Morris, P., 1995. Blunt Thoughts about Sharpening the File. Reformulation, ACAT News Winter, p.x.
Recently, in the middle of a dark and stormy night, a list of "Different States" suddenly appeared on the back page of the Psychotherapy File. It must have been magicked there by the fairies because noone could discover the identity of the author or how the page got there. Despite the fairies, no-one was charmed. They hadn't been consulted. They hadn't been informed. They hadn't been sent copies. A sprite dispatched to investigate returned with evidence that the last occasion that the File was tampered with was some time after Professor Ryle reproduced a copy in his Blue Book of 1991.1 (It is rumoured that two earlier versions are secreted in the archives of the CIA, after entries for lpcress and Magwitch).
The changes, including the addition of a whole page, have not altered, however, the substance of the Psychotherapy File. Officially it may be a flexible filter, all things to all people, but the current subtext is clearly to the contrary. It is a finite object. It is as fixed in form as Mr Blobby. You can prod it and poke it but it doesn't go away or stop smiling. For countless hours opposite one or another patient, those pages have flapped at your knee, stuck to your thumb and forefinger.
Therapists at work may gloss over parts of it, but they don't assume that there could be co-existent versions to choose from. or that one might adapt it to suit the literacy or other needs of a patient, or that the discursive sections of the text could helpfully be separated from those resembling a questionnaire: that it should be re-written. Therapists don't mess around with it. Patients hide their alarm when encouraged to. It is formidable. It is cryptic. It is full of writing. It has achieved iconic status. It has problems.
Amongst the more superficial ones is that there is too much going on relative to the number of signposts written into it. The File gives no rationale for its own structure, nor is there an indication of its relationship to the 16 sessions. This makes it hard to understand in the shortterm. It loses an opportunity for usefulness in the long-term. If one tries to read it as a continuous item, one is perpetually halted. What is its aim? Why is this bit suddenly here? How does it all connect up? Perhaps for this reason, that is, by default. it has acquired much of its usefulness. It keeps slipping out of shape but never slips away. It doesn't seem to know what it is itself. It prompts the use of discipline in the process of exploring meaning. Or does it simply infantilise the patient (if not the therapist) with confusion? Is it a questionnaire? Is it a teaching text? Is it a file? Fie! It puts one in mind of Superman. In his Blue Book Professor Ryle refers to it as a teaching document designed to instruct the patient. He repeatedly talks about giving it to the patient to "read" (rather than to rate). Yet it seems to be mainly as a questionnaire to be completed, initially anyway, that often patients, and perhaps therapists too, perceive it. Iu time, in the course of the "collaborative" activity, the patient night discover what the therapist was talking about when she mentioned its usefulness as a prompt and guide to discussion of problems and procedures. But despite all the writing in it, that message, its purpose in the therapeutic relationship, is left out.
It seems to be a truism in CAT quarters that patients find the Psychotherapy File, or parts of it, difficult to understand, that they often return it marked but with a continent to the effect, "I'm not sure I understood all of it". 'What is one then to make of the patient's rating responses? If doing CAT has a lot to do with educating, then the primary explanatory text given to patients should be simply written and its meaning should be clear. Then their incomprehension would have more to do with the whole individual, or the transference, than with the patient's literacy or receptivity to an unfamiliar view of the world to which CAT sometimes quickly introduces one.
There is the request that the patient keep a diary. This is a heavy-duty matter in the therapeutic relationship and also in practical terns. Neither is reflected in the way the request is made in the File. (I'm not sure it should be in the File.) Without threatening to rap knuckles, there is nothing straightforward about persuading a disinclined non-anal-retentive patient to keep a diary of any kind, let alone one which monitors the uncomfortable bits. To prove that the CAT process is democratic, would the therapist volunteer to summon up the time and self-discipline to keep a methodical diary herself? The patient's reluctance to do homework may be material for therapy, but the homework still doesn't get done. And there is something about the ease with which the request allows the patient to set himself up for "failure" (by not keeping the diary) which renders it somehow inappropriate to have that request fixed on the same document which purports to be about collaboration. The request is not of the same order as the one which requires the patient to mark some boxes. And if the view is that, to the contrary, tasks of different orders may justifiably be mentioned in the File, then why not go the whole hog and also mention Reformulation, SDRs, Rating Sheets and Goodbye Letters?
There are also a number of minor infelicities which invite one simply to gripe. The sections of text are a little long and difficult; they tempt the patient to recover esteem by focussing on the activity sections where the prompts, though not always clear, call always be answered - if one isn't too bothered with being accurate. And what is to be made of the changing person, sometimes "I", sometimes "you", sometimes "we"? And the item-numbering non-system is bamboozling. And there is the sudden assertion (a left-over from the transmutation of an earlier version's explanatory text into a new Trap in the current version) that "People who do not respect our rights as human beings must either be stood up to or avoided". (The Trap would have read better without lobotomizing the original paragraph.) And the word "resistance". incorrectly spelt twice on the duplicated copies of the File, seems a strange choice given that its lay use tends to be political rather than psychological, and in the trade carries such highly-charged psychoanalytic value it seems excessive in a document trying to use plain language. And the attempt, or so it seems, to show we are sensitive to gender issues (Dilemmas no. 10: ",As a woman ... ", "As a man...") actually reflects sexism and sounds slightly patronising. (I find equally wince-worthy the Fear of Hurting "Trap reference" to "rights", a politically-loaded word. dropped in with a whiff of tokenism.) And there are those unfortunate syntactical moments - mostly introduced in the post-Blue Book period. My favourite example is at the end of the Low Self-Esteem Trap. It reads: "...so we give up trying to do anything which confirms and increases our sense of worthlessness." Sounds pretty assertive to me! So much for patients. How do therapists say they cope with the File?
An end-of-first-year trainee whose supervisor not long before had assessed her very favourably, nevertheless asked a fellow trainee for help in devising an SDR. She confessed that because her natural inclination was to work "intuitively" rather than "cognitively", to know "the deep feeling" rather than "being able to track the process", she still didn't understand CAT generally or reciprocal roles in particular. "And what happens," she added, "if the patient brings back the Psychotherapy File and simply says he hasn't got any procedures?"
Her confusion betrayed her suspicion that just as the CAT method did not come "naturally" to her as a therapist, so either not every person actually has these novel entities called "procedures", or their "existence" is a matter of conviction. It was as though, in her view, a person's assumption of the "existence" of "procedures" was as arbitrary as a belief in the four cardinal humours, or in the conformations of the cranium as a phrenological index. You could take it or leave it and CAT people took it.
I've heard less sceptical therapists also new to the use of CAT sometimes suppose that the six Traps, two Snags, etc. of the Psychotherapy File summarise the outcome of academic research which has produced a condensed, reliable synopsis of the spectrum of all possible human procedures - rather than tentative verbal analogues of cognitive, behavioural and affective sequences. The newcomers' assumption has its own logic. Why else, if not for its statistically significant reliability, would the current File appear to be ubiquitous, "finalized", a complete code, "a deliberately established, killed context"?2
A straw poll in casual conversation suggests that whatever therapists are supposed to be doing with the File, they're all doing something different. In our Blue Bible, Professor Ryle gives it a central position: "It is possible to carry out CAT using clinical interviewing, selfmonitoring and the file with no other special procedures. "3 Then I hear on the grape-vine that these days God isn't even looking at the File half the time. He's saying to patients something like, "How're you doin' on the green loop these days? And the red one?" And the sky has not fallen down. I've heard that across the spectrum of CAT practitioners the File is variously regarded as crucial or incidental. It may be employed in sessions, briefly, or at length, regularly, or not, as a prompt to move things along, or out of session only. It may become a shared tool with which therapist and patient explore the concepts of target problems and target problem procedures. For some therapists the notion of the File as a summary of the human psyche is absurdly reductionist and bears no relation to its original purpose. Two therapists to whom I spoke separately referred to it without pausing as "a transitional object". An experienced CAT therapist referred to it as "bullshit". (Of my "front page" summary of the File - which the Editor is reproducing elsewhere in this issue of the Newsletter - that last-mentioned therapist's opinion was that it was even bullshittier. I suppose the attachment of a skeptic to the summary-on-a-page can only be explained in terms of it serving as a personal transitional object, as cribnotes, as psychically nourishing condensed milk.)
One thing that's mercifully clear where all else may not be, is that t h e Psychotherapy File is not a reliable psychometric device. The scores which the patient gives himself are not necessarily a means to discovering his TPPs, indeed, at times indicate denial: zero scores may be assigned to precisely those procedures or states which the patient is unable to confront at the beginning of therapy and which by the end have emerged as of glaring importance - hopefully not only to a despairing therapist. A young patient who seemed later to make quite good use of his CAT, after the first session gave himself zero ratings for these two Dilemmas: (6b) If exposed then I feel either contemptuous of others or I feel contemptible. (7) Either I'm involved with others and feel engulfed, taken over or smothered, or I stay safe and uninvolved but feel lonely and isolated.
When a final draft of his TPPs emerged, they were precisely around these Dilemmas, with minor word changes ("dismissive" rather than contemptuous, "connected" rather than involved).
Another patient thundered rage against her family in an avalanche of blame so pure it will, on her (long-distant I'm sure) demise, find its well-earned niche next to Plato. She went home and added responses to the "Different States" section as follows:
(4) Extra special. Looking down on others. "Would never do that."
(7) Provoking, teasing, seducing, winding-up others. "Never. "
(15) Envious, wanting to harm others, put them down, pull them down. "Never."
(22) Frightened of others. "Never. "
Both the above examples simultaneously confirm and disconfirm the usefulness of the File's "rating" system. It retrospectively reveals both what the patient is anxious to deny and also what will emerge anyway.
While the orthodoxy seems to be that the Psychotherapy File is the first gateway to CAT, its very plethora of contradictory uses, from essential item for trainees to disposable commodity for the Guru, makes it a candidate for Papert's QRTERTY phenomenon: the tendency for the first usable but still primitive product of a system to dig itself in. 4 Or perhaps the source of the File's most profound function is inaccessibly secreted in CAT therapists' collective unconscious, as a species of subterranean Linus-blanket on which, sleeping, we suck. Only then may we wake to face our patients bravely, clutching our overworked Reformulations, our tear-stained Goodbye Letters, and, in my case, with neck bent beneath the albatross of That *@ $%!* Rating Sheet.
Survival cries out for an Exit. Perhaps it lies yonder at the beginning, towards a radical re-examination of the Psychotherapy File? It is not a plane. Perhaps it is the CAT therapist's lifejacket? Then I'd like to see some refinements. A little whistle, dangling, in case of danger? A light that flashes in deep water? A finalized instruction manual which anyone can understand!
Future Self: "Ah!"
1 Ryle, Anthony, Cognitive-Analytic Therapy: Active Participation in Change (England: John Wiley, 1993). Appendix A.
2 Entry no. 68 in extracts from Mikhail Bakhtin's Notes (1970-1971) reprinted in Gail, Saul Morson (ed.), Bakhtin: essays and dialogues on his work (Chicago: University of Chicago Press, 1986), p:181.
3 Ryle (1993), p.18.
4 Papert, Seymour, Mindstorms: Children, Computers, and Powerful Ideas (New York: Basic Books, 1980), p.32-3.
Some reflections on the Malaga International CAT Conference "Mental health in a changing world"
Maria-Anne Bernard-Arbuz, 2013. Some reflections on the Malaga International CAT Conference "Mental health in a changing world". Reformulation, Winter, p.50.
What's it like to have Cognitive Analytic Therapy?
Sloper, J., 2002. What's it like to have Cognitive Analytic Therapy?. Reformulation, ACAT News Spring, p.x.
The Special Needs Project (CAT For Borderline Patients)
Ryle, A., 1995. The Special Needs Project (CAT For Borderline Patients). Reformulation, ACAT News Winter, p.x.
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