Ryle, A., 2000. CAT, Attachment Theory and Cognitivism. Reformulation, ACAT News Autumn, p.x.
CAT originated in an attempt to integrate psychoanalytic and cognitive beliefs and methods; over time it has differentiated itself increasingly from these source models and has incorporated other ideas, notably from Vygotsky and Bakhtin. I am writing this paper in response to the editorial comment in ACAT News Summer 2000 to the effect that Vygotsky/Bakhtin and Attachment Theory represent 'two strands' in CAT, in order to recapitulate aspects of CAT which have proved difficult and confusing and to explain why I believe that Attachment Theory and its associated cognitivist ideas have little to add to our basic theoretical understanding or our practice.
Anna Jellema (1999,2000),in proposing that Attachment Theory should influence CAT more, noted that there was little mention of attachment theory in my writing beyond an acknowledgement of it's introduction of ethological concepts in place of drive theory, a move in line with my own attempts to revise object relations theory. The wider interest in Attachment Theory and the development of its research programme more-or-less coincided in time with the development of CAT, but the two originated and evolved in very different places. Attachment Theory rests on a biological basis and its applications to psychotherapy have came later ;it is welcomed by some dynamic therapists who draw on it to explain or justify particular practices but it has not generated a coherent clinical method. CAT, in contrast, was developed in a clinical context and its slowly growing body of research has remained close to clinical concerns . In constructing its theoretical base the aim was to transform and integrate existing models and tobase it on a developmental model which was consistent with the new flood of observational studies of early development and mother-child interaction.
Attachment Theory was of limited value in this latter respect. While its research has usefully demonstrated correspondences between parental and child 'attachment styles' it has not contributed a great deal to the understanding of how these patterns are transmitted. There seem to be two reasons for this, one theoretical and one technical. The ethological concept of attachment is based on the need of the young for protection from predators and hence on the tendency to seek closeness. But in man, who evolved biologically over 4 or more million years during which social organisation and culture were also evolving, other features will have conveyed evolutionary advantage, notably those which allowed flexible participation in social activities. The blanket term 'attachment ' does not convey how humans are socially formed and the concept of ' bonding, is a reductive account of the intense two-way interaction of mother and baby . Attachment Theory research has relied excessively on its two standardised tools (the Ault Attachment Interview and the Strange Situations Test), with little direct attention being paid to parent-child interaction, and the associated writing has paid remarkably little attention to the mass of other observational research. This has resulted in a neglect of the specifically human, culturally-shaped features with which therapy is most concerned. Aitken and Trevarthen( 1997) point out that Attachment Theory describes the infant as seemingly 'born with a need for maternal care in regulating endogenous physiological tension, but no specific need for organizing psychological structures and processes in cooperation with a human companion'.
Another limit to the clinical relevance of Attachment Theory, derived from the research strategies, is the reduction of the patterns of parent and child attachment styles to a small number of categories, the recognition of which involves laborious and indirect procedures, and the development and change through time of which is little attended to. What is gained in reliability is lost in relevance Because early work did not consider the more disturbed patterns of attachment, Crittenden modified the procedures and of necessity extended the number of categories but this further reduced any possible clinical value of categorisation due to the large number of categories and to the fact that more disturbed patients often meet the criteria of more than one category. . Descriptive methods have more to offer and, as Dawn Bennett has demonstrated (Bennett and Parry,1997 ), the collaborative reformulation used in CAT reliably identifies the significant procedural patterns in borderline patients, using more direct an less time-consuming methods than Attachment Theory. Moreover, CAT reformulation is more powerful in that it describes how interpersonal and self-managing procedures are linked and adds structural understandings.
In proposing that the transmission of attachment styles depended on the development of 'working models of relationships', Bowlby was drawing on the then emerging cognitive paradigm, involving metaphors of information storage and theory building. Within this model children are seen to store representations and develop theories about themselves, about others and about their relationship. Fonagy and Target (1997 ) have recently proposed a link between Attachment Theory and some current theories of how the child acquires a 'theory of mind'., that is to say how others and the self come to be understood in terms of intentions and 'unobservable mental states'. In describing 'the caregiver's ability to communicate understanding of the child's intentional stance' they describe the process of 'representational mapping', exemplified by the following acount of a mother's response to a child's anxiety : 'the mother's representation of the infant's affect is represented by the child and is mapped onto the representation f his self state'. Apart from using 'representation' in two distinct ways, to describe 1)the mother's mirroring and 2)a mental process in the child, the account of mapping another's enactment of an emotion onto a representation of a self state is deeply obscure. But as long as what is going on between mother and child is conceived of as an exchange between two information processors these obscurities are hard to evade. CAT's evolution from an apparently cognitivist to a dialogic understanding. The early adoption and later divergence of CAT from cognitivist assumptions has been one major source of misunderstanding and confusion among CAT trainees and practitioners . The conceptual differences between CAT and cognitivist approaches can be clarified by rehearsing the developmental history of CAT and by considering wider philosophical issues.
In seeking a common language with which to describe different psychotherapies, my first endeavours involved the translation of psychoanalytic concepts into a 'cognitive' (and less ambiguous) language. This move served to obscure (for myself and others) an early and significant divergence from cognitive theory. The construction of a CAT theory grew from the attempt to understand why patients (people) continue to act in ways which do not work and the resulting Procedural Sequence Model emerged from the descriptions of traps, dilemmas and snags. While it drew on behavioural and cognitive sources and language it differed in one critical way in that it identified, as the minimum unit of observation needed to explain the persistence of problems, the procedural sequence . Linking descriptions of external events and context, internal mental processes, external action, and internal assessment of the consequences leading to the confirmation or revision of the internal aim and/or the external action was a more radical ove than at first appeared. It implicitly rejected the assumption that the sources of action and experience are in the individual . The later elaboration of the Procedural Sequence Object Relations Model, with its focus on the clinically crucial reciprocal role procedures as descriptive of current relationships and self management and indicative of early development, underlined this move towards a more permeable and contextually situated model of the self.
Derived initially from clinical work, CAT theory was then further extened through Mikael Leiman's introduction of Vygotskian and Bakhtinian ideas. (Leiman,1992, 1994 ). These were important extensions which the model could incorporate because, from the start, as outlined above, the it had described 'inside' and 'outside' the head as essentially in relation . In this, it represented a rejection of the dominant Cartesian assumptions of Western thought, offering instead a 'dialogic' understanding . Just as it was difficult, in the Middle Ages, to discard the notion that the world was the centre of the Universe, so for many practitioners and critics of CAT it is difficult to discard the assumption that our individual worlds are centred in our individual heads. There are many unreformed Cartesians in the CAT ranks, although (fortunately) the ‘techniques’ of CAT force everyone to adopt dialogic modes to some extent.
Internalisation, not representation. Procedures, not schemas. The alternative, dialogic understanding hinges on three basic assumptions derived from Vygotsky, namely 1)that a child's activity in the presence of (scaffolded by) a more experienced other will come to be repeated independently 2) that the activity and the meanings related to it will involved the joint creation and use of signs and 3)that internalisation is based on sign mediation rather than on representation and that external conversation is repeated as the internal conversation of the dialogic self. Neither speech nor action can be understood as an exchange between a speaker/actor and a passive listener/subject, for the speaker/actor is already located by past actions or utterances and is aiming speech and action towards another whose responses are to some degree already anticipated.
As the child explores physical and social reality he or she acquires the meanings of self and other through the scaffolded experience with others, a process beginning at or soon after birth . This generates, among other things, an implicit 'theory of mind' in that attributing intention, recognising affect and understanding pretence (the demonstration of which provide the experimental evidence for theory of mind acquisition) will be explanatory principles expressed in, and giving meaning to, the everyday experiences of the mother-child dyad.
As therapists, we identify RRPs by generalising from examples of detailed patterns of thought and behaviour and we then use these generalisations to recognise and predict future patterns . It is important to remember that RRPs are our heuristic devices, they do not describe something in the head, whether the something is conceived of as a cognitive centre or a schema library or a representation. Those listed in the cores of diagrams are not mythical motivators or organisers any more than the Pineal gland proved to be the seat of the soul. The playing of a role in relation to another involves a huge range of ( largely rehearsed )mental and behavioural processes. Essentially, procedures are what living people go on doing .
The aims incorporated in many procedures, as described in reformulation, include obtaining recognition, acceptance, validation or care from others, that is to say they relate to 'attachment' but are related to memory, knowledge, meaning, capacities and so on.. In CAT, however, pursuing these 'attachment' aims will be seen to be associated with issues of control and submission and conditional reciprocations and we will also describe the possible reversal of roles expressed in the provision of care for others and will identify related self-managing procedures.
Anna Jellema emphasises the relevance to therapy of the distinction between 'dismissing' and 'preoccupied' attachment styles, the former associated with the avoidance of feeling and the latter with the avoidance of self- reflection and with blaming others. In my view these are more usefully described not as styles but as RRPs in which the reciprocating role of the other (including the therapist) can also be taken into account. The avoidance of feeling or the avoidance of thought manifest in therapy may be consequences of the model or of the personality of the therapist.
All therapists would like to provide their patients with a secure base. But it is not simple. In treating disturbed adults with CAT it would be seen to require the provision of a respecting and non-collusive human relationship which, informed by joint work leading to an accurate reformulation, can 'scaffold' the process of reparative learning.
In developing CAT theory and practice we have argued with and borrowed from and transformed much from other sources and will doubtless continue to do so, but I believe we have created and are still developing an important, far reaching and coherent model of the processes relevant to psychotherapy and the care of psychiatric patients. I accept, of course, that many other therapists working with( or despite) many other theories can be very helpful to their patients, although I also believe that other potentially good therapists work slowly or ineffectively because they are restricted by the understandings and the negative human values embedded in their models.
I do not see CAT as just one more assemblage of techniques ; the ideas and values on which it rests are integral to its practice and are applicable in many areas beyond individual therapy. We always address our patients as whole people and we work at the level of the self to produce very powerful descriptive tools and these tools reflect our dialogic understandings of the development, maintenance and therapeutic transformation of self processes . The specific 'techniques' communicate these understandings and values and support us in offering a respecting, non-reductive and potentially transforming human relationship to even very damaged and damaging patients. For these reasons I have argued in this paper vigorously and unapologetically in defence of CAT and against diluting its theory with Attachment Theory and cognitivist ideas.
Aitken,K.J. and Trevarthen,C.(1997). Self/other organization in human psychological development. Development and Psychopathology,9,653-677
Bennett,D. and Parry,G. (1998) The Accuracy of Reformulation in Cognitive Analytic Therapy: A Validation Study. Psychotherapy Research. 8 (1) 84-103.
Jellema,A.(1999).Cognitive analytic therapy; developing its theory and practice via attachment theory. Clinical Psychology and Psychotherapy,6,16-18.
Jellema,A.(2000) Insecure attachment states: their relationship to borderline and narcissistic personality disorders and treatment process in cognitive analytic therapy. Clinical Psychology and Psychotherapy, in press.
Fonagy,P. and Target,M. (1997) Attachment and reflective function; Their role in self-organisation. Development and Psychopathology, 9 679-700.
Leiman,M. (1992) The concept of sign in the work of Vygotsky, Winnicott and Bakhtin : Further integration of object relations theory and activity theory. British Journal of Medical Psychology, 65,209-221.
Leiman,M. (1994) Projective identification as early joint action sequences : A Vygotskian addendum to the Procedural Sequence Object Relations Model. British Journal of Medical Psychology, 67,97-106.
Book Review of: How Infants Know Minds. Reddy, V. (2008). Harvard University Press.
Ryle, T., 2009. Book Review of: How Infants Know Minds. Reddy, V. (2008). Harvard University Press.. Reformulation, Summer, pp.33-34.
Book Review of: Beatrice Beebe and Frank Lachmann (2002). Infant Research and Adult Treatment: Co-constructing Interactions. Published London: Analytic Press.
Lloyd, J., 2009. Book Review of: Beatrice Beebe and Frank Lachmann (2002). Infant Research and Adult Treatment: Co-constructing Interactions. Published London: Analytic Press.. Reformulation, Summer, pp.34-35.
A credit-card sized SDR and its use with a patient with limited language skills.
Fitzsimmons, M, 2000. A credit-card sized SDR and its use with a patient with limited language skills.. Reformulation, ACAT News Autumn, p.x.
Prevention and Early Intervention for Borderline Personality Disorder in Young People
Chanen, A., 2000. Prevention and Early Intervention for Borderline Personality Disorder in Young People. Reformulation, ACAT News Autumn, p.x.
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