Leiman, M., 1997. Early Signs of Dialogical Sequences in CAT. Reformulation, ACAT News Winter, p.x.
Problem Procedures revisited
In the eighties, the main treatment strategy of CAT was based on the identification of a limited number of procedures that accounted for the patient's presenting problems. These Target Problem Procedures were commonly defined by using the metaphorical descriptions of Traps, Dilemmas and Snags (Ryle, 1979). In the treatment of personality disordered patients this strategy was not successful because the issue of dissociated Reciprocal Roles was not adequately addressed by isolated procedural descriptions. The configuration of procedures became the main focus of interest and has remained so until this day.
We have witnessed a number of configurational descriptions, ranging from `broken eggs' and 'cheddar cheese' diagrams to the 'Core State and loops' illustrations, and the Reciprocal Roles diagrams that are currently popular. When describing the Reciprocal Roles, the therapist is advised to pay attention to the core repertoire of Reciprocal Role Procedures operating in any such State. The therapist should also pay attention to the procedural loops that represent either direct or transformed enactments of the internalised role relationship patterns (Ryle, 1995).
When describing these loops or action sequences that emanate from the pattern, no succinct analytical tool is available. Consequently, the descriptions tend to acquire quite an occasional character. In some loop illustrations general aims or wishes are postulated. In others only a list of external actions are produced, connected with arrows that indicate the sequence. In yet others, the procedural loop is constructed by using a combination of actions, Reciprocal Roles, and Dilemma formulations as falsely polarised assumptions regarding the options for action.
Such a variety within diagrammatic refonnulations is sometimes perplexing for patients, as the descriptions of problematic action sequences in a single diagram may employ different modes of construction. The multitude of descriptive strategies is also frequently puzzling for psychotherapy trainees who feel that the configuration of Core States and procedural loops seem to emanate from the intuitive wisdom of the supervisor. The theoretical confusion regarding Reciprocal Roles and action sequences thus leads into practical difficulties in both therapy and training.
In my view, these problems are partly determined by the integrative gap between our cognitive attempts to describe activity sequences and the Object Relations approach that we use to describe the structure of the mind and the interpersonal patterns, reflecting the internalised Role Relationships. While recognising the dialogical nature of Reciprocal Role Procedures, we still approach action sequences in terms of a nondialogical model of cognitive functions.
Dialogical Sequence analysis
I have tried to find a solution to this problem by studying distinct activity sequences, or Problem Procedures as they were originally called, on the basis of a Vygotskian-Bakhtinian understanding of our mental life as a symbolically mediated, dialogical activity. Instead of describing activity sequences as cognitive cycles beginning from perception and ending in evaluation, as in the Procedural Sequence Model, I try to address the dialogical patterns that mediate our activities, even when they are not directed at another person. Consequently, the procedural sequence has been given a new name, the Dialogical Sequence (Leiman, submitted).
In order to illustrate the concept, I shall present the first utterance of a young patient and describe it as a symptom procedure that is mediated by internalised patterns of Reciprocal Roles, or Dialogical Positions as I prefer to call them.
"It just happens, when I leave the school, I'm sort of getting an empty feeling, I do not know if it is hunger or what. If I happen to pass a bakery I drop in and buy a loaf. When I come home I get a glass of milk. Then I just sit down and eat up all the bread, and then I feel 'Yuck!"'
In this narrative of the patient, the sequence of events is very distinct because the symptomatic pattern is so well established and familiar to her. Its dialogical nature is however not directly discernible. In order to arrive at a proper reformulation of the sequence its dialogical patterns must be inferred. The proposed notation describes the sequence as a combination of internal (dialogical) and external actions. The symptom procedure is represented by actions that carry the process forward and the dialogical patterns that mediate or direct the flow of the sequence.
An example is given in Figure 1: When the girl leaves the school she is feeling lonely. Her sense of connectedness is broken and 'there is nobody out there'. She tries to deal with the loss by an act of consolation in which bread is the symbolic mediator of comfort. However, the ensuing activity (eating the loaf) calls forth another kind of internal dialogue, represented by the 'Yuck!'. A resentful, parentallyderived voice appears and despises her weakness and fatness. A Kleinian account of the sequence might read like this: The girl tries to create the good breast in fantasy by buying the bread. However, she destroys it by her greediness turning it into a damaged breast that then begins to haunt her from within.
At this stage a note on terminology must be made. I am using the terms 'Dialogical Pattern' to indicate the reciprocal arrangement of two roles, or voices as I prefer to understand the nature of internalised roles. Dialogical Position' refers to either one of the poles in the dialogical pattern. (cf Ryle's "State of Mind"); 'Dialogical Sequence' will be used when describing the full procedural sequence that consists of dialogical patterns and actions that may be internal or external. I have called these actions 'transformative' to indicate their role of carrying the sequence forward. The aim is to convey the idea that only those actions that are directly relevant to the flow of the sequence will be noted. They may have structures of differing complexity and may consist of either a few or several distinct sub-actions or operations.
The dialogical pattern is a highly abstracted and fixed description of the dynamic processes going on in the person's mind and in her activities. As pointed out by Mark Dunn in ACAT Newsletter N° 2 (November 1993), Role Procedures may be experienced and described as internal voices. In psychotherapy we trace the often complex juxtaposition of these voices - their content as well as the stance that they seem to adopt regarding the intended actions of the patient. The diagrammatic presentation points out the positions from which the voice seems to act and to which the patient posits herself, while remembering that, because of being internalised in dialogical form, switches to the reciprocal pole frequently occur.
The above dialogical construction of the symptomatic procedure, called Dialogical Sequence Analysis (DSA), provides both therapist and patient with valuable cues about the kind of internalised Object Relations that can soon be examined in other activities of the patient and in the transference. This is the chief merit of the proposed notation. By sensitising patient and therapist to the dialogical quality of any action pattern (for instance, symptom procedures), reformulation can begin at an early stage of the first session, or even at the assessment interview, by using whatever material the patient brings up. The therapist should however be aware of the fact that, at such a very early stage, only tentative hypotheses about the patient's salient Dialogical Sequences can be made. In human life there are no fixed meaning patterns that could be exhaustively described by such notions, based on our first impressions.
Examining the many voices of patient utterances
The DSA is a device that may be used to arrive at generalised descriptions of the patient's Problem Procedures. In order to generate the dialogical patterns, we must recognise their traces in the patient's verbal utterances and the accompanying nonverbal cues. Mikhail Bakhtin's theory of utterance and especially his methods of examining novelistic discourse (Bakhtin, 1981; 1986) have affected my way of listening to the audiotaped sessions. Bakhtin's ideas have alerted me to the simultaneousness of different topics and to the positional switches occurring in the patient's discourse. I also try to observe the presence of 'another's voice' that can be detected by the patient's choice of words, changes in pitch and tone of voice, or changes in intonation - sometimes even in the syntactic composition of the utterance.
I shall briefly illustrate the conceptual background to this approach by reproducing the first utterance of the patient in the first session. Being a translation from Finnish, it does not convey adequately the shades in the patient's verbalisation and, in addition, the very important paralinguistic cues are missing in the transcription. Despite these shortcomings, I hope the ideas behind dialogical analysis, and the value of doing it on patient utterances, will become clearer.
Three different Dialogical Patterns were noted. These have been written out in Normal Type, Italics. and Bold.
[First words are missing] ... [there was nobody]... to whom I would have told anything.. . that was the most important.. [reason]... and then.. an event that.. that burdened the so badly... and I just needed to tell somebody about it.. . and then the fact that I do not.. I'm totally tied in knots with myself so that I do not quite.. it is as if I did not know myself... I do not know what's wrong with me and... (Therapist: Hm.)..
and then yes... (sigh).. it all... actually, everything should be OK, we should not have any... with my partner, I mean... particular problems, but.. (sigh) yet.. (sigh) last Saturday I.. I did something.. very wrong and.. I was unfaithful and... and I do not quite know what it was that.. why I did it... So that was the... a long time already, for several years I've felt that I should.. should go to somebody.. to talk about.. always, but... it's like one hadn't previously got it done, but now.. now.. now (chuckle) it became a must. .. I had so.. such an awful strain that I just had to go somewhere.. .
If we take this passage as a narrative, it does look very disjointed. However, if we approach it as a multivoiced dialogue it begins to make sense. It is a good example of the simultaneous presence of three different addressees to whom the patient relates; that is, a) to the therapist as an unfamiliar person who does not yet know the details, b) to the patient herself, and c) to a rather dismissive and judgmental figure who does not want to listen and later reproaches the patient over what she has done.
The important internal dialogue that reveals two positions can be recognised in the Bold Type passages. The positions that seem to be enacted can be paraphrased as the voice of a child who cries "I need to tell you!" and a parental voice that starts by declaring "Everything is OK. What's the trouble?" Then, as the story goes on, the parental voice gets upset. "What have you done, for heaven's sake!?" This is represented by the word 'wrong' which is not the word of the patient. It is the voice of a disapproving adult.
The conceptual tool of Dialogical Sequence Analysis and the use of Bakhtin's methods to examine multi-voiced utterances have opened up interesting possibilities to study the complex discourse going on between patient and therapist. They are particularly valuable in making sense of the first session, or the assessment interview, and help generate assumptions of the Problem Procedures of the patient. I currently rely on this approach both when listening to the patient in the session and when supervising CAT trainees.
There is another potential area of use that is worth examining. In psychotherapy process research an increasing number of measures have been developed, aiming to trace recurring maladaptive action patterns in the patient's narrative. Luborsky's Core Conflictual Relationship Theme method is currently a very influential measure in the psychoanalytically oriented process research field (Luborsky & al. 1994; Luborsky & Crits-Cristoph, 1988). The FRAMES approach by Dahl (1988), and the Role Relationship Models Configuration method by Horowitz (Horowitz, 1987; Eells & al., 1995) represent closely related approaches to problematic interpersonal action sequences.
Dialogical Sequence Analysis may have its place within this family of research tools. The main difference between these measures and the DSA lies in the assumption that all our mental actions are dialogically structured. We may thus detect reciprocal patterns in many aspects of patient utterances beyond those explicitly addressing interpersonal relationship issues. In this sense the DSA, being inspired by Object Relations theory and elaborated by the Bakhtinian understanding of dialogical phenomena, allows us to examine the truly multi-voiced nature of the patient's psychological processes.
Bakhtin, M. (1981). Discourse in the novel. In The dialogic imagination. Translated by Caryl Emerson and Michael Holquist. Austin, TX: University of Texas Press.
Bakhtin, M. (1986). Speech genres and other late essays. Edited by Caryl Emerson and Michael Holquist. Austin, TX: University of Texas Press.
Dahl, H. (1988). Frames of mind. In H. Dahl, H. KAchele & H. Thoma (Eds.). Psychoanalytic process research strategies. New York: Springer-Verlag.
Dunn, M. (1993). Some subjective ideas on the nature of objects. A.C.A.T. Newsletter, Nr. 2, 16-17, London, UK., November, 1993.
Fells, T.D., Horowitz, M.J., Singer, J., Salovey, P., Daigle, D., & Turvey, C. (1995). The role-relationship models method: A comparison of the independently derived case formulations. Psychotherapy Research, 5,154-168.
Horowitz, M.J. (1987) States of mind: Configurational analysis of individual psychology (2nd ed.). Northvale, NJ: Jason Aronson.
Leiman, M. (Submitted). Procedures as dialogical sequences: A revised version of the fundamental concept in Cognitive Analytic Therapy.
Luborsky, L. & Crits-Christoph, P. (1988). The assessment of transference by the CCRT method. In H. Dahl, H. Kfichele & H. Thoma (Eds.). Psychoanalytic process research strategies. Berlin:. Springer-Verlag.
Luborsky, L., Popp, C., Luborsky, E. & Mark, D. (1994). The Core Conflictual Relationship Theme. Psychotherapy Research, 4, 172-183.
Ryle, A. (1995). The practice of CAT. In A Ryle (Ed.). Cognitive Analytic Therapy: Developments in theory and practice. Chichester: John Wiley.
Ryle, A (1979). The focus in brief interpretive psychotherapy: Dilemmas, Traps and Snags as target problems. British Journal of Psychiatry, 134, 46-54.
This paper was presented at the ACAT Conference, 2-3 March 1996.
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