns of interaction of one incident with a patient is often (though not always) a good description of the patient’s main problem procedures or coping strategies. It is not advisable or practical to teach ‘doing CAT as a therapy’ to an in-patient team but teaching the relational elements of CAT through learning to sketch difficult moments together is a good supportive psycho-educational step to working alongside specialist staff providing CAT or other interventions. Such relational awareness can help teams understand the patient better. It can inform difficulties and opportunities in assessment, care planning, risk management and responding more sensitively to challenging behaviour. Maps help staff to avoid going head to head. They encourage side-by-side relating. It can guide methods of diverting rather than getting entangled and exploring how, rather than why, things are the way that they are. The teaching method for this work is as described in speed supervision below.

Speed supervision

In teaching CAT to very many groups I want to get across the idea that the only way to understand CAT is to experience doing it. In the process of experimenting with teaching formats, I happened upon the idea that if we did our own approximate version of ‘speed dating’ or ‘speed talking’ people in pairs could work up an initial sketch of a situation and then move along the line to the next person and explain the sketch to them and see if they could refine it. My starting point, before using clinical material, is usually a picture that tells a relational story. Each pair works up a sketch that tries to tell the relational story expressed by the picture. After five minutes one of them takes the sketch to explain it with reference to the picture to the next available person in line. The diagram is amended and developed in the process of the discussion. Each turn takes five minutes and is concluded by returning to report on progress with the diagram to the first partner. It is a dialogic and multiply voiced learning experience. Subsequent large group discussion helps compare notes and develop understanding of how to make diagrams. Demonstrations of doing diagrams from therapeutic incidents are provided for the whole group. We then go back to the speed supervision and reverse roles and repeat the exercise with one partner in the pair describing a critical incident in their work and the other partner developing a helpful sketch of the relationships involved. Again after ten minutes the person who has helped make the map gives it to the person they helped who takes it along the line to the next available ‘mapmaker’ and explains it to him or her for another five to ten minutes before returning to the first person to report back and make further amendments. Through this process of speed supervision - with the help of some introductory diagrams, examples on power point and some demonstrations for the group of how to go about things - even the most novice groups have got hold of the richness of the collaborative activity of mapping whilst talking. The buzz and vitality of such joint activity is full of couples leaning towards each other. It seems to help if everyone is working in close proximity at proper tables. The table offers security, texture and the ability to lean in, look down at the drawing and up at each other. It also allows the hands freedom to communicate in front of us. Hands and voices are central to our communicative abilities and they work well together when there is a big piece of paper between us to help the process of expression and understanding.

Words of caution

Any preferred approach to a therapy has its limits. It needs words of caution. The very active, joint mapping and writing approach described here is best suited to clients with motivation and with therapists who are willing to be transparent and have a bit of a go. Tony Ryle’s famous dictum ‘push where it moves’ applies and no approach or method is helpful against the grain of reluctance, contempt or too much anxiety. However one example from a secure forensic setting is worth citing. The male patient was scathing about the therapist and the therapy. He sat defensively and with hostility through several initial sessions. Eventually the therapist in desperation tried out sketching on a piece of paper what she thought was going on between them. The client leaned over to look and disagree, pointing to how he thought it was. He was still hostile but his hostility was being channelled and expressed on paper. They started negotiating over the words and arrows of an emerging diagram. Therapy had begun and the paper and pen had made an impossible relationship safe enough to begin work. To paraphrase and further bend the oft-quoted, Vygotskian notion of the developing relationship between teacher and child (that what the child does with the adult today he will do on his/her own tomorrow), what the therapy relationship will do on paper with a map this week, it will do with hands in the air the week after and with thoughts in mind the week after that.

Concluding remarks

CAT can be a radically shared activity. In the process it can be creative, tactile and delicately and respectfully intimate in ways that are surprising. Something of the underlying human ‘musicality’ of movement, attunement and co-creation described by Trevarthen (2010) and others is involved. When we relate we relate in several modes and ways at once. Map and talk is an art form with its own musical qualities, rhythms and technique. It calls upon multiple intelligences. It has echoes of art therapy, or of being a teacher in primary school. It brings all our cognitive, emotional, social and kinaesthetic intelligences in a multiple, relational intelligence. As I suggested it is playful working. On the one hand there is the interpersonal experience of a real relationship of learning together through the simplicity and transparency of the activity. At the same time it is an enactment magnet for the client’s and the therapist’s patterns of interaction. Over the years I have worked therapeutically with individuals and groups in a great variety of ways. I would say nothing has come close to this experience of the tentative, pen and paper, shared mapping of patterns, positions, problems and possibilities with another person.

A more extended version of this paper with details of sketches and diagrams in relation to pictures and of clinical cases, teaching materials and detailed guidelines on speed supervision, self supervision and some of the theoretical understanding of relational skills and awareness under the general title of ‘Map and Talk’ is available from Stevegpotter@gmail.com Forthcoming one day workshop on ‘Drawing Diagrams with the Client’ in London on November 6th 2010 (see the ACAT website and this issue).

Steve Potter is both a CAT and Psycho-dynamic Psychotherapist registered with the UKCP. He has been widely involved teaching, supervising and practising CAT at introductory, skills certificate, practitioner and psychotherapy levels. He is based in Manchester and is part of the CATalyse/CAT North group of trainers and is also involved in training in-patient and professional teams in Hull, Lincoln, Cheshire and Wirral and Poland. He wants to see the relational aspects of CAT’s model applied to psychological health beyond the remit of the mental health professions in education, the arts and the voluntary sector.

References:

Bruner, J. (1985) Acts of Meaning Harvard University Press
Horowitz, M. (2005) Understanding Psychotherapy Change AMA
McGoldrick, M. (1985) Genograms: Assessment and Intervention. Norton Professional Books
Ryle, A. (2004) Writing by patients and therapists in Cognitive Analytic Therapy, Chapter in Writing Cures. Edited Bolton, G. et al., Routledge
Ryle, A. (1975) Self-to-Self, Self-to-Other: The World’s Shortest Account of Object Relations Theory’. New Psychiatry (Members copy available ACAT Web Library)
Ryle, A and Kerr, I. (2002) Introduction to Cognitive Analytic Therapy Wiley
Malloch, S and Trevarthen, C. (2010) Communicative Musicality OUP

Full Reference

Potter, S., 2010. Words With Arrows The Benefits of Mapping Whilst Talking. Reformulation, Summer, pp.37-45.

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