Developing the CAT model of obsessionality

Transcription

1 More is More Developing the CAT model of obsessionality Jason Hepple FRCPsych UKCP reg. CAT psychotherapist and training supervisor Somerset Partnership NHS Foundation Trust Chair of the Association for Cognitive Analytic Therapy (ACAT)

2 Cognitive Analytic Therapy (CAT) A developmental and relational approach Describes relational role-play using reciprocal roles Describes in letters and maps out patterns so that they can be seen and brought into dialogue (particularly those re-enacted in the therapy relationship) Tries to negotiate exits or different ways of relating

3 Reciprocal Roles If we look down on a person or a group of people they can experience themselves as dismissed and beneath contempt, and can respond to try and gain the upper hand by becoming contemptuous and critical of us. This is the reciprocal role: Contemptuous Disgusted Contemptible Disgusting

4 Cognitive Analytic Therapy (CAT) We expect the world to carry on being as we have experienced it to be We use the same ways to survive the world that have served us well in the past (even if they are really getting us into trouble the non-revision of dysfunctional procedures - Ryle) More than that, we often provoke others to reciprocate in the roles we have come to know and expect The dance ) Some template maps:

5 Narcissistic Map Grandiosity Omnipotence Pride Shame / Doubt Admired Alone Admiring Reflecting (No needs) Contemptuous Disgusted Contemptible Shamed Disillusion Envy, Contempt and Rage

6 Borderline Map Seeking rescue (Identification with the aggressor) Ideally Caring Ideally Cared For (Fusion / Bliss) Abusing / Controlling Abused / Controlled Fear Disillusion Anger, Revenge, Jealously Guilt for the monster ( one fears) one has become

7 Attachment Map Uncontaining Neglecting Neglected Uncontained Abandoning Abandoned Annihilating Annihilated Anxiety Greed Grief Dread

8 Some Ideas and Metaphors Starting points: Obsessionality is hard to treat It may be understandable developmentally and in our socio-cultural context The need to get out of the dance and get in to the real story

9 Greed - Klein Greed is an impetuous and insatiable craving, exceeding what the subject needs and what the object can give. Melanie Klein 1956 The destruction of the object is incidental to the ruthless acquirement. Hanna Segal 1964 Draining / exhausting Nothing can be spared to be given Guilt and regret for one s own greediness Nothing good can be kept in / digested or kept down A victim of his own greed More is More Obsessionality and Eating Disorders

10 More is More - Greed In the 21 st century: Money, shopping, tattoos, body modification and plastic surgery, body image and weight loss, hair extensions, sun tanning (and fake tans), technology and screen time, hygiene and cleaning etc

11 Mirror Time The ritualisation of more is more as an initially self-soothing intrapersonal procedure seeking (and never getting in a lasting way) a narcissistic reward / resolution. As the mirror time becomes more demanding, the act of trying to obtain the desired end point becomes the end point and has damaging interpersonal consequences (isolation, selfabsorption, greed).

12 Overvalued Ideas An overvalued idea is an acceptable, comprehensible idea pursued by the patient beyond the bounds of reason this patient s whole life comes to revolve around this one idea. Sims, 1988 Not delusional as basis may be understandable Found in: anorexia, morbid jealousy, dysmorphophobia, parasitophobia, hypochondiasis, obsessionality (but slightly different as home grown but disowned quality and can mutate ) Non-negotiable (but may appear to be negotiable!) Often off the map in terms of dialogue

13 Attachment and Safety There is a noticeable clinical link between obsessionality and fear of loss of attachment and concern for the safety of self and others. There is often an early loss / abandonment or the experience of an uncontaining / neglecting other (for example, an obsessional parent).

14 The Raft Symptoms and symptom complexes such as eating disorder or OCD are seen to originate in the need to replace or avoid forbidden or feared reactions to unmanageable experiences. The role of many symptoms is illustrated by a story - I think a Buddhist one - of a drowning man who was saved when a raft drifted by. In recognition of his gratitude he strapped the raft to his back and carried it for the rest of his life. Many symptoms can be relieved by the recognition and modification of the avoided procedure. Tony Ryle, 2014

15 The Cult and the Contract The contract has been signed (but not fully read) at a time of great need and fear. The contract demands the joining of a secret cult where self-sacrifice and servitude will manage the fear but it is not clear how long it will need to go on for or what the end point actually is. High status is sometimes briefly achieved in a dysfunctional peer group (for example, IP units or by being a special patient ).

16 The Interrogation In a non-consensual interrogation, the interrogatee is likely to do / say whatever is apparently needed by the interrogator, while secretly reinforcing the view that their hidden core beliefs / values are not negotiable. The illusion of a therapeutic alliance and secondary gain ( for example, referral to a specialist unit). The client as greedy and demanding with the therapist / carer exhausted and drained

17 The Catcher in the Rye J.D.Salinger 1945 Loss of younger brother Allie The catcher Origin of obsessional defences

18 The Burden The narrative aspect of CAT A reformulation in the form of a story

19 A Formulation The burden is the magical solution created at a time of great fear and dread (related to loss of attachment or fear of loss) The burden is an internalised relationship and is greedy The burden makes the client greedy in relation to real others The burden gets heavier over time and becomes the problem the origins are forgotten or disavowed The actual effect of carrying the burden is that future attachment is avoided ; the disavowed procedure: If I get close to anyone I fear they will abandon me or I will annihilate them. PS: The angel is deceitful (self-deception)

20 Isolation Disavowed Forgotten The Burden Greedy Striving Drained Doubt Desired but never fulfilled Annihilating Abandoning Abandoned Annihilated Guilt Leave me alone Contemptuous Rejecting Admiring Admired Guilt Dread Grief Contemptible To receive is to attach and there is nothing left to give

21 Possible Exits - Greed Focus on the greed based enactment in the therapy relationship the exit must be giving and receiving. What can the client risk taking from the therapy? What can he spare to give? Freely Giving Gratefully Receiving (Gratitude)

22 Zone of Proximal Development Stay where you are rather than go forward alone; engagement is about giving and receiving not just the therapist s striving Small tasks Arriving on time Completing a form Reading a passage of a book Bringing a dream Engagement brings the possibility of attachment to the therapist Bringing the angel with you tolerating a triangular relationship

23 Possible Exits - Attachment Daring to risk attachment in the therapy and real relationships Loss and grief for the past, the wasted time, the end of therapy Building real relationships and networks Just talk about their life Tony Ryle Containing Empowering Allowing separation (Self)-Contained Safe to explore

24 Thank you

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