ICATA Journal
Mapping sexual diversity using Cognitive Analytic Therapy: a qualitative, cooperative enquiry with the LGBTQ+ community
Cite as: Mapping sexual diversity using Cognitive Analytic Therapy: a qualitative, cooperative enquiry with the LGBTQ+ community. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 5(1), 19-39. https://www.internationalcat.org/volume-5-2
Int. Journal of CAT & RMH Vol. 5, 2023 / ISSN2059-9919
Abstract
Cognitive Analytic Therapy (CAT) is concerned with intrapersonal and interpersonal patterns and procedures, formed through early interactions with others and the world around us. CAT does not pathologise distress and does not lean on a diagnostic framework, instead it lends itself to understanding the complex subjectivity within identity formation, and how sexuality may interact with our Self, others and society. This paper utilises CAT theory and practice research to understand sexuality and introduce a CAT map of sexuality. This map was developed with members of the LGBTQ+ community (n=8) and encompasses commonalities observed in relational patterns and procedures, despite intersectionality and unique context. The CAT map of sexuality is not an attempt to generalise and suggest that all LGBTQ+ individuals will internalise these unhelpful patterns and procedures due to negative external influences, it is instead an attempt to understand sexuality and the complexity of self-other and self-society relationships as an LGBTQ individual. Clinical recommendations include affirmative practices, acknowledging societal snags and influences, and creating a safe and accepting space which invites individuals to bring their connected self into the room.
Keywords: cognitive analytic therapy; sexuality; LGBTQ; authentic Self; internalised homophobia
1. Introduction
1.1 Cognitive Analytic Therapy and the development of the Self
A core feature of Cognitive Analytic Therapy (CAT) defines the ‘Self ’ as both a relational and social concept, built on an internalised framework of patterns and reciprocal roles (RRs) that one is exposed to during childhood (Ryle & Kerr, 2020). This framework, comprised of observed patterns, becomes a shorthand map for how an individual makes sense of the world, and thus mediates how we interact with the Self and others in future (Ryle, 1975). This developmental process does not occur in a vacuum; both internal factors such as epigenetics and predispositions, and external factors such as existential and cultural influences, shape these internalised patterns and procedures (Laws, 2019). Emphasis is also placed on inherited cultural dialogue; either abstract dialogue with culture through our ancestors of which the imagined is as important as the concrete, and external dialogue occurring in everyday life with others (Bakhtin, 1986). Therefore, the Self is a dynamically constructed state, shaped by cultural norms and beliefs, social and societal meanings, and political context and becomes crystallised in early adulthood following a period of exploration and expression (Laws, 2019). This has been referred to as achieving the ‘mature, individual, phenotypic Self’ in CAT, comprising of an integrated and dynamic structure (Ryle and Kerr, 2020). Conversely, if negative or harmful RRs are internalised during our early experiences, maladaptive or restrictive reciprocal role procedures (RRPs) will emerge, creating a trauma-induced or dissociated Self structure (Ryle and Kerr, 2020).
1.2 Sexuality & the Self in CAT
Historically, LGBTQ+ people have been positioned on the outside of ‘normal’, as criminals, perverts or mentally ill. These societal assumptions were accepted by the majority throughout history and enforced by those in power, for example, Margaret Thatcher introduced ‘Section 28’ in the late 1980s which made discussing same-sex relationships in schools illegal, until it was later repealed in 2003. Moreover, medical professionals pathologised homosexuality through the invention of diagnostic criteria for ‘homosexuality’ and ‘sexual orientation disturbance’ which gave rise to the prescription of conversion therapies going on to harm to thousands of LGBTQ+ individuals for decades (Przeworski, Peterson, & Piedra, 2021). The UK government is currently debating the legality and ethics around conversion therapy 30+ years later, with evidence suggesting it is still practised today (Talbot & Finlay, 2022).
The UK has made considerable progress in recent years regarding the law. However, around the world anti-gay laws thrive. Hungary recently banned LGBTQ+ couples from adopting children and Russia extended its ‘gay propaganda’ law in 2022 making it illegal for any person or media outlet to spread positive messages about homosexuality. The lack of equality for LGBTQ+ individuals worldwide perpetuates the narrative about being worth less than their heterosexual counterparts regarding freedom, respect and rights. The minority stress model of sexuality highlights how distal and proximal stressors faced by the LGBTQ+ community, such as microagressions, discrimination, concealment of one’s sexuality, internalised homophobia, or a lack of emotional support, leads to poorer mental health outcomes than their heterosexual peers (Alessi, 2014). Indeed, Stonewall, in their nationwide 2018 survey of LGBTQ+ mental health, found that 52% of LGBTQ+ adults have experienced symptoms of depression at some time in their lives, and one in eight LGBTQ+ young adults had attempted suicide in the year the survey was undertaken, significantly higher than for their age matched heterosexual peers (Stonewall, 2018). Moreover, discrimination based on sexual orientation can extend into the therapy room, with research showing that this understandably correlates with a poorer therapeutic relationship and outcomes (Macdonald, 2014; Nadal et al., 2011).
Homophobic and transphobic attitudes and beliefs have been created through a sociocultural lens over time, as sexuality and gender are understood and constructed socially and culturally (Denman & de Vries, 1998). CAT establishes a middle ground in the biological versus psychological debate, as it understands that every part of the Self is created in interaction with others, influenced by the political, cultural and social lens of the time. Therefore, CAT is well suited to understand the sociocultural and political context relevant to the experiences, and therefore distress and wellbeing of the LGBTQ+ community (Lloyd & Pollard, 2018).
5. Conclusion
The Self has a complex developmental trajectory, influenced by interactions and observations throughout childhood which are internalised, forming a framework which mitigates one’s future interactions with others, self and the world. Harmful experiences, such as rejection, exclusion and othering can internalise unhelpful RRs and feelings of shame, and for individuals with diverse sexualities these harmful interactions can lead to a hiding or masking of one’s authentic self. Through dialogue with LGBTQ+ individuals, a CAT map for understanding sexuality and the Self is proposed with the aim of supporting CAT practitioners to make space for sexuality within CAT. The map acknowledges some of the RRs and RRPs likely to be around for LGBTQ+ individuals, and places internalised homophobia and societal influences on the map whilst maintaining relational awareness about the wider context. This weaving together of the theory underpinning the development of the Self and LGBTQ+ history seeks to normalise, educate and most importantly generate further dialogue and thought in relation to how CAT makes space for the self-society relationship.
3. Results: the changing face of the map
Common RRs and RRPs were identified in each participant interview, regardless of one’s other intersecting identities and unique experiences, and the mapping process joined these dots to create a shared way of relating to sexuality. Most self-other RRs were present from the first iteration of the map, as earlier participants found it easier to describe interactions with others and society around coming out or exploring their sexuality. As the interviews progressed, a clear consensus on preferred language emerged, and as participants 4 and 5 were interviewed they were able to build on the preliminary self-other RRs and procedures and relate these to self-self RRs and clear dilemmas for participants.
Participants 7 and 8 did not add anything new to the map or suggest different language, however, they corroborated the patterns already documented and spoke about feeling validated and seen having been presented with a later version of the map. The following figures 1- 8 show the developing map as it evolved from participant 1 to participant 8.
Figure 1. Evolving Map
Participant 1 map:
Participant 2 map:
Participant 3 map:
Participant 4 map:
Participant 5 map:
Participant 6 map:
Participant 7 map:
Participant 8 map:
Note. With participant 2 we add a hypervigilance trap alongside the feeling state of fear. Instead of a state of incongruence there was a response of feeling disconnected from a sense of self. With participant 3 we added a line between feeling visible or invisible and moved the reciprocal role of excluding and shaming to be alongside the rejecting one whilst also anxiously observing others. We added with participant 4 an additional reciprocal role dilemma of either remain safe but restricted or be authentic and possibly unsafe and vulnerable to judgement. There was a procedure of striving to fit in in other ways as a response to the fear and rejection. With participant 5 there was a focus also on societal stereotypes and internalised homophobia feeding into shame and feelings of there being something wrong with me. There was a fuller naming and tracing out of striving to fit as a procedure between concealing and being rejected. Maps for participants 7 and 8 were more or less the same as the preceding one.
Following the interviews a final draft of the map was created (figure 2); a co-created CAT map of sexuality. By the last two interviews the map reached saturation and captured the range of stories prevalent across all dialogues. The map is described further in this section and describes a disconnected self-state, self-self, self-other and self-society reciprocal roles, traps, snags and dilemmas.
Figure 2: CAT map of sexual diversity
3.1 The disconnected Self
The idea of living with two versions of the Self, described by all eight participants, echoes the identity incongruence and dissonance discussed in the available sexuality and gender identity literature (Morrow & Beckstead, 2004; Przeworski, Peterson, & Piedra, 2021). Potter (2020) draws on Winnicott’s attachment theory to describe a ‘false Self’ that protects or hides the true Self, following harmful interactions with others; ‘the legacy of trauma is managed, but at a price of a partial loss of self ’ (Potter, pg 168, 2020). In the context of sexuality, we understand this trauma as the othering, oppression and criticism described by the participants, causing fear and shame. These RRs, experienced early in development were internalised and contributed to a self-state which felt incongruent with their true self. Ryle and Kerr (2002) name the consequence of this internalisation a ‘dissociated self-state’, and Potter (2020) refers to a ‘false self ’. However, within the context of sexuality and based on the preferred language of participants, it is proposed that this is called the ‘disconnected Self ’.
3.2 Reciprocal roles and procedures Experiences of being an ‘outsider’
Experiences of being an ‘outsider’
Throughout the dialogue, self-other and self-society RRs emerged describing how early experiences of ‘othering/exposing – outsider/ different/exposed’ became internalised and contributed to unhelpful patterns and procedures. Some participants interacted with messages in the media and on television; for example, a lack of LGBTQ+ represent- ation in Hollywood films, media reports or religious debates about homosexuality being sinful or wrong. Other participants experienced othering directly from caregivers or peers in their early years, as they communicated disgust or rejection when participants shared their true self. This othering was intolerable and was therefore linked to unmanage- able feelings of fear and shame. Fear consumed dialogue at times, with examples of being exposed and the consequence of this being shared.
Rejection and the ‘anxiously observing trap’
Connected to this fear were the RRs rejecting/judging – rejected/judged, which were also familiar RRs for participants in their interactions with others and the Self:
‘Being different welcomes judgement and rejection. . . from people who think they should be scared of me or that I’m not normal. . . I just didn’t know who I was, so I started to judge myself all the time too. Everything I wore, every time I looked in the mirror.’ (P2, pansexual female).
For participants, judgement and rejection filled self-other interactions in early life, and subsequently their self-self-interactions as a teenager and adult. Participants also described rejection from family and friends following coming out as LGBTQ+. These interactions, regardless of how frequently they occurred, became significant relational expectations and influenced participant’s thoughts and behaviour moving forward. ‘I’m different’ and ‘what will people think’ were powerful beliefs that all eight participants had experienced at some point in their lives, forming part of an ‘anxiously observing’ trap:
‘I feel different, therefore I anxiously observe others and my environment, worrying about what people will think of me or do to me. This leads to me hiding my sexuality and striving in other areas to be liked or fit in, but ultimately leaves me feeling like more of an outsider or cut off as I am not being whole self.’
This trap captured the participants desire to fit in and to not feel different, which was often to avoid the familiar RRs of rejecting/othering/ exposing/judging. Traps often highlight the cyclic nature of these maladaptive strategies, and for most of the participants this trap contributed to self-self RRs of rejecting/judging. For some participants, the fear of these patterns repeating led to avoidant behaviours, in which they only involved themselves in accepting and affirming circles, removing the need for ‘anxiously observing’. Several participants recalled early experiences of accepting – accepted from attuned and compassionate others, however, this did not appear to alleviate the impact of the few negative experiences of rejecting/othering/exposing/judging.
Denying the Self and the ‘concealment dilemma’
Participants also described the self-self RR; concealing/hiding/denying/ repressing – concealed/hidden/cut off/repressed. This could take many forms; one participant described exploring their sexuality later in life after years of repression and denial due to societal pressures and family values, whereas others described dressing to fit with societal gender norms and binary rules rather than expressing themselves accurately for a fear of this ‘outing them’. The degree of concealment described varied but was a shared experience across the whole sample. Ultimately, this concealment led to a dilemma which was universal in all participant narratives and spoke to the everyday repeated ‘coming out’ that is ‘sadly just part of being queer’:
‘Either I stay safe and conceal my sexuality, but I feel restricted, disconnected and isolated from my community and others. . . or I am authentic and true to myself, but potentially unsafe and vulnerable to the judgement of others.’
This dilemma, presenting restricted options born out of these early experiences of being judged or on some occasions abused and hurt by others and society, contributes to the ‘disconnected Self ’. Participants described this as a ‘lose-lose’ scenario, which fits a dilemma in CAT, which is described as a false choice (Ryle and Kerr, 2020). One participant described the movement through these procedures very powerfully, capturing the complexity and lasting impact of these early RRs. They explained how previous family rejection regarding their sexuality caused intense feelings of fear and threat moving forward, as they understandably wanted to avoid the hurt and shame that accompanied this rejection. Fear, prompted by beliefs about the consequence of being different, created hypervigilance around others. This anxiously observing activated their threat system and they found themselves searching for clues or hints about others’ values and beliefs; including mentioning LGBTQ+ news stories to assess the responses and facial expressions of others. This state and uncertainty prompted the concealment of their sexuality from others, and on occasions resulted in them denying or ignoring it as they attempted to date opposite sex individuals. Ultimately, this perpetuated the feelings of disconnect and caused them to question their identity, which was very distressing.
Shame and conforming to societal norms
Robert Watson discusses the harmful RR excluding/shaming – excluded/ shamed experienced by LGBTQ+ individuals, which is internalised and consumes future interpersonal and intrapersonal relationships (Ryle and Kerr, 2020). All participants had experienced this RR in their relational dance with societal norms, rules and messages, and sadly some participants had experienced it in interactions with others. The belief ‘there is something wrong with me’ felt powerful throughout the dialogue, as this was discussed on an explicit conscious level and on an unconscious, underlying level. Participants who experienced this belief at an unconscious level talked about internalised homophobia, which refers to the process of repeated negative attitudes, discrimination and abusive and homophobic language becoming internalised and contributing to an internal belief system that views sexuality diversity as wrong or immoral. This powerful snag perpetuates shame and was described by some as a real barrier to integrating and accepting the Self. Similarly, societal stereotypes snag efforts to heal shame and integrate our Self, showing the world diverse sexualities and identities. One participant described how :
‘I used to think my ‘gay self ’ wasn’t worthy of love. . . because I’d been told being gay was a sin and wrong as a kid in Church. So I cut that part of me off for so long. Just hid it, because I thought it was wrong too. I was ashamed of that part of myself because on some level, I learned to believe it was wrong to be gay.’ (P4, female lesbian)
These snags perpetuate feelings of shame, and participants described a dilemma which they face in the wake of this shame and societal influence:
‘Either I conform with societies binary and heteronormative rules and feel like there is something missing, or I live as myself and I am cast out by society for being different.’
Conforming was described in multiple ways with varying degrees of severity regarding the impact on Self-concept or daily life. Some participants lived their lives in a heterosexual relationship to please others, and some conformed through everyday decisions about holding their partners hand in public or correcting a stranger when they misgendered their partner. These decisions were enactments of familiar RRs as participants criticised/judged themselves or faced it from others, or were punished/abused by others and themselves. Ultimately, these actions and interactions lead back to the dilemma of being safe and restricted, or authentic and vulnerable.
3.3 Exiting towards a queer healthy island
In opposition to the disconnected Self introduced in the map, the LGBTQ+ community describe an ‘authentic Self’. Therefore, this alternate self-state described by participants, formed the foundation for a queer healthy island. Participants acknowledged the power of reclaiming discriminatory language, with queer being an example of this. Although it is not used and liked by the whole LGBTQ+ community it is now widely accepted as a general term to describe the diversity and flexibility within the LGBTQ+ community, endorsed especially by younger LGBTQ+ individuals.
Wilde McCormack (2017) introduces the concept of healthy islands in CAT, a place where the healthy Self resides and can begin to restore and rebuild after a crisis, or produce a landscape of helpful, revised RRPs. Participants found that entering into accepting/affirming/valuing RRs with others generated a space which felt safe and compassionate enough to develop exits on to a healthy island. As always in CAT, practising and modelling exits can form part of the therapeutic relationship, therefore, creating a safe space and accepting and affirming a client’s sexual orientation is crucial. The principles of affirmative therapy are discussed in a CAT context by Watson (see chapter 9; Ryle and Kerr, 2020), highlighting the importance of self-reflexivity and critical engagement with one’s own values or bias, keeping up to date with LGBTQ+ issues, acting ethically and curiosity.
A ‘healthy island’ feels extremely important to create with LGBTQ+ individuals, however, must be created in the context of a culture in which LGBTQ+ discrimination and hate is still present. It can feel rather hopeless when societal snags cannot be altered and hold a position of power on the map; however, Denman and de Vries (1998) proposed that by understanding feedback (e.g., criticism or judgement) elicited in one’s procedures as prejudice, rather than real and valid feedback in response to the Self, we can adjust the internalised self-evaluation based on previous faulty feedback. Indeed, this self-acceptance and self- compassion were discussed frequently during the interviews, and through dialogue were conceptualised as exits fighting against powerful internalised homophobia, shame and discrimination. The words pride, community, safety, belonging and allies held power within the dialogue, and served as a reminder that these elements are also exits, helping LGBTQ+ individuals feel worthy and equal.
4. Discussion
4.1 Clinical implications
This map of sexual diversity offers a relational alternative to the minority stress model of sexuality and is the first to incorporate identity develop- ment and acknowledge relational patterns with others and society that may perpetuate a disconnected self-state. There is notable overlap between the concepts captured in the minority stress model for sexuality and the present CAT map, corroborating that concealment of identity perpetuates distress, and that societal rejection and discrimination impacts wellbeing and identity formation and satisfaction. Moreover, a CAT model of gender dysphoria exists (Laws, 2019) which exposes parallels to the procedures and societal snags identified in the current map for sexuality. Laws (2019) draws attention to the cultural norms prevalent for the individual at the time of exploring or sharing their gender identity, which influences the experiences of self-other interactions. Partial acceptance of self was introduced as an important procedure in the gender dysphoria model. This speaks to the concealment dilemma described in the current sexuality map as individuals make judgements about the degree of acceptance likely from others and modify their identity presentation accordingly. Another similarity between the gender and sexuality maps is the presence of fear and shame as core pain, linked to difference, rejection and oppression. The shared oppression, discrimination and rejection from others regarding both sexuality and gender is important to acknowledge, however, the unique challenges faced by those with gender identity are captured within Laws (2019) model. Gender and sexuality are both aspects of identity which are socially constructed and therefore open to judgement and criticism from others dependent on the culture at the time, and it is worth acknowledging how these two aspects of identity can intersect along with others such as race and class, and impact on how you are perceived or treated by others.
In practice, the CAT map provides a frame of reference for health care professionals providing scope for increased understanding and awareness. Clinically, it is hoped that the map will guide the exploration of sexuality for those who wish to examine this part of the Self and have experienced the familiar RRs identified within this collaborative process. This map is merely a guide, for educational and clinical use, and comes with the caveat that not all LGBTQ+ individuals will share these experiences or wish to recognise and revise these patterns.
4.2 Putting homophobia on the map
All participants spoke about their experiences of homophobia, whether this was direct, indirect or in the form of subtle microagressions that have a cumulative impact. Although progress has been made towards a fair and equal society following decades of LGBTQ+ activism, LGBTQ+ related discrimination and hate crimes are still prevalent today. In fact, we have seen an unprecedented rise in homophobia and transphobia, with Home Office figures demonstrating that sexuality-based hate crimes have risen every year in England and Wales from 2016 to the present day (Home Office, 2021). In 2016/17, there were 8,569 of these crimes recorded by police, however, in 2021 this figure doubled as 17,135 sexuality driven hate crimes were recorded (Home Office, 2021). LGBTQ+ clients are seeking therapy in the midst of these societal and cultural contexts, and as affirmative therapy advocates suggests, therapists should educate themselves to enable empathy, understanding and compassion into the relationship (O’Shaughnessy and Speir, 2018).
Psychotherapy is inherently an individual process concerning one’s own states, patterns and procedures, and in CAT, a movement towards a healthier island in which we are consciously aware of unhelpful procedures and able to find exits from these. CAT is rooted in sociocultural and political ideology, stemming from Ryle and Kerr’s (2020) understanding of sociocultural self-development and Bahktin’s dialogical model of the Self (Bahktin, 1992). Therefore, CAT is perfectly primed to make the relationship between Self and society more explicit, allowing therapists to recognise societal factors as ‘snags’ for individuals from minority groups. Mapping societal influences seeks to acknowledge and validate the experiences of our clients, acknowledging that although we can form new ways of relating and find exits from tricky patterns, certain contexts will pull us back in to those unhelpful ways of relating (Ryle and Kerr, 2020).
Potter (2020) introduced the idea of relational awareness, comprising of three dimensions: 1) within us (internal self); 2) between us (interpersonal)’ 3) around us (contextually). As CAT practitioners we are encouraged to develop contextual relational awareness that enables insight and reflexivity regarding self-society relationships. In the case of sexuality, this can help to put homophobia on the map. Potter (2020) suggests that CAT practitioners should occupy a position of curiosity about values, systems and societies which enables the untangling of propaganda, ideology and reality. Also, remaining open to diversity and acknowledging power between client and therapist can help mitigate judgements about fairness and help understand the historical imprint of oppression. Finally, mutual aid and an awareness of how one can contribute, organise and lead is important to combat inequalities and challenges in society which leak into the therapy room (Potter, 2020).
CAT therapists inevitably have their own personal and professional relationships with the political and cultural system we exist within, as well patterns and procedures helping or hindering leading and organising skills. Denman and de Vries (1998) discuss the fine line between where therapy ends and political action must begin, which speaks to this dance. The term ally has long been used by the LGBTQ+ community, as cisgender and heterosexual individuals are asked to use their power and privilege to support the community. The LGBTQ+ affirmative therapy movement calls for therapists to be better allies and affirm diverse sexualities, rather than take a neutral and non-discriminatory stance.
4.3 Strengths and limitations
This explorative study utilised a creative and embodied design to construct shared meaning, in which mapping formed part of the interview process. This method was rooted in social constructionist epistemology, thus provided ample opportunity to co-construct a meaningful interpretation of participant experiences, rather than relying entirely on researcher interpretation within a formal analysis stage.
According to the principles of information power (Malterud, Siersma & Guassora, 2016), which informs sample size decisions in qualitative research, a sample of eight participants provided enough rich data for a study with a focussed aim and case-by-case analysis technique. However, a larger sample would allow for improved diversity of the sample and purposive sampling may achieve a more diverse sample in future studies. Moreover, the CAT map of sexuality is a tentative alternative understanding of sexuality which is bound by context but does hold a degree of transferability across the LGBTQ+ population given the method and sampling. However, is not designed to be a generalised or fixed model as per the nature of CAT and qualitative research. To evaluate the clinical utility of the CAT map of sexual diversity, further exploration with clinical samples and within the context of CAT therapy is required.
References
Alessi, E.J. (2014). A framework for incorporating minority stress theory into treatment with sexual minority clients. Journal of Gay & Lesbian Mental Health, 18(1), 47-66. https://doi.org/10.1080/19359705.2013.789811
Bakhtin, M.M. (1986). ‘Speech Genres and Other Late Essays’. in C. Emerson and M. Holquist (Eds.). Trans. V.W. McGee. University of Texas Press: Austin, TX.
Bakhtin, M.M. (1992). ‘The Dialogic Imagination: Four Essays.’ University of Texas Press: Austin, TX.
Denman, C. & De Vries, P. (1998). ‘Cognitive analytic therapy and homosexual orientation’ in: Shelley, C (eds.) Contemporary perspectives on psychotherapy and homosexualities. London: Free Association.
Home Office, UK Government (2021). Official Statistics Report: Hate crime, England and Wales, 2020-2021. Accessed online at Hate crime, England and Wales, 2020 to 2021 - GOV.UK (www.gov.uk).
Kim, M. S. (2014). ‘Doing social constructivist research means making empathic and aesthetic connections with participants’. European Early Childhood Education Research Journal, 22(4), 538-553. https://doi.org/10.1080/1350293X.2014.947835
Lainson, K., Braun, V., & Clarke, V. (2019). ‘Being both narrative practitioner and academic researcher: A reflection on what thematic analysis has to offer narratively informed research’. International Journal of Narrative Therapy & Community Work, (4), 86-98.
Laws, A. (2019). ‘Gender dysphoria: a psychological model’. International Journal of Cognitive Analytic Therapy & Relational Mental Health, 3(1), 7-27. https://www.internationalcat.org/volume-3-1
Lloyd, J., & Pollard, R. (2018). ‘Introduction: Cognitive analytic therapy and the politics of mental health’. In Cognitive analytic therapy and the politics of mental health (pp. 1-19). Routledge. https://doi.org/10.4324/9780203728857
MacDonald, K. (2014). Sexual orientation microaggressions in psychotherapy. Dissertation Abstracts International: Section B: The Sciences and Engineering, 75(2-B(E)).
Malterud, K., Siersma, V. D., & Guassora, A. D. (2016). ‘Sample size in qualitative interview studies: guided by information power’. Qualitative health research, 26(13), 1753-1760. https://doi.org/10.1177/1049732315617444
Morrow, S. L., & Beckstead, A. L. (2004). ‘Conversion therapies for same-sex attracted clients in religious conflict: Context, predisposing factors, experiences, and implications for therapy.’ The Counseling Psychologist, 32(5), 641-650. https://doi.org/10.1177/0011000004268877
Nadal, K. L. (2013). ‘Sexual orientation microaggressions: Experiences of lesbian, gay, and bisexual people’. Thats so Gay! Microaggressions and the Lesbian, Gay, Bisexual, and Transgender Community., 50-79. https://doi.org/10.1037/14093-004
O’Shaughnessy, T., & Speir, Z. (2018). ‘The state of LGBQ affirmative therapy clinical research: A mixed-methods systematic synthesis’. Psychology of Sexual Orientation and Gender Diversity, 5(1), 82. https://doi.org/10.1037/sgd0000259
Potter, S. (2020). Therapy with a Map: A Cognitive Analytic Approach to Helping Relationships. Pavilion Publishing and Media Limited.
Przeworski, A., Peterson, E., & Piedra, A. (2021). ‘A systematic review of the efficacy, harmful effects, and ethical issues related to sexual orientation change efforts’. Clinical Psychology: Science and Practice, 28(1), 81. https://doi.org/10.1111/cpsp.12377
Ryle, A., & Kerr, I. B. (2020). Introducing cognitive analytic therapy: Principles and practice of a relational approach to mental health, Second Edition. John Wiley & Sons. https://doi.org/10.1002/9781119375210
Ryle, A. (1975). ‘Self-to-self, self-to-other: The world’s shortest account of object relations theory’. New Psychiatry, 24, 12-13.
Talbot, J., & Finlay, F. (2022). ‘Conversion therapy: change the law not the person’. Archives of Disease in Childhood. https://doi.org/10.1136/archdischild-2022-324177
Taplin, K., Greenhill, B., Seddon, C., and McGuire, J. (2018). ‘Service User Experiences of CAT diagrams: an Interpretative Phenomenological Analysis’. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 2(1), 75-96. https://www.internationalcat.org/volume-2-4
Wilde McCormick, E. (2017). ‘Change for the Better: Personal development through practical psychotherapy’. Change for the Better, pp.1-312. https://doi.org/10.4135/9781526438447
2. Method: entering dialogue with LGBTQ+ others
2.1 Aim
The author aimed to hold the social justice principles and theoretical good fit of CAT in mind and co-create a CAT map for sexuality in the form of a sequential diagrammatic reformulation, alongside the LGBTQ+ community. Taplin et al. (2018) explored the helpfulness of mapping patterns and procedures within CAT and ‘understanding the self’ was a superordinate theme endorsed by all participants. Participants felt that visually mapping patterns and procedures allowed them to find clarity, promoted self-reflection, prompted changes in self-perception, and normalised distress through externalising procedures on paper. Mapping can therefore be a powerful tool when exploring sexuality, as it has the potential for exploring ‘the Self ’ as Taplin’s (2018) participants described.
2.2 Design
Given the exploratory aims and objectives, an inductive qualitative approach informed data collection and analysis. A social constructivist epistemological position was adopted, allowing the author to position oneself as a peer researcher and active ingredient in the design and data, constructing meaning in a collaborative way. Social constructivists understand research as a creative and transformative activity, as well as a cognitive and embodied activity (Kim, 2014). These principles speak to the foundations of CAT, and moreover are appropriate for facilitating a creative research design involving physical mapping and playing with language during dialogue.
2.3 Participants
Eight individuals responded to a call out for participants through opportunistic social media adverts and snowball sampling within LGBTQ+ networks known to the researcher. Participants were interviewed using an online video calling platform. Inclusion criteria ensured that all participants had a sexual orientation other than heterosexual, were over 18, and spoke English enabling meaningful dialogue. All participants consented to their experiences and quotes being used in the development and dissemination of this CAT map, with anonymity prioritised throughout.
Four participants identified as female, three as male, and one as non-binary. Three identified their sexuality as lesbian, three as gay, one as pansexual and one as queer. Six participants self-identified being White Caucasian, one as Black, and one as Asian. The age range of the sample was 28-63.
2.4 Procedure
Semi-structured interviews were conducted with participants, enabling an iterative process of learning, mapping and checking understanding regarding the participant’s experiences. The researcher set an a priori target problem (TP) for the purpose of mapping, which can be understood in traditional research frameworks as the research question, to enable focus and specificity; exploring how individuals understand their LGBTQ+ self and how this influences, and is influenced, by others and society.
The researcher mapped in vivo with the first participant whilst using a semi-structured interview guide to prompt the sharing of experiences, thoughts, feelings and memories. This early version of the map, which was co-created with participant 1, was then shared with the second participant and used as the building blocks for participant 2’s interview. This process was repeated, resulting in an evolving map which changed following each interview. This method was deemed most congruent with the process of mapping in CAT and the social constructivist epistemological position adopted, working on a changing and flexible map, respectful of all interacting or conflicting perspectives and narratives.
The interviews included a short explanation of CAT mapping and key concepts to orientate the participant to the process. The interviewer systematically described each component of the map asking the participant for their own experiences, as well as asking a set of standardised questions about the development of their sexual identity and how this had changed over time based on interactions with others or society. Attention was paid to the language used and the diversity of experiences, searching for commonalities in RRs and RRPs despite the differing context for each subject. Interviews lasted approximately one hour, and quotations were noted throughout, alongside the mapping process.
Participants were provided with time at the end of their interview to share any reflections or feelings in response to the dialogue. Signposting to LGBTQ charities and support networks was provided as standard. Finally, the map in its final form was shared with each participant once all interviews had been completed, to achieve data triangulation. The researcher ensured each participant’s experiences and language had been captured meaningfully, whilst allowing for some flexibility given the shared ownership of the procedural map.
2.5 Author Reflexivity Statement
Lainson, Braun and Clarke (2019) discuss the importance of owning one’s subjectivity within qualitative research, as researchers play an active role in interpretation of others’ experiences. This idea of viewing dialogue and data through an emic lens requires careful consideration. Inviting transparency and reflexivity to this process allowed the researcher to remain consciously aware of the topic, and subsequently the map, from multiple perspectives; as a member of the LGBTQ+ community with their own self-other and self-society experiences, as a clinical psychologist and mental health researcher, and as a trainee CAT practitioner interested in self-development and integration. Maintaining a reflective journal throughout this process enabled the researcher to separate their own procedures and patterns from those shared with them. Keeping a target problem (TP) in mind for the map helped to ground the researcher in curious exploration and co-creation, and not move towards personal experiences and emotional responses. Moreover, the dance between researcher and therapist was conflicting at times. Utilising a clinical tool within the interview created a therapeutic space for exploration which felt somewhat different to the more traditional scripted interview that the researcher was more used to.
Acknowledgements
I’d like to extend my sincere gratitude to each LGBTQ+ individual who gave up their time to discuss their experiences with me, and ultimately co-produce the map.