Cognitive Analytic Therapy (CAT) principles and practice

Cognitive analytic therapy (CAT) arose from integration of Cognitive and British Object Relations psychoanalysis. Recently ideas from Russian educational psychology and philosophy - Vygotsky and Bakhtin, have been included.

The model arose from a commitment to research into effective therapy, “From the NHS for the NHS”, on a time-limited (usually 16 or 24) basis. Emphasises therapist and pt collaboration in creating and applying descriptive (re)formulations of presenting problems.

Originally developed as a model of individual therapy CAT now offers a general theory of psychotherapy with applicability to a wide range of conditions in many different settings.

What is CAT?

Distinguishing Features

CAT differs from psychoanalytic therapy in its focus on the description of current problem psychological procedures rather than interpretation. Transference and counter-transference are used in the session to define current relationship and problem procedures.

How do CAT and CBT differ? CAT is rooted in cultural and social process vs. a monadic information processing model (but see Safran and Segal 1996 for a CBT interpersonal perspective). CAT is both interpersonal and intrapsychic, not one or the other.

CAT also emphasises the place and meaning of symptomatic, mood, behavioural and relationship problems within the context of the Pt’s overall meanings, values and self-organisation.

What does CAT involve?

Typically, agreed upon sessions total around 16 for average cases, 24 for more complex, up to 32. The process includes:

• Identifying the presenting problem e.g. - Low mood, Insecurity and feeling overwhelmed by life.
• Target Problem/Aims e.g. - to recognize and cope with my own feelings and emotions.
• Target Problem Procedures e.g. - the only way to cope with confusing feelings is to blank them off.
• Trap, dilemma, snag e.g. - this leads to me feeling emotionally distant from others.
• 4-6 sessions. Jointly arrived at re-formulation. Written letter. Agreed aims and problem procedures.

Diagrammatic re-formulation

Active phase of therapy: In session recognition of TPP. Transference, counter-transference. Reciprocal Role Procedures. Homework tasks. TPP description, recognition monitoring, revision. Exit. Develop meta-cognitive skills “an eye for an I” Explore and relate past life to present ( e.g. childhood abuse) Ventilate and explore hidden/unexpressed affect

Note: Healing power of relationship, zone of proximal development, role . Playing. Creative artwork, dreams etc

End of therapy: Joint goodbye letters. 10 week follow up session.

Case study one: Sue

Sue, 19 year old sexually attacked at 13. History of depression with anxiety, DSH and suicidality. 12 month CBT in C&F team. Referred for ongoing low mood, lack of motivation, bleak and helpless no plans for future. Comes from a perfectionistic family, high performing father, socially adept mother and “perfect little sister”.’

Taught’ to keep emotions inside, if you can’t do it right you’ve failed, if it goes wrong blame yourself not others. Blames herself and doesn’t want to discuss the attack, life is going wrong feels criticised, has given up and feels guilty. Finds it hard to express emotions so initial cognitive work a good place to start – likes keeping diaries and understanding what is going on.

However premorbid personality formation mitigates against a traditional approach – so makes sense to use in-session understanding of problem procedures. Emerging understanding of self helps to plan work on PTSD like symptoms. Good use of cognitive work combined with a dynamic understanding. Is now looking for work and getting on with life and socialising with friends.

Case study two: Jane

Jane, 34 yr old mixed race. Major depression, unresolved bereavement. Substance misuse anger management 15 yr psychiatric history. 2x major suicide attempts. 2x hospitalisation. Father violent alcoholic, left at 3yrs. Rebellious teenager. Mother completed suicide at 20 Disturbed relationship history. Shame and guilt. Initial denial of rage towards mother and father – turned against self. Greatly fears abandonment (very clingy to partner).

Dynamic between: Rebellious anger vs. abandonment. If speaks-up danger of being abandoned, so hides anger submits to authority, seethes with rage and turns anger against self. Recognition and management of anger has been the turning point.

Evidence Base for CAT - A complex area

CAT is an integrative therapy spanning: Cognitive, British OR psychotherapy and general psychotherapeutic technique. As a model CAT can be used as a “scaffolding” to incorporate other approaches: e.g. Motivational Interviewing – The Maudsley. Solution Focused Therapy. Often CAT therapists “skew” their approach V’s “purist approach”

However, see Ryle A (1991, 1995, 2002) for a general discussion of outcome research in psychotherapy and CAT. Roth A, and Fonagy P (1996) ‘What works for whom’. The evolution of the model over 25 years has been accompanied by a near continuous programme of relatively small-scale research into both the process and outcome of therapy.

The Scope of CAT

CAT does not work with diagnostic categories as such but rather a collaborative formulation (bio-psycho-social) of a pt’s problems and distress in the context of an understanding of their lives.

Ultimately CAT attempts to enlist the pt into higher level self-monitoring, but will work with cognitions, emotions and behaviours to this aim or as the case warrants.

Conditions and Complaints

CAT is considered a safe intervention for psycho-neurosis, e.g.: Panic and phobia – makes sense to use behavioural, or symptomatic approaches first

Generalised Anxiety disorder – CAT offers a more fundamental intervention than trad CBT, but this needs evaluation, see Kerr, I (2002)

Obsessional neuroses – see Kerr, I (2001)

Depression (mild to moderate. Usually + antidepressants). Dunn et al (1997), Maloney, Ray (2004)

Unresolved mourning. Kerr, I (1998).

Deliberate Self Harm. See Cowmeadow (1994, 1995) Sheared et al (2000) 1-3 session untrained CAT

Substance misuse, addictions – ‘The Clouds’. Leighton (1997)

Eating Disorders. See Treasure et al (1995) CAT vs. behavioural approach. Also 1997 The Maudsley unit

Post Traumatic Stress Disorder – especially with shame, interpersonal issues or personality issues. Probably best to use e.g. cognitive rescripting first.

Effects of CSA. Pollock (2001) ed

Gender and sexual issues. See Denman and De Vries (1998)

Somatisation

Complex Mental disorders

Personality Disorders. References are legion, but see Ryle, A. Leighton, T. and Pollock, P. (1997)

Management of Medical Conditions – e.g. poorly controlled diabetes, See Fosbury et al (1997). Asthma see Cluley et al (2000) Walsh (2000)

Old Age and Early Dementia, Hepple, Sutter and Ryder (1997)

Attachment Disorders, perhaps pre PD. See Chanen (2000) for an RCT

Learning Disability, King (2000) Carol, R (2005)

Autistic Spectrum Disorder

Psychosis. Kerr (2000) Kerr and Crowley (2001)

Also: Couples, Groups, Organisations