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).[1]:244–245
Ryle, a general practitioner and analytically trained psychotherapist, was undertaking research into psychotherapy practice using repertory grids in the 1970s. He found that the themes eventually addressed in analytic work were in fact present in transcripts from the very first sessions.[2]:196 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. In a 1979 paper, 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.[3] 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.[4]
Subsequently, CAT has been influenced by ideas from the work of Soviet psychologist Lev Vygotsky and Russian philosopher Mikhail Bakhtin. From Vygotsky come concepts such as the zone of proximal development (ZPD) and scaffolding.[5] 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.[6]
In practice
An example of two different reciprocal roles which might be identified during the reformulation phase of CAT.A procedural diagram which might be drawn during the recognition phase of CAT.
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.[1]:247
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.[1]:248
Evidence base
CAT has been the subject of a number of research studies published in peer-reviewed journals. These include randomised controlled trials (RCTs) and other kinds of study. The approach is too new for any systematic reviews 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.[7] A review of CAT research evidence published in 2014 reported that although there were five randomised controlled trials published, research evidence into the approach was dominated by small-scale, practice-based studies. These tended to be with complex and severe clinical groups; 44% of studies reviewed involved personality disorder.[8] A review of CAT looking back over the 30 years to its beginnings[9] contains a meta-analysis of 11 outcome studies of CAT. The overall number of patients treated in the studies was 324 and the average effect size across all studies was 0.83 (95% confidence interval 0.66–1.00). This is a large effect and suggests that CAT is efficacious in treating mental health problems.
Evidence from randomised controlled trials
CAT has been shown to lead to subjective improvement in people with anorexia nervosa.[10][11] It has also been shown to produce significant improvements in adolescents with a diagnosis of borderline personality disorder.[12] A different trial suggested that CAT for adult patients with personality disorders also showed improvements in symptoms and interpersonal functioning, as against controls who deteriorated on these measures.[13] CAT has also been shown to improve patients' management of diabetes.[14] An RCT of the use of a CAT-informed assessment for young people who had self-harmed suggested that it was effective in increasing rates of attendance at community follow-up.[15]
↑ Vygotsky, L. S. (1987). Thinking and speech. In L. S. Vygotsky, Collected works (vol. 1, pp. 39–285) (R. Rieber & A. Carton, Eds; N. Minick, Trans.). New York: Plenum. (Original works published in 1934, 1960).
↑ Leiman, M. (2004). Dialogical sequence analysis. In: H. J. M. Hermans & G. Dimaggio (eds.), The dialogical self in psychotherapy (pp. 255–270). London: Brunner-Routledge.
↑ Fosbury, J; Bosley, C; Ryle, A; Sonksen, P; Judd, S (1997). "A trial of cognitive analytic therapy in poorly controlled type 1 diabetes patients". Diabetes Care. 20 (6): 959–964. doi:10.2337/diacare.20.6.959. PMID9167106. S2CID26113327.
↑ Ougrin, D.; Zundel, T.; Ng, A.; Banarsee, R.; Bottle, A.; Taylor, E. (2011). "Trial of therapeutic assessment in London: randomised controlled trial of therapeutic assessment versus standard psychosocial assessment in adolescents presenting with self-harm". Archives of Disease in Childhood. 96 (2): 148–153. doi:10.1136/adc.2010.188755. PMID21030367. S2CID5637686.
↑ Mann, J & Goldman, R (1982). A casebook in time-limited psychotherapy. New York: McGraw Hill.
↑ Marriott, M; Kellett, S (2009). "Evaluating a cognitive analytic therapy service: practice-based outcomes and comparisons with person-centred and cognitive behavioural therapies". Psychology and Psychotherapy: Theory, Research and Practice. 82 (Pt 1): 57–72. doi:10.1348/147608308X336100. PMID18759998.
↑ Bennett, D (1994). "Readiness to change—the impact of reformulation: a case example of cognitive analytic therapy". International Journal of Short-Term Psychotherapy. 9: 83–91.
↑ Brockman, B.; Poynton, A.; Ryle, A.; Watson, J. P. (1987). "Effectiveness of time-limited therapy carried out by trainees: Comparison of two methods". British Journal of Psychiatry. 151 (5): 602–610. doi:10.1192/bjp.151.5.602. PMID3446303. S2CID28993830.
↑ Kellett, S (2007). "A time series evaluation of the treatment of histrionic personality disorder with cognitive analytic therapy". Psychology and Psychotherapy: Theory, Research and Practice. 80 (3): 389–405. doi:10.1348/147608306X161421. PMID17877864.
↑ Tzouramanis, P.; etal. (2010). "Evaluation of cognitive-analytic therapy (CAT) outcome in patients with panic disorder". Psychiatrike. 21 (4): 287–293. PMID21914611.
↑ Adamopoulou, A (2006). An evaluation of cognitive analytic therapy for psychological problem in patients with multiple sclerosis. Multiple Sclerosis, vol. 12, supplement 1, p. S106.
↑ Hamill, M.; Mahony, K. (2011). "'The long goodbye': cognitive analytic therapy with carers of people with dementia". British Journal of Psychotherapy. 27 (3): 292–304. doi:10.1111/j.1752-0118.2011.01243.x.
↑ Kellett, S.; Totterdell, P. (2013). "Taming the green-eyed monster: temporal responsivity to cognitive behavioural and cognitive analytic therapy for morbid jealousy". Psychology and Psychotherapy: Theory, Research and Practice. 86 (1): 52–69. doi:10.1111/j.2044-8341.2011.02045.x. PMID23386555.
↑ Kellett, S.; Bennett, D.; Ryle, T.; Thake, A. (2013). "Cognitive analytic therapy for borderline personality disorder: therapist competence and therapeutic effectiveness in routine practice". Clinical Psychology and Psychotherapy. 20 (3): 216–225. doi:10.1002/cpp.796. PMID22109975.
↑ Ryle, A.; Golynkina, K. (2000). "Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: factors associated with outcome". British Journal of Medical Psychology. 73 (2): 197–210. doi:10.1348/000711200160426. PMID10874479.
↑ Wildgoose, A.; Clarke, S.; Waller, G. (2001). "Treating personality fragmentation and dissociation in borderline personality disorder: a pilot study of the impact of cognitive analytic therapy". British Journal of Medical Psychology. 74: 47–55. doi:10.1348/000711201160795.
↑ Clarke, S.; Llewelyn, S. (1994). "Personal constructs of survivors of childhood sexual abuse receiving cognitive analytic therapy". British Journal of Medical Psychology. 67 (3): 273–289. doi:10.1111/j.2044-8341.1994.tb01796.x. PMID7803319.
↑ Clarke, S.; Pearson, C. (2000). "Personal constructs of male survivors of childhood sexual abuse receiving cognitive analytic therapy". British Journal of Medical Psychology. 73 (2): 169–177. doi:10.1348/000711200160408. PMID10874477.
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.
Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience.
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including art therapy, cognitive behavioral therapy or interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilized as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.
Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive attention-seeking behaviors, usually beginning in early adulthood, including inappropriate seduction and an excessive desire for approval. People diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic, extroverted and flirtatious.
Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.
Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, overgeneralization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies.
Psychodynamic psychotherapy and psychoanalytic psychotherapy are two categories of psychological therapies. Their main purpose is revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. The terms "psychoanalytic psychotherapy" and "psychodynamic psychotherapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies. Psychodynamic psychotherapy is evidence-based; the effectiveness of psychoanalysis and its relationship to facts is disputed.
The Dodo bird verdict is a controversial topic in psychotherapy, referring to the claim that all empirically validated psychotherapies, regardless of their specific components, produce equivalent outcomes. It is named after the Dodo character in Alice in Wonderland. The conjecture was introduced by Saul Rosenzweig in 1936, drawing on imagery from Lewis Carroll's novel Alice's Adventures in Wonderland, but only came into prominence with the emergence of new research evidence in the 1970s.
The method of levels (MOL) is a cognitive approach to psychotherapy based on perceptual control theory (PCT). Using MOL, the therapist aims to help the patient shift his or her awareness to higher levels of perception in order to resolve conflicts and allow reorganization to take place.
Child psychotherapy, or mental health interventions for children refers to the psychological treatment of various mental disorders diagnosed in children and adolescents. The therapeutic techniques developed for younger age ranges specialize in prioritizing the relationship between the child and the therapist. The goal of maintaining positive therapist-client relationships is typically achieved using therapeutic conversations and can take place with the client alone, or through engagement with family members.
Mentalization-based treatment (MBT) is an integrative form of psychotherapy, bringing together aspects of psychodynamic, cognitive-behavioral, systemic and ecological approaches. MBT was developed and manualised by Peter Fonagy and Anthony Bateman, designed for individuals with borderline personality disorder (BPD). Some of these individuals suffer from disorganized attachment and failed to develop a robust mentalization capacity. Fonagy and Bateman define mentalization as the process by which we implicitly and explicitly interpret the actions of oneself and others as meaningful on the basis of intentional mental states. The object of treatment is that patients with BPD increase their mentalization capacity, which should improve affect regulation, thereby reducing suicidality and self-harm, as well as strengthening interpersonal relationships.
Transference focused psychotherapy (TFP) is a highly structured, twice-weekly modified psychodynamic treatment based on Otto F. Kernberg's object relations model of borderline personality disorder. It views the individual with borderline personality organization (BPO) as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.
Peter Fonagy, is a Hungarian-born British psychoanalyst and clinical psychologist. He studied clinical psychology at University College London. He is a Professor of Contemporary Psychoanalysis and Developmental Science Head of the Division of Psychology and Language Sciences at University College London, Chief Executive of the Anna Freud Centre, and a training and supervising analyst in the British Psycho-Analytical Society in child and adult analysis. His clinical interests center on issues of borderline psychopathology, violence, and early attachment relationships. His work attempts to integrate empirical research with psychoanalytic theory. He has published over 500 papers, and 270 chapters and has authored 19 and edited 17 books.
A clinical formulation, also known as case formulation and problem 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 adjunct or alternative approach to the more categorical approach of psychiatric diagnosis. In clinical practice, formulations are used to communicate a hypothesis and provide framework for developing the most suitable treatment approach. It is most commonly used by clinical psychologists and is deemed to be a core component of that profession. Mental health nurses, social workers, and some psychiatrists may also use formulations.
Common factors theory, a theory guiding some research in clinical psychology and counseling psychology, proposes that different approaches and evidence-based practices in psychotherapy and counseling share common factors that account for much of the effectiveness of a psychological treatment. This is in contrast to the view that the effectiveness of psychotherapy and counseling is best explained by specific or unique factors that are suited to treatment of particular problems.
Supportive psychotherapy is a psychotherapeutic approach that integrates various therapeutic schools such as psychodynamic and cognitive-behavioral, as well as interpersonal conceptual models and techniques.
The mainstay of management of borderline personality disorder is various forms of psychotherapy with medications being found to be of little use.
Schema therapy was developed by Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies. Schema therapy is an integrative psychotherapy combining theory and techniques from previously existing therapies, including cognitive behavioral therapy, psychoanalytic object relations theory, attachment theory, and Gestalt therapy.
Anthony Ryle, was an English medical doctor. He studied at Oxford and University College Hospital, qualified in medicine in 1949. He worked as a General Practitioner in North London, then directed the University of Sussex Health service, and later worked as a Consultant Psychotherapist in St. Thomas' Hospital, London, from 1983 to 1992. While in general practice he realised that a lot of his patients were presenting with psychological problems or distress, which he confirmed by epidemiological studies. He developed interest in psychotherapy and later developed a time limited therapy which can be offered in the National Health Service. This type of therapy is known as cognitive analytic therapy. In the 1960s he moved to Kingston, on the outskirts of Lewes, East Sussex with his wife and four children.
Eclectic psychotherapy is a form of psychotherapy in which the clinician uses more than one theoretical approach, or multiple sets of techniques, to help with clients' needs. The use of different therapeutic approaches will be based on the effectiveness in resolving the patient's problems, rather than the theory behind each therapy.
This page is based on this Wikipedia article Text is available under the CC BY-SA 4.0 license; additional terms may apply. Images, videos and audio are available under their respective licenses.
