Cognitive Analytic Therapy and Later Life

New Perspective on Old Age

Jason Hepple, Laura Sutton, Jason Hepple, Laura Sutton

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781135480844
• Edition: 1
• Topic: Psychology
• Subtopic: Psychopathology
• Index: Psychology

Cognitive Analytic Therapy and Later Life highlights that any attempt to work psychotherapeutically with older people must take into account the effects of working within a context of institutional ageism. It explores the specialist skills required when working with older people, covering: * the delayed effects of early trauma
* narcissism and the re-emergence of borderline traits and dissociative states
* the emergence of treatment resistant depression and anxiety
* the use of the cognitive analytic therapy model to challenge the child centred paradigm of psychoanalytic theory.Clinical psychologists, psychiatrists, psychotherapists, nurses, social workers, and occupational therapists alike will find this an illuminating and thought provoking book.

Part I

---

Ageing, ageism and CAT

The theoretical and psychological context of psychotherapy with older people

---

Introduction

Jason Hepple

---

In the first part of this book we hope to consider the context within which psychological work with older people is grounded. This takes in, first, the way that psychological theory has developed, with particular reference to CAT, and how both an individual’s chronological age and personal life story, generational and cultural identity have been and can be viewed in the context of an interpersonal theory of mind and behaviour. Second, we consider the changing place of older people in Western society, around the concepts of ‘ageism’ and ‘elderhood’.

Negative societal views of old age have had a detrimental effect both on the development of a satisfactory psychological theory that can ‘speak to’ later life with meaning, and on the way that psychotherapy services have, or have not, evolved. To improve matters it will be necessary to develop the psychotherapy theory of later life in parallel with services. More personnel alone will not alter the dominance of the biological model and the way that professionals, often unwittingly, can play out society’s ageist views in the way that work with older people is approached. Awareness of the context of their work with older people, developed through formal training, clinical teaching and supervision based on a theory that is designed for and arises out of work with older people, may be a positive way forward.

In Chapter 1, Laura Sutton and Mikael Leiman provide a sweeping overview of the evolution of CAT theory by a retrospective analysis of four key papers by the founder of CAT, Anthony Ryle, spanning the years 1975–91. Apart from being of great interest to the CAT student who may have struggled with the conceptual leaps bounded by these papers, the theoretical developments described take us more and more into the realm of the interpersonal and the need to find the shared meaning between the individual strangers in the space of a CAT therapy. To deal with the necessary jargon: the theoretical journey of CAT begins with information-processing and cognitive theory (the Procedural Sequence Model – PSM), the integration of object relations (Procedural Sequence Object Relations Model – PSORM) and on into the role of ‘sign mediation’ (semiotics is the study of signs) to produce a Semiotic Object Relations Model (SORT). Mikael Leiman, based in Finland, has been highly influential in the integration of the Eastern European tradition of developmental psychology (loosely arising from Activity Theory) with particular interest in the role of signs and the creation of consciousness and self-awareness through the internalisation of the signs created when two individuals relate. As Ryle puts it, sign mediation is the ‘hyphen between nature-nurture’. This hyphen can be seen to bridge the gap between the individual and the collective and allow object relations to become transformed into truly dialogic (from dialogue) events, taking into account the past (history), the present (the therapeutic relationship) and the future (the open ‘voice continuing to be heard’). It is hard to overestimate how different is his view compared with the ‘demonology’ of object relations and the linearity and lack of other in informationprocessing models. Laura and Mikael argue a powerful case for a theoretical position where constantly evolving and unwinding interpersonal meaning is the essence of psychotherapy. This is a perspective that allows individual culture and historical differences to be fully participative in the therapy and one that is naturally adaptable to work with older people, as they demonstrate through case material.

In Chapter 2, Jason Hepple traces the concept of ageism through both Western society and Western psychotherapy theory. Negative views and stereotypes about ageing and older people are deeply ingrained in both. The question as to what extent contemporary ageism can be seen to be a backlash against the more powerful elderly cohort of the past, with a modern demise of the role of ‘the elder’ in society, is extended in Chapter 3. Perhaps ageism has been slow to establish itself as an identifiable form of oppression, in comparison with racism and sexism for example, due to the fact that it concerns itself with a universal occurrence: ageing and dying. Psychological defences based around denial are needed to maintain an ageist position and to place older people in the category of ‘them’ that is distinct from ‘us’. Seen from the point of view of a CAT ‘snag’, ageism can be viewed as a short-sighted attempt to avoid dealing with existential reality, which generates hostility, fear and unhelpful escape fantasies (unnecessary cosmetic surgery for example). Ageism can be seen as an interpersonal and reciprocal phenomenon that is replayed both intrapsychically and intergenerationally. Awareness of ageism in health and social care settings (and its reciprocal role partner ‘reverse ageism’ – or the contemptuous dismissal of the young by the old) can illuminate both individual and group work. In addition, a psychotherapy theory that moves away from the linearity of Erikson’s stages (ending in old age with the unattractive struggle between ‘ego integrity and despair’), and towards one in which interpersonal and existential challenges permeate development and adaptation throughout life, may be a better way to approach work with older people.

In Chapter 3, Mark Dunn takes a wider cultural and sociological view of elders and ‘elderhood’. He contrasts being chronologically old with being psychologically and socially elder and looks at what needs to happen in order for the young to want to grow old. From the disillusionment with elders in contemporary times, especially in Western cultures, he draws on examples from pre-modern societies and Jungian analysis to examine some of the processes involved in becoming psychologically and socially elder, illustrating these in contemporary context (in business, family life and psychotherapy). From a CAT perspective he draws on the notion that psychological and social development links to increasing one’s repertoire of reciprocal roles, oriented ultimately in elderhood to the continuation of community, rather than to the more restricted aim of ego-strengthening alone, as is the emphasis in most therapies with their traditional middle-age, youth and childhood rather than old-age orientation. This begins also to develop the notion of transition, from adulthood to elderhood, alongside that from childhood to adulthood, as a process not of sequentiality in a linear ‘leaving behind’ of previous ages, but of successive reflection and integration of periods in life where the person, as in notions of elderhood in traditional communities, can draw flexibly on different life experiences timely to the developmental struggles of those to whom they attend.

Finally, in Chapter 4, Madeleine Loates offers an introduction to the practicalities of using the CAT model with older people in a clinical setting. This chapter aims to prepare the ground for Part II of the book, where CAT is applied to a range of specific and severe psychological problems that arise in later life (narcissism, trauma, borderline traits, involution and dementia). This chapter offers an introduction to the CAT tools and terminology used in this work with older people, and gives an overview of the type of patients who may most benefit from a CAT approach. Through case material she shows how CAT can help an older person ‘manage the unmanageable’ in dealing with traumatic memories and, through the therapeutic relationship, allow reconnection with the return to ‘being in dialogue’ with the self and others.

Chapter 1

---

The development of the dialogic self in CAT

A fresh perspective on ageing

Laura Sutton and Mikael Leiman

---

Working as a therapist to older people helps the practitioner to see the need for cultural-historical context in the very concepts that are developed to guide practice and scientific inquiry. Part of this is the multiple layers of meaning that are encountered. For example, in order to convey the nature of human relatedness, CAT involves the concept of a ‘reciprocal role’. An example of a more damaging reciprocal role is ‘criticising to crushed’, conveying the unrelenting feel of such related experience. The word ‘criticising’ however has a modern tone to it, in contrast to the word chiding’ that a client in her early 70s used. This word was unfamiliar to some younger therapists, yet conveys a sense of moral admonishment linked to the contexts of the day. Thus, Knight (1996) talks about cultural differences, but over time, rather than geographical distance. He discusses this need to be sensitive to word usage, especially with those he refers to as ‘earlier born cohorts’. He comments on the lack of methodological sophistication in studies of memory, where most studies are cross-sectional and so confound the issue of ‘age’ differences with such cohort effects; studies that use cohort-appropriate words for instance have shown better learning. Working with much older clients makes it easier to see how words speak profoundly to collective discourse. Indeed clients themselves comment upon social, economic and political change which is not easily accommodated in conventional therapy theory.

The story of the development of theory in CAT over its last twenty years and more is intriguing in this regard, because it has adopted analytic and cognitive concepts in light of their historical underpinnings; and through dialogue with other concepts in other settings in other times, for example from child development and semiotics, has transformed them from their individualistic bases into notions of shared activity mediated through dialogue. It is this longevity of perspective on meaning which matches the longevity of perspective of older clients, with its potentially transformative qualities if allowed to be in dialogue. More intriguing still is CAT’s notion of the dialogic self, or, more properly, dialogic-self processes, because these processes are considered to continue throughout life, from its very beginning to its very end, making the self permeable throughout life. It upholds the need to ‘be in dialogue’ throughout life for the self to continue to be constructed, reconstructed and sustained. Because these processes are important, whatever one’s age, and are not attached to any one chronological age in particular, the dialogic self is in a sense an ‘ageless self’.

Intrigued by this, Laura Sutton approached Mikael Leiman to see if it would be possible to write a chapter to present CAT theory to gerontology and psychogerontology. Our resultant chapter aims to orientate the reader to the process of the development of theory in CAT, both to show how the notion of the self as dialogic process came about, and to explain what this is. It aims to be a general reader in this respect, offering a reading of, and commentary through, four landmark papers over CAT’s development, in order to stimulate debate about the implications of this approach to theories of personal development in later life. We begin with some contextual issues surrounding CAT’s current position.

Contextual issues

Cognitive Analytic Therapy – CAT – is showing an ever diversifying practice within a relatively coherent conceptual framework. There is now ‘standard CAT’, very brief interventions, and long-term CAT. There are couples and group versions and specialised approaches to different patient groups (Ryle and Kerr 2002). This variety in practice raises an interesting question: What holds the approach together? Here there seem to be two developmental directions. One emphasises professional unity by creating codes of practice, norms for appropriate CAT delivery and so on. The other aims at developing flexible and high-order concepts that can function as analytic tools in various practical contexts. The former endorses professed codes of practice, for instance recommended ways of using the CAT tools, such as the ‘reformulation letter’ or ‘sequential diagrammatic reformulation’ (the ‘SDR’), or a faithful adherence to the PSORM (procedural sequence object relations model, below) as the final explanatory model. In contrast, the latter sees the most important unifying task as developing the basic concepts (the reciprocal role, procedural sequence, self state) further through empirical inquiry.

This is an interesting sociological issue. Professionalistic tendencies in psychotherapy are closely tied with the market economy and its regularities. Basically, professional boundaries function to restrict influx to limited markets, regulated by codes of practice and modes of gaining expertise, which then bring the spirit of ‘doing it properly and according to accepted standards’ to the field. Thus professionalism has an inherent tendency to conservatism and different therapies are positioned so as to compete. Innovation easily becomes looked on as though it is ‘deviation’. A tendency to standardise practices by setting criteria for adequate delivery then, ironically, starts to counteract scientific development and crossfertilisation. This is of course happening not only in psychotherapy, but generally in these times of evidence-based medicine. Here there is a tension between evidence-based practice and practice-based evidence (Mace et al. 2000). In the latter, scientific concepts are open to development when they are combined with practice in different developing settings with dialogue between therapies able to establish common important therapeutic processes, for instance the importance of the quality of the therapeutic relationship to outcome.

Dilemmas, traps and snags represented the first mode of formulating recurring and problematic action patterns.

1. Traps – Negative assumptions generate actions which produce consequences seemingly reinforcing the assumptions. For instance, in the placation trap, feeling uncertain about himself, a person tries to please people by doing what they seem to want. As a result he ends up being taken advantage of by others, which makes him angry or depressed and reinforces his uncertainty.
2. Dilemmas – The person acts as though available action or possible roles were limited to polarised alternatives (false dichotomies) usually without being aware that this is the case. An example of an interpersonal dilemma, prescribing for the person two contrasting, and equally costly, ways of relating might read ‘either a ruthless bully or a compliant martyr’. Personal dilemmas, similarly, represent polarised options with regard to one’s own activity e.g. ‘either I keep feelings bottled up or become vulnerable, out of control and make a mess’, a common dilemma often leading to rigid self-control.
3. Snags – Appropriate goals or roles are abandoned (a) on the (true or false) assumption that others would oppose them, or (b) independently of the views of others, as if they were forbidden or dangerous. The individual may be more or less aware that he acts in this way and may or may not relate this to feelings such as guilt.

Box 1.1 First formulation of target problem procedures (Leiman 1994)

In his papers at the end of the 1970s, Anthony Ryle, founder of CAT, clearly regarded high-level conceptual integration as a basis for developing psychotherapeutic practices as an alternative to narrow professionalism. This spirit of innovation and non-dogma was a key feature of CAT’s early stages where the main aim was to help those who work with difficult cases to do better psychotherapeutic work in practical settings with many limitations. The conceptual tools (the ‘dilemmas’, ‘traps’ and ‘snags’ – Box 1.1) and the practice of reformulation were combined with whatever therapeutic skills were available in order to improve the quality of the work that was done anyway.

After all, the majority of people are treated in institutional settings that still do not know anything about the most basic psychotherapeutic orientation and skills, which very much includes such settings for older people. The spirit of innovation and non-dogma remains a vital part of CAT alongside the recent professionalist tendencies, as understanding the theory and practice of CAT via a thorough professional training enables the practitioner to offer this kind of supervisory and consultative work. For the purposes of this chapter, in order to convey the evolution of understanding the self as dialogic process, we shall concentrate on the conceptual level.

The ‘A’ and the ‘C’ story in CAT

In CAT, object relations theory in psychoanalysis provided the original model that Ryle wished to translate into cognitive terms. From the PSM (Procedural Sequence Model, Box 1.2) to the PSORM (Procedural Sequence Object Relations Model, Box 1.3), CAT is now consolidating in ‘semiotic object relations theory’ (Ryle 2001). We shall refer to this as SORT. This is very new, so it would be inappropriate to try and ‘box’ it, but it is a fascinating conceptual journey with some interesting landmarks, namely Ryle’s papers: ‘Self-to-self and self-to-other’ in 1975, ‘A common language for the psychotherapies’ in 1978, ‘Cognitive theory, object relations and the self’ in 1985, and ‘Object relations theory and activity theory: a proposed link by way of the procedural sequence model’ in 1991.

1. Define aim (maybe in response to external event).
2. Check aim for congruence with other aims and values, i.e. for personal meaning.
3. Evaluate situation, and predict one’s capacity to affect it, and the likely consequences of achieving the aim.
4. Consider the range of means or roles (sub-procedures) available and select the best.
5. Act.
6. Evaluate (a) the effectiveness of the action and (b) the consequences of the action.
7. Confirm or revise (a) the procedure and (b) the aim.

Box 1.2 The Procedural Sequence Model – PSM (from Ryle 1990, p. )

In ‘Self-to-self and self-to-other’ in 1975, the concept of reciprocal roles was introduced to replace the concept of internal object relations in psychoanalysis. The story of the development of the concept(s) of ‘object relations’ in psychoanalysis is a complex one, with different and conflicting views between analysts over time and lineage, indeed with such conflicts within individual analysts’ writings, such as those of Freud and Klein. How this was engaged with in terms of re-articulating their notions in a more accessible way is at the heart of the early evolution of CAT, the 1975 paper being an early, and ‘pre-cognitive’, example. From the point of view of our chapter, a key distinction lies in being able to see ‘monologic’ and ‘dialogic’ positions. For example, Freud’s classical drive theory is ‘monological’ whereas his notion of ‘superego’ is a forerunner of the ‘dialogical’ line. This is because his concept of the ‘superego’ (conscience) entails the need for another person: the superego is the type of concept that is representing the idea that a part of our self is derived from an other. In contrast, the notion of ‘drive’ is representing the concept of an unconscious and innate instinct as motivating: there is no ‘other’ in this – hence, ‘monological’ (from ‘monologue’ rather than ‘dialogue’). The ‘self-to-self, self-to-other’ paper can then be positioned as representing an early freeing from an over-reliance on the monologic (and archane) aspects of psychoanalysis, in t...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• List of Figures, Boxes and Tables
• Notes on Contributors
• Foreword
• Acknowledgements
• Abbreviations
• Introduction
• Part 1
• Part II
• Afterword