Reformulation: Education, Collaboration or Coercion?

Note:- As it is somewhat laborious to explain terms throughout the body of the text, key words as pertaining to Cognitive Analytical Therapy nomenclature will be explained here. However, for a full explanation of terms and concepts the reader is invited to read Anthony Ryle’s and Ian Kerr’s ‘Introducing Cognitive Analytical Therapy’ (2002).

CAT – Cognitive Analytic Therapy.

Problem Procedure – usually refers to Target Problem Procedure.

Psychotherapy File – a written questionnaire given to patients to assist them to think about their lives and to begin choosing the various Problem Procedures.

Target Problem (TP) – a problem area which the patient and therapist have chosen to work with throughout therapy.

Target Problem Procedure (TPP) - a sequence of behavioural and mental events which maintain the Target Problem.

TPP’s are listed within the psychotherapy file and are divided into:

Traps – where a negative belief leads to an action which results in the negative belief being confirmed. This sequence of events is circular in nature.

Dilemmas – similar to a double edged trap whereby a patient feels forced to decide between two undesirable courses of choices or action, these take the form ‘either – or’, or ‘if – then’.

Snags – another circular pattern, here the patient may have a reasonable aim/goal to change their life but the plan is self detonated when the person sabotages his/her own success or believes others have sabotaged this success.

Reciprocal Role – CAT’s concept of ‘Object Relations’. In brief, how an experience of another person can be divided within the self into the received role, or the giving role. This is a way of relating to other people, e.g. receiving criticism or giving criticism, or a way in which internally the self can relate to itself, e.g. we can criticise ourselves and feel criticised by ourselves.

Reciprocal Role Procedure – a (usually thought of as negative) Problem Procedure which arises out of a Reciprocal Role.

Reformulation – the CAT term for ‘formulation’, the emphasis is on a new ‘retelling’ of a patient’s life story and problems in the light of new understanding being derived from a psychodynamic understanding of the person’s background and life.

The cornerstones of Reformulation are: Description, Recognition and Revision (of the Target Problems and Procedures). Technically Reformulation refers to a list of TP’s and TPP’s, a prose letter and a mapped diagram (known as Sequential Diagrammatic Reformulation or SDR).

ZPD - zone of proximal development. The space between current level of ability and the entirety to which a person could potentially reach with the assistance from another, e.g. from a therapist.



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According to Frank (1986) patients come to psychotherapy largely because they are demoralised by their symptoms, dysfunctional relationships and the sense that life is going wrong. The psychotherapist collaborates with the patient in formulating a plausible story that makes sense of symptoms in light of their past/early life and current difficulties. The patient is helped to regain his/her moral and provided with a means to move onto a happier life (see Frank, 1986). This description seems to parallel the concerns of this essay which is to discuss the topic of ‘(re)formulation’ in CAT, in relation to its educative aspect; the collaborative nature of the therapeutic relationship which may lead to a jointly agreed formulation; or contrarily, how a formulation can be used to browbeat a patient into accepting a framework that has little relevance to his/her life.

‘Reformulation’ can be seen as a CAT specific word which relates to ‘retelling’ to the patient his/her story as it is understood by the patient but with major assistance from the therapist so that the story is reformed. Reformulation is divided into two: a written letter to the patient (prose Reformulation and also a list of Target Problems and procedures which maintain these problems: i.e. TP’s and TPP’s); and a diagrammatic representation (known as Sequential Diagrammatic Reformulation, SDR) drawn to show how various dysfunctional factors operate in a circular sequence. Although Reformulation is often spoken of as a letter and a diagram in my opinion it should more properly be thought of as a process which begins with assessment, leads to the patient reflecting upon his/her life, relationships and symptomatic difficulties, carefully reflecting upon and completing the CAT psychotherapy file and perhaps completing other mood/symptom monitoring homework. Over four to five sessions the patient and therapist consider and review the life in its entirety. The Reformulation process can be seen as the ‘central specific feature of CAT’ (Ryle and Beard, 1993) which, in part, distinguishes it as a distinct therapeutic modality (See also Ryle, 1991). The purpose of this essay is to suggest that at best Reformulation should aim for education within a collaborative therapeutic encounter whilst avoiding the ever present danger of coercion.

Let us begin by looking at how Reformulation acts as an educative device to assist the patient. According to Butler (1998) a psychological model (such as CAT, CBT, psychoanalysis etc) is a means to conceptualise a patient’s difficulty in terms of the assumptions of that model; (Re)formulation is where theory meets the person in interaction with the therapist. Theoretical as well as practical knowledge is used to guide thinking about the ‘chief features of a case’ as presented by the patient, see Denman (1992). In CAT Reformulation is used to help explain the past and make sense of the present and hopefully will suggest what to modify in order to influence the future. CAT Reformulation is based on the view that psychopathology is the result of repetitive maladaptive patterns which may be interpersonal or intrapsychic and that these patterns can be identified and explicitly described in the Reformulation, accurate description leads to current recognition and, hopefully, later revision of the problem procedure.

Patients are often bewildered by the disturbing nature of their symptoms, often they have attempted a number of measures to alleviate their distress and cease self destructive patterns, for instance they may have received advice from family/friends, consulted self-help books or resulted to prolonged periods of introspective thinking; no doubt these methods are useful for some but for patients who reach mental health services in distress it is usual that this self-help has not had the desired result. It is not unusual to hear such comments as” it always happens to me” or “I know I’m my own worse enemy but I can’t seem to stop making a mess of life”. It is as though some patients dimly realise that their own attitudes, thinking and behaviour is at the root of their troubles.

It is for these patients that Reformulation seems so useful. Initially from the psychotherapy file patients begin to critically review their own lives. As the patient considers his/her problems in terms of the listed problem procedures he/she begins to perceive that the many difficulties are in fact one or a few self perpetuated problem procedures that continually play themselves out, it is as though ‘the words may change but ‘the song remains the same’. Shortly after seeing the familiar pattern of their procedures described patients may begin to understand the self repeating circular nature of these procedures as the nature of the various operating traps, dilemmas and snags begins to make sense. The Reformulation letter helps to explain the patients’ life and history in a way which restores a degree of meaning to past and early experiences.

For many people a number of ‘meanings’ have become scripted onto a number of negative early life experiences. I worked with a woman in her 50’s who remembered being repeatedly beaten as a child by her mother, her father colluded although did not participate in this ‘punishment’. My client felt her beatings to be justly deserved and had developed the belief that she was evil to account logically for the abuse which she had suffered, indeed at the time her mother had told her she was evil – thus the beatings counted as “fair pay”. Here, one purpose of the Reformulation was to counteract the misleading family myths which my client later came to see as “lies” and misconstrued logic. Reformulation can in a similar manner restore meaning to events distorted by the patient’s own defences; a young woman I worked with had an idealised mythological view of her father which was projected onto other men in adult life with disastrous effect. With this case it was important for the Reformulation to link together a number of fragmentary and confusing memories and to place them into an ordered sequence, the Reformulation was also able to show how the early meanings generated from these experiences had generated a number of dysfunctional procedures which had operated over a number of years and were exceedingly resistant to change. Accurate description of these problem procedures both from an historical and current life perspective and by noting the danger of there occurrence within the therapeutic encounter helped considerably in their revision. The description of how outcomes had serves to cement these harmful patterns helped the patient to understand why her own methods to facilitate change had previously proved unsuccessful and importantly helped the patient to understand her own role in her procedures; also the importance of ‘procedural change’ as opposed to changing the content of her life/experience now became the main goal of therapy.

Hopefully we can see from the above that Reformulation becomes an educative tool or a means to induct the patient into an understanding of the CAT model of psychotherapy. Reformulation can be seen here as a form of education with a difference – i.e. applied to the field of self-knowledge (Ryle 1994), content from the patient’s life is used to illustrate the model which allows CAT to become a real, live and relevant therapy. Issues of transference, reciprocal role enactment or procedural re-enactments are explained and examined in an understandable fashion which helps prevent these from becoming ‘inflated or mystical concepts’ (Ryle and Beard, 1993). The patient is guided into seeing the importance of past relationship/experience, to realising how meanings are imported onto events and how patterns of relating (or intrapsychic internal relating) are formed which are difficult to revise even in the event of later alternative experience/information and how later these patterns become maladaptive ‘coping’ strategies. The diagrammatic (SDR) method of describing someone’s problem procedures further illustrates to the patient the feedback loop and hence persistence of life’s difficulties. An attempt is made to alter how a person experiences manages and understands themselves.

This method of guided self-education is similar to some extent to the means in which knowledge and meaning is acquired developmentally during childhood. If we consider the work of Vygotsky (1978): his focus was mainly on the growth of intellectual development but can usefully be applied to psychotherapy, his work has many similarities to object-relations theory. Vygotskian and object-relations theory see interpersonal experience as the basis for the formation of higher mental structures. For Vygotsky the mind or consciousness is not seen as an entity that arises of itself or even as a system that later self-maintains; rather learning and becoming a person occurs in interaction with other people. Language acquisition (although humans have an innate genetic predisposition), the acquirement of facts and of the meanings subscribed to them all occur in the social medium of human relating. Language can be seen as a developed system of signs that initially are used between two or more people, in effect a ‘jointly elaborated interpsychological sign’ (see Leiman 1992). ‘Meaning’ also arises initially within an interrelational context and is the main mode of transmission of culture and culturally based meaning. Language and meaning allows people to make sense of their universe, their social system and ultimately of their own self-sense of personhood. Internalisation of language is another important concept from Vygotsky which parallels object-relations theory. Language and hence meaning can be seen as a set of ‘tools’ which people carry around (i.e. internalised), tools give people power but also can be used to their own or to others disadvantage. For Vygotsky learning occurs when two people (a teacher and a pupil) meet and the teacher orders, controls and represents information/experience in a way that previously was inaccessible to the pupil, it is as if the teacher gives to the pupil a new mental representation of an experience which the pupil internalises and can thereafter use for him/herself. So what occurs outside in the space between the teacher and pupil later becomes internalised and portable for the pupil, Vygotsky uses the term ‘scaffolding’ to describe how the teacher assists. It is as if there is an amount of ‘space’ in which the pupil can learn – his/her ‘zone of proximal development’ (ZPD). With assistance from a teacher a child’s/person’s ZPD is greatly extended so someone can learn much more with assistance from another than they can by themselves.

With sensitivity Reformulation can be seen to apply Vygotskian ideas - as explained briefly above. The patient’s story told in language is ascribed a new set of meanings, the transmission of meaning occurs within the therapeutic space between patient and therapist, the therapist working sensitively within the patient’s ZPD. The Reformulation letter/SDR becomes a powerful tool of language-description and new meaning to help transform the patient’s life. A new tool is often a means to assist someone out of an old problem, but note the interpersonal nature of language/relationship is seen here as vital – otherwise self-help manuals may well have put an end to the activity of psychotherapy! Vygotsky maintained ‘What the child does with an adult today she will do on her own tomorrow’; in a similar way what a patient learns/reconstructs with his/her therapist today he/she will be able to do on his/her own tomorrow.

Also implicit in the quote is the understanding that teaching, as understood here, is not a didactic authoritarian approach (e.g. as ‘classroom teaching’ may once have been) but a sensitive collaborative two persons’ interaction. CAT aims towards the same collaboration. The collaborative nature of Reformulation is seen as integral to CAT; health care professionals and perhaps behavioural therapists are stereotyped as ‘doing unto’ others, therapists from a psychoanalytic or Rogerian tradition are perhaps seen as ‘being with’ their patients. CAT aims at ‘working with’ people where each of the dyad informs and constructs meaning from material for the other until a jointly agreed construction is reached.

We have spoken as if collaboration exists defacto, as if it arises from the therapeutic process per se. However, it is important to substantiate that the therapist and client are on the same ‘wavelength’ or at least can move towards and accommodate each other. For example a CAT may not be practicable with a patient who wishes to use therapy for a sounding board or who feels it important to be understood but does not wish to alter any of their life procedures. In a situation such as this it may be considered disingenuous of a therapist to ‘offer’ something which is soundly unwanted or unwise to suggest that the patient ‘ought’ to accept what is not wanted. In a similar manner one may not wish to offer CAT to a patient who is looking for another model of psychotherapy: - e.g. if a patient (perhaps a student) is looking for Rogerian therapy. Unless ‘collaboration’ is kept in mind the dangers of coercion exist and in this case Reformulation could be used as a tool to ill effect.

But what if a patient and therapist agree on the identified CAT model and disagreement arises during Reformulation? Maybe the therapist has not ‘heard’ the patient’s narrative to its true intent or perhaps the therapist is trying to follow his/her own agenda without recognising the needs of the patient – this type of activity could be construed as coercive. Or, perhaps the patient does not agree that she is not evil or perhaps an ‘idealised misview’ of her father is not accepted. The use of language which fits inside the patient’s frame of reference can be useful and can be seen as working within the ZPD of the patient; however, for some patients who remain ‘stuck’ or perhaps are unused to psychologically sophisticated concepts the use of a ‘forced Reformulation’ may be seen as unsafely coercive. For such patients accurate description in a less interpretative manner may be more useful and could be seen as working within the current ZPD A guideline often used in CAT is that accurate description precedes recognition and only when recognition has occurred can revision be attempted.

Remaining inside the current ZPD of a patient with whom the CAT model has been made explicit and keeping to a joint formulation of targets and procedures is perhaps the best means to keep Reformulation educative and collaborative.


REFERENCES:-

Butler, G. (1998) ‘Clinical Formulation’. In, Comprehensive Clinical Psychology. Bellack, A.S. and Hersen, M. (Eds). Pergamon Press

Denman, C. (1992). What is the point of a formulation? Allen and Unwin.

Frank, J. (1986) Psychotherapy – the transformation of meanings. Journal of the Royal Society of Medicine. 79. 341-346.

Leiman, M. (1992). The concept of sign in the work of Vygotsky, Winnicott and Bakhtin: Further integration of object relations theory and activity theory. British Journal of Medical Psychology. 65, 209-221.

Ryle, A. (1991). Cognitive-Analytic Therapy: active participation in change. A new integration in brief psychotherapy. John Wiley and sons Ltd.

Ryle, A. and Beard, H. (1993). The integrative effect of Reformulation: cognitive analytic therapy with a patient with borderline personality disorder. British Journal of Medical Psychology 66, 249-258.

Ryle, A. (1994). Persuasion or Education? The Role of Reformulation in Cognitive Analytic Therapy. International Journal of Short-term Psychotherapy. 9, 2/3, 111-118.

Ryle, A and Kerr, I.B. (2002).Introducing Cognitive Analytical Therapy, Principles and Practice. John Wiley and sons Ltd.

Vygotsky, L.S. (1978). Mind in Society; The development of Higher Psychological Processes. Cambridge, Mass; Harvard University Press.

Wittgenstein, L. (1978). Lectures and Conversations on Aesthetics, Psychology and Religious Belief. Oxford: Blackwell