Cognitive Analytic Supervision – a Relational Approach
edited by Deborah Pickvance - Published: (2017) Routledge
Deborah Pickvance has assembled chapters from an impressive range of experts in the field of Cognitive Analytic Therapy (CAT), and invited them to turn their attention to the process of supervision. This book therefore offers a rich variety of chapters on different aspects of supervision, through which the key features of cognitive analytic therapy gradually emerge. In particular, the collaborative nature of the supervisory relationship, which echoes the therapeutic relationship in CAT, the supervisor being constantly open to what the supervisee wants from the supervision, asking for feedback and adjusting the approach accordingly. The book also refers frequently to what is probably the unique selling point of CAT, the ability to draw out visual representations of relational patterns in CAT diagrams or maps. The book starts with some general chapters on the helpfulness of supervision and the CAT approach.
Written to be accessible to therapists who have little or no knowledge of CAT, several of the first few chapters start with a basic description of the key elements of ‘what CAT is’. As an experienced CAT therapist and supervisor, this was a little irritating for me. The third chapter, by Eva Burns- Lundgren, is a lovely basic introduction to CAT as a therapy, and to CAT supervision, and I think it would have been better to put that as the first chapter, and then encourage other contributors to refer to it, rather than repeat that information. I very much liked Annie Nehmad’s chapter on the ‘healthy supervisor’ and her ability to translate into CAT terms, other expert writers on supervision. It was also useful to read Carolyn Lawson’s summary of research in her chapter ‘What makes Supervision helpful’.
I enjoyed less some of the chapters in section 2 and section 4 where the focus was on the type of patient being supervised, and so the suggestions about supervision really felt like just a summary of how to work with a particular client group. I can see that this would be useful if I was about to change fields, or to start supervising someone working in an area that I had no experience of, but I think I would be looking for more in-depth articles than that provided here. Also, the choice of patient type seemed a bit arbitrary – for example, where were the chapters on supervising those using CAT with patients in older age services, or physical health departments?
Having said that, for me the best chapter in the whole book was by Jessie Emilion and Hilary Brown on ‘Intercultural supervision’. I loved this chapter, both the content and their writing – I wanted them to carry on and write the rest of the book too, perhaps they will write their own book at some point? Also useful were the chapters on supervising non-CAT therapists by Mark Westacott and supervising CAT consultancy by Angela Carradice. Both of these raised issues that I have not thought enough about when doing these kinds of supervision – particularly the focus at the start on clinical roles of the supervisee and what they want to get out of the supervision sessions. Both of these writers also described interesting clinical scenarios which made the issues come alive.
The chapters which I personally found most interesting, were those in section 3, the more general focus of the methods and tools of supervision, regardless of the client characteristics. These chapters helped me to stop and think about what I actually pay attention to when supervising. Is it aspects of the group dynamics, described by Jane Blunden and Hilary Beard, the map making illustrated by Steve Potter, the competence of the supervisees, or slowing down and being mindful of the microcosm? I was disappointed that Steve Potter did not describe the use of CAT diagram ‘templates’ – either his own, or the one developed by Michael Knight, as I think these are really useful as a supervision tool in teaching trainees who are new to CAT and have no idea where to put things as they start to map in with patients. However, he does include in his chapter some lovely examples of mapping the supervision relationship provided by Cheryl Delisser.
I suspect everyone will have a different favourite chapter or section, and it will depend a bit on where they are in their journey as CAT therapist or supervisor. This book should definitely be required reading for anyone doing their CAT supervisor training, and will also be useful to dip in to for those changing field or starting to supervise CAT consultancy or non-therapists. I was left, most of all, reassured by the wealth of incredible talent and experience in the CAT community and with the sense that the future of CAT is indeed in very capable hands.
Alison Jenaway
Cite as: Jenaway, A. (2017). Cognitive Analytic Supervision – a Relational Approach [Review of Cognitive Analytic Supervision – a Relational Approach, by D. Pickvance]. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 1(1), 179–180. https://www.internationalcat.org/_files/ugd/ff32b4_9ecd2f235a11408f95b85b3a2d4d4675.pdf
As an adjunct to the review Debby Pickvance reflects on the relational process of editing her book.
CAT Supervision – a relational approach, published in September 2016, is a multi-voiced creation, containing nineteen chapters written by twenty-four authors; within it there are several frameworks for understanding supervision, all recognisably CAT. As its editor, I saw my job as one of forging a channel through which experienced supervisors could communicate their experience and knowledge to others. In addition, I wanted the voices of supervisees to be heard, as these are rare in supervision literature, so there are quotes from supervisees about their experience of supervision. Above all I was keen to avoid bland generalities and hoped that readers would gain a strong sense of the clinical base from which everyone wrote, the pulls and pushes of the real human relationships at the core of supervision and the subtleties of choice, judgement and style used when supervising. I wanted the book to give a CAT perspective on issues which challenge supervisors and create tension in supervision and on approaches which make supervision a containing, productive, enjoyable and stimulating experience for supervisees. I was keen too that the gender ratio of the authors would mirror that of CAT therapists and so most contributors are women.
Producing the book has been a truly collaborative effort and without the help of many people it would never have come in to being. Having no prior experience of editing or publishing I turned to old hands, both within and outside the CAT world. Along with invaluable advice some gave me ominous warnings to expect that one or two chapters would not arrive, and I would have to write them myself. Fortunately, all the chapters did arrive. The contributors have been enthusiastic, cooperative and responsive. All were seasoned supervisors, many were already authors of books and papers, but several were new to writing for publication. In asking people to write for the book I found I was drawing on a strong and willing community of therapists and supervisors. In some way collaborating on the book has made that community stronger.
The idea for the book first occurred to me when a CAT therapist asked me about training as a CAT supervisor. When I tried to think what she could read about CAT supervision I drew a blank. Apart from a handful of sentences in some of the CAT books nothing had been published at that time; this was before Robert Marx’s (2011) article appeared. Most therapy models have at least one book on supervision written from within the model, but CAT did not. And so the idea was born – a book that would plug that gap.
Of course, it begged the question: what is a CAT view of supervision? Could we simply describe supervision by applying CAT concepts to it or is there more to say? It seemed right to articulate a view of CAT supervision as part of the relational tradition of therapy.
‘Relational’ is a word that runs the risk of being used as a loose catch-all, so I wanted to define its meaning when applied to CAT supervision clearly. The more I read the more I realized that supervision of CAT fitted comfortably alongside other developments in relational theory and practice through the 1970s and 80s. Every chapter of the book reflects a relational perspective, whether summarising research on supervision, describing the process of supervision or the qualities and skills of a supervisor or issues in supervising specific areas of CAT practice.
The book came out a few days before Tony Ryle’s death. Tony refused to be treated as a guru and was always keen that other people developed the model. The book is a testament to his success in doing just that and a tangible example of his huge legacy. It is a tribute not only to the power of his ideas, but to his ability to inspire others and to his willingness to share and develop his ideas with others. Tony had been encouraging and supportive of the book, and wrote an endorsement for it despite being frail. He never saw the complete book – the publisher, Routledge, was about to send him a copy when the news of his death arrived – but he had read several chapters and was very pleased to find within them some new developments in the model. The contributors all wanted to dedicate the book to him and wrote the dedication jointly.
For Marx, R. (2011) paper, see Psychology and Psychotherapy: Theory, Research and Practice, 84: 406-424.
Debby Pickvance
Cite as: Pickvance, D. (2017). As an adjunct to the review Debby Pickvance reflects on the relational process of editing her book. [Review of CAT Supervision – a relational approach, by D. Pickvance]. 181–182. https://www.internationalcat.org/_files/ugd/ff32b4_9ecd2f235a11408f95b85b3a2d4d4675.pdf
The World Within The Group: Developing Theory For Group Analysis
Martin Weegman - Published, Karnac Books, London
Martin Weegman, in this innovative and thought provoking book, wishes to expand the social and clinical horizons of group analytic thinking. In doing so he emphasizes the importance of the cultural context and setting of how we live our lives and he highlights the essential interconnectedness and relational dynamics in human interaction as paramount in any comprehensive understanding of individual and social developments. Outlined in a series of disparate essays, drawing on different but related themes, he presents the reader with an eclectic blend of philosophy, historical analysis, social theory and clinical experience. His aim is to connect group analytic theory and practice to the wider domain, showing how it can influence and expand our understanding of how we function together individually and socially outside, as well as within, the boundaries of the clinical setting.
The group analytic principle that all individual processes cannot be conceptualized independently of the social/group matrix in which they occur is persuasively outlined in chapters on working with intersubjectivity, group analytic theory and practice, philosophy, the English Reformation and one on the narrative dimensions of human life. There are also chapters on the exclusionary matrix, and Stevenson’s novel Dr Jekyll and Mr Hyde, which illustrate the need for negative constructions of the ‘other’ to reinforce the solidarity of the in-group and points up the conflictual struggles we have with the negative aspects of human duality.
The significance of relational thinking, reciprocal dialogue and reflective inquiry are also highlighted throughout the book, countering the prevailing notion that things can somehow be known, fixed or discoverable by evidence-based scientific activity. The intrinsic value of viewing life as an emergent (open- ended) activity, located in dynamic, interactive processes, is emphasized by explorations of historical, religious and cultural ideas, practices and developments and the chapter on the social unconscious is a rich and stimulating essay on how we continually create discursive worlds and imagined spaces to establish order to our understanding and perception of social and individual meaning. These organizing principles help create social cohesion, giving us a sense of living within ‘‘safe enough’ containing contextual structures. However, the consequences of this can be good or bad, ordered or disordered, depending upon the particular individual and social perspectives in any given cultural or historical situation. In terms of individual psychotherapy models, like CAT, these discursive world views highlight how self-destructive reciprocal relational structures can lead to limiting internal horizons which distort how we see ourselves in relation to others and constrict and constrain our ability to adapt and make positive therapeutic change.
These constantly changing spaces are adaptive to setting, cultural conditions and to external and internal events. They are not false or illusory but are essential as good working hypotheses, enabling us to function individually and socially. The author affirms that group analytic thinking, focusing, as it does, upon contextual containment, intersubjectivity and relational dynamics, is well placed to contribute to our understanding of the complexity of these processes.
The book finishes with a chapter on group analysis in contemporary society, which reflects upon the importance of the democratic, ethical, political and social implications of group analytic theory and practice and how these can be utilized to help us understand the world we live in and negotiate the way ahead. There is also a useful glossary of the main concepts and their historical and academic relevance attached.
This is a stimulating and at times, complex and challenging book, which will reward readers outside of the group analytic field who are interested in human relational dynamics, the tensions between the individual and the group and the private and public aspects of ourselves.
Ian Simpson. London.
Cite as: Simpson, I. (2017). The World Within The Group: Developing Theory For Group Analysis [Review of The World Within The Group: Developing Theory For Group Analysis, by M. Weegman]. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 182–183. https://www.internationalcat.org/_files/ugd/ff32b4_9ecd2f235a11408f95b85b3a2d4d4675.pdf
Thinking in Cases
John Forrester - Published: Polity
John Forrester has changed the way I think about case studies. His argument reaches across psychoanalysis, Foucault, Winnicott and Kuhn and finishes with a review of the idea of case histories in terms of gender based on the work of Robert Stoller, the man Forrester passionately calls the last psychoanalyst. This collection of essays offers a rich diet of reflection for the practitioner of relational approaches to therapy such as CAT. The essays, published posthumously after the author’s untimely death invite a ‘circulation’ of ideas around what makes the discipline of ‘thinking in cases’ representative of and participative in something more general. He explores whether a case study can count as a form of scientific practice. He wonders at Freud’s eloquence in writing up cases (judge them by their truth not their eloquence). He makes a case himself of the overlapping intellectual Jewish lives of Freud and Einstein and takes a close look at Kuhn’s key work on the structure of scientific revolutions.
Forrester, who was a postgraduate student with Kuhn, says the second edition of The structure of scientific revolutions (1977) revised the popular but confusing idea of paradigm with two component ideas: the relational matrix of social practices that make up a scientific community in a particular discipline or period and the idea of an exemplar which Forrester redefines as ‘shared reasoning with cases’. The use of exemplars is at the heart of scientific practice for Kuhn and Forrester and this chimes well with CAT which has built its understanding from careful and accurate description of cases in their relational context.
As a reader of Forrester’s book I am intrigued. Psychoanalytic imagination is alive and kicking. As a CAT therapist and as one who as an examiner has closely read and marked many case studies, I know that the case story is at the centre of our practice. But how do we test the truth of the account before us. Or indeed the one which we shape in our minds as a ‘CAT case’ from the client’s unfolding story in the consulting room? How do we distinguish the case as exemplar – one story within a conversation of stories about our work – and the case as casuistry – the moralistic plea to live in a certain way such as the Good Samaritan?
One truth test for Forrester would be evidence of those moments of self- doubt, transference, confusion and acknowledged failure. A good case story is not necessarily a ‘good’ case. How do we judge the CAT therapist in his or her ability to weave a self-conscious, self- curious account of the client’s story with the story of the therapy or treatment? Would the client present a different case if they were the author? In teaching the client to be their own CAT therapist are we also teaching the client to be their own case historian? We get a glimpse of this in the client’s good-bye letter which is appended to all ‘marked’ CAT cases for examination.
In sum this collection of psychoanalytic essays offers some pointers to a relational approach to thinking together about the myriad of cases that make up the story of mental health, illness and its treatment. For the CAT practitioner who cares about the analytic A in CAT it is a good read.
Steve Potter
Cite as: Potter, S. (2017). Thinking in Cases [Review of Thinking in Cases, by J. Forrester ]. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 1(1), 184–185. https://www.internationalcat.org/_files/ugd/ff32b4_9ecd2f235a11408f95b85b3a2d4d4675.pdf
The Future of Psychological Therapy: From Managed Care to Transformational Practice
(Ed) John Lees (2016) - Published: Routledge
This polemical collection of essays edited by John Lees, with a thoughtful and thought-provoking foreword by Andrew Samuels, constitutes an important resource and articulation of concerns about ‘psychotherapy’ as ‘delivered’ through the IAPT (‘Increasing Access to Psychological Therapies’) initiative in England, and about its broader managerial and political context. Samuels, in his otherwise sympathetic foreword, does note some issues arising with the collection. These include how best to convince opponents at whom the book is partly directed, and the question of why relational therapists should necessarily be opposed to ‘neo- liberal’ politics. These the book only partially addresses.
The collection offers a trenchant critique of IAPT and its conceptualisation as a kind of mechanical, ‘quick fix’ means of mending citizens efficiently, and of getting them back to work (part of Lord Layard’s original rationale, doubtless well-intentioned). Mental health problems are seen here simply (and, given the evidence, wrongly) as technical problems, and in terms of symptoms and behaviours, arising somehow ‘within’ the heads of individuals, and regardless of their relational and social formation or context, or possible broader existential or spiritual concerns. Few would dispute the aim of offering more help to more people, but rather how it is conceived, and how it is done. (In IAPT largely through some form of ‘dilute’ CBT, or ‘state therapy’ as Samuels notoriously described it!) Curiously, CAT is described as part of IAPT, and as essentially ‘cognitive’ (Morgan Ayrs).
Variously the essays describe an unholy alliance existing between IAPT, CBT, a commodified and commercialised health care system run by a ‘new public management’ (NPM), and its neo-liberal broader context. These are at times virtually co-identified and conflated, in part understandably. The book is mostly preoccupied with the prevalent situation in the UK, and especially England, apart from one chapter (Bento) noting parallels and problems within the ‘HMO’ system in the US. This does limit its generalisablity. This political context in England is seen as increasingly neo- liberal and free-market, with its NPM approach to delivering health care in the NHS. This is characterised by a top-down ‘managerialism’ that views health care (and health professionals) as essentially commodities in an increasingly commercialised setting. They note it is consequently preoccupied with and ‘espouses’ the Ms of managers, markets, measurements, (and money), to the neglect and detriment of quality and of real cost-effectiveness, and also the well- being, concerns, views or expertise of front-line staff, critical in the delivery of good care. Such a system wilfully neglects and fails to address or ‘contain’ (Simpson) the inevitable anxiety and ‘risk’ (Totton) inevitably engendered by such work in such settings. Things simply can’t (and shouldn’t) always be controlled. Indeed some authors argue persuasively that one task of therapy is opening up and challenging ‘things’, including the socio-political establishment. In this context too patient-centred care or real choice suffers. An important implicit question arises as to whether in such circumstances it eventually becomes impossible to maintain a secure place in which to do meaningful, effective therapy. Many relational therapists may feel this has already happened in the NHS in the UK.
Throughout this collection there is an impressive, manifestly humanitarian and impassioned, commitment to care and concern, and respect for individual clients/patients in their whole-life complexity. In many ways this appears to constitute the core of the collective critique in the book. However, the very assumption that this humanitarian and ‘relational’ counter position in itself (opponents might argue this is worryingly based essentially on intuition and personal, ‘anecdotal’ experience), with its critique of current dominant ‘scientific’ evidence-based approaches (as enshrined in e.g. NICE guidelines or current classification systems of ‘mental illnesses’) represents a convincing radical alternative (e.g. to managers, commissioners or politicians) appears problematic. Most relational therapists would doubtless agree about the very serious limitations of these approaches (‘a scientific and political mess’ as one leading psychiatric authority recently noted, off the record). They would also argue that ‘process’ type, qualitative and socially-embedded research is hugely important. Lees describes the wealth of such experience within the relational therapy tradition as constituting ‘transformational research’.
But there remains a ‘tua res agitur’ – i.e. an important need to demonstrate that our various approaches are more effective than simply e.g. social support or befriending (a non-finding in many RCTs e.g. of psychosis, or PTSD), are reasonably cost-effective (especially with taxpayers’ money), user-friendly, or, at the least, do no harm. And there is still an urgent ‘meta-challenge’ to integrate these various dimensions of research. As Parry and Richardson properly noted in a landmark Department of Health report almost two decades ago, unevaluated practice is simply no longer acceptable. The history of health care (including mental health and psychotherapy) is littered with examples of well-intentioned treatments which possibly delayed improvements (however ‘measured’), or actually caused harm. The question is how, meaningfully, given the complexity of mental health and the inadequacies of current approaches to ‘diagnosis’ and evidence, we undertake these evaluations. It is not clear that from its impassioned position, and perhaps partly due to it, this book overall rises to this meta-challenge.
Thus, as Samuels notes, these arguments might not do too well in the imaginary scenario of persuading politicians, commissioners of managers responsible for health care why the various protagonists of these relational approaches should also be funded to work as they like, for as long as they like, in a taxpayer-funded system, as the argument might be seen. The approach apparently advocated (by Loewenthal – a major relational therapy campaigner), of adopting a ‘theory-free’ approach to clinical practice seems paradoxical and not obviously helpful.
Incidentally, the authors are really quite various ranging, arguably at times mutually contradictorily, from e.g. psychoanalytic (including Jungian, Lacanian, group analytic) to humanistic, anthroposophical, and integrative. How far these represent genuine differences or not is an issue, along with the spuriousness of ‘brand name’ debates, from a ‘common factors’ perspective, but is not really named or addressed. This is unfortunate as there is an argument to be made that we don’t need large RCTs of every new variant ‘therapy’ to justify them, and about what constitutes evidence for (likely) effectiveness of any psychotherapy. The questions are rather more about nuances of effect including e.g. strength of therapeutic alliance, cost- effectiveness, user-friendliness, or drop- out rates. And the evidence is that these are features of a more fundamentally relational approach to mental health and therapy – including, paradoxically, CBT when effective!
(Ironically, adherence to formal NICE- type evidence approaches will – ultimately – discredit the exaggerated claims for effectiveness of CBT as the ‘real-world’ effectiveness results of, especially, ‘dilute’, brief CBT emerges).
If these comments sound critical it is more out of frustration given some challenges that might have been productively addressed and weren’t. Otherwise this collection represents an important resource and rallying point, and contributes powerfully to the argument that a more compassionate, caring and ‘effective’ alternative exists to the current status quo of the NHS and its socio-political context.
Ian B. Kerr, Stirling, Scotland
Cite as: Kerr, I. (2017). The Future of Psychological Therapy: From Managed Care to Transformational Practice [Review of The Future of Psychological Therapy: From Managed Care to Transformational Practice, by J. Lees]. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 1(1), 185–187. https://www.internationalcat.org/_files/ugd/ff32b4_9ecd2f235a11408f95b85b3a2d4d4675.pdf