Ryle, A., 1995. The Special Needs Project (CAT For Borderline Patients). Reformulation, ACAT News Winter, p.x.
This research project based at Guy's Hospital is now in its third year, with over twenty patients recruited. More experienced and more intensively supervised therapists are involved, and the research is carried out with the participation of Martin Marlowe and Katya Golynkina (psychologist) at Guy's, and in association with Dawn Bennett, who is developing methods of analysing audiotapes in Manchester. Some preliminary results will be presented at the ACAT Conference and at the Society for Psychotherapy Research meeting in March. In this brief article I will describe some of the developments which may be of wider interest to CAT therapists.
This group are hard to treat because their central characteristic is difficulty in sustaining relationships - they repeat this in daily life and in all sorts of therapies. Treatment fails because they are difficult and because countertransference collusion (i.e. reciprocating negative procedures) is hard to avoid. This means that, even more so than in less disturbed patients, early reformulation is essential. Usually a start should be made in the first session, specially seeking to describe procedures likely to lead to dropping out of therapy.
Reformulation is also different in these patients: they may manifest many familiar procedures, but underlying these is the more fundamental problem of fragmentation. When reformulating borderlines we must seek to identify their two or more Self States and, on that basis, their confusing State Shifts. Diagrams are essential and should take the form of Self State Sequential Diagrams (SSSDs).
Evidence of separate self states may be gleaned from the history, from early interactions, and by following up positive responses to the last section of the Psychotherapy File (Unstable States). Some Psychotherapy Files now have, in addition, a section on "Different States;" (Editor's note: a list of 23 common States (see page 20 of this Newsletter) is preceded by this paragraph: "Everybody experiences changes in how they feel about themselves and the world. But for some people these changes are extreme, sometimes sudden and confusing. In such cases there are often a number of states which recur, and learning to recognise them and shifts between them can be very helpful. Below are a number of descriptions of such states. Identify those which you experience by ringing the number. You can delete or add words to the descriptions, and there is space to add any not listed.") and this too can initiate a conversation about states. In fact in most cases patients grasp the idea without difficulty and usually provide their own graphic names for each state.
Once listed, the states need to be characterised; this involves patients in selfmonitoring, a process which can also lead to the recognition of State Shifts. To complete this, all the states can be rated against the descriptions listed in the Self States Grid, adding further descriptions if the patient or therapist wish to do so. This can be analysed as a repertory grid to give a map of how states are related, but even if this is not possible the rating task itself is integrating. Where there is no one state in contact with all the others, these ratings may need to be done while in each of the states (and they are not always cooperative). The data from this, linked with the other information, allows the construction of the SSSD in which each self state is identified by its main Reciprocal Role Repertoire, and in which the procedures generated from each, especially those leading to State Shifts, are described. (Colour coding of each Self State and its procedures is helpful.) These diagrams are essential for patient selfmonitoring and for the avoidance or correction of collusion, i.e. of behaviours which reciprocate a damaging RRP or which mirror or intensify fragmentation by not picking up State Shifts.
Clarification and Apology: States and Self States
In the development of this model and method CAT terminology has, alas, not always been clear or consistent. Here is how it should be:
A state (or state of mind) is what the patient experiences subjectively. In CAT terms it represents the expression of a Role. A Self State, on the other hand, is the model we construct, in which the "building blocks" need to be Reciprocal Role Procedures. Thus a patient may describe a "Zombie" state - cut off from feeling and from others. We need to know the reciprocal role to that state for that patient, if we are to understand our response or our part in inducing the role. For example, the Zombie state could be a response to another perceived as threatening. Or it could be to another perceived as vulnerable (become a zombie rather than risk hurting a vulnerable other).
It was misleading to label the Self States Grid by that name - it should be re-named the States Grid or the States of Mind Grid.
The self states model can explain different kinds of state shift. One kind can reflect role reversal while in the same self state, for example from feeling abused to becoming abusive. Another, still within the same self state, can be a switch between alternative roles in relation to an unchanged reciprocal, for example in relation to another or the self seen as critical, a switch from being striving to being rebellious. Such switches may occur in any patient, but the full self state switch, which is more disorienting and which is characteristic of borderline patients, represents a shift to a different self state with a different reciprocal role repertoire. For example, the familiar change from "ideally cared for by an ideal carer" to "furious and betrayed by an abandoning abuser".
I hope this clears the (my) confusion of terms.
In order to guard against the common problem of inadvertent collusion in treating borderlines, great emphasis is placed both on the reformulation and on heightening therapists' self-awareness when with their patients. To reciprocate any of the patient's array of role procedures is to respond in terms tied to one self state, and can therefore heighten fragmentation. Only by establishing a shared base outside the system can integration be encouraged.
THERAPY EXPERIENCE QUESTIONNAIRE (R) (2)
Patients normally go through a number of changes in how they feel about therapy and their therapists. These are important to recognise as they can help the understanding and control of feeling in daily life. This questionnaire is part of our research into therapy. Please fill it in quite soon after each session, and please be frank. Bring the completed form to the next session; you can hand it in in the envelope so that it goes straight to the research files, but, if you wish to talk about what you have indicated on it with your therapist, then do so whan you hand it in. Thank you for helping.
Score each statement with a number from 1-5 where:
1 = not true at all
2 = not true
3 = may or may not be true
4 = true
5 = very true
"AT THE LAST SESSION I FELT...":
1. I felt my therapist valued me as a person
2. I felt my therapist was not interested in my feelings
3. I felt really angry with my therapist
4. I felt totally in tune with my therapist
5. I felt therapy was giving me clear new understandings
6. I felt-blanked off from my feelings
7. I felt my therapist was useless
8. I felt my therapist had a special interest in me
9. My feelings were just as difficult as ever to deal with
10. I felt lonely, as if there was no-one there
11. I would have liked to hurt and humiliate my therapist
12.1 really admired my therapist
13. I felt my therapist and I worked well together
14. 1 felt my therapist was just doing a job
15. I felt like not coming back to therapy
16. I felt lucky to have such a good therapist
17. I did not feel that my therapist accepted me as a person
18. I felt I was in my shell, out of reach
19. I felt humiliated by my therapist
20. I felt that I did not want to separate from my therapist
21. I felt my therapist was genuinely interested in helping me
22. I did not want to show my therapist what I was feeling
23. I felt judged and criticised by my therapist
24. I felt almost blissfully close to my therapist
25. I felt no clearer about my problems
26. I felt my therapist was more like a computer than a person
27. I felt my therapist looked down on me
28. I felt that I was my therapist's favourite patient
29. I felt that my therapist was cold and distant
30. There was no way I could convey what I really felt to my therapist
31. I think my therapist just wanted to show me what a mess I am in
32. I felt that my therapist understood me totally
33. I felt that I had to give in to my therapist
34. I felt that I had to please my therapist
35. I felt envious of my therapist
36. I wanted more looking after from my therapist
One helpful practice has been the requirement on therapists in the project to audiotape all sessions and to play them back before supervision. This is a source of initial trepidation but has been found to be of considerable benefit. I believe ALL CAT TRAINEES should have this experience. You can, when listening, identify both the things you've missed and those you have done well. In the project, therapists are encouraged to bring examples where they have made good links between the diagram and either the patient's stories or events in the room.
In addition to this, the research requires patients and therapists to rate each session, the patients using the Therapy Experience Questionnaire (TEQ), and the therapists the Sessional Grid. For the research, these are analysed after the end of therapy as a grid to give seismographic records of Transference/Countertransference changes through therapy. Therapists find the quick rating of each session helps focus their minds on what went on. Patients may, and sometimes do, discuss particular TEQ items. It is also the case that a rough positive versus negative score can be worked out from selected items, and this can indicate changes not explicitly picked up in the session. The TEQ is designed for borderlines. Its predecessor, the Experience of Therapy Questionnaire, is shorter and simpler; some of the items are given positive points and others negative points; the sum of these is the score. These crude devices serve, perhaps surprisingly, to clarify progress for clinical work. For the research they identify those sessions in which some clear shift takes place and audiotape analysis can focus particularly on these.
Dawn Bennett has completed analyses of audiotapes of reformulation sessions using meticulous (time-consuming) research techniques to identify the themes, and has found that CAT patient-therapist pairs produce diagrams where these themes are indeed represented. (She will report on this at the ACAT Conference.)
Reading about CAT for Borderlines:
Case histories: Hilary Beard's account (Ryle and Beard, Br. J. Med. Psychol. 66, 249), and Mark Dunn's variations on the theme in the Int. J. Short-term Psychotherapy, Issue on CAT, 1994 vol 9 2/3. Also in that issue Martin Marlowe on self states theory (called sub-personalities...)
Two papers are in press (Ryle and Marlowe, Int. J. Short-term Psychotherapy; and Ryle, Br. J. Med Psychol.) on self states theory, the self states grid and the SSSD and Transference/Countertransference. If you'd like a copy, send a large sae to me at the Munro Clinic. And dont miss Ryle (ed) CAT: Developments in theory and practice, J. Wiley sons, due out in May 1995.
Letters to the Editors: Improve Your Reformulation and Contribute to Research - Try the States Description Procedure (SDP)
Ryle, T., 2003. Letters to the Editors: Improve Your Reformulation and Contribute to Research - Try the States Description Procedure (SDP). Reformulation, Spring, p.5.
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.
Sequential Diagrams, Reflections and Suggested Revisions
Ryle, A., 1998. Sequential Diagrams, Reflections and Suggested Revisions. Reformulation, ACAT News Autumn, 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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