Jane Bradley, Paula Cox and Jennifer Scott, 2016. A Hopeful Sequential Diagrammatic Reformulation – Four Years On. Reformulation, Summer, pp.30-39.
Back in summer 2012, I wrote an article in Reformulation about my work in the Personality Disorder Service in my Trust and in particular the use of including a healthy SDR in order to build on strengths and identify this diagrammatically as a place to build on. I now feel it’s time to build on this concept further.
Isn’t it great being a CAT Practitioner! As we all know CAT is a relational model that draws of theory from Object Relations, Developmental models, CBT, Vygotsky and others. The older I get the more I realise that for the majority of our day to day lives relationships are the source of joy, happiness, contentment, safety, anxiety, anger, frustration etc., be that our relationship with ourselves or our relationship with others. From the minute we wake up we are pretty much in relation with others and of course, always in relationship with ourselves which is why CAT makes so much sense to me. I can’t think of a single diagnosis in mental health services that doesn’t involve a relationship that has become a source of distress be that self to self or self to other/other to self. CAT gets right down to the ‘nitty gritty’ of it all, the origin, the impact on development and how the distress is maintained in the here and now on a daily basis, developing recognition, understanding and ultimately changes.
When I started my CAT training back in 2006, I was struck by the lack of attention given to the positive aspects of our clients or the fact that the SDR did not map out the healthy therapeutic relationship that had been developed between the therapist and the client. This puzzled me because the SDR did not seem to give a full picture, but a picture of difficult relationships and unhelpful patterns of behaviour. Nearly always there is one or more positive relationship in someone’s life be that another person, a dog or a cat or even a garden.
The World Health Organisation suggested in 2010 “For many people the classic narrative following psychiatric diagnosis is one of hopelessness, lack of self- esteem, loss of life opportunities and loss of control”. But these are exciting times to be working in mental health services. There are so many changes going on to promote recovery, hope, building on strengths. There is a movement going on towards recovery focussed work drawing on people’s strengths and being ‘hopeful’ in practice. In my Trust we have a Recovery Program. Their aim is to promote a workforce focussed on CHIME – connectedness, hope, identity, meaning & empowerment.
Traditionally psychotherapy has been based on a deficit and disease model of mental health (i.e. therapy aimed at symptom reduction). Bateman & Krawitz (2013) recognise the need to work on strengths and remain hopeful. Padesky, Kuyken and Dudley (2009) from CBT viewpoint recognise the need to focus on strengths. Nehmad (2010) urged us to build on a client’s healthy parts of themselves in a presentation she gave at the ACAT conference.
Seligman (1991, 2000; cited in Magyar-Moe, 2009) proposes that depressive symptoms could be explained by lack of well-being, lack of positive emotion, engagement and meaning in life. He therefore developed the concept of Positive Psychotherapy. This aims to increase well-being by building positive emotions, character strengths and meaning. This can be achieved by tailoring psychological intervention around the following 7 principles of positive psychology
In CAT we have such a great opportunity to use the tools of the SDR to create a diagrammatic representation of our client’s strengths including healthy relationships. Sadly without a healthy map, we pathologize the healthy relationships that a person may have had brief experiences of when growing up by naming them as “Ideally caring – Ideally cared for” reciprocal roles on the SDR which whilst they were at the time seen through the eyes of a child as ideal care because they were in such stark contrast to the more dominant damaging reciprocal roles, they were none the less healthy examples of good care which go unrecognised as such. So rather than these good examples and experiences of good care being attributed to a healthy map, they become pathologized as unrealistic on the SDR.
I would hate in the current climate of hope and recovery, to see CAT left behind and seen as a therapy stuck in the old school of thinking. I work in a Personality Disorder Service and although the service has changed to more of a consultancy service now, when I wrote my article in 2012 it was a therapy service and the clients referred to us were clients that the CMHT teams were struggling with and it was felt that longer term therapy was more appropriate than the shorter term psychological intervention offered in the CMHT’s. Over the years I have worked with many clients with a diagnosis of borderline personality disorder. Sometimes the referral was delivered with a “good luck - she’s a nightmare!!” But always without exception I have managed to dig out from the darkest of despair an aspect of every client’s life that is functioning well or has functioned well that I feel has to be mapped out diagrammatically.
There are so many ways of arriving at this and I have illustrated this with a few brief case studies. Having mapped out an SDR built on our client’s difficult early relationships using our skills of listening, being available, understanding, demonstrating attunement, being respectful and just plain caring, we have that discussion often in the Reformulation letter about the possibility of our client feeling that at times we are on the SDR. However given that the client has already trusted us with their life story the most likely situation is that our client does not experience us on the map most of the time but that the relationship can be drawn up and should be drawn up as a healthy map which might look like this (See Figure 1 below).
If our client does feel we are on the unhelpful SDR we can then discuss an alternative to our client’s perception, validating that we understand why they may have felt that way and trying to unravel what happened to create this and considering an alternative understanding, that is hopefully on the healthy map. This way we are using an opportunity to promote our client’s ability to mentalize about what happened instead of jumping to conclusions and making assumptions due to their limited repertoire of RR.
I once worked with a client who had a horrendously abusive childhood for which they experienced immense rage. Their SDR made horrible reading and their reciprocal roles were activated regularly. Yet despite this, this client was a brilliant parent and we were able to map out as well as the SDR a healthy map based on these positive relationships. In one of our sessions a potential rupture occurred where my client felt that I was on the SDR. The session came to an abrupt end and I was sent a message afterwards to say that my client was unsure they wanted to continue with therapy. However my client did return to our next session and spent the session expressing rage towards me and others. From a mentalizing viewpoint, I knew that there was no point in attempting to make sense of what had occurred because my client was too aroused to be able to think about what might have been going on in the previous session. Instead I listened closely and hoped my client’s arousal would subside, which finally it did. I expressed that I was sorry that my client had experienced so much distress and asked “where do we go from here?” My client replied that they had felt listened to, validated, understood and respected, and that they wanted to continue with therapy. When we thought about this event in the next session, using both maps we were able to make sense of what had occurred, understand the misunderstanding and think about how this might occur in other relationships outside of the therapy. Using the healthy map with my client has not only demonstrated the healthy relationships in their life but also gave us insight into the very core of who my client was – a good person with many strengths. It was also used to map out the therapeutic alliance that existed between us which enabled us to repair the potential rupture and enabled changes to take place in my client’s life outside of therapy.
Another example of how I used the healthy map was with a client that I was doing five session CAT with. This client had been in services for ten years plus with anxiety and depression. My client was gay and carried enormous amount of guilt about being gay particularly as my client had been sexually abused by a same sex sibling thus believing they were in some way responsible. The abuser was favoured by my client’s mother and put on a pedestal particularly as this person had been successful in business. However the abuse had been kept a secret by my client for fear of not being believed and the abuser not wanting to lose the admiration of mum, made sure of this by threatening to expose my client’s sexual orientation. My client had periods in life of being able to function but only when they lived away from the family home. However due to a failed relationship my client had returned to the area they had grown up in where once again their debilitating anxiety and depression took over their life leaving my client too unwell to leave and start again somewhere else which is what they wanted to do. It was at this point that I was asked to do ‘5 session CAT’ to help inform my client’s care planning. Once we had been able to draw up a SDR built around the current difficulties for my client, I asked my client “if you were able to wave a magic wand and your life was very different, what would it look like?”. My client replied that they would be living in another city where they had friends who had offered my client accommodation. I asked how their relationship with themselves would need to change in order to achieve this. My client stated that they would need to believe in them self and have confidence in their ability to do the work they had done well in the past. My client was able to think about the need to be understanding and compassionate self to self particularly in times of distress instead of attacking and blaming. My client recognised the need to be able to accept the help of the friends knowing that they valued my client for who they were. We were able to explore what it was about my client that these friends liked and my client was then able to recognise their kind, caring qualities. From this we were able to map out some healthy reciprocal roles think about the need for my client to be in these reciprocal roles self to self and think about the things needed to be done in order to be able to sustain this. I remember clearly my client asking the care coordinator and I with a look of hope in their eyes as they looked at the new map drawn up on the whiteboard “do you really think I can do this?” to which we both replied that we knew they could because the healthy map also represented the person we both knew they were. This client left the last session with hope and optimism in their eyes and did take up the offer of their friends and moved. A carefully managed transfer of care to the local CMHT in order to support my client short term during the transition was organised and four years later, this client is still living there and no longer in services. For me the mapping out of those healthy reciprocal roles was so powerful for this client, the recognition of their strengths and the power of our belief in their ability to make changes empowered them to ‘bite the bullet’. I’m not convinced that ‘Exit strategies’ placed on the SDR are as powerful as actually seeing those healthy reciprocal roles mapped out on a more hopeful map.
Another lady I worked with using 24 sessions of CAT had a history of severe physical and emotional neglect. One of her difficulties had been her struggles to manage her emotions in particular her frustration, resentment and anger when in order to avoid judgement, criticism and rejection she would strive to appease others at the cost of her own needs. Despite being an excellent mum to her children her sense of self-worth was non- existent. Using the healthy map to map out the relationships she had with her children we were able to give her an understanding of her strengths in terms of self to other, in this case her children, and help her to see that she needed to be the good parent to herself. We were able to identify the things she needed to do in order to achieve this self to self which included setting clear boundaries with her family and friends, to be more attuned to her own emotional world and her own needs so that she was able to express these assertively to others. She was able to use both maps to make sense of where she was and what she needed to do to get back on to the healthy map.
The ‘Looking after me’ sheet that I spoke of in my previous article has also been adapted so that it is used as a tool to get from the not so healthy SDR to the healthy SDR. I adapt it to become personalised to the client I am using it on so that I can put in the ways he or she has learnt to self soothe in times of distress enabling her to reduce her arousal and make sense of what has happened to get them to that point. Also I include skills that we have been working on in the therapy in the problem solving section. An example of one that I used recently is set out below:-
After my article about a Healthy SDR was published in Reformulation in 2012, I was asked to present the concept to the CAT Service in my Trust. One of my colleagues who works in one of our Affective Disorder Teams has incorporated using the healthy map into her CAT practice and what follows is her story and how she uses it:-
“When I first heard Jane talk about the healthy map I was enthused. It had always felt a bit uncomfortable writing “this is not all of you” across the top of the SDR, apologising for not focusing on the positive as this was not where the problems lie. Hearing Jane talk about using people’s strengths to aid their recovery made a lot of sense to me and using this within the CAT model was very exciting. To explicitly map out these strengths , to recognise and validate, to reformulate as a strength (often they can go unnoticed), adapt them to the difficulty (revise), over all helping to sustain exits; knowing the strengths procedures to the same level of detail as the TPPs.
I have used the healthy map with a number of clients and have adapted some of Jane’s suggestions. I don’t always produce 2 maps but overlay the strength RR and procedures onto the SDR, colour coding the SDR. Strengths being in green; some RR/procedures being amber, where often there is choice to move use a exit/healthy RR or to get caught up in an unhelpful procedure; an unmet need/unmanageable feelings being in red. The team I work in (a secondary care affective disorder team) is recovery focused and often uses this colour coding when drawing up crisis plans i.e. what intervention works depending on the client’s level of distress. The colour coding is something the client is already familiar with, so it works well with the SDR. The aim is not necessarily to avoid the red/amber areas but to use the green strengths to manage them differently.
For example one client worked incredibly hard running his business as well as looking after his own family. He ignored his own needs, trying to please both his business colleagues and do the best for his wife and children. Having got through a difficult time in his life, when he finally allowed himself to relax, he described shattering into many pieces, feeling overwhelmed, lost and broken. A quick fix was demanded by his critical/controlling self and he often asked in the session “How long till I am better?” However when this was explored , the thought of being “better” and returning to work was too much and led client to start dissociating in the session. It felt safer to stay unwell and be cared for. He felt he had two choices to be fighting fit or stay unwell. Using his strengths, we’d identified he was nourishing and encouraging towards his wife and children, we started to talk about being nourishing towards himself and to continue to have nourishing activities in his life as these were essential to his mental health and not to be seen as a luxury or being selfish. In the sessions I would use phrases like “When that demanding critical voice pops up trying to pull you into the amber and red parts of your map, you can ask yourself” “ Is this thinking healthy?, What would my mum say?” “What would I say to others in a similar position to me?” “What could I do instead, to nourish, take care of myself right now?” “Answering these questions will hopefully pull you back into green healthy parts of your map. “ The client too would come to sessions talking about his week using phrases such as “I was in the red this week but managed to spend some time in the green too.” He began to accept his recovery was a journey to a different destination , rather than a quick fix, the healthy aspects of the SDR also showed him the paths he forgotten to walk previously, helped gain a balance in his life and that there could be, relaxation and enjoyment without appearing selfish.
I know myself when I struggled with trauma in my own life, when my therapist took the time to recognise and validate my difficulties I felt heard, listened to and understood, and when she went on to recognise and validate my healthy procedures I felt empowered and hopeful of finding some acceptance/peace in the future (which was a great surprise to me) rather than trying to return to the past, which inevitably was keeping me stuck”.
In the process of having this article edited I was asked if my practice has changed from what I was taught ten years ago in terms of the outcome and the resolution of therapy as a process. I don’t believe it has changed but it has evolved perhaps as I have evolved not only as a practitioner, but as a person. Please don’t misunderstand me. The process of assessment where I am listening to the quality of emotional experiences, interpersonal relationships, recurring themes or relationship patterns, personal and family history and history of the nature of the problems, in short listening to my client’s story is crucial. If I need to use the Psychotherapy File as part of this process, then I use it. The Reformulation Letter is written around session four to convey that I have listened, understood and validated. The SDR is developed between myself and my client following on from this and all the difficulties clearly mapped out together. But during this process I will have also learnt that my client has strengths and it may be that at this point I will illustrate that whilst the SDR represents the dominant patterns, there is what may seem a small part to the client but actually a very important fact, that my client has strengths often in terms of healthy relationships that it feels wrong to leave out of the story. My healthy mapping evolved perhaps from not being able to find a piece of paper big enough to have both maps on side by side but I do place both maps side by side on the table I am working on and use the ‘Looking after me sheet’ named above as a means of recognition - the ‘watchful eye’ concept, to bridge the gap. I use the two maps to illustrate that this is the whole of you not just the SDR with the unhelpful reciprocal roles and patterns. The healthy map represents a diagrammatic representation of the more functional part of my client that may have been neglected or ignored. ‘Exits’ focus on changing responses and actions but drawing this up diagrammatically can illustrate how these changes also feed in to more healthy relationships with self and other. For example learning to express my needs to others feeds into being attuned and responsive towards myself but also allows others to be responsive and leaves us hopefully feeling listened to, rather than ignored and neglected. If we don’t express our needs to others, others don’t hear us. In other words the exits represent the patterns that will maintain more healthy relationships.
Last year whilst at the British and Irish Group for the Study of Personality Disorder, I was chatting to two members of Emergence whom I had worked alongside in the delivery of the Knowledge and Understanding of Personality Disorder (KUF) in my Trust. I was delighted to see that they were enjoying their lives and had both completed their Masters Degrees since the roll out of the KUF. I asked them, what they felt it was that had allowed such a change to take place after so many years in services. They both agreed on their response which was having their strengths recognised and been given back responsibility for themselves and their lives.
I can’t imagine now working without using a healthy map be that in my 1.1 therapy with clients which I continue to do or with my five session CAT Consultancy sessions with client and care coordinator or when I am formulating with teams about a client. Isn’t optimism and recognising people’s strengths all part of being emotionally intelligent? Don’t we know from our own personal appraisals as part of our professional development how important it is to have our strengths recognised? Surely our clients need healthy maps to provide the scaffolding for hope, development, change and recovery. It’s my belief that they do and I will continue to practice as a hopeful CAT Practitioner because one thing is for sure, if I was receiving therapy I would want to feel that recovery was possible and a healthy map is a good starting point!
Bateman, A. W. & Krawitz, R. (2013). Borderline Personality Disorder, An evidence-based guide for generalist mental health professionals. Oxford University Press.
Bradley, J. (2012). A Hopeful Sequential Diagrammatic Reformulation. Reformulation, Summer, pp. 13-15
Kuyken, W., Padesky, C. A., and Dudley. (2009). Collaborative Case Conceptualization: working effectively with Clients in Cognitive-Behavioural Therapy. Guildford Press.
Magyar-Moe, J.L. (2009). Therapist’s Guide to Positive Psychological Interventions. Academic Press Publications.
Nehmad, A. (2010, July). A CAT Perspective on Theorising, Eliciting and Strengthening the Healthy Self. Paper presented at ACAT Conference.
Ryle, A. and Kerr, I. B. (2008). Introducing Cognitive Analytic Therapy, Principles and Practice. John Wiley & Sons, Ltd.
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