Introducing Cognitive Analytic Therapy

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Anthony Ryle. Introducing Cognitive Analytic Therapy

Table of Contents

List of Tables

List of Illustrations

Guide

Pages

Introducing Cognitive Analytic Therapy. Principles and Practice of a Relational Approach to Mental Health

List of Figures

About the Authors

Preface to the Second Edition

Preface to the Second Edition

Acknowledgments

The Structure of the Book

Further Information

1. The Scope and Focus of CAT. Summary

CAT Is an Integrated Model

CAT Is a Collaborative Therapy

CAT Is Research Based

CAT Evolved from the Needs of Working in the Public Sector and Remains Ideally Suited To It

CAT Is Time‐Limited

CAT Offers a General Theory, Not Just a New Package of Techniques

CAT Has Applications In Many Clinical and Other Settings

2. The Main Features of CAT. Summary

Background

The Early Development of CAT Practice

The Theoretical Model

The Development of a Vygotskian and Bakhtinian Object Relations Theory

The Development of the Basic Model of Practice

The Development of Sequential Diagrammatic Reformulation (“Mapping”)

The Course of Therapy. Initial Phase

Mid Phase

Time Limits and Ending

The Clinical Aims of CAT

Case History: Bobby (Therapist Steve Potter)

Background

Assessment and Reformulation

The Course of Therapy

Termination

Follow‐Up

Concluding Remarks

3. The CAT Model of Development of the Self. Summary

The CAT Concept of Self

Neuroscience Research and the Self

The Permeability of the Self

Cultural Relativity of Models of Self

Studies of Infant Development

The Contribution of Vygotsky's Ideas

The Social Formation of Mind

Sign Mediation

Internalization

The Zone of Proximal Development (ZPD)

Developmental Studies of Role Acquisition

Bakhtinian Contributions

Contrasts with Other Concepts of Self

Cognitive Psychology and Cognitive Therapy

Genetics and Temperament

Our Evolutionary Past

The Evolution of Cognitive Capacities and of Culture

Evolutionarily Pre‐Programmed Psychological Tendencies

4. The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy. Summary

Abnormal Development of Self and Its Consequences

Persistent Negative Role Patterns

Avoidant, Defensive, and Symptomatic Role Replacements or “Coping Strategies”

Dissociation

Implications of Relational Adversity, Stress, and Trauma for the Developing Self

Broader Implications of a Relational Adversity and Trauma (“Deficit”) Based Model of Psychopathology

Common Therapeutic Factors

Damaged or Abnormal Development of the Self and the CAT Model of Therapeutic Change

Understandings of “Transference” and “Counter‐Transference” and Avoiding Collusion

Use of Personal and Elicited Counter‐transference

Identifying and Reciprocating Counter‐transference

Self‐Esteem

The “False Self”

Who Does the Therapist Speak for?

Implications of Our Evolutionary Past for Psychotherapy

Concluding Remarks

5. The Practice of CAT: Selection and Assessment of Patients for Therapy. Summary

Referral

Assessment Information

The Conduct of the Assessment Interview

Nora

David

Nick

Debby

Evelyn

Diana

The Six Cases

Other Considerations

Assessing Motivation

Combining CAT with Other Treatment Modes

Assessing the Risk of Self‐Harm and Suicide

Assessing the Potential for Violence

“Paper and Pencil” Devices and Questionnaires

Treatment “Contracts”

Concluding Remarks

6. The Practice of CAT: The Early Reformulation Sessions. Summary

Case Formulation and CAT Reformulation

The Process of Reformulation

The Reformulation Letter

Case Example (TR)

General Principles of Writing Reformulation Letters

Diagrammatic Reformulation or Mapping

General Principles of Creating Diagrams or Maps

Historical Background: Simple “Flow Diagrams”

Diagrammatic Reformulation or Mapping: Practical Considerations

Single or Multiple Cores in Diagrams

Example of Mapping

Case Example: Dominic (Fictionalized) (IK)

Reformulation Letter to Dominic (Fictionalized)

Exits and Aims

The Order and Process of Reformulation

Formal Evaluation of the Impact of Reformulation

Concluding Remarks

7. The Practice of CAT: Later Phases of Therapy, Working at Changing and Ending. Summary

Later Sessions—General Considerations

Change and the Working Alliance in the “ZPPD”

Making Use of Transference and Counter‐transference in Enabling Change

Transference, Counter‐transference, and the Working Relationship of Therapy

Dialogic Sequence Analysis. Case Example: Alistair

Technical Procedures

Rating Progress

Recognizing Enactments and Procedures as they Occur

Recapitulating and Reviewing Sessions

Homework

Accessing Painful, Possibly Traumatic, Memories and Feelings

Not Recognizing Enactments and Procedures as they Occur

The CAT Model of Resistance and of the “Negative Therapeutic Reaction”

Dropping out of Therapy

Recognizing Enactments and Procedures at Termination and Ending Well

Case Example: Rita (Therapist Kim Sutherby)

Case vignette (IK): Example of (fictionalized) goodbye letter (penultimate session) and response from patient

End of therapy (last session) response letter (verbatim with permission) from Gail

Concluding Remarks

8. The CAT Model of Therapist Activity and of Supervision. Summary

The Competence in CAT (CCAT) Measure

Therapist Activities in CAT

Acknowledgment, Exploration, and Linking

Negotiation, Seeking Consensus, Explanation, and Contacting Unassimilated Feelings

Case Example: Grace (Therapist Michelle Fitzsimmons)

Therapist: Sarah Littlejohn

Supervision of Therapists in CAT

Audio‐tape Supervision

Dialogical Sequence Analysis

“Parallel Process”

Group Supervision

Reflective Practice

Distance Supervision

9. CAT in Various Conditions and Contexts. Summary

The Problem of Diagnosis. Diagnosis and Formulation

Competing Paradigms

The Scope of CAT

Strategic Issues: When to Address Symptoms Directly

Case Example: Susan (Therapist IK)

The Reformulation Phase

Rating Progress

CAT in Some Specific Conditions and Settings. Anxiety Related Disorders

Generalized Anxiety Disorder

Obsessive–Compulsive Disorders

Panic and Phobia

Depression

Unresolved Mourning

Trauma and Post‐Traumatic Stress Disorders

Case Example: Richard (Therapist Ceri Evans)

Case Example: Tamara (Therapist Alison Jenaway)

The Effects of Child Sexual Abuse

True or False Recollections of Abuse

Somatization, “Somatoform Disorders,” and “Medically Unexplained Symptoms”

CAT and the Management of Medical Conditions

Management of Insulin‐Dependent Diabetes

Management of Asthma

Eating Disorders

Deliberate Self‐Harm

Intellectual/Learning Disabilities and Neurodevelopmental Disorders

Case Vignette (Jamie Kirkland with Laura Brougham and Mandy Boyce)

Psychosis

General Considerations

A CAT Perspective on Conceptualizing and Treating Psychotic Disorders

Particular Considerations around CAT for Psychotic Disorders

Case Example: Sarah (Therapist IK)

Substance Abuse

CAT in Old Age and Early Dementia

Sexual and Gender‐Related Issues. General Considerations

Therapeutic Considerations

Perinatal Mental Health

CAT in Forensic Settings

CAT with Children and Adolescents

CAT in Primary Care

CAT in Groups and Organizations

CAT Across Cultures

Case Example (Ann Treesa Rafi)

Reformulation letter

Concluding Remarks

10. The Treatment of “Severe and Complex”Personality‐Type Disorders. Summary

The Concept of Personality Disorder

Borderline Personality Disorder (BPD)

The Causes of BPD

The CAT Multiple Self States Model

The Therapy and Reformulation of Borderline Patients

Aids to Reformulation

Summarizing SDP Data

Case Example: DEBORAH (Therapist Anna Troger)—Illustrating Additional Use of Repertory Grid Techniques and the “States Description Procedure” (SDP)

Results

The States Description Procedure (SDP)

The Course of Therapy

Narcissistic Personality Disorder (NPD)

The MSSM and NPD

Therapy with Patients with Features of NPD

Case Vignette (Anonymized) of a Patient with NPD‐Type Disorder. Alison

Olivia (Therapist Anna Troger)

Case History. Sam (Therapist Kate Freshwater)

Conclusion

The Treatment of “Severe and Complex,” Personality‐Type Disorders: CAT and the Research Evidence

Concluding Remarks

11 The “Difficult” Patient, Contextual Reformulation, Systemic Applications, and Reflective Practice. Summary

The “Difficult” Patient

Causes of “Difficult” Behavior. Physical Causes

Psychiatric Causes

Staff Team Dynamics

General Approaches to the “Difficult” Patient

Contextual Reformulation

Constructing a Contextual Reformulation

Examples of Contextual Reformulations

Brenda (Therapist IK)

Paula (Therapist IK)

Broader Uses and Applications of Contextual and Systemic Approaches

Reflective Practice. Background

CAT and Reflective Practice

Concluding Remarks

Afterword

Distinctive Features of CAT

The Continuing Expansion of CAT

The Evidence Base and Research

The Implicit Values of CAT

Glossary

Appendix 1. The Psychotherapy File

Keeping a Diary of Moods and Behavior

Patterns that Do Not Work, but Are Hard to Break

Traps

Dilemmas (False Choices and Narrow Options)

Choices about myself

Choices about how we relate to others

Snags

Difficult and Unstable States of Mind

Different States

Appendix 2. Cognitive Analytic Therapy (CAT) Competences for Individuals with Personality Disorder

Knowledge of CAT Theory

Knowledge of Key Features of CAT

The Psychotherapy File

Reformulation

Knowledge of the CAT Theory of BPD

Key Skills of CAT

Reformulation

Constructing the Sequential Diagrammatic Reformulation (SDR) (or “Map”)

Constructing Target Problem Procedures (TPPs or “key issues”)

Formulating Aims or Exits

Moving Between Task and Process

CAT Methods of Intervention

Ability to use CAT Skills to Manage the Ending of Therapy

Ability to use CAT‐Specific Measures to Guide the Intervention

CAT Skills of Particular Relevance for Work with Borderline Personality Disorder

Engagement

Developing the Reformulation

Sustaining and Consolidating Positive Change

Using CAT to Facilitate Work with Wider Systems (Contextual Reformulation)

Appendix 3. Personality Structure Questionnaire (PSQ)

Appendix 4. Repertory Grid Basics and the Use of Grid Techniques in CAT

References

Index. a

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Second Edition

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Termination is inevitably an issue, however, and the last sessions are seldom easy for the patient or the therapist. Almost no therapist (including the authors!) will ever feel that enough has been done and that “a bit more” might not be helpful. In CAT, the practice was introduced of exchanging “goodbye letters” at the penultimate (probably preferable to enable subsequent discussion), or last session. The aim of the therapist's letter is reflect on and to offer an ideally accurate (not blandly optimistic) account of the course of therapy and on what has and has not been achieved (jointly) in terms of modifying problem RRs and RRPs and relieving problems, to look to the future, and to identify where further work may be helpful. The tone of the letter should aim, as ever, to be collaborative and dialogical, and be informed by a genuine relational involvement (but not collusion) on the part of the therapist. The letter should stress that this is simply the view of the therapist. Feelings of disappointment, anxiety, or possibly anger by the patient, despite what may have been achieved, are expressly noted or predicted and thereby, incidentally, also “allowed.” This letter gives the patient a reminder of the unidealized person of the therapist (assisting the “withdrawal of transference”) and of the tools of the therapy, and is intended to help the internalization of the experience overall. In the same way, the letter from the patient (always suggested but not always produced!) invites thoughtful reflection and open expression of feelings, including about the therapy relationship. For many this represents a new experience (a new RRP), and an important change from previous coping patterns (RRPs), for example of “disempowered and silently soldiering on at great personal cost.” These exchanges are seen as an important aspect of “ending well.” Follow‐up at about 3 months is usually arranged. In many cases, change is maintained or expanded more thoroughly than either therapist or patient expect. If this is not the case, further follow‐up or “top up” sessions may be arranged or possibly treatment through another modality (e.g., group therapy or trauma processing work). Decisions about further treatment of whatever kind are best postponed until the effects of the therapy have become stabilized and the experience of termination has been completed. They should always occur in the context of reflective discussion in supervision (see Marx, 2011; Pickvance, 2017).

The aims of CAT therapists are, in a sense, modest. We seek to remove the “roadblocks” that have maintained restriction and distress and have prevented the patient's further growth, and we aim to assist in the development of more adequate “route maps” and of ways of being and of living life. This occurs partly through the experience of a new, benign, therapeutic relationship. In so doing we also aim to engender some hopefulness where previously there may have been little or none. But we do not offer to accompany the patient along the road. Obstacles to change are various and in CAT are seen to include: self‐reinforcing ineffective procedures; restricted, avoidant, or symptomatic procedures; sabotaging inner critical “voices”; and disconnected, dissociated Self processes. We do not believe we should seek to explain, let alone claim to share or replace, the wisdom and creativity of artists, writers, and philosophers. CAT also developed as a pragmatic model. In the inner‐city London out‐patient service where CAT developed, it appeared to be a satisfactory treatment for over two‐thirds of patients and of some benefit to many of the remainder. Similar outcomes are reported in naturalistic studies in other countries (e.g., Garyfallos, Adamopoulou, & Mastrogianni, 1998) and in more recent comparative studies in the UK (e.g., Marriott & Kellett, 2009). Some of these went on go on to further treatment, such as more CAT, group therapy, or cognitive‐behavioral work on unrevised procedures, assisted by prior reformulation (Dunn, Golynkina, Ryle, & Watson, 1997). More recent outcome data suggests similar results are being obtained across an increasing range of patient problems, severity, and settings (see Calvert & Kellett, 2014). It may also be that CAT is more effective for some patients if undertaken over a somewhat longer time, or in separate blocks with intervals. Its combination or alternation with other interventions, such as creative therapies, psychodrama, or group work, would almost certainly be helpful for patients who are hard to engage emotionally or who need more time to explore alternatives. Further and ongoing research is of course needed, although funding and support remain in general hard to find for psychotherapies, and notwithstanding that some approaches appear more “politically” acceptable and better promoted at any given time.

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