Leiman, M., 1993. The Problem of Relating TPs and TPPs. Reformulation, ACAT News Autumn, p.x.
When reading Annie’s polemic against the new orthodoxy in the Newsletter (January -93) I felt somewhat confused. I am not used to attaching the idea of one correct conceptual or practical approach to the immense complexity of human personality and the ways m which activity sequences get structured in the course of development, and I would certainly not think of one standard way of condensing that complexity in therapy.
Incidentally, in our trainers’ training programme we have addressed the issue of the relationship between presenting problems and the underlying problem procedures under the heading ‘Symptoms and Procedures’. As a comment, largely supporting Annie’s reservations against a one-to-one hypothesis, I would like to tell how we have approached the issue.
Before going into that, I must express my current view of the terms involved (presenting problem/symptom -> TP; maladaptive procedure -> TPP). Presenting problems usually refer to the self-attributions that the patient has created regarding symptoms and their personal meaning. Similarly, when the problem is a life crisis, a persisting relationship issue, etc., the presenting problem refers to the personal sense of the issue, i.e. how the patient conceives his or her situation. In the PSORM symptoms and life problems are related to a structure of underlying procedures with different positions and functions. The complex analytical task of identifying and describing the procedural repertoire, when successfully carried out in dialogue with the patient, will lead to the formulation of target problem procedures.
Thus I understand that TPs refer to ‘symptoms’ and TPPs to ‘procedures’, in the context of defining aims for CAT. They are ‘technical’ devices used by the therapist in the process of clarifying the psychological complexity of the patient They axe used as tools for identifying focussed areas of joint work after a broad examination of the patient’s procedural repertoire. I would not use the terms TP and TPP when trying to understand the patient’s way of thinking and acting. That is the matter of procedures. That is why we have called our clinical studies ‘symptoms and procedures’.
We have studied our theme since January in three of our monthly meetings by presenting cases that seem to pose special difficulties in relating the presenting problem to some underlying procedures. Another way of saying this would be that we have studied cases that are difficult to reformulate.
So far we have been able to single out four different kinds of relationship. We expect to find more, which only serves to emphasise that reformulation is, and will remain, a painstaking process. Our conceptual tools are quite helpful in guiding us, but they will not solve the practical task of finding the specific constellation of procedures, their idiosyncratic contents, and their complex mediational links with the presenting problems or symptoms.
The first, and simplest, kind of relationship is encountered in the symptomatic procedure. A patient begins to binge every time he feels lonely and detached. The action sequence involving the symptom can easily be described by the patient ‘I feel cut off from others, empty and gloomy. I go to the shop and buy some food. I do not intend to eat all of it up, but I cannot stop. Then I feel terribly guilty: What the patient cannot describe at the outset are the internal dialogues that mediate the stages in the sequence (i.e. the internalised RRPs). To unveil them will be a task of therapy.
Another person with a perfectionist disposition, usually consisting of a set of self-management procedures to ward off extreme neediness associated with a sense of unworthiness, starts trembling in situations involving performance of any sort. Often eating out with others is enough to produce the symptom. Eventually the frequent appearance of the symptomatic sequence leads to an avoidance trap, reinforced by the appearance of the symptom. Feelings and fantasies are involved in the symptom sequence that might be described as follows: ‘I feel unworthy. I must conceal it by being a flawless person. I cannot be sure that my performance will be immaculate. Trembling appears as a combination of excessive control and fear. Alas it betrays me and exposes my unworthiness.’
In the latter case example we may recognise that the perfectionist self-management procedures generating the symptom also produce another self-management procedure, i.e. the avoidance trap. Both are intimately connected to an underlying reciprocal role procedure (needy and unworthy - critical and rejecting). According to the wisdom of the PSORM, we would expect that the symptomatic procedure is related to some core reciprocal role procedures, even if unconscious as in the first case.
The mediational link between the symptom and the underlying RRP helps clarify the appearance of secondary anxiety as well as the tendency of the symptomatic procedure to become more and more generalised. In the second case the underlying RRP invests the symptom with a strong sense of shame; it reveals the patient’s unworthiness that he has desperately tried to conceal. Avoidance is an attempt to manage the symptom.
The second kind of relationship between symptoms and procedural structures is the case where the symptom acts as a sign of dissociative shifts. I recently treated a man who was suffering from severe panic attacks. These attacks occurred in situations that tended to evoke a dissociated set of destructive RRPs of the type abusive-abused and contemptuous...contemptible For instance, he felt stopping in traffic lights unbearable and panicked. In the course of therapy he recognised how persecuted he felt by the car driver behind.
A third, more complex kind of relationship between symptoms and underlying procedures may be encountered in some somatic patients. The symptom, or illness, does not seem to have any meaning i’ul connection to any maladaptive procedures whatsoever. At the outset we may only be able to identify a seemingly functional self-management procedure by which the patient tries to cope. It may take a long time before the therapist gains any understanding of the subtle and complex forms of mediational links that place the illness into a meaningful personal and interpersonal context (in terms of internalised RRPs).
The fourth kind of ‘unclear relationship’ between symptoms and procedures resembles the previous case. We see an increasing number of patients who have faced a sudden and detrimental life change, for instance, by having lost their job. If there are symptoms they are crisis related. Often anxiety and concern are all that we can see. Yet the person’s relation to the problem situation reveals underlying RRPs internalised during earlier development, relating to issues of continuity. Someone retains a sense of trust and hope, another feels as if he is plunging into an existential abyss, etc. A crisis or rather, why a particular event has become a crisis for this person, also illustrates what were the (relatively successful) procedures that were used before the sudden change.
We may study the crisis, very usefully, with the patient in terms of underlying procedures, but these are examined in a context that locates them quite differently to ordinary neurotic problems. Instead of ‘symptoms and procedures’ we face ‘events and procedures’, the difference being in the fact that the patients commonly construe the events as external and ‘objective’ things. The first thing in therapy is then to help the patient examine the personal sense of the event. That leads to an analysis of the procedural repertoire accounting for the meanings involved.
Going back to the issue of the relationship between TPs and TPPs, it seems evident that, in many cases, it would be a mistake to force a singular connection between the target problem and one main target problem procedure. In some cases, when permitted by the patient’s procedural repertoire and the simplicity of its structure, it may be an excellent way of focussing time-limited therapeutic work, If successfully done, it certainly has an immediate appeal to the patient as it will give him or her a refined attribution regarding the ‘cause’ of the symptoms or problem. Most of our patients do not, alas, belong to this group.
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States Characterisation Procedure (SCP) for supporting the reformulation of patients with borderline/dissociative features
Ryle, A., 2007. States Characterisation Procedure (SCP) for supporting the reformulation of patients with borderline/dissociative features. Reformulation, Winter, pp.9-11.
Meditation on the Phenomena of Anxiety in CAT Clinical Training
Dunn, M., 1993. Meditation on the Phenomena of Anxiety in CAT Clinical Training. Reformulation, ACAT News Autumn, p.x.
Validating Conceptual Aspects of the Reformulation Process in CAT
Donias, S., 1993. Validating Conceptual Aspects of the Reformulation Process in CAT. Reformulation, ACAT News Autumn, p.x.
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