Cognitive Analytic Therapy for Borderline Personality Disorder

Cognitive Analytic Therapy for Borderline Personality Disorder SPD Network Meeting Aberdeen 4th June 2009 Ian B. Kerr NHS Lanarkshire, Department of Psychotherapy, Coathill Hospital, Coatbridge,

Cognitive Analytic Therapy

www.acat.me.uk

“Cognitive Analytic Therapy: Active Participation in Change” Anthony Ryle 1990 J. Wiley & Sons

“Cognitive Analytic Therapy: Developments in Theory and Practice. (1995) Ryle, A. (Ed). (Wiley & Sons) “Cognitive Analytic Therapy and Borderline Personality Disorder: The Model and the Method.”(1997) Ryle, A. (Wiley & Sons). “Introducing Cognitive Analytic Therapy: Principles and Practice.” (2002) Ryle, A. & Kerr, I.B. (Wiley & Sons).

‘In the beginning is the relation’. - Martin Buber, ‘I and Thou’ (1958).

Cognitive Analytic Therapy • Object-relations informed approach to cognitive therapy (including personal construct theory) transformed by Vygotskian activity theory and Bakhtinian concepts of the dialogic self.

Cognitive Analytic Therapy • Based on a radically social model of self which is seen as fundamentally constituted by internalised, socially-meaningful, interpersonal experience and is described in terms of a repertoire of ‘reciprocal roles’ and their procedural enactments.

Cognitive Analytic Therapy • Influence in recent years of findings in developmental research (e.g Trevarthen) stressing the infant’s capacity for and active pre-disposition to ‘inter-subjectivity’. • Implies the socially and culturally determined formation of the self through collaborative, meaningful, sign-mediated activity.

‘Human beings are biologically predisposed to be socially formed’. A. Ryle. • Bruner, J. (2005). Homo sapiens, a localised sub-species. Behavioral and Brain Sciences, 28, 694-695.

Cognitive Analytic Therapy • From this perspective it can be argued that there can be no such thing as individual psychopathology - but only socio-psychopathology. • (NB Winnicott- ‘there is no such thing as a baby…’)

Infant Observation Research (Stern, Trevarthen et al) Verbal self from c.18 months: meaning (the relation of thoughts to words), results from interpersonal negotiations. (Stern) Ultimately awareness and understanding of states of mind and intentions of others by c.3-4 years. (“Theory of Mind”) Stress on joint, sign-mediated intersubjectivity ab initio. Infant characterised predominantly by joyfulness, curiosity and activity in “companionship”. (Trevarthen) Importance of real experience on development (eg effect of depressed care-giver – Murray). Infant liable to depression, frustration, shame.

Infant Observation Research (Stern, Trevarthen et al) Early “emergent self” – carers act as physiological regulators but infant capable of, and predisposed to, active intersubjectivity and gradually increasing collaborative playfulness. (“innate motive formation” – IMF – Trevarthen) Core self by c.6 months – agency, coherence, affectivity, Procedural memory of interactions with others linked to sense of core self. (representations of interactions that have been generalised = RIGs – Stern) Subjective self and gradual awareness of the worlds of others by one year; “shared framework of meaning and means of communication” (Stern)

Infant Observation Research (Stern, Trevarthen et al) No evidence for early states of fusion. No evidence for early complex operations such as “splitting” or “projective identification”. No evidence for dominant, inherent predisposition to anxiety and destructiveness.

‘Reciprocal role’ - complex of implicit relational memory, perception (including beliefs, values and meanings) and affect – often associated with a dialogic voice . Repertoire of reciprocal roles seen to underpin all mental ‘activity’ whether conscious or unconscious.

‘Reciprocal role procedure’ - stable pattern of interaction originating in early internalised relationships which determine current patterns of relations with others and of self-management. Enactment of a role always implies another, whose reciprocation is sought or expected.

Vygotsky & ‘Activity Theory’ • Concepts of ‘internalisation’; ‘psychological tools’ ; ‘zone of proximal development’ (‘ZPD’).

Vygotsky & ‘Activity Theory’ • ‘Any function in a child’s development appears twice - or on two planes. First it appears on the social plane and then on the psychological plane. First it appears between people as an interpsychological category and then within the child as an intrapsychological category. This is equally true with regard to voluntary attention, logical memory, the formation of concepts and the development of volition. We may consider this position as a law n the full sense of the word, but it goes without saying that internalisation transforms the process itself and changes its structure and functions. Social relations or relations among people genetically underlie all higher functions and their relationships.’

Lev Vygotsky • ‘The very mechanism underlying higher mental functions is a copy from social interaction; all higher mental functions are internalised social relationships. These higher mental functions are the basis of the individual’s social structure. Their composition, genetic structure and means of action, in a word, their whole nature is social.’ • (from ‘The Genesis of Higher Mental Functions`)

Lev Vygotsky • Psychological tools – ‘sign-mediating’ cultural artefacts which can influence the mental activity of others or of oneself internally. Their mastery may require prolonged use and practice.

Lev Vygotsky • Zone of proximal development – the gap between what an infant can achieve on its own unaided and what can be achieved with the active assistance of an enabling other - or a peer group.

Bakhtin and Notions of the Dialogic Self • ‘I am conscious of myself and become myself only while revealing myself for another. The most important acts constituting self-consciousness are determined by a relationship toward another consciousness ( toward a thou)… not that which takes place within, but that which takes place on the boundary between one’s own and someone else’s consciousness , on the threshold… a person has no internal sovereign territory; he is wholly and always on the boundary; looking into himself, he looks into the eyes of another or with the eyes of another’.

Cognitive analytic therapy • Now a mature model of development and psychopathology. • Increasing amount of work ‘using’ the model (as opposed to simply ‘doing’ it as therapy) - (Potter). • E.g. work on re-conceptualisation of self in old age and dementia, in psychosis, in consultancy work and CAT-informed clinical practice.

Basic CAT • Behaviour and experience organised by ‘procedures’. • These link perception, appraisal, action planning, prediction with action and the consequences of the action, which are evaluated leading to confirmation or revision. • Reciprocal role procedures - to play or enact a role is to anticipate or elicit the reciprocal.

Basic CAT • Reciprocal role procedures are early in origin, are general and resist revision. • They embody parental and cultural meanings and values transmitted by pre-verbal signs and, later, language. • An individual’s repertoire of role procedures determines both interpersonal relationships and the internal dialogue of thought and self-management.

Cognitive analytic therapy (CAT) • Essentially time-limited (usually 16-24 sessions). • Pro-active, collaborative (‘doing with’), highly structured. • Aims through extended assessment phase over first few sessions at joint description of key problem (reciprocal) role procedures by means of written (narrative) and diagrammatic reformulations. These should also effectively offer a sensitive, (micro-) cultural descriptive dimension.

Cognitive analytic therapy (CAT) • Subsequent work focuses on the enactments, of these both outside and during sessions. • Use of transference and counter-transference understood as enactments of repertoires of reciprocal roles. • Final summary (‘goodbye’) letters by therapist and patient. • Labour intensive!

Dominic was a young psychology student brought up and studying in the UK, but of Chinese ethnic background who had been referred from a student health service for a psychotherapy assessment because of difficulties in studying, depression and a recent self-harm attempt. He appeared initially withdrawn and uncommunicative and sat looking at the floor for several minutes. In response to a general enquiry about how things were he became angry about “having to go through all this yet again” and anyway “what was the point of it all”. He immediately followed this by looking up and apologising profusely for his outburst saying that he was wasting my time because he had to get on with things anyway and there were plenty of people out there who needed my help more that he did. Eventually he confided that he felt pretty fed up and hopeless and could not see his way forward doing a course that he was not sure that he wanted to do but had to carry on with in order not to let his parents down. Again there was a brief moment of anger at the attitudes of Westerners towards their parents and older people in general when discussing the implications of always having to please his parents. It appeared that he tended to keep his worries pretty much to himself feeling “you ought to be able to manage”. His worry about not managing seemed to him compounded by his being gay which in his original culture, he said, was seen as a sign of weakness and certainly not something he could discuss with his family. He did feel however that a small part of him did want to sort things out for himself – although it was hard to know how – and maybe finish his course and possibly even become a therapist himself one day. He agreed that perhaps it was this small part which had in the end brought him along to our meeting.

(Dominic - possible SDR) *criticising conditionally loving criticised conditionally loved ‘my fault’, ‘am worthless’ briefly self assertive but, feel guilty and *criticised apologetic strive to perform and please or, defiant, rebellious, *criticising ‘depressed’ ODs results in emotional isolation, exhaustion, can’t manage – confirms worst assumptions

Although initially devised as a time-limited therapy for ‘neurotic’ type out-patient populations, the model has been further developing to deal with more ‘severe & complex’ (e.g. personality, psychotic) disorders in a range of modalities/settings. CAT – recent developments

CAT models of ‘severe and complex’ disorders. Seen to involve deeper levels of damage to the self and its processes beyond existence of a repertoire of maladaptive RRs/RRPs. This will include failure of integration of RRs, impairment of self-reflective capacity and of executive function. Usually understood as due to developmental deprivation/trauma in context of biological /neuro-cognitive vulnerability.

CAT models of ‘severe and complex’ disorders. Psychopathology is always seen as rooted in and highly determined by repertoire of RRs and therefore, critically, to include an (internalised and frequently re-enacted) relational component.

CAT and borderline personality disorder • ‘Deficit’ model of psychopathology. • Trauma-induced dissociation rather than repression/conflict seen as primary mechanism. • In addition to maladaptive reciprocal role procedures, describes and addresses multiple ‘self states’.

CAT and borderline personality disorder • Postulates different levels of damage to self due to developmental deprivation/trauma (possibly in conjunction with e.g. poor impulse control, poor self-reflective capacity and tendency to dissociate): • Level 1: Restriction and distortion of the procedural repertoire. • Level 2: Disruption of integrating procedures. • Level 3: Deficient and disrupted self-reflection.

CAT models of ‘severe and complex’ disorders. From a CAT perspective, ‘severe and complex’ disorders could be seen in part as ‘self-state and relational disorders’.

deserve punishment poor self care, ‘deserve nothing, do nothing’ give people a ‘bad time’, (e.g. partner) self harm neglecting, abandoning abusing upsets people, rejected, put down, alone, feel ‘whole world against me’ feel even worse, nothing changes some relief, but nothing changes neglected abandoned ‘OK’ for a while, but.. abused self harm may explode into ‘justified’ rage if feel abused ‘cut off’, ‘numb’, do drugs always let down desperate, unmanageable feelings seek perfect care - expect too much caring, trying to help fearful, fed-up, burnt-out, rejecting staff

Contextual reformulation • Systems based approach using techniques of cognitive analytic therapy (CAT) as well as some features of family and group therapy. • Permits non‑confrontational, collaborative mapping of patient’s self-state and role enactments and their effects on others. • Helps establish therapeutic alliance and communicates that patient has been listened to and understood.

Contextual reformulation • Educates patient into effects of behaviour and staff into patient’s subjective ‘self‑state’. • Mapping may also be containing and educative for staff (especially about splits in team) • Permits owning of ‘negative’ emotions and responses which may not feel professionally allowed (e.g. anger) by locating these in a non‑judgmental system of causality. • Permits discussion of these difficulties by whole team. • Stimulates thought about the patient’s inner world beyond getting stuck in negative responses (‘vicious circles’) to difficult behaviour.

A Fictionalised Case Example: Anna - Background Young woman in mid 20s with a long history of anorexia and ‘borderline’ personality difficulties. Multiple hospital admissions for emergency treatment of anorexia and for serious self-harm episodes (overdoses and cutting). Spent several months in a residential therapeutic community but discharged to local hospital after self harming in the wake of her best friend’s suicide and her own involvement with a member of nursing staff. Referred for further assessment for psychotherapy by despairing local psychiatrist and community mental health team.

Anna - Background Currently living alone in small flat paid for by parents in a small town in a very socio-economically deprived area. Feels very isolated and rarely goes out - spends lots of time on the internet where she also obtains illicit medication (e.g analgesics, thyroxine). Had previously started university after doing well at school (was very competitive) but dropped out in first year because of mental health problems.

Anna - Background Family background characterised by atmosphere of tension between parents. Father (an aggressive alcoholic accountant) very preoccupied with material wealth and ‘succeeding’ in life. Mother tried to keep the peace and not offend or upset her husband - described as the ‘queen of denial’. Anna forced to attend a distant private school which she hated and sometimes wouldn’t attend due to ‘sickness’. ‘Couldn’t tell anyone about this. Younger sister Mary was less pressured and somehow more ‘thick-skinned’ but has also had problems with anxiety. Tells Anna she should now be able to ‘pull herself’ together and get on with life.

Anna - Presentation At presentation states that sees no point in living nor any future and that perhaps only a small part of her wishes to think about any further attempts at treatment. Part of her would rather join her dead friend Susan whom she envies. Appears very wary and rather hostile towards therapist. (Requests that a painting in the consulting room which is slightly squint be straightened up). Relates that she is still abusing laxatives and medication (e.g. thyroxine) and eats only liquid baby food. Her body mass index (BMI) is apparently only about 14. She refuses to see local eating disorder service who she says don’t listen to her or take her seriously. However agrees to see CPN intermittently and attend a (different) psychiatrist for occasional review.

Anna - Therapy In the absence of any more specialist intensive treatment service locally she is offered, and agrees to, an initially time-limited (24 sessions with subsequent review) course of CAT. Remains worryingly underweight (looks like ‘skin and bone’) although continues to feel overweight and to believe that this would be disgusting to everybody including her therapist. Serious concern about her (cognitive) ability (concentration and memory) to make use of therapy. During initial months remains mostly very gloomy and hopeless about change or about any future. Attends regularly apart from two periods when she is re-admitted to hospital following self harm episodes. One of these occurs during a period of therapist absence and when CPN is off ill with no replacement.

Anna - Therapy Supported by regular contact with her mother from whom she receives some (mostly practical) support. Has worries about contact with father whom she rarely sees and about whom she clearly has strong feelings but about she is reluctant to talk. Is ‘able’ to engage with the work of reformulation which she finds ‘illuminating’ and acceptable. This appears to firm up the therapeutic alliance considerably and to provide an agreed joint understanding which can be reasonably referred to. Repeated calls over this period from other colleagues (eg psychiatrist) about ‘dealing’ with her and whether therapy is ‘working’.

Anna – Reformulation Letter Dear Anna, This is a letter attempting to summarise some of the key issues which seem to have emerged in the course of our initial work together and to try to think about how they are impacting on your life at present as well as to think about what might historically lie behind them, as we have been doing. I hope that this will ultimately help you to move on to a more rewarding future. We have already attempted to sketch some of this in a diagrammatic form which I think by your account seemed quite useful although I think it seemed also quite disturbing and upsetting in some ways as well. This will only be my version of what we have been talking about and is very much open to your feedback or modification….

Anna – Reformulation Letter …in looking back over some of the things I have jotted down over the past few months I am very struck by the importance for you of not having other people’s versions of events or their expectations imposed upon you which does seem to have been your experience very frequently throughout your life, both in childhood and more recently. In fact looking back at our very first meeting one of the first things you said to me was that you felt that you had not really ever been listened to. In looking back over some of my notes I am also struck by just how painfully difficult life must seem to you day-to-day and this was also reinforced by looking through your psychotherapy file again where you highlighted some very extreme and difficult states…..

Cognitive Analytic Therapy for Borderline Personality Disorder