Introduction

Psychological distress, suffering and disorder in some form has undoubtedly occurred, although evidently to varying extents, in all human societies across the ages, with a multiplicity of causes. However the ways in which this is experienced, manifest, and understood varies enormously, as have the ways in which help may been sought and offered, if at all. In many settings worldwide very few people seek or are given help from Western style mental health services but may rather do so from, for example, members of an extended family or community, from religious practitioners, or from traditional healers. Significantly, people who experience distress or disorder may not seek help, seeing this as inappropriate or shameful, or may be fearful of the negative consequences of stigma (Thornicroft, 2006). This would include many in contemporary Western cultures despite a considerable increase in recent decades in the availability and popularity of psychological treatments in many countries. Many critics would see this ‘psychologising’ or ‘medicalising’ trend as, in part at least, an inappropriate professionalisation of human distress and suffering, including for groups such as refugees, based on inappropriate, crude and limited models (see e.g. Ingleby, 1980; Bracken, 2002; Thomas et al., 2005; Summerfield, 2008; Middleton, 2015; Bracken, Giller and Summerfield, 2016; Melville and O’Brien, 2017; Kopua, Kopua and Bracken, 2019). Many would likewise criticise, without necessarily offering an adequate alternative conceptualisation, an increasing extension of Western psychiatric approaches into non-Western countries, as propounded notably for example by the Movement for Global Mental Health (see Patel et al., 2011), well-intentioned as that may be. It is note- worthy that these developments are inevitably having an effect on local approaches to treatment or indigenous healing practices, including in India (Sood, 2016).

These broad challenges also apply to the still evolving CAT model. Indeed given its use within established health services in the West, where many CAT practitioners work and where the model originated, some writers (see Foozoni, 2010; Lloyd and Pollard, 2019), whilst acknowledg- ing the strengths of the CAT model, have criticised an arguable collusion with individually-focused, reductionist, biomedical ‘illness’ type approaches. This will, properly, continue to be an area for ongoing debate. However CAT theorists historically have trenchantly criticised the damaging limitations of such approaches and have predicated the model on a largely, although not entirely, socio-culturally formed and located Self and consequently on a whole-person, transdiagnostic therapeutic approach (Ryle and Kerr 2002; 2019; Kerr et al., 2015). Nonetheless, serious mental health problems resulting from pervasive, longstanding damage to the structures and processes of the Self, as for example described in the multiple self states model (MSSM) of personality type disorders (Ryle, 1997; Ryle and Fawkes, 2007) have been conceptualised therefore as ‘disorder’. This may be frequently, but not always, characterised by disability and/or overt distress to Self or others. From this viewpoint, the frequently long-standing severity and structural complexity of such health problems is seen to merit description as ‘disorder’ in order to conceptualise and treat them, and it would be seen as a serious disservice therapeutically to these persons (‘clients’ or ‘patients’) to do otherwise, or describe them simply as ‘distress’. However from this viewpoint descriptions of ‘disorder’ based simply on check lists of symptoms and behaviours, as occurs in e.g. the DSM (American Psychiatric Association, 2013) and ICD (World Health Organisation, 1990; 2019) systems, although originally well-intentioned efforts at improved validity, would be seen as seriously inadequate and often positively unhelpful (Ryle and Kerr, 2019; and see discussion by Frances, 2013). CAT theorists would stress that such ‘disorder’ is multidimensional in character (including for example possibly the genetic through to the socio-political) but is also manifest in and experienced by an individual. Problematically, both the ‘individual’ Self and its disorders will be, both subjectively and ‘objectively’, highly variable culturally (see below). Historically, CAT theorists (Ryle and Kerr 2002; 2019) have therefore stressed the importance of culturally-sensitive, developmental biopsychosocial formulation and reformulation. Ryle and Kerr (2002; 2019) note that diagnosis and formulation play separate and complement- ary roles which need to be recognised. However clear and valid description of groups of ‘disorders’ are important for communication, treatment and research (see e.g. Chanen et al., 2008), whilst needing also to be individually-focused and culturally-sensitive. Some CAT authorities however (e.g. Mikael Leiman, personal communication) would consider such approaches to be inappropriate to the complex field of mental health and psychotherapy. These complex issues, partly semantic in nature, but with their serious implications, will properly continue to be an area of highly charged debate (see Margison, 2019).

Addressing psychological distress and disorder is complicated by the fact that the incidence and prevalence of problems varies enormously (see e.g. Wilkinson and Pickett, 2009), broadly speaking depending on personal and sociopolitical circumstances, and also on the collective well- being and function of a given society and its cultural character. This would include the extent to which it is individually-minded and focused, or more communal and collective. A very considerable literature now attests to the effects of factor such as inequality, poverty, or unemployment (Stieglitz, 2012; James, 2018; Krugman, 2020; Weich and Lewis, 1998; Wilkinson and Pickett, 2009). Strikingly these factors do not stand in a direct simple relationship, in that the experience of these factors depends also on the quality of collective life which may evidently be a mitigating factor. The latter may be adversely affected by collective loss of purpose and pride or a sense of belonging, as may occur in oppressed or demoralised classes or groups within any society, or within indigenous communities and cultures as a result of colonisation and its traumatic effects both economic and psychocultural (Fanon, 1961/1963; Kirmayer et al., 2003, 2017; Mills, 2014; NiaNia, Bush and White, 2016; Kopua, Kopua and Bracken, 2019). A history of economic colonialism and cultural hegemony e.g. as with the British in India (see case example below), along with recent forces of globalisation, will leave significant conscious and unconscious ‘traces’ in so-called developing, although possibly sophisticated and very old, cultures.

These various dimensions of mental health present a considerable challenge to any, including current Western, models whether more biomedical or socio-psychological, which implicitly aspire to be universal. Given the recognised social and cultural major determinants of mental health and disorder and its treatment, Ryle and Kerr (2019), argue that any meta-conceptualisation or adequate model must incorporate both psychologically and neurobiologically-based understandings of human intersubjectivity and relationality, both immediate and communal, in order to understand the aetiology and occurrence of mental disorder, however conceived. Understanding the ways in which many more sociocentric and traditional societies and cultures offer a form of ‘resilience’ as they function, and how they understand and address ‘mental’ distress and disorder more collectively could make an important contribution to improving Western models. It can be argued that these approaches with their implicit emphasis on relational and sociocultural dimensions of mental health and well-being also map onto and confirm what we do already ‘know’ and accept with regard to common effective treatment factors. These include notably strength of therapeutic alliance (see e.g. Roth and Fonagy, 2004; Castonguay and Beutler, 2006; Norcross, 2011; Lambert, 2013; Wampold and Imel, 2015), and to social ‘connections’ (see e.g. James 2018; Hari, 2017), and to the importance of social context in both presentation of disorders and in rehabilitation (see Harris, Brown and Robinson, 1999). But it is also evident that social context and the way in which it is internalised, including in more traditional societies, may also be part of the problem. This too requires a valid and more comprehensive model of mental health to address it.

This outline of a challenging situation is notably different from the descriptions of and approaches to cultural variability of mental disorder usually articulated in most Western models (see summaries in e.g. Sadock, Sadock and Ruiz, 2015; Harrison et al., 2018), even the more thoughtful. These typically see mental disorder as a constant, underlying, more or less endogenously-arising entity cross-culturally which may simply vary in its expression and detection rates, rather than being a different entity depending on context. Formally diagnosing someone as ‘depressed’ (and see case example below) and locating an illness ‘within’ them, even if there does exist some genetic vulnerability (see discussion by Plomin, 2018), is very different from saying this person is located within and shaped by a particular socio-cultural context, and has been a victim of a stressful, hostile context which may be dysfunctional and possibly ‘unsurvivable’ (and see discussion in Kirmayer et al., 2017).

Understandings of a largely socio-culturally constructed self as articulated in CAT and also by group analysts and more explicitly relational psychodynamic therapies (Dalal, 1992; Mitchell, 2000; and see Bruner 2005; Brown and Zinkin 1994; Bateman, Brown, and Pedder, 2000) imply furthermore that the very ‘felt sense’ of the individual self and its sense of relation to others will be very different in different cultures. Any cross- culturally valid model or meta-conceptualisation of mental disorder will need to be adequately sensitive and flexible to accommodate differing concepts of self, its subjectivity, and its disorders, and to address the socio-cultural context in which any disorder may occur (see discussion by Krause, 1998; and Bhui and Morgan, 2007). This is a major challenge, implicitly addressing as it does multiple epistemological domains.

The cognitive analytic therapy model (see Ryle 1990; Ryle and Kerr 2002; 2019; Ryle et al., 2014; Kerr, Hepple and Blunden, 2016) arguably offers a deeper understanding of, and respect for, cultural diversity based on a concept or ‘organising construct’ of a largely relationally, dialogically (see Leiman, 2004) and socially-formed Self, underpinned development- ally by our human capacity and need for intersubjectivity and relationality. This is understood to underlie the transformative psycho-developmental process of ‘internalisation’ of socio-relational experience as proposed by Vygotsky (see summaries in the context of CAT in Ryle and Kerr 2002; 2019; Kerr, Hepple and Blunden, 2016; and see Wertsch, 1985; Bruner 2005). As such CAT can be seen to offer an attempt at a more comprehensive meta-cultural model of psychological development and disorder. In addition to understanding and working with the largely relational and social origins of the Self and its internalised reciprocal roles, CAT also offers an approach that helps people identify and modify unhelpful coping patterns (reciprocal role procedures) arising subsequently. These may manifest as both Self-other and Self-Self procedures which may be clinically ‘symptomatic’ (see case example below). Importantly all of these enactments of RRs and RRPs are likely to occur within the therapy relationship and challenge it. Identifying and working with these is a key aspect of CAT (see case example below) and contributes powerfully to the creation of a strong therapeutic alliance.

In many ways this paper represents the outcome of a dialogue its authors began following a presentation of this challenging case made by one of us (ATR), which seemed to merit publication, about how to attempt to locate and interpret this use of CAT within a broader consideration of the implications of socio-cultural context and the challenges this raises for models of mental disorder in general and also CAT. These are variously major interests of both authors despite their differing backgrounds. We will now offer a description of a broadly successful therapy undertaken in south India and illustrate some of the very particular challenges arising in this context. This will highlight the considerable personal and therapeutic challenges faced by a young female therapist in this context working with a much older male with problems around intimacy and sexuality, abuse of alcohol and an associated ‘depression’. This work occurs in the context of a presentation that would not be described as ‘psychologically minded’ in a Western therapeutic sense. We will also aim to reflect on and consider how and why this therapy was challenging and how it helped and enabled change. We will then also aim to reflect on the use of a model such as CAT in differing sociocultural contexts and to consider some of the possibly irresolvable challenges this may raise and their implications.