Understanding the Conversational Model of therapy

The Conversational Model of Therapy (CMT) is a contemporary form of relational psychotherapy that evolved from psychoanalytic psychotherapy. It integrates aspects of neuroscience, developmental psychology, and linguistics, and is used primarily for treating disorders of self.

CMT is based on the premise that our sense of self develops out of the relationship with our primary caregivers. Optimal psychic development or emotional maturity occurs when these relationships are stable and sufficiently responsive. More specifically, our concept of self develops through relational experiences with the external world. Within CMT this process is known as analogical relatedness.

The Conversational Model focuses on two key areas – the development of self, and the identification and integration of trauma into a coherent sense of self.

The origin of the Conversational Model of Therapy

CMT was devised by the English psychiatrist Dr Robert Hobson, and further developed by the Australian psychiatrist Dr Russell Meares. Growing understanding of CMT in the 1990’s meant that people who had previously been considered ‘unanalysable’ now had a viable and effective treatment option. Current research has also found CMT to be as effective as Dialectical Behavior Therapy (DBT) for the treatment of Borderline Personality Disorder.

What conditions are helped by the Conversational Model?

CMT works best for conditions that exhibit incoherent or fragmented states of mind caused by trauma or stress. These include:

  • Borderline Personality Disorder (BPD)
  • Treatment-resistant depression
  • Repeated self-harm
  • Somatoform and anxiety disorders, and
  • PTSD and Complex PTSD

The aim of CMT in treating these disorders is to foster a stable sense-of-self, identify, process, and integrate trauma into a coherent, secure state of mind.

How the Conversational Model of Therapy works

The concept of consciousness developing in hierarchical stages was first explained by British neurologist, John Hughlings Jackson, in the late 19th century. Each stage emerges from the previous one to form a new representation; starting with the basic elements of sensory motor function and advancing towards higher and more complex states of consciousness. Trauma or stress can interrupt this process and halt progression or even cause regression to an earlier stage.

CMT Hierarchy of Engagement – Stages of Self Development and Integrating Trauma

  1. The Provision of Safety: The need to feel safe is one of our deepest primal needs. In humans, safety is conveyed using soft, gentle facial expressions and speech and also through the provision of a warm and secure environment. The CMT therapist’s role in a clinical setting is to re-establish safety and connectedness via patient-centered language, empathic attunement, and validation of affective states.
  2. Fostering the Personal: Engagement at this stage focuses on the emotional and physical experiences of the patient which may be difficult to access due to a traumatic event. The therapist uses specific techniques to help the patient develop the language to describe their state of mind and corresponding feelings. This ability to reflect on experiences also helps the patient develop the ability to emotionally regulate in subsequent stages.
  3. Identification and Transformation of the Traumatic System: When the patient reaches this stage, the therapist uses more complex language to discuss the shifts in the patient’s self-state. Drawing attention to these shifts and exploring them helps the patient develop a greater awareness and understanding of each state and its personal meaning. Through this process, the traumatic memory can be identified, transformed, and repaired – allowing it to be neutralised and integrated into the patient’s consciousness and sense of self.
  4. The Expectational Field and Defensive Relational Configurations: Engagement between the patient and therapist from this point is increasingly bidirectional. Together, they can identify the defensive patterns of behaviour that have developed due to a subconscious expectation of the initial trauma reoccurring. They can explore how these expectations are impacting experience and can look for more helpful and flexible relational strategies.
  5. Expanding Collaborative Intersubjectivity: In this final stage, traumatic memory systems have been transformed and integrated and the patient has a new capacity to engage in collaborative discussions, which can further stimulate their emotional development. Greater degrees of freedom are experienced in relatedness and there is a discovery of a mutual pleasure, which motivates and enlightens ongoing experience.

What happens in a CMT session?

The primary aim of CMT is to foster a sense of connection between the therapist and the patient which allows the patient to progress sequentially into higher stages of consciousness. However, the stages can overlap, and the patient can move back and forward between them. The therapist will look for subtle changes in the patient’s state of mind and use these to guide the next steps.

CMT sessions can continue for anything from 12 months to 2 plus years dependent on the degree of impairment and trauma histories. Regular twice weekly or weekly sessions provide the best outcomes. Additionally, CMT can easily be integrated with other therapeutic interventions, such as art therapy, Eye Movement Desensitisation Reprocessing (EMDR), yoga, and medication, for example.

At Mindful Synergi, we use the most appropriate treatments and interventions for your situation with the ultimate aim of helping you achieve a more stable sense of self and increased emotional regulation, improving your ability to manage and cope in your daily life.

References and further reading

Meares, R. (1999). The contribution of Hughlings Jackson to an understanding of dissociation. The American Journal of Psychiatry, 156(12), 1850.

Meares, R. (2004). The conversational model: an outline. American Journal of Psychotherapy, 58(1), 51.

Meares, R. (2012). Borderline personality disorder and the conversational model: A clinician’s manual. WW Norton & Company.

Meares, R., & Jones, S. (2009). The role of analogical relatedness in personal integration or coherence. Contemp. Psychoanal., 45(4), 504-519.

Graham, P., & van Biene, L. (2007). Hierarchy of engagement. Self in Conversation, 177-196.

Korner, A., & McLean, L. (2017). Conversational model psychotherapy. Australasian Psychiatry, 25(3), 219-221.