What does it mean to have a sense of self and how do we develop it? Ellie* tells me: “I don’t know where my edges are”.  She is a petite 20-year-old, referred to our service from the pain clinic due to unexplained, chronic pain in her arms and back. We have met before, a few years previously, but she was using a wheelchair then, and was convinced that the pain was a physical problem that could be diagnosed and cured. She was not really interested in therapy. 

So what does it mean, to not know where your edges are?  In cognitive analytic therapy (CAT), we think of the self as consisting of the many different roles that we experience growing up. We learn both the way we are treated, the feeling role such as “cared for”, “validated”, “boundaried”, and “corrected”. We also learn, through example, the doing role of the other – “caring”, “validating”, “setting limits”, and “correcting”. 

These roles are internalised and go underground, deep into our felt sense of who we are, and our beliefs about ourselves, and about how relationships are likely to be. As CAT therapists, we see these roles as the building blocks of the developing self. These roles can be seen acted out in the imaginary play of the child, switching between the “doing” and the “done to” roles as different characters are brought into play. As we grow up through adolescence, we start to act out these roles within ourselves, so that we can care for ourselves, validate ourselves, set limits on ourselves, and correct ourselves. We learn who we are and where our edges are, by bumping up against the edges of others, testing limits and boundaries, and hopefully being calmly and firmly, corrected, and then forgiven.

Of course, some people have very different relationship experiences growing up, either within the family, or within a social setting, which rejects, excludes or abuses. Ellie was scapegoated by her family and blamed for everything that went wrong. As the oldest child, of busy, stressed parents, she was expected to grow up quickly and be responsible for her younger brother and sister. She was punished excessively for every minor transgression or mistake, both hers and those of her siblings.

The roles she experienced were “blaming to bad” and “punishing to punished”. When she tried to speak out to defend herself, she was punished further, and when she spoke out to those outside the immediate family, she was not believed. I am not surprised that she stopped speaking about her experiences all together. If you are always in the wrong, it is safer to say nothing. No wonder she did not welcome therapy two years ago. She describes curling up in a ball to try and disappear. This she now links with the pain in her shoulders and back.

Now she is away from her family, living in a different country, studying for a degree, and trying to find her voice. She is hesitant to tell me things that happened to her as a child, worried that I too will blame her and not believe her. Each time I don’t reject her, she is surprised. Living away from her family where people are kinder, she is starting to uncurl and sit up straighter. Can she take the risk to speak and act in the world to discover where her edges are?

In CAT, therapist and client map out these relationship roles with words, arrows, and images; creating a diagram. We draw an “observing eye” in the corner of the paper to represent Ellie starting to see the patterns from a slight distance. This helps us point out how she expects me to react in the same way as her family, and how that changes her behaviour. If she can see the pattern with me in the therapy room, she can make a choice to do something different, and then perhaps start to change the way she relates to people in her life outside therapy. If she can recognise the way she treats herself as a repetition of the way she was treated as a child, then she can make a choice to do something different with herself, to ‘parent’ herself in a different way. She can develop new roles that are more compassionate, more reassuring.

Using her CAT diagram, we add colourful arrows as exits from the old unhelpful patterns.  We write on them new ways of thinking and behaving, such as “remember that when things go wrong, it is not always my fault” and ‘take the risk to sit up straight and find my voice’.  Looking at the diagram is a way for her to remind herself of these new, healthier ways of relating.

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Clinical information in this article has been anonymised, and all patients whose material appeared in this account have given their permission for it to be included.

Dr Alison Jenaway is a consultant psychiatrist in psychotherapy in the Liaison Psychiatry Service in Cambridge.