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We can change.

2011-09-13 by smapg

Contents

Foreword

Dr Anthony Ryle

Acknowledgements

Introduction

Part One All About Change

1 Change is possible

Part Two Feelings, Emotions and Relationships:

with ourselves, others and symptoms

2 Reciprocalrole relationship procedures

3 Emotional states, depression and eating disorders

4 Problems and dilemmas within relationships

Part Three Getting Offthe Symptom Hook:

naming the problem

5 Traps

6 Dilemmas

7 Snags and self-sabotage

8 Difficult and unstable states of mind

Part Four Gathering Information

9 Examining the impact of our beginnings

Part Five Making the Change

10 Writing our life story

11 Targeting the procedures that create

problems and deciding on aims for change

12 Putting a diagram in your pocket

13 Techniques for working through

the process of change

Part Six Changing within a Relationship

14 Love is not enough

Part Seven Holding on to Change

15 How to hold on to change

Appendices

Appendix 1 The Psychotherapy File: an aid to understanding

ourselves better

Appendix 2 Personal Sources Questionnaire (PSQ)

Appendix 3 Mindfulness exercises and meditations

Appendix 4 Personalrating chart

References

Furtherreading

Resource addresses

Index

Foreword

We are all born to particular parents at a particular time and in a particular

place and our early experiences combine with our inherited temperaments to

form us into recognisable individuals – ourselves. The journey through

infancy, childhood and adolescence to adulthood is a complicated one and,

while most of us acquire a more or less stable and satisfied sense of ourselves

and an adequate grasp of the world we live in, we all collect some habits or

dispositions or beliefs which serve us badly but which are so much part of our

sense of ourselves that we do not question them. Unless and until,that is, we

find ourselves suffering from unreasonable anxiety or frequent depression or

unexplained physical symptoms or become aware of ways in which our life is

not going as we hoped or intended. At this point we may stop and think

about how our life has been and we may talk to family and friends and receive

helpful support and advice. But for many more troubled people there is a

limit to how useful that may be, partly because those we choose to talk to will

often be selected (not consciously) because they can be trusted to respond to

us in the way we expect and not to challenge our problematic aspects and

partly because,if they do challenge them, we may be unable to take on board

what they are saying. This is not because we are stupid,it is because,to a far

greater extent than we usually realise, we all live suspended in a web of relationships

with others, some from the past and some present, and it is this web

of connections with others which sustains our sense of being ourselves. Or it

may be that,in the face of early experiences that were emotionally unmanageable,

we have learned to conceal ourselves and to mistrust others to the

extent that there is nobody we can feel safe enough with to show our pains

and to expose what we may feel to be our weakness.

It is at such a time that this book can be of particular value. Liz McCormick

combines a wealth of experience as a psychotherapist with a gift for writing

and an attitude which is fully respecting of the reader. Those seeking simple

categorisations of distress or illness linked to prescriptions of how to get better

will be disappointed,for there are no over simplifications of the problems

and no dispensing of ready-made solutions. Instead,readers are invited to

think clearly about their difficulties and to feel directly the meanings of their

past and present experiences. The common tendency to think about psycho-

logical symptoms as if they were analogous to physical illnesses and to treat

them with medication or simple symptom-oriented therapies is reinforced by

some psychiatrists and by the power of the pharmacological industry. It can

be difficult for many people to realise that their moods and symptoms are the

physical manifestations of difficulties in living and can signal the need for

change. That symptoms may be partly physical in origin and may sometimes

require medical treatment is of course acknowledged here, but the book aims

to emphasise the value of understanding the links between one's distress and

how one leads one's life. By indicating the possibility of understanding and

changing the thoughts,feelings and behaviours which underlie our depres-

sion, anxiety or headaches and our unhappiness or difficult relationships,it

allows passive suffering to be replaced by an active engagement in identifying

and changing damaging and restricting aspects of our own natures.

To help in this task the book starts by offering clear descriptions of common

problematic patterns of thinking and acting. These usually repeat unhappy

patterns experienced early in our lives or represent our early attempts to solve

problems through means that have themselves become harmful or restricting.

We are usually only partly aware of our own patterns and here common ones

are usefully illustrated by examples and are linked to exercises that support

self-discovery and indicate possible alternative ways of coping. This is unfamiliar

territory for most people and exploration needs the help of a guide.

A particular strength of the book is the way in which one has the experience

of being in dialogue with the author; one is not being given instructions and

a guide book so much as one is invited to participate in the construction of

one's own map and to conduct one's own exploration. This means that

readers,to benefit, must accept their share of the work. This is not a book to read

while waiting for the bus;it demands concentration and the ideas need to be

thought about actively through the day. Change will not come about in a

flash of realisation,it will require sustained attention. The structure of the

book supports this and it will be most valuable to those who go through it

systematically and at their own pace. As well as helping one to think clearly

about negative aspects of oneself Liz McCormick draws on her knowledge

of Buddhist ideas to propose mindfulness techniques which can enlarge

self-awareness.

The book can help many people through many problems and can contribute

to enlarging what can be called emotional literacy but it does not

claim too much for itself. Enduring what cannot be changed is not a skill that

can be taught but learning to recognise what can be changed and knowing

how to begin to change will be greatly clarified by reading this book. Further

reading from a wide spectrum of viewpoints is listed and guidance on how to

find appropriate psychotherapy is provided. But whether or not further help

is needed,I warmly recommend it as an excellent place from which to start

the journey.

Anthony Ryle

Acknowledge
ments

This book is based on the model oftime-limited therapy created and initiated

by Dr Anthony Ryle at Guy's and St Thomas's Hospitals called Cognitive

Analytic Therapy, CAT for short. Since 1984 CAT and CAT therapists have

grown in numbers, and this method offocused therapy is now taught and used

in different settings within the National Health Service in the UK.I am

extremely gratefulto Tony Ryle for encouraging me to write a self-help book

based on his work, and for his help with the first, second and now the third edi-

tion, as well as his supervision and clinical support over many years of my own

practice as a psychotherapist. Dr Ryle, now retired to Sussex, and I spenttwo

days together going overthe new materialforthis edition. Most ofthis third

edition is new writing and the changes reflectthe mostrecent developments in

CAT theory, particularly the use ofreciprocalrole relationship understanding,

less stated in the second edition. Dr Ryle's contribution has been invaluable. He

brings not only his extremely finely focused clinical mind but also his ability to

getto the root of something and simplify it, and his great humanity.

Many, many CAT colleagues have contributed to the formation ofthis self-

help book, based upon the collective work in CAT therapy. Forthis third edi-

tion Sage sent out a questionnaire aboutthe use ofthe book in different

settings to thirty colleagues. All ofthem took the time to reply in detail and

nearly all ofthe comments Ireceived have been addressed in this edition,

with enormous gratitude.

Gratefulthanks go to Annalee Curran and Shakir Ansari who read the original

early drafts, and to my many other CAT colleagues, particularly Deirdre Haslam,

Jackie Baker, Dr Julia dark, Liz Fawkes, Jon Sloper, who runs the ACAT website,

the late Angela Wilton and Mark Dunn, all of whom contributed ideas and cases

forthis book. Thanks also to Susan Needham for editing the chapter on couples

and to ⅢY partner, Keith Maunder,for his inspiring idea forthe cover.

At a wonderful meeting of CAT supervisors and therapists in March my

questions and issues aboutthe changes in CAT theory and practice were

shared with a group of colleagues to whom I am extremely grateful. This most

recent work has,Ithink, helped me to see thatI, as writer, and this book also,

have been able to 'Change for the Better'.

I would also like to acknowledge my many teachers ofthe practice of mind-

fulness: Ven Thich Nhat Hanh, Vietnamese Zen Buddhist; Tibetan Buddhist

nun and author Pema Chodron; Buddhist psychologist Dale Asrael; Becca

Crane atthe North Wれles Centre for Mindfulness, Bangor; my dearfriends

and colleagues Nigel WCllings and Philippa Vick, with whom I have sat, and

mulled overtricky questions around spiritual practice. There are countless

others whose texts and practices I have been enriched by and learned from,

including my Suffolk coastal sangha. For all spiritualteachings I am pro-

foundly grateful.

A special thank-you goes to allthe patients who agreed to have theirlife

stories, charts,letters and diagrams used for publication. All names and some

details have been changed to protecttheiridentities. Their examples show us

how difficulties can be faced and how lives can be changed.

Change forthe Better has had a curious journey since its first publication by

Unwin Hyman in 1990.It became an 'orphan book' when its publishers were

taken over by HarperCollins two weeks after publication, and forthe years fol-

lowing was notreadily available in bookshops. Nevertheless it survived,

largely thanks to the continued interestin CAT and the growth in training

programmes fortherapists at ACAT.In 1997 a new edition was prepared for

Cassell who were soon to be amalgamated into Continuum Books. And then,

in 2002 Continuum sold its health list to SAGE, where the book currently

rests.I would like to thank Sage for commissioning this new edition and for

theirinterestin achieving such a thorough production and completely

revised content. So for nearly twenty years Change forthe Better has survived

the vagaries of publishing and found its way into many different settings keen

to focus on change and self-help: universities, day centres, career counselling

services, psychotherapy training and GP practices. As well as being offered to

patients on waiting lists or as self-help,it has also been used usefully for

students in training, particularly in CAT.Itis easy to read and user-friendly.It

takes complex ideas born out ofresearch and practice in psychotherapy and

simplifies them for general reading.

I am grateful for the interestin the book and to the number of readers who

have written to me about how they have been able to make use ofit.I am par-

ticularly grateful for the support of ACAT.

The author and publishers would like to acknowledge and thank the fol-

lowing for permission to quote materialfrom: My Father's House, copyright

Sylvia Fraser,1989. with permission of Vエrago Press; Understanding Women

(Penguin Books,1985), copyright Louise Eichenbaum and Susie Orbach,1983;

Treating Type A Behavior 切れ切 Your Heart(Knopf,1984) by Meyer Friedman and

Diane Ulmer; a report by Anne de Courcy in the London Evening Standard; an

interview with Jane Fonda by David Levin in You magazine (17 September

1989).

Also, Becca Crane atthe Centre for Mindfulness, North Wales, Bangor, and

Jon Kabat Zinn, author of Wherever We Go There We Are,for permission to

use the One Minute Breathing Exercise and the Awareness of Difficulty

Exercise, and the Mountain Meditation and the Loving Kindness Meditation;

Dr J Fisher and Pat Ogden atthe SensorimotorInstitute, Boulder, Colorado,

for use ofthe arousal diagram in Figure 1.2; and M. Broadbent, S. Clarke and

A. Ryle ofthe Academic Department of Psychiatry, St Thomas's Hospital,

London,forthe use ofthe Personal Sources Questionnaire in Appendix 2.

Introduction

The present is the only time that any of us have to be alive -to know any-

thing -to perceive -to learn -to change -to heal…

John Kabat Zinn, Full Catastrophe Living (1990)

How many times in a day do we think about change? I wish.I wish I hadn't.

I wish they didn't.I wish I could. How often when things go wrong do we

wish it were different,that perhaps we were different? And how often do these

wishes remain as remote dreams that can only come true with the help of a

magic wand?

Perhaps we try hard at something. We strive hard to make it work, employ-

ing everything we know. We work at our jobs, at being nice to people, at mak-

ing relationships, developing hobbies; we try something new. But still we feel

inside that something is wrong; we feel unhappy,lost, hopeless, doomed.

Things go wrong outside: we don't fit in, our jobs perish, partners leave, or we

can't rid ourselves of habits or thoughts that make us feel bad. So we try to

make changes – a new look,job, partner, house – and for a while we are glad,

and things are different. But then the same bad old things start happening

again and we feel
worse – worse because our hope of change fades. We feel

stuck or jinxed and anger and helplessness begin to well up. Perhaps we are

beginning to believe we actually are that miserable, stuck person we see in the

mirror every morning at whom we wantto lash out.

This book is about change.It sets out methods ofidentifying what we can

change about ourselves and our behaviour. When we lessen the hold of

assumptions and attitudes based on our early need to survive we allow more

space for developing the natural'healthy island' within. The 'healthy island'

is comprised of our own basic goodness, and allthe positive experiences we

have had where a healthy sense of ourselves has been reflected. The healthy

island is always near, even though often we do not see it orfeelit because it

is eclipsed by our problems.

This book suggests practical, manageable ways to make changes:

●We can learn to become better observers about what happens to us.

●We can identify the patterns, based on our earlier need to survive,that dom-

inate how we conduct ourselves.

●We can revise these old survival beliefs which we take for granted, but which

become redundant when they getin our way.

We can then allow space forthe healthy island thatis always in us even when

we cannot see orfeelit.

We can help to nourish the healthy island within by identifying and practising

different ways of expressing ourselves.

We can change, by recognising the difference between the old survival self,

dominated by faulty thinking, and the energy ofthe healthy island.

When we change the problematic patterns, we change ourlives.

We don't, however, change the fundamental core of our being,the individual

seed of ourreal selves with which we were born, and I will explain that more

fully in Chapter1. But we can change the hold that survival-self-thinking has on

ourlife:the way itlimits our choices and leads to things going wrong. We are

usually unaware that such processes inform our everyday choices because we

learned them very early on, and they are all we know. The wild deerin the for-

est who wounds herleg mightlie low so as notto be seen and preyed upon.

Alternatively, she may remain with the other deer, butlimp behind at a dis-

tance; she may even find someone who will shelter herforlife. People are no

differentin their survivalresponses.If we survive a harsh early life by develop-

ing a brittle coping self, we come through the hard times when otherwise we

might have gone under. However, we emerge into adulthood with survival pre-

sumptions that make it hard to get close to others orto be touched by life's

beauties. And the difference between the deer and a human being is that we

are able to contemplate alternatives. And itis when life challenges us through

our difficultfeelings or habits, or when things have gone very wrong for us,

that we confront aspects of ourselves we had previously taken for granted.

This book aims to help people who wish to do something active abouttheir

lives, who find themselves saying:'Does it have to be like this?'It will provide

methods forindividual self-examination,for checking out patterns,for self-

monitoring,for making personal maps to illustrate the kind ofthinking webs

we weave that ensnare us. And it will offer ways for changing the patterns

that are no longer working.

Here is an outline ofthe steps we shallfollow:

We identify problems and the thinking,feeling and reciprocalroles that

accompany them.

We begin to name the sequences or patterns we take for granted, but which

actually limit our choices.

We write ourindividuallife story, how it has been for us since the beginning,

and link what has happened to us with the traps, dilemmas, snags and unsta-

ble states that have become our everyday reality.

We begin to notice the sequences when they occurin daily life, and write them

down.

We make maps so we can look at where we are in the sequence throughout

everyday life.

We make realistic goals for challenging and changing the sequences.

We begin to experience more of a healthy island inside, more 'real' bits of

ourselves, because forthe firsttime, we have more space and energy.

We process and bearthe shifts that come with change

We find helpful ways to hold on to change.

The changes we may make from this book are achieved by using conscious

will and effortto revise old patterns that are no longer working. Once we do

our part, using strengths developed by actively thinking about how we oper-

ate, we often stimulate other changes which are less conscious in origin.

Many people who actively engage in the process of helping themselves find

surprises and treasures. They find they have more inside them than they

thought. The numerous threads running through ourindividuallives which

may have felt chaotic startto make sense. We begin to feelthere is more in

life than the tunnelled-vision way of keeping going that many of us are

reduced to when things are not going well.

We all carry a part of us which is wounded in some way. How we carry this

wound makes the difference between a passive attitude of'I am a depressive,

no one can help me' and the active There is a part of me which is depressed

and I will address it and take care ofit\ Once we engage with ourselves in this

way we are much more open to enjoy and use ourinner world ofimagina-

tion, dream and insight, and to accept ourselves.

Each of us can take up the challenge oflooking at ourselves afresh:to see

whatthings we can change and to acceptthose we cannot, and to know the

difference. Setting aside time to ponder on what we can change, and actively

working to achieve those changes, means that we free ourselves from the

restrictions ofthe past, and that our changes are changes forthe better.

About Cognitive Analytic Therapy

CAT evolved as an integration of cognitive, psychoanalytic and, more

recently, Vygotskian ideas, with an emphasis on therapist-patient collabora-

tion in creating and applying descriptive reformulations of presenting prob-

lems. The model arose from a continuing commitmentto research into effective

therapies and from a concern with delivering appropriate,time-limited treat-

mentin the public sector. Originally developed as a model ofindividualther-

apy, CAT now offers a generaltheory of psychotherapy with applicability to

a wide range of conditions in many different settings.

The practice of CAT is based upon a collaborative therapeutic position, which

aims to create with patients narrative and diagrammatic reformulations of

their difficulties. Theory focuses on descriptions of sequences oflinked exter-

nal, mental and behavioural events.Initially the emphasis was on how these

procedural sequences prevented revision of dysfunctional ways ofliving. This

has been extended recently to a consideration ofthe origins ofreciprocalrole

procedures in early life and theirrepetition in currentrelationships and in self

management.(Anthony Ryle and lan Kerr,Introducing Cognitive Analytic

Therapy, 2002)

Cognitive Analytic Therapy was pioneered by Dr Anthony Ryle at Guy's and

St Thomas's Hospita
ls in London as a time-limited integrated therapy.It has

been used with increasing demand in numerous different settings within the

British National Health Service since 1983. and CAT is now available in

Finland, Australia, Spain, Greece and France.

About mindfulness

A basic definition of mindfulness is 'moment by moment awareness'. This

awareness helps us to stay present, with whateveris arising, so that we may

experience itfully. Developing the capacity for mindfulness helps us in the

journey of exploring ourinner worlds.It helps us to see things clearly and

also to develop great calm. When we combine a non-judgemental acceptance

to our mindfulness we are able to look deeply atthe more difficultthings, and

to find compassion forthese difficulties.

On retreat at Arnhem in Holland in June 2006. Zen Buddhist Thich Nhat

Hanh said:

The practice of mindfulness is to remain in the present moment withouttry-

ing to change or avoid it.It has the quality of attention that notices with-

out choosing/ a sun that shines on everything equally. The energy of

mindfulness carries the energy of concentration and establishes us in the

here and now.It allows us to touch the island within. Only when mindful-

ness is established can we know whatis happening in the present moment.

The new information that science has offered in recent decades makes it

clear that something can be done to alleviate many social and mental

health problems.

Sue Gerhardt Why Love Matters (2004: 217)

Change is possible

Why change?

Everyone seeks change for differentreasons -to feelless anxious perhaps,to

overcome debilitating problems like depression or phobia,to feel more in

control oflife,to stop making destructive relationships. Or perhaps we seek

change because we feel sad or bad, unhappy or empty; because things keep

on going wrong, but we aren't quite sure why. We may not necessarily be

aware that change is what we want until we begin to look more closely at our-

selves and at ourfamiliar patterns of behaviour. Just being prepared to look at

ourselves from a different perspective is already embracing change.

We all have our own unique character, gifts and tendencies, as well as our

genetic patterning.In early life this potential selfis a bitlike a seed planted

into the garden ofthe family. Using this image it's easy to see thatits growth

and developmentis bound up with the nature ofthe soil and its environ-

ment. We cannotisolate ourselves from our context within culture,language,

family, our own biology and history.Inevitably some seeds will be planted

in an acid soil when their growth is more suited to alkaline; others may be

pruned too early as their shoots are only just beginning to grow; some will

land on stony ground. Some seeds, which perhaps have the potentialto

develop into peaches or pears, experience alienation when those caring for

them are trying to raise oranges or apples and their own pear or peach nature

goes unrecognised and unfulfilled.

All of us mustfind ways of dealing with these early experiences in orderto

survive.Itis usually later on, when we have suffered a blow,that we have an

opportunity to take stock, and to see our partin things. This gives us an

opportunity to revise the patterns of behaviour based upon adaptations to

others that have restricted our natural self. There are five reasons we might

seek change:

Getting fed up with feeling like a victim.

Wanting to see and understand our partin chaos or crisis

Becoming aware of our own destructiveness.

Realising thatthere is more in us than our'coping' selves.

Longing to feel well and 'whole'.'Whole'in this context means accepting and

living our own true nature just as itis, pleasures and suffering,likes and dislikes

and embracing the hand we have been dealt, however meagre and limiting it

may have once felt.

Survival self and seed self

Using the metaphor of nature, we know that Mother Nature brings different

seasons, and that herlaws decree devastation and death, as well as care and

nurture and birth ofthe new. We have rains and deserts, earthquakes and hur-

ricanes as well as spring and summer. Just as nature constantly shows us its

creative adaptations, so most'human' seeds have to develop a 'survival self

in orderto manage the less than ideal conditions oftheir early life. Few seeds

are given the ideal soil. Developing a survival self,together with a package of

coping tactics for adapting to a difficult, hostile orjust strange environment,

is always necessary, and a mark ofthe human capacity for adaptation. Human

beings are extremely creative!

Understanding and contrasting the difference in energy and flexibility

between the survival self, with its often restricting ways ofliving and relat-

ing, and the potential of a healthy selfthatis able to reflect, observe and

transcend identification with suffering,is atthe heart ofthe experience of

psychotherapy.

The healthy island

Throughoutthis book we will be looking at some ofthe ways in which we

have become accustomed to think and feel about ourselves and other people.

When we train ourselves to use our conscious mind to reflect on the patterns

and choices made from our survival self, we can challenge the patterns that

are no longer useful or which can actually make things worse.In so doing, we

are clearing the ground for our healthy island, with our natural observing self

and its creativity.

Reciprocalroles in relationships with ourselves

and others

No one grows in isolation. The seed is in reciprocalrelationship with the soil

in which itis planted. We are intimately bound up from the time of our con-

ception with an 'other' and our brain wiring and nervous systems develop in

reciprocalrelationship with 'others'. Our model of'other' may be builtfrom