CAT in dialogue with Mindfulness: Thoughts on a theoretical and clinical integration

Jayne Finch, 2013. CAT in dialogue with Mindfulness: Thoughts on a theoretical and clinical integration. Reformulation, Winter, p.45,46,47,48.


Mindfulness and mindfulness based interventions

How much time do we spend preoccupied with the past, ruminating on what has already happened and wishing that things could have been different? How easily do we slip into worrying about or planning for the future, as though we were able to control it? So often we can become lost in our own minds, lost in judgements and striving and reacting to thoughts as though they were facts; unaware of what is really unfolding in this very moment. The present moment; the only moment any of us ever have. How many moments of our lives are wasted in this way? How much additional suffering do we cause ourselves by non-acceptance of whatever is already here in this moment, by attempting to resist or turn away from the sources of our pain or by trying to cling onto appealing thoughts and fantasies?

Mindfulness, an ancient Buddhist practice, can be defined, in contrast to this habitual, “automatic pilot” mode as the awareness that emerges from “paying attention in a particular way: on purpose, in the moment and non-judgementally” (Kabat-Zinn, 1994). Retraining and taming the unruly mind in this way helps us to generate greater awareness, to see more clearly and to bring a greater degree of acceptance to whatever we find in the present moment. The attitude that we bring with our awareness is key and there is a strong emphasis on cultivating a stance of kindness, curiosity and compassion towards ourselves within the practice. The ways that awareness and attention can be anchored are varied but the focus is often on helping us to get out of our heads and back into our bodies, in touch with direct sensory experience. Rather than getting caught up in endless cycles of rumination we are encouraged to observe thoughts as they arise, seeing them simply as another mental phenomenon occurring within the mind. Not us, not the truth, just thoughts.

The relevance of mindfulness to modern society has become increasingly well recognised as programmes such as Mindfulness Based Stress Reduction (MBSR, pioneered by Kabat-Zinn and colleagues in 1979) have demonstrated benefits to the physical and mental well-being of participants (for example see Grossman et al., 2004 and de Vibe et al., 2012) including increases in self compassion (e.g. Shapiro et al., 2007). Mindfulness practice has also become an important component of several psychological therapies which are aimed at treating a wide range of mental health difficulties (often referred to as the “third wave” of cognitive behaviour therapies, these include Linehan’s Dialectical Behaviour Therapy (1993), Hayes et al.’s Acceptance and Commitment Therapy (1999), and Gilbert’s (2009) Compassion Focussed Therapy). Originally developed in 2002 by Segal and colleagues as a maintenance version of CBT for depression, perhaps the most prominent mindfulness-based intervention (MBI) currently is Mindfulness-Based Cognitive Therapy (MBCT, Segal et al., 2013). MBCT has been shown to be particularly effective in reducing rates of relapse for those with three or more previous episodes of depression (a group that seems to be characterised by a greater degree of adverse early life events) and is now being usefully applied to a range of difficulties including addictions, anxiety disorders, auditory hallucinations, chronic fatigue and bipolar disorder.

Alongside an acknowledgement of the valuable clinical applications of mindfulness, it also seems important to remind our selves that mindfulness is much more than a therapeutic intervention for those experiencing physical or mental health difficulties. Rather, it offers up an alternative way of being for any of us who wish to become more present in our daily lives; it teaches us to relate to our experiences differently so that we are both more aware of and open to them but also more liberated from our habitual ways of responding. So how might this increasingly popular approach be in dialogue with CAT? From my own personal experiences I would argue that mindfulness can have far reaching benefits for those who choose to explore its philosophy and practices, and as a trainee CAT practitioner I am struck by the helpful links that can be made between these two approaches. Both Walsh (2003) and Wilde McCormick (2004) have previously invited CAT practitioners to consider how these two approaches may complement one another; for more in depth discussions on the integration of CAT and mindfulness, and the practical applications of this, the reader is also directed to Marx and Marx (2012) and Wilde McCormick (2012).

Dialogue between the theoretical backgrounds of CAT and mindfulness.

CAT’s scientifically and theoretically based view of the universal importance of intersubjectivity and social relatedness to our species has much to offer in dialogue with mindfulness. To explore this conversation further it would be helpful to know what some of the key agents of change in mindfulness are proposed to be. As Shapiro and colleagues (2006) explain, the “reperceiving” process in mindfulness allows us to disidentify with and observe the contents of consciousness i.e. if “I” can see this thought/emotion/sensation, then “I” must be more than it, in this way we can “be with” our experiences rather than be defined or controlled by them. They argue that this cognitive and affective shift parallels the developmental processes observed in children as they become increasingly able to decenter from their own internal experience and take the perspective of another. In this way mindfulness is seen as the continuation and extension of a normal developmental process. This focus on separating ourselves from the contents of consciousness speaks to and is further extended by CAT’s concept of internal dialogue. Rather than seeing the self as unitary, CAT views the “I” more as a “federation” and posits that “the internalised voices of others can dominate the dialogue, defining reality and providing a running commentary of judgement which may determine what aims may be pursued” (Ryle and Kerr, 2002, p.36). Crucially, what CAT adds here is the importance of our social and relational origins in influencing our internal dialogue. Fundamentally, the stated aim of the therapist in CAT to “identify the restrictive and damaging voices and to encourage the emergence of a more reflective, independent, superordinate and complex ‘I’” (often denoted on CAT maps by the image of an observing eye, “the eye which becomes an ‘I’” (Ryle and Kerr, 2002, p.36)) seems to have much in common with the reperceiving process in mindfulness (to explore the nuances of these comparisons further, see Marx and Marx, 2012).

The relationship between mindfulness and the "3 Rs" of CAT.

Reformulation

We are well aware that a key strength and defining feature of CAT is an early, jointly created, relational reformulation which seeks to help the patient generate an alternative, more self-compassionate perspective of their experiences and suffering. This reformulation guides the work of therapy and provides both patient and therapist with a tool to assist in the (non-blaming) recognition of problematic relational patterns as they occur in the moment. The hitherto relatively internal/individualistic focus of the third wave cognitive behaviour therapies that include components of mindfulness could perhaps be enriched and complimented by CAT’s relational and dialogical focus. The individualised reformulation in CAT provides a “scaffolding” for the therapy and a place within which to ground a variety of possible therapeutic techniques and interventions. This early, jointly created exercise in compassion, reflection and reperceiving is well aligned with what MBIs intend to cultivate and could offer a stronger foothold for the work of therapy for patients who may not feel able to make use of a stand-alone MBI (such as MBCT) without this scaffolding process. Mindfulness in turn has much to offer to the recognition and intervention stages of CAT.

Recognition

An intellectual knowledge of our own procedures (facilitated by the letter and map in CAT) is a necessary first step on the journey of change, however, being open and aware enough to identify procedural enactments as they occur in the moment is surely the crucial second stage of recognition that opens up choice points for us in terms of how we then respond. Many people will be helped enormously in this process by the specific naming and drawing out of procedures within the reformulation letter and SDR in CAT, and by the use of out-of-session monitoring and within session recognition of enactments as they occur. However many of us will still struggle at times to cultivate sufficient intention and moment-by-moment awareness to allow us to stand back from and truly notice our most tenacious and compelling patterns of thinking, feeling and behaving. In the way that mindfulness practice can teach us to come back, again and again (with tenacity!), to noticing and “decentering” from our thoughts, I would argue that it can help us significantly with this second task in the three R’s of CAT.

By way of reciprocation, the ability of CAT to “flag up” from an early stage in therapy the particular roles and procedures that are likely to be around for any given individual could add much to MBIs by giving participants an awareness of how their own roles/procedures may interact or interfere with the process of learning to practice mindfulness (for instance, snags that may lead to sabotage of the process or roles that may compel one to be unhelpfully critical or idealising of it). Additionally, CAT’s ability to help people make sense of the origin of their more unhelpful patterns leaves greater room for self compassion and if this understanding were generated prior to undertaking an MBI it may make noticing and unhooking from these patterns in a gentle manner more possible. For example, if a person begins to see more clearly, during an MBI, how frequent and pervasive their critical thoughts are without having had the prior opportunity to make sense of why this pattern has emerged for them (relationally speaking) they may be more likely to fall into a further trap of self blame, or even disillusionment with the process itself.

Revision

The revision of faulty procedures and unhelpfully narrow or damaging reciprocal roles are key areas for the work of therapy in CAT. Revision can often spring naturally from good enough recognition of problem procedures; at other times different therapeutic techniques are helpfully employed to assist with making changes to beliefs, behaviours and ways of relating to self and others. The beauty of the CAT model is the flexibility of approach it allows from within its structured and containing framework. It permits space for creativity and for interventions to be tailored to the particular preferences of patient and therapist and the relationship between them. We would hope that by the end of therapy the patient will have strengthened or begun to develop a range of healthier reciprocal roles. The provision of a “good enough” therapeutic relationship will be crucial in this process, and often patients are able to internalise aspects of this in being more compassionate towards them selves. Essentially, mindfulness also allows us to embody and develop a different way of being in relation to ourselves. All therapists or trainers teaching mindfulness to others need to have their own regular mindfulness practice and this is crucial in being able to truly embody, and help participants feel their way into, a more mindful, compassionate and accepting stance. When we are in relation to another who is able to embody these ways of being, we are perhaps more able to begin to develop these ways of being with ourselves also. The reciprocal roles that therefore are cultivated when we engage in mindfulness practice might be thought of as follows:

We are taught to notice and observe our experiences, and to intentionally and patiently return our minds to this focus again and again. We are encouraged to do this with gentle curiosity and kindness, letting go as best we can of the need to judge ourselves or “discrepancy monitor” by comparing our experience to how we imagine it should be, or would like it to be. In doing this we are taught repeatedly to accept whatever is already there in the present moment, without trying to “fix it” or push it away – rather than avoiding painful feelings we gradually learn to open to them, to explore them. The ultimate intentions of mindfulness point more to self-liberation than self improvement, through practice we are freed from the patterns of mind and behaviour that can keep us trapped and are able to truly experience our interconnectedness with each other.

In contrast to these roles, we may find ourselves occupying the positions below when we remain in the “mindless” automatic pilot mode: (see diagram on the following page)

Conclusion

Mindfulness based interventions are becoming increasingly popular both within and outside of the health service; it would seem that the relevance of this ancient practice to our modern lives and to our well-being is now becoming well recognised. Up until now MBIs as applied to mental health difficulties have tended to be linked with the more individualistic, internally focused third wave cognitive therapies, perhaps most notably MCBT. There is therefore now a real opportunity for a fruitful dialogue to be deepened between CAT and mindfulness; to map the territory of commonalities and to allow each to shape the other in whichever ways will ultimately be most useful for our patients.

Comment on Jayne Finch's article by Heinz Kobler, Clinical Psychologist and Mindfulness teacher

In a recent article, Georges Dreyfus, a Buddhist scholar, expands the contemporary understanding of mindfulness beyond non-judgemental awareness, in the present moment of our experience. Referring to classical Buddhist texts, he makes the point that non-judgementality and present focus is only a component, perhaps a first teaching step, in what he calls ‘wise mindfulness’. He argues that mindfulness does not merely involve a passive attending but an active holding of the object of our attention in a temporal framework, which allows evaluation. He proposes that this attentive holding of information involves the working memory, which allows us to make sense of the experience. It does therefore not only involve bottom-up processing, whereby our mind is open to experiences, but also top-down processing involving the retention and integration of information. It is within this fuller awareness that increased understanding and wise action can arise. In this sense it creates a closer relationship with cognitive theories.

At the same time, mindfulness goes beyond the conceptual modality. Through mindfulness we aim to arrive at and cultivate an understanding that our bodily and mental states are impermanent. We can therefore liberate ourselves from attachments to expectations and fixed ideas which, when they are contravened, are the source of suffering.

In summary, this expanded view of mindfulness suggests closer proximity between mindfulness and theoretical and therapeutic approaches such as CAT. At the same time there are distinctive differences, which can nevertheless be brought together in a fruitful collaboration.

Full Reference

Jayne Finch, 2013. CAT in dialogue with Mindfulness: Thoughts on a theoretical and clinical integration. Reformulation, Winter, p.45,46,47,48.

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