Daniel

 The Scope and Focus of CAT

Summary

CAT evolved as an integration of cognitive, psychoanalytic, and, more recently, Vygotskian

and Bakhtinian ideas. It is characterized by a predominantly relational understanding of the

origins of patient problems and symptoms and an explicitly empathic, pro-active, and compassionate

therapeutic stance, with an active focus on issues arising within the therapeutic

relationship. From the beginning it has emphasized genuine therapist–patient collaboration

in creating and using descriptive reformulations of presenting problems. As such it offers a

respectful, whole-person, “transdiagnostic” approach that represents a challenge to many

prevalent “diagnosis”-led services. The model arose from a continuing commitment to research

into effective therapies and therapy integration, and from a concern with offering appropriate,

time-limited treatment in the public sector. Originally developed as a model of individual

therapy, CAT now offers a general theory of development and psychotherapy with applicability

to a wide range of conditions in many different settings and in various “contextual” and

systemic

approaches.

In order to locate cognitive analytic therapy (CAT) in the still expanding array of approaches

to psychotherapy and counseling and to indicate the continuing developments in its theory

and practice, its main features will be briefly summarized in this introductory chapter.

CAT Is an Integrated Model

One source of CAT was a wish to find a common language for the psychotherapies. While

there is a place for different perspectives and different aims in psychotherapy, the use by

the different schools of ostensibly unrelated concepts and languages to describe the same

phenomena seems absurd. It has resulted in a situation where discussion is largely confined

to the parish magazines of each of the different churches or to the trading of disparaging

insults between them. Despite the growth of interest in integration and the spread of

technical eclecticism in recent years, the situation has not radically altered. CAT remains, we suggest, one of the few models to propose a comprehensive theory that aims to address

and integrate the more robust and valid findings of different schools of psychotherapy as

well as those of related fields such as developmental psychology and infant observational

research, neuroscience, epidemiology, and sociology.

The process of integration in CAT originated in the use of cognitive methods and tools

to research the process and outcome of psychodynamic therapy. This involved the translation

of many traditional psychoanalytic concepts into a more accessible language based

on the new cognitive psychology. This led on to a consideration of the methods employed

by current cognitive-behavioral and psychodynamic practitioners. While cognitive-behavioral

models of therapy needed to take more account of the key role of human relationships

in development, in psychopathology, and in therapy, their emphasis on the analysis

and description of the sequences connecting behaviors to outcomes and beliefs to emotions

made an important contribution. Psychoanalysis overall offered three main important

understandings, namely its emphasis on the relation of early development to

psychological structures, its recognition of how patterns of relationship derived from

early experience are at the root of most psychological distress and difficulty, and its understanding

of how these patterns are repeated in, and may be modified through, the patient–

therapist relationship.

Neither cognitive nor psychoanalytic models, however, appeared to acknowledge adequately

the extent to which individual human personality or the “Self” is formed and maintained

through relating to and communicating with others and through the internalization

of the meanings developed in such relationships, meanings which reflect the values and

structures of the wider culture. In CAT, the Self is seen to be developed, constituted, and

maintained through such interactions.

CAT

Is Research Based

The historic failure of psychodynamic therapists to evaluate seriously the efficacy and

effectiveness of their work and their resistance to doing so, partly for understandable reasons,

led in the past to a lack of serious support in the NHS (National Health Service) in the

UK for therapy in general. It appears also to have contributed, paradoxically, to the current

frequently indiscriminate and uninformed application of an “evidence-based” paradigm,

important as evidence is, that is crude and problematic given the multidimensional complexity

of mental disorder and treatments for it, and also given the increasing recognition

of “common factors” in effective therapies and treatments (Castonguay & Beutler, 2006;

Gabbard, Beck, & Holmes, 2005; Greenberg, 1991; Lambert, 2013; Norcross, 2011; Parry,

Roth, and Kerr, 2005; Roth & Fonagy, 1996; Wampold & Imel, 2015). The outcome research

that led on to the development of CAT pre-dated these developments, originating in a program

dating back to the 1960s that aimed to develop measures of dynamic change. While

the “formal” research base for CAT remains relatively slender (Calvert & Kellett, 2014), the

evolution of the model over the last 30 years has been accompanied by a continuous program

of largely small-scale but important research into both the process and outcome of

therapy, and also the use and evaluation of CAT in contextual or consultancy type

approaches, and this continues on an expanding scale. In addition, a number of more “formal”

randomized controlled trials have been successfully undertaken in recent years, notably

for “borderline personality”-type disorders (see Chapter 10). One consistent research

finding has been the apparently superior effectiveness of CAT in engaging “difficult” or

“hard to help” patients’ of whatever diagnosis, and retaining them in treatment (Calvert &

Kellett, 2014).

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

Despite the proliferation of treatment models, a considerable proportion of psychologically

distressed and damaged people in the UK (and in most other “developed” countries, let

alone in the “developing” world) do not have access to effective psychological treatment.

It should, however, be noted that Western models of mental disorders and treatment, of

whatever kind, are certainly not applicable without considerable re-conceptualization in

different socio-cultural contexts worldwide. In many socio-cultural settings, psychological

distress or disorder will be conceived of and responded to quite differently, or indeed not underpinning CAT, and its collaborative approach to meaning-making, may enable the

model to be used flexibly and helpfully in these other contexts (see Chapter 9). Emerging

experience with CAT around the world has certainly been encouraging (see Chapter 9).

Meantime CAT, by providing a therapy that can be offered at reasonable cost, while being

effective across a wide spectrum of “diagnoses” and a wide range of severity, is making a

contribution to meeting the needs of many patients in many, although significantly not all,

Western countries.

Most CAT therapists in the UK and elsewhere have worked in the NHS, or public health

services, as nurses, occupational therapists, social workers, psychologists, or psychiatrists.

We are, for the most part, experienced in, and largely committed to, work in the public sector.

We share a social perspective which assumes that psychotherapy services should take

responsibility for those in need in the populations we serve, and should not be reserved for

those individuals who happen to find (or buy) their way to the consulting room. It does,

however, appear, not surprisingly perhaps, that CAT is becoming a popular model of therapy

in the independent sector where, in some countries more than others, many therapists

make their living, and may offer an important provision of treatment. Here, its time-limited

but radical “whole-person” approach appeals to many clients who may have, possibly

serious, psychological difficulties. As a model of brief therapy it is of course, for very different

reasons, attractive to health insurance companies.

Our own social perspective and sense of commitment is not new. The following description

of the NHS was sent to demobilized servicemen in 1950: “It will provide you with all

medical, dental and nursing care. Everyone, rich, poor, man, woman or child, can use it or

any part of it. There are no charges except for a few special items … But it is not a charity.

You are all paying for it, mainly as taxpayers and it will relieve your money worries in times

of illness” (quoted in Wedderburn, 1996.) Despite the chronic underfunding of mental

health services and of psychotherapy in particular, both in the UK and elsewhere, we

believe that these principles can still be fought for and that CAT can contribute to their

realization.

CAT

Is Time-Limited

CAT is undertaken with an explicit focus on time limitation (not simply brevity), and on

what we have previously described as “ending well” (Ryle & Kerr, 2002). “Ending” from a

CAT perspective will be described more fully below in Chapters 2 and 7. Typically, however,

an initial CAT therapy contract would be for 16–24 sessions, given that for many such

a period is clearly clinically effective. A focus on time limitation also helps maintain focus

and addresses the major problem of therapeutic “drift,” or creating an unhelpful dependency

on the part of the patient, or indeed a mutual, ongoing narcissistic gratification for

both therapist and patient. In CAT, “ending well” is seen, therefore, as an important aim in

itself. However, therapy may need sometimes to be extended longer term in treating more

disturbed and damaged patients (see, e.g., discussion of “borderline”-type disorders, or

psychosis in Chapters 10 and 9). Therapy may also be shorter (e.g., 4–8 sessions) where the

threshold to consultation is low, for more focal problems, or for less distressed or less  damaged

patients. Some patient groups (e.g., adolescents) may find longer (or indeed any!)

formal therapies hard to engage with, and contracts may need to be modified collaboratively

and accordingly.

CAT

Offers a General Theory, Not Just a New Package

of Techniques

The book aims to describe and illustrate the methods, techniques, and tools developed in

CAT and its underlying theory. While largely concerned with individual therapy, applications

and uses in other modalities are considered, as are the wider implications for psychotherapy

theory. While some CAT techniques could be incorporated in other treatment

approaches (and vice versa), the model and the method involve much more than simply

application of a range of disparate techniques. Psychotherapy patients can make use of a

great many different psychotherapy techniques and there would be no point in simply

offering a new combination of these under a new label. So why do we need theory?

One robust finding from psychotherapy research is that therapists employing some clear,

credible theory generally do much better clinically (Castonguay & Beutler, 2006; Gabbard

et al., 2005; Lambert, 2013; Roth & Fonagy, 1996). And in health care more generally, plausible,

humane, and scientifically-based theories are also much more likely to facilitate

effective treatments, including those with a major psychosocial component. Another

robust finding is that the patient’s perception of the therapist as sympathetic and helpful is

associated with a good outcome (Castonguay & Beutler, 2006; Gabbard et al., 2005;

Greenberg, 1991; Lambert, 2013; Norcross, 2011; Roth & Fonagy, 1996; Wampold & Imel,

2015). In one important recent study, the strength of the therapeutic alliance in working

psychologically with patients suffering from psychotic disorders was noted to be the key

predictor of outcome, including prediction of adverse outcomes in association with a poor

therapeutic alliance (Goldsmith, Lewis, Dunn, & Bentall, 2015). This being so, a major part

of any therapy model must be concerned with how to achieve this and achieve a strong

“therapeutic alliance,” given that the central problem for many patients is that they are

often unwittingly damaging or disruptive in their personal relationships and, mostly for

very good reasons, are mistrustful and possibly destructive of offers of help from others.

Working successfully with these enactments is never easy but becomes increasingly important

and difficult as more disturbed patients are considered. Being helpful means more

than being nice, indeed it may frequently involve being very challenging. However, in CAT

this would always be undertaken in a benign, non-judgmental manner, even when clearly

drawing attention to the unhelpful consequences or effects of problematic enactments on

others, including on the therapist. This would be undertaken always with at least implicit

reference to previously agreed reformulations (maps and letters). This also has the effect of

depersonalizing and externalizing (or “defusing”) any problematic enactment beyond the

immediacy of the therapy relationship and, hopefully, restoring a collaborative dialog.

Such therapist “challenges” would be undertaken, therefore, in the context of, and contribute

toward, a positive therapeutic alliance. This is aided in turn by working through and

resolving such potential ruptures (“tear and repair” episodes) by means of the tools and the

relational style of the therapy (see Chapters 2 and 8).

A crucial quality required, therefore, is to respect the patient enough to be honest.

Techniques need to be understood in relation to the complex human issues that are at the

heart of therapy. Those used in CAT, whether adapted from other approaches or specific to

CAT, have, as their main aim, the development of the patient’s capacities to know, reflect

on, and ultimately control and replace unhelpful and distressing thoughts, actions, and

experiences, and to benefit from the internalization of a benign, healing therapy experience.

Other tools and techniques are designed to maintain the therapist’s adherence to the

methods and values of the approach (see Chapter 8). These provide a framework within

which a sincere and often intense working relationship can flourish. Practice embedded in

theoretical clarity must be combined with accurate empathy and compassion if therapists

are to be able to reach and maintain an understanding of their patients’ experiences and at

the same time be fully aware of their own role in enabling and encouraging change. These

may also assist in the inevitable dangers of collusion, whether with a patient in therapy, or

with pressures imposed by the context of service provision. The latter may include, for

example, pressures to get through waiting lists, avoid risks, or to achieve immediate, but

frequently superficial, clinical “results.”

CAT

Has Applications In Many Clinical and Other Settings

Overall, CAT by now offers, in our view, a robust, comprehensive framework within which

various helpful clinical treatments may be offered, and which also offers a means of reconceptualizing

many challenging problems (e.g., dementia, the “difficult” patient, “personality

disorder,” psychosomatic disorders, psychosis, and so forth; see Chapters 2 and 9).

We note that, inevitably, further major conceptual and clinical challenges exist for CAT, as

for any other current model, some of which are addressed elsewhere in the book. This book

is primarily addressed to those in training or already working therapeutically with psychologically

distressed or disturbed individuals, but also to those colleagues who, while not

“doing therapy,” have important clinical and other (e.g., managerial, judicial) responsibilities.

We believe that psychological and relational understandings should play a larger part

than is now the case throughout health services, such as the NHS, and beyond. This would

include management of groups such as psychiatric patients with major mental disorders,

forensic patients, the “mentally handicapped” or “intellectually disabled,” and also, for

example, in schools and in other social settings (see Chapter 9). We believe that psychotherapists

should ideally play a central role in supporting and training staff in these fields.

In all these fields experience is accumulating of applying CAT, and the model appears to be

accessible and useful to many patients and clinical staff (see Chapters 9 and 11). While both

psychodynamic therapies and cognitive therapy have contributed historically to these

fields, neither, in our view, adequately conceptualizes or mobilizes the therapeutic power

of the relationship between patients and those looking after them in a way that is clear,

structured, and, above all, clinically helpful. Importantly, CAT also appears to offer an

effective, relationally underpinned, structured, and containing framework within which

health professionals frequently feel empowered and “liberated” to enact, properly and

safely, the care and compassion that most bring to their work. For many this may be

repressed and disallowed in many present day, commodified, and highly defensive health care systems (see Lees, 2016; Lowenthal, 2015). Nonetheless, these qualities are recognized

to lie at the core of any effective health (or social) care (see Youngson, 2012). We believe

that CAT has a major generic contribution to make in these areas, offering a distinct, coherent,

and teachable model of social and interpersonal development, interaction, and wellbeing

that can enable individuals, staff groups, and services to respond helpfully, rather

than react collusively, to their patients, and which may also have important applications

outside clinical practice (see Chapters 9 and 11).