Incorporating mentalizing skills into Cognitive Analytic Therapy (CAT)

Jane Bradley, 2019. Incorporating mentalizing skills into Cognitive Analytic Therapy (CAT). Reformulation, Winter, pp.39-42.


This paper looks to explore the relationship between CAT and Mentalization skills, acknowledging previous contributions from Bateman et al (2007), that noted some similarities, but then went to great lengths to articulate the differences between CAT & MBT. However I consider that by incorporating mentalizing skills into my CAT work this enables my clients to develop their ability to recognize and understand an internal dialogue within themselves and in their relationships with others, improving their relationships self to self, self to other and other to self. To illustrate this I present a case study that demonstrates how the inclusion of mentalizing skills enabled my client, who’d been immersed in her unmanageable feelings and resulting problematic patterns, to increase her ability to pause and reflect from her ‘watchful eye’ position on her CAT map and be more curious about her own mind and the mind of the other within the safety of the therapeutic relationship. The case illustrates the development of simple format to use with my CAT clients that has wider uses in situations where mentalizing has been lost.

Mentalizing (also a relational model) is in short – keeping mind in mind and holding in mind the mind of others. When we are mentalizing we see the other person’s perspective, while also making it possible to hold on to who we are inside a relationship. It’s about holding ourselves in mind and recognizing that the other has a mind that is different to our own and we can’t possibly know for certain what’s going on for them - we may have some ideas, but we don’t know for certain. Through mentalizing our own feelings, we can learn to know our own thoughts and assumptions and understand that they are the reason for our behaviour. It creates a sense of being in control of one’s actions and creates self-awareness and a sense of identity. Allen et al (2003), suggest that Mentalizing is the key to regulating our self and our emotions and is the basis for meaningful, sustaining relationships. My own reflections suggest that mentalizing and non-mentalizing are relevant concepts in all areas of our lives where we are relating to others. Barley (2018) adds “Our social dependence influences our development and day-to-day wellbeing. To this end, our mentalizing capacity is a lynchpin. If we have good mentalizing capacity, we tend to enjoy better interpersonal and intrapersonal relationships and we tend to self- regulate better and have a healthier sense of self”.

Bateman and Fonagy (2011) suggest that mentalizing is having the capacity to reflect on our feelings and thoughts, why we have them and how they influence what we do whilst reflecting on the thoughts and feelings of the other and how they influence what the other does. They further suggest that without mentalizing capacity there is more potential for misunderstandings and thus disruption in relationships. In CAT terms we may think of this as being able to develop our capacity to be curious within our relationships self to self, self to other and other to self, our ‘Watchful Eye’.

Maintaining a dialogue with ourselves and others, we need to both hold the capacity to reflect on our own mind and that of the other and to reflect on our own and the emotions of the other to ensure that our conversation goes smoothly. When this doesn’t happen we or the other can be left feeling misunderstood which often generates powerful emotions such as confusion, frustration, anger, hostility, defensiveness and rejection. The CAT map being relationally positioned provides an anchor to ground mentalizing capacity as it demonstrates how we can make assumptions about the mind of the other based on our internalization of early relational patterns.
Bateman and Fonagy (2011) suggest that mentalizing is a dynamic process and when we become emotionally aroused particularly when feeling threatened and caught up in difficult emotions, our ability to be reflective is reduced and we are likely to find ourselves in a non-mentalizing state. In its extreme this can be recognised in CAT terms within the concept of Tony Ryle’s (2002) Self States Model and even more extreme within the realm of dissociative disorders.

Bateman and Fonagy (2011) refer to “pre-mentalizing modes of functioning” or non-mentalizing ways of interpreting experiences which are particularly relevant to this article, and so I will give a brief definition;

Teleological mode – actions speak louder than words for example “you did not give me a hug, so you must not like me”. In this situation no thought is given to what might be going on for the other.

Psychic equivalence mode – mental reality = outer reality for example “whatever I think and feel is real. That’s how it is”. Alternative perspectives disappear and there is an exaggerated sense of one’s own opinions and personal experiences.

Pretend mode – disconnection from feelings so that the conversation takes on the characteristics of a monologue. Sometimes humor is used and difficult feelings are shrugged off.

However rather than pathologizing non-mentalizing, in my experience we all have the capacity to find ourselves in these modes of functioning at times and one visit to current dialogue taking place in Parliament demonstrate this wonderfully!

Adshead (2018) suggests that a child’s development of mentalizing skills requires a secure attachment with the caregiver and that if parents have good mentalizing skills they are more likely to have children who develop a secure attachment. However with many clients we work with in secondary care services, they have often developed insecure attachments due to neglectful, inconsistent, unpredictable relationships with care givers, which, in CAT can then be understood through patterns and procedures and further represented on a map.

We know that complex clients frequently have a very limited repertoire of reciprocal roles, which often creates unrealistic expectations of, and false assumptions about, the other, thus maintaining unmanageable feelings, repeating unhelpful patterns and subsequent interpersonal difficulties. In my role in the Personality & Relational Services I use my CAT skills in many ways including helping teams hold their own mind and the mind of their clients in mind, thus making sense of the “stuckness” that is often experienced.

Recently I worked with a lady within a five session CAT Consultancy intervention. In our Trust we refer to this intervention as ‘5 session CAT Care Planning’ as it is used to help the client and the staff member plan future interventions and understand the difficult roles and patterns everyone seems to find themselves in. We had completed our five sessions and what became very clear was that this lady’s reciprocal roles and target problem procedures (TPPs) were being re-enacted on a daily basis because she was in a psychic equivalence mode of non-mentalizing - ‘whatever she thought and felt was real’ and teleological mode, ‘actions speak louder than words’. She described herself as “ready to pounce” which left her experiencing life limiting levels of anxiety. For her it was far too risky to let her guard down and contemplate that in reality others may not be on her CAT map. She was able to recognize that she too could be at the top end of her reciprocal roles but “better to be safe than sorry”. I was able to share with her “We have worked out that you get into this ‘waiting to pounce’ state of mind. Can we think together more about this and try to understand what happens in your mind when you get like this?” (See Figure 1 for CAT map).

Thinking relationally, and working through the map we noted a pattern of repeatedly being stuck in non-mentalizing states, and I suggested further work on mentalizing skills. I was also very aware of her state of emotional arousal around all relationships and wanted to convey a feeling of safety, working side by side, literally, in order to limit the possibility of her experiencing me as powerfully controlling to controlled, one of her predominant reciprocal roles.

Using CAT, the map and mentalizing skills to guide my client through this process of mentalizing, we could think about what may be going on for her and what may be going on for the other. She was due a visit from council and felt threatened and anxious, fearful of being judged, criticized and blamed, which may have serious implications for her. Her fear was based on experience of a previous visit that felt unpleasant, resulting in her being verbally aggressive on the doorstep.

Sitting side by side we thought about the visit and I wrote down on a piece of A4 paper ‘The situation’ using my client’s words. We moved on to ask “What are your thoughts about the situation?” which was both mapped and written so we could hold this in mind, including her feelings about this situation, how it might impact on her behavior and what she hoped might happen as a result of this council visit. She could see on the map that her anxiety and fears of being judged and criticized placed her in her threatened, “ready to pounce” position.

On a new sheet of paper, we then repeated the process with my client thinking about the mind of the other – the visitor from the council. There was a touching moment when after pausing for reflection and calm, my client was able to consider the mind of the council worker and, based on her visitor’s previous experience of meeting her, thought this visitor was probably thinking that she wished she didn’t have to do this visit, that she was probably terrified and that this would result in her visitor behaving in a very defensive manner to protect herself. It was like a “light bulb moment” for her, and was even more so when we were able to realise that what her visitor really wanted out of the meeting was to help and support my client. Both she and the council worker wanted the same thing. From this moment I could support her to find her own ‘Exit’ for the visit. She would be ready for her visitor, open the door, offer her a cup of coffee and now, being able to hold mind in mind, see the visitor as less of a threat and explain the struggles she was experiencing.

I waited with bated breath for our next appointment and my client returned the following week to tell me that meeting had gone well and that she was getting the support she needed. Not only that but following her meeting she had applied her new mentalizing skills to an interaction with her parents, one that would normally have resulted in her telling them what she thought of them and then leaving in an angry manner. The process of sitting side by side in a non-threatening way, talking it through together, writing it down alongside the use of the CAT map, had enabled my client to mentalize about both situations.

Following this experience I drew up the format to use as a tool (see figure 2) alongside a CAT map to prompt mentalizing in different contexts. I use mapping in 1.1 supervision, in reflective group supervision with teams or in any situation where there seems to be a relational difficulty. Using the CAT map as a prompt with this mentalizing tool allows me to help clinicians stop, pause and reflect on their own mind and the mind of the other, rather than reacting to the actions of the other. With the ever growing demands of secondary care services clinicians frequently find themselves under so much pressure and less capacity or room to think. The tool could therefore be used by care coordinators with clients in ongoing work, beyond CAT therapy. 

For CAT practitioners mentalizing is not a new concept or practice as we use the map to help clients recognise where they are and where the other might be on their map. However I feel mentalizing offers CAT the space and containment to focus on and develop the curious, reflective aspect of CAT - the ‘Watchful Eye’ - being able to recognise where the client is on their map by curiously wondering about the mind of the other. This mentalizing tool could be added to the CAT tools (letters and map) for the client to take away and use outside of the sessions and when therapy has ended. In this way the EXIT of mentalizing, holding mind in mind, rather than reverting to the old unhelpful TPP that kept the client stuck in unhelpful patterns and procedures, could be seen as something for the client to continue to work on. In reciprocation the CAT map offers MBT an excellent aide memoire, a visual aid to prompt the curious, reflective stance, which is the underpinning feature of mentalizing. Rather than highlighting the differences as noted by Bateman et al (2007) perhaps CAT and MBT can be seen to more complement one another. 

References

Adshead, G., (2018). Attachment, Complex Trauma and Personality Disorder: Using Theory to Think. London: N Science Workshop [Unpublished item].
Allen, J. G., Bleiberg, E. and Haslam-Hopwood, G. (2003). Mentalizing as a compass for treatment. In: Oestergaard Hagelquist, J. (2017). The Mentalization Guidebook. London: Routledge.   
Barley, A. (2018). Holding Mind in Mind. Therapy Today, 29 (7), 34-38.  
Bateman, A.W., Ryle, A., Fonagy, P., & Kerr, I. B. (2007) Psychotherapy for Borderline Personality Disorder: Mentalization Based Therapy and Cognitive Analytic Therapy Compared, International Review of Psychiatry, 19 (1), 51-62
Bateman, A. W. and Fonagy, P. (2011). Handbook of Mentalization in Mental Health Practice. Arlington, VA: American Psychiatric Publication.
Ryle, A. (2002). Introducing Cognitive Analytic Therapy: Principles and Practice. London: Wiley

Full Reference

Jane Bradley, 2019. Incorporating mentalizing skills into Cognitive Analytic Therapy (CAT). Reformulation, Winter, pp.39-42.

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