Dr Rosemary Carter Chartered Consultant Clinical Psychologist

1. Reflections on using Cognitive Analytic Therapy with client diagnosed with Dissociative Identity Disorder Dr Rosemary Carter Chartered Consultant Clinical Psychologist CBT Psychotherapist and Supervisor amd CAT Practitioner Lead for Solihull Psychological Services Birmingham and Solihull Mental Health Foundation Trust With thanks for help with slides: Mark J Walker, CAT Therapist, Trainer and Senior Supervisor. And Angela Carradice, CAT Therapist, Clinical Psychologist

2. CAT: An Integrative Model ‘CAT is an Object Relations informed approach to Cognitive Therapy, transformed by Vygotskian Activity Theory…..’ (Ryle 2002) Vygotsky:Social Formation of mind, Sign mediation, Internalisation, Zone of Proximal Development Bakhtin: Dialogic model of self – I relate and am therefore in a constant state of becoming Behaviourism: Focus on Target Problems and Aims/Exits Cognitive Therapy: Self-monitoring and challenge of identified irrational beliefs

3. CAT: An Integrative Model • 16 sessions (24, 32+) • Three Rs – (Reformulation, Recognition, Revision) • Patterns (Reciprocal Role Procedures: RRPs) – a repertoire of patterns of how we relate to ourselves and others • Use of Maps (Sequential Diagrammatic Reformulation) • for location of transference events • Letters (Reformulation letters and End of Therapy Letters) • Supervision

4. Reciprocal Role Procedures • CAT looks at interpersonal behaviour in terms of each person taking up a role in relation to the person with whom they are interacting, and anticipating the response (or role) that the other person gives • http://www.youtube.com/watch?v=apzXGEbZht0

5. Neglects self Don’t maintain relationships Neglecting Ignored Yearning for perfect care, never enough Allowed others to neglect him/her Others feel shut out

6. Abuse self, cut to punish, take risks because deserve to be a victim, don’t make changes as think I am unworthy of good things In relationships, expect abuse so attack first and push away Abusive Critical Automatic internal self critic, persecute self, undermine sense of self Bad inside Helpless victim Drawn to people who are familiar, abuser after abuser Others pull away e.g. either scared of bully or overwhelmed by victim Try to be good enough by trying to be perfect at everything, can’t keep it up, collapse and give up

7. Perfect love and care Protective Specially loved and protected Bear in mind the pull here: Intention to be here: Acting from here: Critical Controlling abusive Valuing Respectful Understanding Containing Rejecting Not trusting Abandoning Trapped Not good enough Victim Rejected Abandoned Alone Valued Respected Understood Safe

8. CAT: Multiple Self-states Model (MSSM) (Ryle, 1997, Pollock, 2001, Ryle and Kerr, 2002) • Multiple Self States Model (MSSM) in CAT developed to help in working complex cases where dissociation is evident • Dissociated self-states, state-switching containing limited range of role-patterns (Ryle 1997) e.g. abandoning, abusing, contemptuous • The whole is championed with all the different self-states so as to avoid reinforcing separateness and dissociation.

9. CAT: Multiple Self-States Model • 3 levels of disturbance (Pollack et al., 2001) • LEVEL 1: Reciprocal role procedures (neglected, abused) • LEVEL 2: The ability to organize the procedures for the task called meta-procedures. When difficulties arise – fragmented and self-states emerge; incoherence with memories; dissociative shifts • LEVEL 3: The ability to reflect on this is limited; memory in one state that is lost when in another state

10. ASSESSMENT Psychometric Assessments: • Completed Clinical Outcome and Routine Evaluation (CORE) • Dissociative Experience Scale-II (DES-II: Carlson and Putman) • Psychotherapy File (Cognitive Analytic therapy (CAT) Questionnaire • States Questionnaire (CAT)

11. Treatment Goals: ISSTD (2011) • Integration is the primary and over-arching goal of any psychotherapeutic intervention of DID: ISSD (1997) suggesting 3-6 years of bi-weekly appointments ?! • To validate the internal reality without promoting fragmentation whilst helping her achieve control over aspects of herself to reduce vulnerability • Phased approach (Tri-phasic Chu 2011; Curtoise, 2010; ISSTD, 2011; Van der Hart et l., 2006)

12. Phase 1: Stabilisation • RISK MANAGEMENT • SUPPORT NETWORK • ENGAGING and ACCEPTING all the different parts/states • COMPASSIONATE: Its understandable……with responsibility of keeping yourself and others safe • SAFEGUARDING • DISTRESS TOLERANCE SKILLS; safe place; regulatory skills (grounding techniques; breathing and refocusing attention (mindfulness); mentalizing and relational skills; • ASSERTIVE SKILLS • PARTS – present, attunement etc (Seigal, 2010)

13. Phase 2 • Phase 2: Treatment of Traumatic Memories • only when there is a degree of cooperation among dissociative parts/states. Sharing the memory from first person not third person. Accepting, owning and adapting to what was and is ‘this happened to me’. (This what happened to me’ These are my feelings and my actions’ and presentification (I am here now, and I am aware of how my past affects me in the present and in my future expectations) • 3rd – 1st person dialogue • Utilising the Reformulation Letter (‘hearing it back’) • The Map: where are you; recognising jointly and then on her own • Revision: Developing and utilising ‘exits’ • Monitoring risks and safeguarding

14. Phase 3 • Phase 3: Integrating Traumatic Memories and rehabilitation • Focusing on being involved in present life, conflict between desire to change and intense fears of doing so; grieving; on-going struggles; • Recognising themes of loss; • Preparing for ending • The end of therapy letter and exchange

15. Reflections • Doubt and disbelief; anger; numbing out; frustration; ‘rescuer’; protecting the vulnerable abused; ignoring and colluding; forgetting supervision ‘after’ the session; forgetting time; fearful; ‘not good enough’ can I do this? • Tailor to individual • Roller coaster – be prepared for uncertainty and confusion • Other self-states might exist • Find an expert supervisor • Validate all aspects of the individual –including anger and fear • Switching is about coping as well as avoiding • Hold the ‘client’ whilst referring and accepting and understanding of the ‘parts’ • Prioritise working in reducing risk • Share information with team, safeguarding etc • Don’t just work with the ‘victim’ be prepared to work with the anger and potential for ‘abuse’ in some form (self-abuse and abusive elements). Be aware of colluding and avoiding; blank spots

16. Contributions and Limitations of CAT • Going at client’s pace – ZPD is in the CAT model (window of tolerance) • Timing of re-formulation letter – can be done slowly- verbally • Map – ‘not all the parts are on there’ • Can develop slowly, use of images (right brain) • Therapy has a compassionate understanding through different mediums – visual map, letter, verbally (also use Russian Dolls). It is an integrative model.

17. Contributions and Limitations of CAT • Therapeutic Relationship – transference, counter-transference within CAT framework . • Map: • to support the team (splitting) • for supervision to ‘hold’ and ‘contain’ • for the client (where appropriate) • MSSM – has similarities with Structural Dissociation Model • Eye becomes the ‘I’ – dual awareness –(neurobiological evidence of Medial Pre-Frontal Cortex)

18. Find out more: • http://www.acat.me.uk