Fast and slow thinking

Some reflections on CAT in a fast paced Improving Access to Psychological therapies (IAPT) service in the South of the UK

These jottings are my experiences of using CAT in an IAPT Service where I worked for eight months. I had a workload of thirty patients a week: six a day, five days a week. The rule was six sessions; eight at most. I did CAT primarily in a CBT environment. The words: ‘evidence base and medical model loomed large. Would I be working in a system that denies the environment and social context in which people live? Would I be expected to recite a pre-determined script? Would I be able to be there in the room with the other person in their ZPD (Zone of Proximal Development-Vygotsky)? How was I going to adapt CAT to a 6-session format? It felt like a conveyor belt of patients, with no time in-between to think about each person? I would have to do all my thinking with them in the sessions.

Realizing I would have no time for letters. I told my clients that I would jot down the key words in our conversations to help have an accurate description of where we were going on for them and also between us. Coping better with unmanageable feelings was often the focus or target problem. Our jottings became maps of reciprocal roles that heightened or soothed seemingly unmanageable emotions. We did lots of mapping that showed how things played into each other. I hoped it would help build a shared understanding and I photocopied everything we did each session and gave it to them to read and alter if they wished. From the first few sessions of this, we co-created a joint map which served as an SDR or therapy map for our remaining sessions.

I have also always believed that Intuition is useful but if I jump to the wrong conclusion, mostly the client tells me and the mapping helps this. In CAT, I like my role of NOT being the expert but rather of being with them and together mapping out how they relate to themselves and others.

I link this to Daniel Kahneman who is the only psychologist to win a Nobel Prize in economics. He writes about fast (type 1) and slow (type 2) systems of thinking: type 1 is a short cut, seen it before, know it, almost instant jumping to conclusion. Type 2 is slow, you think things through. I wonder if psychotherapy expertise under pressure of time and driven by protocols becomes so embedded it risks being type 1, fast thinking applied easily a bit like driving a car, or playing the guitar. Intuitive fast thinking is tempting, even necessary in brief therapy but the collaborative mapping process acts as a counter weight and invites a slowing down and gives the client a visual platform to challenge the therapists thinking. I think actively mapping with the client helps me integrate fast and slow thinking or therapy intuitions and more reflective practice. This is where CAT is brilliant because we are there to ask them if that is right as we map things out together. In CAT language: the observer position is in Kahneman’s language type two.

What does anyone else think? Fast or slow please add a blog comment?

Marisa Poggioli
CAT Practitioner and Supervisor   Italy

REFERENCES

Kahneman D. (2013) “Thinking Fast and Slow” Farrar, Strauss and Giroux
Marzillier J. (2014) The flawed nature of evidence-based psychotherapy, BPS Psychotherapy section review 51,
Tovey H & Baker Intuition in clinical practice: the pleasure and the pain. Clinical psychology forum 257 – May 2014

Thank you to my friend Chris Lawes for talking though this with me

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