Tony Ryle’s appetite for Debate, and how it led to New Developments in the Co-creation of Reformulation Letters: Empowering to empowered?

Dr Alison Jenaway, 2018. Tony Ryle’s appetite for Debate, and how it led to New Developments in the Co-creation of Reformulation Letters: Empowering to empowered?. Reformulation, Summer 2018, pp.12-14.


Introduction

This paper has been developed following my presentation, with Steve Potter, at the Tony Ryle Legacy day on 10th March 2017. I took the lead in organising the programme for the day and the ACAT board were keen for the day to be a mix of memories of Tony Ryle and his contributions, balanced with newer ideas and recent developments. My correspondence with Tony’s son, and those who knew him well, confirmed the belief that Tony would not have wanted the day to be all about him - he apparently would have wanted no flowers or fuss of any kind. I had also been greatly influenced by Steve Potter’s article in Reformulation (Potter, 2016) on “the Narcissism of an idea”. This paper, which I read when I was planning the Tony Ryle Legacy day, and therefore thinking a lot about him, made me realise what an incredible skill it is for a person to invent a whole new therapy and manage to avoid making the idea a “narcissistic cult” that cannot be questioned. Indeed, Tony even managed to invent a therapy model where questions and flexible approaches were built in to the very fabric of the work. Looking back, this was vital in allowing me to make the commitment to train in a particular therapy, and become part of the organisation, as I seem to be an integrator by nature, and had struggled with other, more dogmatic seeming models. The kind of questions that I asked did not seem to be welcome in those other arenas, but seemed to be positively required in the CAT world. Quite early on in my involvement with ACAT, I took on the role of editing the CAT Newsletter (which later became Reformulation) and I remember Tony Ryle sending in an article complaining about how little the members of ACAT were contributing to debate about the model. He wrote:

“We need research and conceptual argument if CAT is to remain a developing model and method,… As regards concepts, when will someone produce a serious critique of some aspects of CAT?….These are only a few ideas, there are lots more floating around in the 150+ CAT heads about which we hear nothing…”(Ryle, 1998)

I contacted Steve Potter, who I knew was experimenting with writing Reformulation Letters jointly with clients, during a session, and asked him if he was prepared to present with me, as a way of responding to Tony’s challenge to us all to debate the model. In particular, I wanted to critique the traditional process of writing Reformulation letters.

Critique of Traditional Style Reformulation Letters and a spontaneous reply

One of the things that I love about CAT is the deliberate “non-expert” stance of the therapist. The idea that we are exploring things together, that you, as the patient, know more about yourself than I know about you, particularly after only 4 sessions! Our CAT diagrams are supposed to be co-created gradually with the patient in session. Sometimes the therapist leading and making suggestions, sometimes the patient leading and noticing new links. It is always particularly rewarding when the patient points to bits of the diagram, or takes up the pen and starts writing themselves. However, the traditional Reformulation letter has not been created in this way. The therapist is the one who has to put all the work in, struggling to make sense of the story, how much detail to put in, what to leave out, how things fit together. It is then written up as a somewhat daunting document, usually typed out, and presented as a kind of “summary of your life”. I know that this process can be done in many different ways and that I am perhaps presenting a caricature, but I have the feeling that the reciprocal roles most in evidence at this point in the therapy would look something like this:

Clever therapist writing
to
Anxious patient receiving

In general, I think these are the roles that we try to avoid in CAT. 

The idea that we, as CAT therapists, are to be encouraged to question, debate and develop the model, made me respond positively to a patient of mine who spontaneously wrote a reply to my Reformulation letter. Rather than just thinking “that was interesting - but not what we do in CAT”, I was able to think “why don’t we always do it this way?”. I started asking my patients to reply with their comments, ending my letters with “these are my thoughts, and I am sure that you will have some of your own. Please write back to me with your responses to this letter.” And my patients started writing back. I described this in more detail in a previous issue of Reformulation (Jenaway, 2011) but still, when I mention it during CAT teaching days, people seem to react as if it is a new idea that they have never come across. I was also disappointed that it was not mentioned at all in the new CAT supervision book (which I read in detail as I was reviewing it). My own narcissism comes in to play here, it is clearly the best way to do it, so how can I get it into the mainstream and encourage more people to have a go? Most importantly, I think it shifts those early “Reformulatory” Reciprocal Roles to:

Therapist understanding, suggesting, curious, encouraging a response
to
Patient understood and empowered to reply

Some of the effects of Encouraging Written Replies

I have noticed a shift in myself, now that my letter is just the start of a correspondence, rather than the final article. I feel more relaxed about it, it doesn’t have to be perfect, or even complete, it is just a start. Whether the person writes back, or not, provides an early indication of how much the patient is engaged in the therapy as a collaborative endeavour. I have just finished working with a young person who made me feel increasingly frustrated about her inability to make any changes, while telling me how desperate she felt. Anything that I suggested might help, or gave her to read, was either “forgotten” or “lost” at some point during the week between sessions. In my frustration, I looked back at the start of the process and yes, you guessed it, she had never written back to my Reformulation Letter. Although I try to be understanding and accepting of whatever people bring, or of people not managing to write back, if they have made no effort at all then it usually signals that they are hoping for a “magic wand therapy” in which I will suddenly be able to make change happen for them without any effort on their part. It can be useful to address this early on, rather than get angry at the end because of the lack of progress.

The early exchange of letters can also reveal whether therapist and patient are actually on the same wavelength in the therapy. In the past, I have assumed that this was true, and taken the patient’s passive agreement of my understanding contained in the Reformulation letter to them as “accurate”, only to find, much further into the therapy, that they were not really on board with the process at all. That our wires were crossed and, while I was perhaps helping them work towards a “good enough” place, they were expecting me to help them continue in their more preferred or ideal state. If you discover this early on, it can be much easier to slow right down, or even backtrack to a simpler way of explaining the process of CAT. The exchange of letters feels like a much more open and honest contracting of what we are going to be working on for the rest of the sessions.

Finally, something can emerge through this process, which has not yet been revealed in the sessions so far. Some patients, who find speaking about their feelings, or their history, difficult, can suddenly emerge, like a butterfly from a chrysalis, through their writing. I have recently worked with a young woman like this, with whom the early sessions were quite difficult, as she seemed unable to trust me enough to risk telling me how she was feeling. She did manage to write back to my Reformulation letter, though, and it felt as if she had revealed more in that letter than she had in the previous three sessions. Having seen my reaction to her letter, she came to the next session with another letter, which started “I can see that you like me to write to you…”. This became a regular way for her to start the session, bringing me a letter about what she wanted to think about that day. At the Tony Ryle Legacy event, I described another young girl who was referred to me following an urgent liver transplant with concerns that she was not taking her medication. She told me that she had an “anti-authoritarian approach to life” and we were able to agree that this was probably not the best way to cope with a liver transplant. Following my Reformulation letter to her, she wrote back. This was a long and complicated reply with very obscure words, and, as she read it to me, I found myself thinking “she is trying to say something really important here but I don’t understand the words”. I felt that I had to try to express this to her, even though my comments could be heard as critical. In fact, she laughed and said “Oh that is Painted Veil speech, we do that in my family all the time - no-one ever says how they really feel”. She was referring to the book by Somerset Maugham, and the film of the same name, which she had seen as a young girl and hated, because it reminded her of the way her family communicated. This became a metaphor through the rest of the therapy, for when she was avoiding saying how she really felt about something, and we added “Painted Veil Speech” to her CAT diagram, as a way of hiding how she felt.

In summary

I would love this idea of exchanging Reformulation letters, to be accepted as a mainstream technique by the CAT therapy community. It has made me realise how hard it is for new ideas to be incorporated, as there is no “official manual” of CAT therapy techniques. It depends very much on who your teachers and supervisors are, and whether you have read every issue of Reformulation or not! A CAT colleague, Carol Gregory, and I have discussed trying to develop a collection of all the techniques that CAT therapists use in their therapy, particular in the “middle phase” of CAT, which is much less defined. This could become a kind of online resource which could be added to gradually. Do please get in touch if you have a favourite technique that you would be willing to share. We are in the process of developing a template that people could fill in to include the source of the technique, relevant references, when it can be helpful to use it, and any handouts or worksheets that people have developed. 

If you are interested, please email me at alisonjenaway@googlemail.com.

References

Jenaway Alison, “Whose Reformulation is it anyway?” (2011), Reformulation, winter issue 37, pp 26-29.

Potter Steve, “Brexit means Brexit: the narcissism in an idea” (2016), Reformulation, winter, issue 47, pp 41-42.

Ryle Tony, “Curiosity and CAT”, (1998) ACAT Newsletter, issue 9, Feb.

W. Somerset Maugham, The Painted Veil, (1925)

Full Reference

Dr Alison Jenaway, 2018. Tony Ryle’s appetite for Debate, and how it led to New Developments in the Co-creation of Reformulation Letters: Empowering to empowered?. Reformulation, Summer 2018, pp.12-14.

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Dr Alison Jenaway, 2018. Tony Ryle’s appetite for Debate, and how it led to New Developments in the Co-creation of Reformulation Letters: Empowering to empowered?. Reformulation, Summer 2018, pp.12-14.

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