Chapter 10 – Cognitive Analytic Therapy (CAT):




Abstract




This chapter introduces some recent developments in the application of Cognitive Analytic Therapy (CAT). After a brief, illustrated, overview of CAT; its theoretical base, its structure and its evidence base, it will concentrate on three more recent developments: eight-session CAT for anxiety and depression in non-specialist mental health psychological therapy services, CAT in groups and CAT reflective practice groups.





Chapter 10 Cognitive Analytic Therapy (CAT): Developing the Model and the Method



Jason Hepple



Introduction


This chapter introduces some recent developments in the application of Cognitive Analytic Therapy (CAT). After a brief, illustrated, overview of CAT; its theoretical base, its structure and its evidence base, it will concentrate on three more recent developments: eight-session CAT for anxiety and depression in non-specialist mental health psychological therapy services, CAT in groups and CAT reflective practice groups.


For an extended overview of CAT see [1, 2].



Overview of CAT



Theoretical Base


CAT, as its name implies, represents an integration of ideas from cognitive psychology and some elements of psychodynamic theory. Its originator, Dr Anthony Ryle, started out as a GP before developing his ideas in a university health service and then as a consultant psychotherapist at Guy’s Hospital in London. He was struck by the volume of emotional and relational problems presenting in primary care and was interested in ‘the non-revision of dysfunctional procedures’; essentially exploring the question: ‘Why do people keep repeating the same relational patterns that take them back to where they started?’ In a nutshell, he suggested that these patterns or ‘procedures’ are survival strategies developed earlier in life that are no longer helpful. He developed tools to describe these procedures in both narrative (reformulation letter) and visual forms (mapping) so facilitating recognition of the relational ‘re-enactments’ of these procedures that can lead to subsequent revision and the discovery of ‘exits’.


The main theoretical influences for Ryle’s ideas include the object relations theorists Fairbairn, Guntrip, Winnicott and Ogden. On the cognitive side he drew upon the ideas of George Kelly and admired his collaborative exploration of the client’s world using repertory grids. In essence, Ryle sought to ‘re-state object relations ideas in a cognitive language and to generate an approach compatible with observational studies of early development’ [1]. Ryle also replaced the interpretation of unconscious process with a more collaborative and ‘doing with’ mapping out of relational sequences, including the relational ‘enactments’ that go on between client and therapist in the course of the therapy; a restatement of transference and countertransference.



Structure of the Model


CAT originated as a 16 weekly session model of individual therapy, designed to offer a time-limited, collaborative and focussed therapy that was affordable in public health services but that had the depth and interest in the past to help people with more complex personality-based problems resulting from abuse, neglect and trauma. CAT has always been more concerned with a jointly authored developmental formulation of the person’s problems than in symptoms, diagnostic categories or an illness model of mental health. There is early negotiation of ‘target problems’; the focus of the work of the therapy, and the linking of these to ‘target problem procedures’ that are subdivided into ‘traps, dilemmas and snags’. These procedures are relational formulations of the ‘survival strategies’ mentioned above.


Typically at session four, the therapist reads out a prepared ‘reformulation letter’ to the client, which empathically retells the co-constructed client’s story making links with the past and the target problems and their related procedures. It also tries to anticipate how these procedures may re-enact themselves in the therapeutic relationship (an anticipation of negative and positive transferences that may both help to understand the therapeutic alliance and may also threaten it). An example of a short, truncated, fictional reformulation letter:



Dear Jonathan,


(Introduction, context and target problems)


Now that we have reached session four of our sixteen sessions of CAT therapy, I am giving you this reformulation letter, as I said, where I am trying to link the problems you have brought to therapy with patterns that we have identified from your past experience. This letter is yours to keep but is only a draft and we can alter anything that is not right. You are welcome to write a reply to this letter if that would be helpful to you.


You came to therapy feeling very lonely and isolated. Since returning to your home town after college you have ‘existed’ in your flat and have not made any friends or found anything regular to engage in. You have suffered from depression and feeling like you would rather be dead but you say that you ‘do not have the courage to kill myself.’ You have tried antidepressants but they did not seem to help. You had a course of Cognitive Behavioural Therapy (CBT), but although you identified with the patterns identified by the therapist, you felt that this did not help you to make any changes in your life and you told me that you felt that the therapist was just ‘going through the motions’ and was not really interested in you; you were ‘just another statistic’.


We identified two broad target problems: one connected to your ‘minimal existence’ that we framed as ‘not being able to have anything for myself’. The second connected to your difficulty relating to other people that we framed as ‘other people look down on me as a failure’. In the section below I will try to link these to the things that you have told me about your childhood.


(Reformulation of earlier life experiences)


Your childhood came across to me as very lonely. You told me that you were brought up on a farm as an only child. Your father was always out on the farm and when he did come home, was tired and withdrawn. He felt that children should be ‘seen and not heard’. Your mother had lots of interests outside of the home and was active in the Women’s Institute and local amateur dramatics. She was also out a lot and seemed to have no time for you. You learned to pass the time alone, sometimes just sitting in ‘your tree’ or lying on your bed staring at the cracks in the ceiling. I can feel how lonely and desolate this must have been for a child who needed love and encouragement. This makes me feel very sad for you.


As time went on your mother took to drinking and everything you did seemed to annoy her and be wrong. She told you that you needed to be ‘self-sufficient’ like she was and not be ‘needy’ and ask for attention or things. This is illustrated by the terrible story of what happened to Dasher, your dog. You were so pleased when you father brought Dasher home to keep you company. Dasher became your best friend but one day when you came back from school your mother had given Dasher away as she said he was a nuisance as he needed walking when you were at school and that she couldn’t afford to feed him. You never found out where Dasher had gone. You were distraught but neither of your parents seemed to care and you made a resolution never to risk loving anything again.


At school you always felt that you did not fit in as the farm was a long way from any other kids’ houses and you always had old clothes and shoes and were picked on for being ‘the farm kid’. After a time you learned to keep yourself to yourself and the other kids just ignored you or sniggered at you as you set off on the long walk home. I can feel some anger in you about the way you were treated by them. Why would you want to mix with other people in the future when they are so cruel?


… … … … … ….


Target problem: I can’t seem to have anything for myself


Target problem procedure (Snag): because of my experiences as a child I learned that if I attached to something and loved it (like my dog Dasher) it could be taken away as a punishment, leaving me distraught and alone and feeling that nothing was fair. It seemed safer to invest no emotional currency in things for myself to appear self-sufficient. As I have grown up this has meant that I have nothing for myself and live in an empty flat. I am lonely and sad and left feeling that life has singled me out as a loner and a loser. Maybe it is as if I am now punishing myself?


Target problem: other people look down on me as a failure


Target problem procedure (trap/dilemma): because of the way that you were bullied and ostracised at school you learned to feel that other people look down on you for the way you look. You told me that you feel there is something in you that ‘broadcasts failure’. This makes you more determined to be ‘self-sufficient’ and not need friends or a relationship as other people are cruel and uncaring. Sometimes you look down on them as ‘morons’ and ‘breeders’. This confirms your alienation and leaves you lonely and isolated.


(Anticipation of re-enactments in the therapy relationship)


Jonathan, thank you for getting this far in therapy and for giving me a chance to get to know you. I can feel how hurt and angry you are because of how your life has ended up. I am hopeful that we can find a way forward but I am worried that you may not be able to risk having this therapy for yourself, or feel that I am just ‘going through the motions’ like your last therapist and that you may then feel angry with me and stop coming to our sessions to protect yourself from further disappointment. It will be good to talk about any of these feelings if they come up so that we can continue to work together on making your life better for yourself.


In the middle, or ‘recognition’ phase of a CAT therapy, the client and therapist work together on visual maps that are another way of gaining an overview or ‘observing eye’ on these procedures. At the heart of these maps are ‘reciprocal roles’, a simple restatement of cause and effect in relational templates from the client’s past.


Figure 10.1 shows the visual representation of the example snag given above. The reciprocal role punishing / depriving to punished / hurting / unloved is called a ‘self-state’. The Multiple Self States Model (MSSM) forms the basis of CAT’s understanding of the survival of trauma and dissociation.





Figure 10.1 An example of a target problem reformulated as a CAT ‘snag’.


The final phase of a CAT therapy is called the ‘revision’ phase and the emphasis is on how these patterns from the past play out in day-to-day life. The client and therapist jointly work on recognising these re-enactments in recent events (including in the therapeutic relationship) and on the finding of ‘exits’ that take the client ‘off the map’. In the final session there is the invited exchange of ‘goodbye letters’, where the therapist reflects on the therapeutic journey and the insights gained. An example of a brief fictional goodbye letter to Jonathan:



Dear Jonathan,


I am writing to you as promised to mark the last regular session of our CAT therapy. I am pleased that we have got to the end together and I would like to thank you for sticking with me when you began to have doubts as to whether anything could really help. In session 12 you were able to express your anger to me and we were able to explore how you felt both inferior to me (as a professional) and in some ways superior to me, as part of you had written me off as a ‘trumped up guru’ who had no idea what it was like to have experienced the desolate childhood that you had told me about.


Following this session you were able to write the ‘no-send’ letters to your mother and father and we shared some of the anger and sadness and the realisation that they were unlikely to really change how that they have always related to you. We looked at some exits: we realised that ‘self-sufficiency’ was a good survival strategy for the child you were but that now the neglect and punishment has turned on yourself and that you have a choice to give the world another try. Perhaps our therapy relationship has shown you that someone else can see you as an interesting and bright young man who is yet to really venture from the tree you have been hiding in for so long. It was great that you managed to go to the appointment with Employment Support and are due to start voluntary work. I was pleased to see that you had bought some new jeans and trainers for the appointment too! Looking to the future I see no reason why you can’t grow to have friends, a relationship and the family that you told me you would love but had given up on.


I wish you all the very best for the future and look forward to hearing how things have been going at our follow-up appointment.


There is typically one follow-up session after three months. CAT can be delivered over 24 sessions with three follow-ups for more complex clients.



The Evidence Base for CAT


For a detailed review of the small but encouraging evidence for CAT see the discussion in the review paper ‘CAT at thirty’[2]. In this paper Steve Kellett comments that: ‘This analysis suggests that there is evidence of the effectiveness of CAT under routine clinical practice and clinical trial conditions across a diverse range of presenting difficulties.’ The quoted weighted effect size (d+ = 0.83) indicates that: ‘CAT for mental health problems has large effect on reducing psychiatric symptoms.


Noteworthy studies include a positive randomised controlled trial (RCT) of 24-session CAT with three follow-ups and some longer-term follow-up data, comparing CAT with treatment as usual in a population of clients with mixed personality disorder presentations in a clinical setting [3]. An Australian trial applied CAT to adolescents with features of borderline personality disorder, comparing CAT with a model of ‘Good Clinical Care’ and retrospectively with ‘historic treatment as usual’. CAT produced the most marked improvement in ‘externalising difficulties’ and para-suicidal behaviour [4, 5] There is an encouraging pilot RCT of CAT with clients with bipolar disorder [6]. A randomised dismantling trial of eight-session CAT for anxiety and depression in a non-specialist service concludes that eight-session CAT has a large effect size in treating depression (d > 1.5, p < 0.01) [7]. Finally, there is published the first trial of Group CAT (GCAT) for woman survivors of sexual abuse [8].


CAT has also been applied clinically in a range of settings including later life [9], intellectual disability [10], working with mental health teams [11], offenders [12] and diabetes management [13].

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Jun 6, 2021 | Posted by in PSYCHOLOGY | Comments Off on Chapter 10 – Cognitive Analytic Therapy (CAT):
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