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Concepts of the Self, Social Inequality, Culture and Power in reflecting on therapeutic work with Asylum Seekers and Refugees: A Cognitive Analytic Approach

Dr Claire Wilson, 2017. Concepts of the Self, Social Inequality, Culture and Power in reflecting on therapeutic work with Asylum Seekers and Refugees: A Cognitive Analytic Approach. Reformulation, Winter, pp.44-47.

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This article came about following some thoughts on using key Cognitive Analytic Therapy (CAT) concepts in working with asylum seekers and refugees, whilst writing an essay for my CAT practitioner training. This is an area of particular interest due to my work in a complex PTSD service which is experiencing increasing referrals for individuals seeking/gaining asylum in this country following experiences of war, torture, trafficking and other traumatic events.

This client group can have a profound impact on the therapist/team working with them and CAT can be a helpful model to reflect on this both within the individual trauma-focused therapy or stabilisation work that we offer but also to aid reflection on wider systemic issues such as problems faced around disempowerment, loss and social inequality whereby systemic and contextual reformulation can be useful.

CAT, Culture and the Socially Developed Self

For me, the reason why CAT is a particularly useful framework for this work is the core concept of the ‘self’ as socially and dynamically constructed, with social meanings and cultural values seen as important components of the development of the self (Ryle and Kerr, 2002). Drawing as it does on Vygotsky’s activity theory and Bakhtin’s dialogic model of the self means CAT thinking is intrinsically embedded in concepts of cultural and societal influence and an inherently inter-relational framework (Brown 2010).

Such an approach highlights that culture, social inequality and power factors are highly significant influences on the individual’s development and therefore of importance even within individual therapeutic work. Rhona Brown (2010) writes about the limitations of focusing predominantly on individual psychotherapy and how CAT should be applied to consider the social context including the role of disadvantage and trauma linked to social and material deprivation, social inequality and current experiences of discrimination. Psychological difficulties have been associated with indications of inequality including unemployment, low income and poor education (Melzer et al., 2004; cited in Howe, 2013). All such factors are highly relevant to working with asylum seeker and refugee clients and have the potential to powerfully influence psychological wellbeing and therapy efficacy.

Culture and mental health

Ryle and Kerr (2002) introduce the concept of ‘culture mapping’ stating that psychotherapists should aim to be free of normative cultural values and instead use collaborative reformulation within CAT to explicitly include cultural assumptions. Different cultures may also express emotional distress in other ways for example in terms of more somatic complaints, more overt anxiety or depression or a repression of distress through procedures around ‘coping’ or ‘soldiering on’ (Ryle & Kerr, 2002). It is interesting to think about how this fits with Western healthcare systems. Are we likely to be overly reliant on our own Western assumptions and judgements around how distress would/should manifest and how do people of different cultures then gain access to the services they really need?

Linked to this, Toye (2003) discusses how the social and political dimension of people’s experience has always been an important aspect of CAT theory and practice. Toye cites three universal aspects of social and cultural differences of particular relevance to therapist-client relationships including different ways of using language; differences in assumptions, beliefs and values; and differences in status associated with social, economic and/or ethnic group membership.

It is felt that these areas should be thought about within therapy and in supervision to ensure culturally informed care. Similarly Brown and Msebele (2011) suggest we should be making racial inequality more explicit as a priority in our work, feeling that issues of race and racism are rarely named in the therapy room or put onto the diagram despite the potential for very powerful reciprocal role procedures.

Hagan and Smail (1997) suggest ‘power mapping’ as a way of considering the different cultural and societal factors influencing the individual and could therefore be a helpful tool for working with this client group. They look at proximal and distal influences with individual distress being conceptualised as the outcome of a social process with powerful influences on the individual outside of their control. They highlight that therapy only addresses the proximal influences to any degree, which includes domestic and work situation, education, personal relationships and family. Distal influences over which the therapist has little to no influence are politics, economics, culture, information, media and so on. They consider that certain groups of individuals are more susceptible than others to mental health problems for these reasons – children, members of disadvantaged socio economic groups, ethnic minorities and women are all considered to be subjected to more oppressive social forces which may then manifest in individual distress. Traditional psychological therapies may then be ineffective and unable to target the cause of distress.

How then does the therapist respond to the helplessness/powerlessness they may experience in the face of these distal factors they are unable to influence? This can be a powerful dynamic in working with asylum seekers and refugees. Papadopoulos (2002) refers to the potential ‘closed system’ of victim-saviour that refugees and therapists can easily co-construct and the challenges this brings. In CAT terms we could think about the impact of bringing a ‘Rescuing Saviour – Helpless Victim’ role into the therapy and the potentially disempowering nature of this. CAT provides a framework within which we can bring these complex dynamics and external influences into the individual therapy. Used thoughtfully, this can allow these issues to be explored in a way which enhances rather than hinders the therapy process.

What does CAT have to offer?

For all these reasons, CAT therefore could offer something quite unique to inform therapy with asylum seekers and refugees in terms of the concept of the socially formed self and to provide a way to represent these aspects within an individual therapy. Part of the challenge can be the wider influences on this client group and attending to these powerful external problems and issues. For individuals who may have experienced torture or persecution in their country of origin, the impact of being ‘uprooted’ and leaving your own country, culture and family behind is very difficult particularly when we consider the sense of self as being socially formed with an importance attached to feeling connected with others. Individuals can also experience ongoing guilt and shame at being in a place of safety whilst likely having relatives still in their country of origin who may still be in danger, sometimes as a direct consequence of their actions for example political affiliations or translating for UN forces. People may lose contact with their family members and never know if they are dead or alive. Torture itself can be seen a method to deconstruct the sense of self, both psychologically and physically and the ongoing impact of this can be profound even when physical safety is in place. To ignore these aspects of the individual’s experience and the impact on their sense of self would be to neglect vital clinical material.

Judith Herman talks about how a secure sense of connection with caring people is the foundation of personality development and that when this connection is shattered, a traumatised person loses their basic sense of self. She describes how this “can be rebuilt only as it was built initially, in connection with others” (Herman, 1992). This seems particularly pertinent for this client group and CAT can bring these elements into the therapy room – the therapeutic task of ‘witnessing’ and ‘being alongside’ clients who have been through such traumatic experiences, often at the hands of others – is a vital part of the therapeutic task and CAT has much to offer here in terms of allowing a sense of the ‘whole person’ to be understood.

In a very interesting paper, Ahmadi (2011) talks about political influences on healthcare systems, on reciprocal roles and of using CAT to understand these wider and potentially unhelpful influences on individuals and organisations. The imposition of targets and aims are discussed as creating a Dominant Self State whereby ‘powerful professionals’ and ‘helpless clients’ are left feeling “repeatedly silenced, crushed and exploited”. They discuss how the response to this may be a Rebel Self State (threatening organisational structures providing a short-lived, turbulent sense of power) or an Acceptant Self State (allowing organisations to seduce them and their patients into their ruling order). This might not have an obvious connection to working with asylum seekers and refugees, but I was struck by the SDR outlined in the paper having similar aspects to the beginnings of a CAT formulation with one of my clients, a Kurdish man from Iraq, who was a ‘freedom fighter’ against the dominant ruling force in Iraq at that time, for which he was imprisoned and tortured/interrogated. Roles Ahmadi outlines around Threatening – Scared/Silenced; Oppressing – Crushed; and Consuming – Exploited/Dispensable all mirror initial formulation and conversation about his roles/self-states as influenced by his experiences in Iraq. He saw his father and his grandfather in an exploited/oppressed position, their land and independence taken away from them year on year by the ruling forces. He described how he became a ‘freedom fighter’ to avoid that helpless place himself – the Rebel State. A more integrated sense of self seems like an important part of his therapy journey as he has previously defined himself by what he is fighting against and CAT is helping us to develop a shared language to consider these multiple influences. He told me of a Kurdish ‘motto’ of ‘it’s better to have a short but brave life’ and we considered the influence of these cultural narratives around adversity on his RRPs and procedures. Reading Brown’s 2011 ‘Flowers by the Window’ article and the reference to the “chronic discrimination” that the Kurdish people have endured in such cases highlights the importance of reflecting on how a culture might collectively find a way to manage generations of trauma. I am finding that CAT with this client, although in its early stages within our work, can bring together his individual experience and the inter-generational and cultural influences he is subject to in terms of the influence on his own emotional struggles.

Challenges in therapy

In working with this client group there is often a tension between the task of therapy and the reality of the different pressures and problems that may affect the individual. Reciprocal roles and procedures can be re-enacted within the therapy and it can be helpful to use a model such as CAT to understand such processes and keep focused on the therapeutic task whilst at the same time not ignoring important wider issues and neglecting to bring them into the therapy room. For example in relation to the Powerful-Powerless role that the client may find themselves in, for example trying to navigate a daunting and often intimidating legal/asylum system with the client having little voice or agency – the therapist may also experience transference and counter-transference responses of feeling powerless or ineffective which may lead to a desire to avoid or abandon the therapy or feel hopeless about its efficacy in the face of this powerlessness. They may also have a ‘pull to rescue’, and see the client only as a powerless victim in relation to powerful and oppressing persecutors as discussed earlier. Brown (2011) demonstrates several of these issues in her fictional account of a CAT therapy with an Alevi Kurdish woman from Turkey and highlights the possible dynamics of a being a western therapist in that context. The therapist ‘Pauline’ begins to note her shame due to her relative privilege as a professional British woman and the “limitations of psychotherapy in resolving the societally-located pain and distress described by this client”.

Interactions within the room are further complicated if an interpreter is required. Emilion et al (2011) describe this process and the potential enactments around this. They described how the presence of the interpreter can be both negative and positive and that a dialogical approach can be helpful to consider this therapeutically. From my experience both client and therapist can feel exposed and vulnerable with this ‘third’ person in the room, and the interpreter can feel powerless at times constrained by their professional role and their connection with the material in the room. With one client of mine, the importance of the therapeutic ‘triangle’ in the room was highlighted. As therapy progressed it became clear he felt unable to talk about some of his political actions (leading to torture and imprisonment) in front of the interpreter as he perceived her to be part of the same political system he had been fighting against (due predominantly to her conservative dress and covered head). In a subsequent debriefing session, the interpreter did acknowledge that she struggled to believe such politically motivated torture did occur in her country and we actually went on to work with another interpreter whereby he felt much more comfortable and able to open up. We were able to map this role together (Abusing/Oppressing/Disbelieving to Silenced/Powerless) which allowed us to consider the parallels in that he was also abused as a child and not believed by his mother when he tried to speak out. This is a potentially complex set of dynamics and the balance between working through difficulties and using another interpreter when the ‘fit’ does not feel safe for the client is paramount.

Conclusions

Within this article I have attempted to highlight some of the key areas where I believe CAT can offer an understanding of the social development of self, power, culture and social issues that could be helpful to consider in therapeutic work with asylum seekers and refugees. A culturally informed therapy can be instrumental in assisting the more flexible application of Western therapies such as CAT for this population and CAT can provide a framework within which to incorporate these factors. Power and powerlessness are an important part of therapy with this client group and this needs to be considered by the therapist both in terms of the client individually and perhaps within our own responses and feelings about working with this client group more generally. When faced with such adversity and extreme experiences so different from our own, we can become more acutely aware of the limitations of a very individualised approach and find it hard to apply our usual ways of working and identify how we can be of benefit as a therapist. In my clinical work with this client group I have found that using CAT terms and reciprocal roles has allowed a consideration of the multiple voices and cultural influences on the individual and can allow these to be acknowledged, witnessed and thought about. The concept of reciprocal roles can be a useful means of understanding and articulating these internalised aspects of social relationships and to open up dialogue with the client and wider parties around issues of social power and inequality and the impact of this within the therapy relationship.

Dr Claire Wilson

Clinical Psychologist and CAT Practitioner working in the Humber Traumatic Stress Service, Humber NHS Foundation Trust (clairewilson16@nhs.net).

References

Ahmadi, J. (2011). What are the most dominant Reciprocal Roles in our society?. Reformulation, Summer, pp.13-17.

Brown, R. (2010). Situating Social Inequality and Collective Action In Cognitive Analytic Therapy. Reformulation, Winter, pp.28-34.

Brown, R., 2011. Flowers by the Window: Imagining Moments in a Culturally and Politically Reflective CAT. Reformulation, Summer, pp.6-8.

Brown, H. And Msebele, N., (2011). Black and White Thinking: Using CAT to think about Race in the Therapeutic Space. Reformulation, Winter, pp.58-62.

Emilion, J. (2011) Is three a crowd or not? Working with Interpreters in CAT. Reformulation, Summer, p.9.

Hagan, T., and Smail, D. (1997) Journal of Community and Applied Social Psychology, Vol. 7, 257-267. Downloaded from www.acat.me.uk – 02/02/2016.

Herman, J. L. (1992). Trauma and Recovery: From domestic abuse to political terror. London: Pandora.

Howe, L. (2013). The ethical implications of social class in the practice of CAT. Reformulation, Summer, p.36-39.

Melzer, D., Fryers, T., Jenkins, R. (2004). Social Inequalities and the Distribution of the Common Mental Disorders. Maudsley Monograph 44. Psychology Press, Hove & New York.

Msebele, N., and Brown, H. (2011) Racism in the Consulting Room: Myth or Reality? The Psychoanalytic Review, Vol 98, pp. 451-492. Downloaded from www.acat.me.uk – 03/02/2016.

Ryle, A. and Kerr, I. (2002). Introducing Cognitive Analytic Therapy Principles and Practice. Chichester: Wiley.

Papadopoulos, R. K. (2002) Refugees, home and trauma (p.9-39) in Papadopoulos, R. K. (Ed.) (2002). Therapeutic care for Refugees: No place like home. London: Karnac Books.

Toye, J. (2003) Cultural Diversity and CAT. Reformulation, Autumn, pp.25-29.

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Full Reference

Dr Claire Wilson, 2017. Concepts of the Self, Social Inequality, Culture and Power in reflecting on therapeutic work with Asylum Seekers and Refugees: A Cognitive Analytic Approach. Reformulation, Winter, pp.44-47.

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