What to do in the Middle?

Between the beginning and the end is the middle

All models of therapy have a beginning, middle and an end.  Even long term or open-ended therapies have phases of focused work with times of review, or episodes of work that come to an end and have their middle phase.  Brief, structured, time-limited therapies are by definition making conscious and therapeutic use of time.  The passing of time, in this context, might be seen as one of the tools to work with and to develop shared use of and ownership over.   If we don’t work actively and collaboratively with time it will work actively on us.

The beginning of therapy receives a lot of attention with issues of selection, suitability, assessment, alliance building and formulation.  The ending is discussed in terms of loss, difficulties ending and readiness to end, and practicalities of fair provision for all.  But the middle phase of therapy, despite being where processes of change succeed or fail, is relatively neglected.  It is easy to procrastinate, give more time, collude or get distracted or lost in the middle of therapy.   With CAT, with its emphasis on early and active reformulation and active use of a planned ending, the middle is even more important.

Two linked therapies

At the heart of Cognitive Analytic Therapy is the shared activity of reformulating current issues and problems.  Reformulation is a triangular process.  It develops a shared plan to link the detail of current symptoms and problems  to the experience of the therapy relationship in relation to the bigger picture of the interaction of self in the world past and present.  This triangle of shared activity seeks to be transparent and self-reflective.  How the work is going depends upon joint awareness of, and responsibility for how the immediate relationship in the therapy room is playing its part. It is a relational activity and there are key relational skills:

•             actively engaging and joining in whilst sustaining an observing eye

•             showing the client how to tolerate and learn from hovering between more than one perspective

•             working up and down the perspective taking ladder between big picture and small detail

•             moving between a person-wide focus and problem centred focus.

It can be helpful to characterise this as doing two therapies at once: one being more cognitive, problem and task focused and one being more analytic , holistic and person focused.  All therapy has two levels of tasks to complete.  At one level there are personal problems to understand and resolve.  At another level with the act of solving particular problems there are general lessons about self in the world, the influence of the past on the present or consciousness raising about social position and restriction that can be addressed hand in hand with solving problems.

An argument for CAT as an integrative, pragmatic and relational therapy is that it weaves these two level of therapeutic and educational tasks together.   The transparency and collaborative nature of the approach means that it is more likely that moments of being too caught up in the detail or the past or the emotions of the present can be countered by the agreed focus of a time limited therapy. Feeling a sense of shared control, practising negotiation of needs and reactions is likely to help develop  a secure base, a more reflective capacity and a willingness to stay with and work through unmanageable feelings (otherwise known as core pain in CAT).

For a fuller discussion of the issues about being in the middle of therapy download this pdf   In the middle of therapy 2014 Potter

Look forward to responses.  Steve Potter

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