Cognitive analytic therapy
Encyclopedia
Cognitive Analytic Therapy (CAT) is a form of psychological therapy initially developed in the United Kingdom by Anthony Ryle. This time-limited therapy was developed in the context of the UK's National Health Service
with the aim of providing effective and affordable psychological treatment which could be realistically provided in a resource constrained public health system. It is distinctive due to its intensive use of reformulation
, its integration of cognitive and analytic practice and its collaborative nature, involving the patient very actively in their treatment.
The CAT practitioner aims to work with the patient to identify procedural sequences; chains of events, thoughts, emotions and motivations that explain how a target problem (for example self-harm) is established and maintained. In addition to the procedural sequence model, a second distinguishing feature of CAT is the use of reciprocal roles (RRs). These identify problems as occurring between people and not within the patient. RRs may be set up in early life and then be replayed in later life; for example someone who as a child felt neglected by parents perceived as abandoning might be vulnerable to feelings of abandonment in later life (or indeed neglect themselves).
based on ideas from cognitive and analytic
therapies. It was originated when Anthony Ryle, a psychiatrist and analytically trained psychotherapist, was undertaking research into psychotherapy practice using repertory grid
s. He found that the themes eventually addressed in analytic work were in fact present in transcripts from the very first sessions. However the slow, exploratory nature of traditional analytic therapy meant that these were not always addressed early and assertively, with the result that therapy, while effective, took a long time to produce results. He proposed a shorter, more active form of therapy which integrated elements from cognitive therapy
practice (such as goal setting and Socratic questioning
) into analytic practice. This would include explicitly formulating the problems experienced by the patient, and sharing this formulation with the patient to engage them in psychotherapy as a co-operative enterprise.
Subsequently CAT has been influenced by ideas from the work of Vygotsky
and Bakhtin. From Vygotsky come concepts such as the Zone of Proximal Development (ZPD) and scaffolding. The ZPD implies that new tasks set for the patient (for example, tolerating anxiety about social situations) should extend what they do beyond their current capabilities, but only by a small and achievable amount. Scaffolding involves the therapist providing support for the patient's efforts to change, but varying this level of support as the patient's needs change.
Bakhtin provided concepts such as dialogism from which come techniques such as Dialogical Sequence Analysis. This is a structured attempt to identify and visually display sequences of behaviour, thinking, and emotions so that the patient becomes more aware of these and can start to modify them.
The approach is always time-limited, typically taking place over 8-24 weekly sessions (the precise number being agreed at the start of therapy). Sixteen sessions is probably the most common length. In the first quarter of the therapy (the Reformulation phase) the therapist collects all the relevant information, asking the patient about present day problems and also earlier life experiences. At that point the therapist writes a reformulation letter to the client. This letter summarises the therapist's understanding of the client's problems. Particular attention is given to understanding the connection between childhood patterns of behaviour and their impact on adult life. The letter is agreed between patient and therapist and forms the basis for the rest of the work.
After the reformulation letter the patient may be asked to complete diaries or rating sheets to record the occurrence of problems and their context. During this period (known as the Recognition phase) patient and therapist construct a diagrammatic formulation to illustrate the unhelpful procedures which maintain problems for the patient. The aim of this phase is to enable the patient to recognise when and how problems occur.
In the second half of the therapy work moves into the Revision phase, where patient and therapist identify and practice "exits" from the procedural diagram established in the previous phase. For example a problematic procedure might move a patient from feeling angry to taking an overdose. An exit might involve expressing the anger in some way as an alternative to self-injuring behaviour.
At the end of the therapy, patient and therapist each write "goodbye letters" which they exchange, summarising what has been achieved in the therapy and what remains to be done. After the end of the agreed number of weekly sessions, planned follow-up sessions take place to monitor and support the changes that have been made. Typically, a 16-session CAT might be followed up by a single session one month after the end of therapy, and a final one three months later.
. These include Randomised Controlled Trials
(RCTs) and other kinds of study. The approach is too new for any systematic review
s of RCTs to have been conducted, and therefore is not yet explicitly recommended by name by the UK National Institute for Health and Clinical Excellence
(NICE). However NICE has recommended that there should be further research of CAT, for example in Borderline personality disorder.
. It has also been shown to produce significant improvements in adolescents with a diagnosis of Borderline Personality Disorder
(BPD). CAT has been shown to improve patients' management of diabetes.
. Case series and single case studies have also been published describing the use of CAT in dissociative psychosis, the treatment of offenders, brain injury, deliberate self-harm
, dissociative identity disorder
and Histrionic personality disorder
.
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
with the aim of providing effective and affordable psychological treatment which could be realistically provided in a resource constrained public health system. It is distinctive due to its intensive use of reformulation
Clinical formulation
A clinical formulation is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an alternative approach to the more categorical approach of...
, its integration of cognitive and analytic practice and its collaborative nature, involving the patient very actively in their treatment.
The CAT practitioner aims to work with the patient to identify procedural sequences; chains of events, thoughts, emotions and motivations that explain how a target problem (for example self-harm) is established and maintained. In addition to the procedural sequence model, a second distinguishing feature of CAT is the use of reciprocal roles (RRs). These identify problems as occurring between people and not within the patient. RRs may be set up in early life and then be replayed in later life; for example someone who as a child felt neglected by parents perceived as abandoning might be vulnerable to feelings of abandonment in later life (or indeed neglect themselves).
Sources and origins of CAT
As the name implies, CAT evolved as an integrative therapyIntegrative Psychotherapy
Integrative psychotherapy may involve the fusion of different schools of psychotherapy. The word 'integrative' in Integrative psychotherapy may also refer to integrating the personality and making it cohesive, and to the bringing together of the "affective, cognitive, behavioral, and physiological...
based on ideas from cognitive and analytic
Psychoanalysis
Psychoanalysis is a psychological theory developed in the late 19th and early 20th centuries by Austrian neurologist Sigmund Freud. Psychoanalysis has expanded, been criticized and developed in different directions, mostly by some of Freud's former students, such as Alfred Adler and Carl Gustav...
therapies. It was originated when Anthony Ryle, a psychiatrist and analytically trained psychotherapist, was undertaking research into psychotherapy practice using repertory grid
Repertory grid
The Repertory Grid is an interviewing technique which uses factor analysis to determine an idiographic measure of personality. It was devised by George Kelly in around 1955 and is based on his Personal Constructs theory of personality.- Introduction :...
s. He found that the themes eventually addressed in analytic work were in fact present in transcripts from the very first sessions. However the slow, exploratory nature of traditional analytic therapy meant that these were not always addressed early and assertively, with the result that therapy, while effective, took a long time to produce results. He proposed a shorter, more active form of therapy which integrated elements from cognitive therapy
Cognitive therapy
Cognitive behavioral therapy is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present...
practice (such as goal setting and Socratic questioning
Socratic questioning
Socratic questioning is disciplined questioning that can be used to pursue thought in many directions and for many purposes, including: to explore complex ideas, to get to the truth of things, to open up issues and problems, to uncover assumptions, to analyze concepts, to distinguish what we know...
) into analytic practice. This would include explicitly formulating the problems experienced by the patient, and sharing this formulation with the patient to engage them in psychotherapy as a co-operative enterprise.
Subsequently CAT has been influenced by ideas from the work of Vygotsky
Lev Vygotsky
Lev Semyonovich Vygotsky was a Soviet psychologist, the founder of cultural-historical psychology, and the leader of the Vygotsky Circle.-Biography:...
and Bakhtin. From Vygotsky come concepts such as the Zone of Proximal Development (ZPD) and scaffolding. The ZPD implies that new tasks set for the patient (for example, tolerating anxiety about social situations) should extend what they do beyond their current capabilities, but only by a small and achievable amount. Scaffolding involves the therapist providing support for the patient's efforts to change, but varying this level of support as the patient's needs change.
Bakhtin provided concepts such as dialogism from which come techniques such as Dialogical Sequence Analysis. This is a structured attempt to identify and visually display sequences of behaviour, thinking, and emotions so that the patient becomes more aware of these and can start to modify them.
CAT in practice
The model emphasises collaborative work with the client, and focuses on the understanding of the patterns of maladaptive behaviours. The aim of the therapy is to enable the client to recognise these patterns, understand their origins, and subsequently to learn alternative strategies in order to cope better.The approach is always time-limited, typically taking place over 8-24 weekly sessions (the precise number being agreed at the start of therapy). Sixteen sessions is probably the most common length. In the first quarter of the therapy (the Reformulation phase) the therapist collects all the relevant information, asking the patient about present day problems and also earlier life experiences. At that point the therapist writes a reformulation letter to the client. This letter summarises the therapist's understanding of the client's problems. Particular attention is given to understanding the connection between childhood patterns of behaviour and their impact on adult life. The letter is agreed between patient and therapist and forms the basis for the rest of the work.
After the reformulation letter the patient may be asked to complete diaries or rating sheets to record the occurrence of problems and their context. During this period (known as the Recognition phase) patient and therapist construct a diagrammatic formulation to illustrate the unhelpful procedures which maintain problems for the patient. The aim of this phase is to enable the patient to recognise when and how problems occur.
In the second half of the therapy work moves into the Revision phase, where patient and therapist identify and practice "exits" from the procedural diagram established in the previous phase. For example a problematic procedure might move a patient from feeling angry to taking an overdose. An exit might involve expressing the anger in some way as an alternative to self-injuring behaviour.
At the end of the therapy, patient and therapist each write "goodbye letters" which they exchange, summarising what has been achieved in the therapy and what remains to be done. After the end of the agreed number of weekly sessions, planned follow-up sessions take place to monitor and support the changes that have been made. Typically, a 16-session CAT might be followed up by a single session one month after the end of therapy, and a final one three months later.
The evidence base for CAT
Although relatively new, CAT has been the subject of a number of research studies published in peer-reviewed journalsAcademic journal
An academic journal is a peer-reviewed periodical in which scholarship relating to a particular academic discipline is published. Academic journals serve as forums for the introduction and presentation for scrutiny of new research, and the critique of existing research...
. These include Randomised Controlled Trials
Randomized controlled trial
A randomized controlled trial is a type of scientific experiment - a form of clinical trial - most commonly used in testing the safety and efficacy or effectiveness of healthcare services or health technologies A randomized controlled trial (RCT) is a type of scientific experiment - a form of...
(RCTs) and other kinds of study. The approach is too new for any systematic review
Systematic review
A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...
s of RCTs to have been conducted, and therefore is not yet explicitly recommended by name by the UK National Institute for Health and Clinical Excellence
National Institute for Health and Clinical Excellence
The National Institute for Health and Clinical Excellence is a special health authority of the English National Health Service , serving both English NHS and the Welsh NHS...
(NICE). However NICE has recommended that there should be further research of CAT, for example in Borderline personality disorder.
Evidence from Randomised Controlled Trials
CAT has been shown to lead to subjective improvement in people with Anorexia nervosaAnorexia nervosa
Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
. It has also been shown to produce significant improvements in adolescents with a diagnosis of Borderline Personality Disorder
Borderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...
(BPD). CAT has been shown to improve patients' management of diabetes.
Evidence from other methodologies
Comparative studies have suggested CAT to be at least as effective as other forms of brief psychotherapy, person-centred therapy and cognitive behavioural therapy and interpersonal psychotherapyInterpersonal psychotherapy
Interpersonal Psychotherapy is a time-limited psychotherapy that focuses on the interpersonal context and on building interpersonal skills. IPT is based on the belief that interpersonal factors may contribute heavily to psychological problems. It is commonly distinguished from other forms of...
. Case series and single case studies have also been published describing the use of CAT in dissociative psychosis, the treatment of offenders, brain injury, deliberate self-harm
Self-harm
Self-harm or deliberate self-harm includes self-injury and self-poisoning and is defined as the intentional, direct injuring of body tissue most often done without suicidal intentions. These terms are used in the more recent literature in an attempt to reach a more neutral terminology...
, dissociative identity disorder
Dissociative identity disorder
Dissociative identity disorder is a psychiatric diagnosis and describes a condition in which a person displays multiple distinct identities , each with its own pattern of perceiving and interacting with the environment....
and Histrionic personality disorder
Histrionic personality disorder
Histrionic personality disorder is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriately seductive behavior, usually beginning in early...
.