So how truly collaborative are we?

Maryanne Steele, 2013. So how truly collaborative are we?. Reformulation, Summer, p.33,34,35.


Introduction

In this first of two short articles, I would like to look at how we understand the term ‘collaboration’ and whether there are certain qualities within each of us which might help or hinder our ability to engage in a collaborative therapy with our clients. I would also like to extend this topic in the next article to think about working collaboratively as a CAT supervisor. I will look outside the CAT model to see how collaboration is understood within other models.

‘CAT evolved as an integration of cognitive, psychoanalytic and, more recently Vygotskian ideas, with an emphasis on therapist-patient collaboration…. (Ryle and Kerr 2002, p 1)

This ‘therapist – patient collaboration’ theme is in the fi rst sentence of what I regard as the ‘CAT Bible’ ‘Introducing Cognitive Analytic Therapy’. However in Tony Ryle’s earlier book, Cognitive Analytic Therapy (1995), there is scarcely any mention of collaboration even in the second chapter on ‘The Practice of CAT’, which goes into great detail about the nuts and bolts of the tools! So how did the theme of collaboration gain enough momentum to fi nd its way into the fi rst sentence of the 2002 ‘Bible’? It seems to have become a given by the time this book was written. In my practitioner training between 2003-2005, being collaborative was explicit in the emphasis that was put on this way of working and being. This term is also liberally used within various training days and in CAT descriptive literature.

Ryle and Kerr (2002) state that what is distinctive about CAT is ‘the collaborative, non-hierarchical nature of the therapeutic relationship.’ They also acknowledge that “what aspects of CAT are the effective ingredients in successful therapy has not been fully demonstrated ……..our main belief is that the two main factors are (1) the joint creation and use of reformulation tools and their availability in written and graphic form and (2) the internalisation of these as the signs developed in the course of a collaborative and non- collusive relationship’. (p.15))

So what do we mean by collaboration?

Julie Starr in her book ‘The Coaching Manual’ (2010) gives a simple, but in my view, a quite challenging explanation of what being collaborative means. It is used in the context of coaching but I feel it is appropriate here as food for thought.

‘By collaborative coaching we mean that the coach and the person being coached are working on creating changes together. As a collaborative coach, you do not ‘fi x’ someone, solve problems for them or assume any position of superiority or higher knowledge.

Instead, the coach adopts the principle that the person being coached probably knows more about their own situation than the coach does. The coach believes in the ability of the individual to create insights and ideas needed to move their situation forward. The task of the coach is to use advanced skills of listening, questioning and reflection to create highly effective conversations and experiences for the individual. For the person being coached, the relationship feels more like a partnership of equals, rather than anything parental or advisory. (p.17)

So how are these advanced skills acquired? For me, through reading each word carefully, it highlights the enormity of what CAT therapists in training sign up to in learning the practice of CAT and it also seems a reasonably accurate view of how one aspires to be with a client. But I wonder how successful we are in practice?

The conventional route into CAT training is to have a core profession within a health or social care setting. We are told about the ‘traditional polarisation’ between those who are good at ‘doing to’ and those who are good at ‘being with’. The CAT therapist is good at ‘doing with’ Kerr (1998b, p. 55-59). He goes on to say that ‘this highlights the fact that CAT involves hard work for both patients and therapists and also that much of this work is done together and that the therapy relationship plays a major role in assisting change …………our patients are not pupils or children and their capacities need to be respected, mobilised and enlarged through the joint creation of new understandings’. (Ryle and Kerr, 2002, p.3)

But Kerr( 1998b), also cites the example of health care professionals being good at ‘doing to’ their patients So where does that put me as a former health care professional who has moved into counselling and psychotherapy? How consistently do I stay collaborative and ‘doing with’ and what might cause me to move out of this place into ‘doing to’? Do I recognise myself within these three places; the ‘doing to’, ‘being with’ and ‘doing with’? What makes me move between these roles within a session? What might also make other CAT therapists and psychotherapists, many of whom have a core health or allied profession where ‘doing to’ is a more common model than ‘being with’, move between these roles? They (Ryle and Kerr, 2002, p.2) describe ‘surgeons and some behaviour therapists’ as being good at ‘doing to’ and………. ‘nurses in long term care and many dynamic psychotherapists’ as good at ‘being with’. But there is a tension in this statement. Tony Ryle was a psychiatrist. Many founder CAT therapists were also core health professionals who trained subsequently in CAT and who are identifi ed by Ryle and Kerr as being good at ‘doing to’ or ‘being with’ not ‘doing with’.

How collaborative am I?

I have to add here that I am also an integrative counsellor so have had to work hard within my original person centred orientation to try and uphold the importance of the therapeutic relationship but still fi nd concepts like ‘unconditional positive regard’ really diffi cult to aspire to. So do I succeed when I am doing CAT? Do the powerful tools of CAT; the SDR, the reformulation letter, the goodbye letter, the rating sheet and the states diagram, allow me to fool myself into believing I am being collaborative? After all I have jointly created an SDR with my client as the good books tell me to do. I have written a reformulation letter that asks for comments and states that it is a draft so I feel I am enabling my client to have a say. And if I choose to use, what some CAT therapists see as the dreaded rating sheet, but a tool that I often incorporate into my practice, then I, as the therapist checks with the client what target problems (TP’s) and target problem procedures (TPP’s) we prioritise. Or do I?

There is obviously an element of subjectivity in how we hear a client’s story and what reciprocal roles (RRs) are drawn. The client will fi ll in the procedures for us but maybe sometimes the emphasis we put on the RR chosen can skew the therapy. Certainly the reformulation letter is a minefi eld of the therapist’s subjectivity in the structuring, the phrases and metaphors chosen, even if they are the client’s. Certain metaphors might resonate with the therapist more than others and more weight might be unwittingly given to one metaphor over another. I have struggled with this: Having started to doubt my objectivity and also my ability to truly collaborate and deliver a collaborative therapy I now look at my qualities as a person and what I bring to the room. How aware am I of my own SDR, my RRs, my procedures, when trying to dig myself out of my own traps and dilemmas, which a client can elicit in me? How do I keep within a collaborative dance and how often do I seek to lead the dance?

Other perspectives on collaboration

Drawing on Bakthin’s concept of ‘outsideness’ and the ‘excess of seeing’, (Bakthin, 1990, p.23) focuses our attention on the privileged position of the therapist as the outsider, and the therapist’s role in sharing their ‘excess of seeing’ with the client in an empathic and collaborative way. As Bakhtin points out, there is an ethical duty attached to the privileged position of outsideness:

The most important aspect of this surplus is love… This surplus is never used as an ambush, as a chance to sneak up and attack from behind. This is an open and honest surplus, dialogically revealed to the other person…” (Bakhtin,1984, p. 299)

McCullochVaillant (1997), from a non-CAT perspective, describes that she collaborates with a patient when: there is enough affective capacity to motivate action authentically and enough cognitive capacity to control and direct it (p.300- 310). She talks about ‘encouraging’ a patient to implement a jointly agreed plan but says that she will ‘instruct’ patients if they are not able to do so by exploring ‘the defences and anxieties that are obstructing the desired action.’ So there is something again here about the therapist using their ‘excess of seeing’ to know when to ‘encourage ‘and when to ‘instruct’.

From a critical perspective, Proctor (2002) evaluates how different therapeutic models conceptualise collaboration. She is scathing of CBT’s description of the collaborative relationship as being ‘actively involved in the therapy’ saying that this obscures power issues and involves the client agreeing with the therapist. She also discusses the Foucauldian perspective where collaboration is seen merely as the client internalising the therapist’s ‘norms about the right and helpful way to think’. In relation to person centred counselling, Proctor describes how Rogers wanted to lessen the therapist’s role as an expert and to aim for a more ‘egalitarian’ therapy. Proctor cites Masson (1989) who argues that Rogers was ‘idealistic and unrealistic’ in that therapists fi nd it diffi cult to feel unconditional positive regard towards clients and furthermore observes that therapists will add their own bias to what clients say.

So perhaps collaboration in the way that Starr (2010) describes it in ‘The Coaching Manual’ is also an idealised view?

If we seek to be guided by Bakhtin’s ‘excess of seeing’ it is useful to know when collaboration is an idealised view and when it is something to aim for whilst recognising our human limitations. It can be used further to refl ect on when collaboration can be mistaken for collusion.

Hepple (2010) quotes Anthony Ryle as describing ‘the primary purpose of CAT tools’ ….is to ‘encourage/ guide the therapist to stay on the relational rails; to remain in dialogue with the client’. This is a key clarifying statement. The CAT therapist needs to use CAT tools and yet stay within a collaborative relationship – to ‘do with’.

So how collaborative can CAT be in practice or are there particular qualities within all of us, whatever our previous history, which can contribute to ‘doing with’. What are these and can these be identifi ed and developed? I have looked outside CAT literature for some ideas on this; Guy (1987) cited in Aveline (2000) writes about therapists’ qualities in terms of ‘functional and dysfunctional motivators’…which emphasize the personal qualities of ‘empathic concern, respect, being realistically hopeful, self awareness, reliability and strength.’ Amongst Guy’s (1987) six ‘dysfunctional motivators’ are therapists who seek to gain self healing through work, use work as a form of compensation to fulfi ll their need to be over caring and to fulfi l the desire for power. It is a very sobering summary of some of the qualities that could hinder collaborative working.

Hepple (2010) describes the therapist as a collection of ‘persons’ or selves, a unique person and it is this unique person that is brought into the interpersonal relationship. This ‘working model’ or collection of selves is developed though what Aveline, (2000) describes as ‘family circumstance, life events, gender, race and culture which combine with inherited predisposition to form a unique individual’ (p.319) There is also the political context within which we live. Therefore the concept of being collaborative could have signifi cant meaning in a liberal society, yet not even exist as a concept within a more authoritarian state or family. Guy (1987) highlights what is crucial is an ability to ‘enter empathically into a world of meaning with others’.

Marrone (2000), states ‘In my dialogue with the patient I am not following a particular recipe. I am not using a prescribed technique. What I am doing is ‘lending’ so to speak through my own free associations, my internal working models – which have earned a relative sense of security and integration through many years of personal analysis, supervision, theoretical learning, group work and life experiences’ (p. 151).

This seems to be to similar to Pollard’s (2011) interpretation of Bakhtin in which she describes the need for ‘insideness’ as a counterbalance to Bakthin’s ‘outsideness’ and the wisdom to know the difference between the two.

Conclusion

So it seems that although awareness about our ‘working model’ or different ‘selves’ and their evolution is an important factor in the qualities needed for collaborative work, what is more important is that, as Marrone (2000) says, we ‘constantly work and rework’ ….. our working model ‘through personal therapy, supervision and refl ection in order to engage, the ‘observing eye’; Bakthin’s ‘surplus of vision or excess of seeing’ in relation to ourselves as well as to others.

Hepple (2010) sums it up well with this quote from Bakhtin “The first step in aesthetic activity is my projecting myself into him and experiencing his life from within him…I must put myself in his place and coincide with him… followed by a return into myself…for only from this place can the material derived… be rendered meaningful ethically, cognitively, or aesthetically” Bakhtin, (1990).

So perhaps, if our ‘working model’, our self, the self we bring into our therapeutic work is well oiled, cared for and in a fi t place to constantly allow not only reflection but more importantly reflexivity to be part of our practice, we will be more able to use our ‘excess of seeing’ to help us stay more acutely aware of the fine line we steer between ‘doing to’ and ‘doing with’ if we are to be authentically collaborative in a way that enables useful therapeutic work to take place.

In the second part of the article in the next issue of Reformulation, I would like to look at whether we can, as therapists, practice ethically if our internal ‘working models’ are not reworked constantly. I will look at some of the more the complex client groups that CAT claims to work well with such as people who have been diagnosed with Borderline Personality Disorders. We aim to work towards the integration of the many selves with this client group. But in order to do so we need to be constantly looking in on ourselves to ensure that we are grounded and integrated as far as possible. We need to try constantly to hold our own SDR’s in mind when we are with our clients. Otherwise how ethical can we be as therapists using the powerful tools of CAT?

Full Reference

Maryanne Steele, 2013. So how truly collaborative are we?. Reformulation, Summer, p.33,34,35.

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