Cognitive Analytic Therapy
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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 The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...
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).


Sources and origins

As the name implies, cognitive analytic therapy (CAT) evolved as an integrative therapy based on ideas from
cognitive Cognition refers to "the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, thought ...
and analytic therapies. CAT was also influenced in part by George Kelly's constructivism. Kelly had developed
personal construct theory Within personality psychology, personal construct theory (PCT) or personal construct psychology (PCP) is a theory of personality and cognition developed by the American psychologist George Kelly in the 1950s.For example: (first published 1955); ...
and the repertory grid method, and Kelly's approach to therapy "offered a model of nonauthoritarian practice" that psychotherapist Anthony Ryle found appealing. 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. 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 Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one therapeutic approach within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Co ...
practice (such as goal setting and
Socratic questioning Socratic questioning (or Socratic maieutics) was named after Socrates. He used an educational method that focused on discovering answers by asking questions from his students. According to Plato, who was one of his students, Socrates believed t ...
) 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 Soviet psychologist
Lev Vygotsky Lev Semyonovich Vygotsky (russian: Лев Семёнович Выго́тский, p=vɨˈɡotskʲɪj; be, Леў Сямёнавіч Выго́цкі, p=vɨˈɡotskʲɪj; – June 11, 1934) was a Soviet psychologist, known for his work on psy ...
and Russian philosopher
Mikhail Bakhtin Mikhail Mikhailovich Bakhtin ( ; rus, Михаи́л Миха́йлович Бахти́н, , mʲɪxɐˈil mʲɪˈxajləvʲɪdʑ bɐxˈtʲin; – 7 March 1975) was a Russian philosopher, literary critic and scholar who worked on literary theo ...
. From Vygotsky come concepts such as the zone of proximal development (ZPD) and
scaffolding Scaffolding, also called scaffold or staging, is a temporary structure used to support a work crew and materials to aid in the construction, maintenance and repair of buildings, bridges and all other man-made structures. Scaffolds are widely use ...
. 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 The twentieth century Russian philosopher and literary theorist Mikhail Bakhtin wrote extensively on the concept of ''dialogue''. Although Bakhtin's work took many different directions over the course of his life, dialogue always remained the "mast ...
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.


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.


Evidence base

CAT has been the subject of a number of research studies published in
peer-reviewed journals An academic journal or scholarly journal is a periodical publication in which scholarship relating to a particular academic discipline is published. Academic journals serve as permanent and transparent forums for the presentation, scrutiny, and ...
. These include
randomised controlled trial A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical t ...
s (RCTs) and other kinds of study. The approach is too new for any
systematic review A systematic review is a scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from published studies on t ...
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 The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care in England that publishes guidelines in four areas: * the use of health technologies within ...
(NICE). However NICE has recommended that there should be further research of CAT, for example in
borderline personality disorder Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong ...
. 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. A review of CAT looking back over the 30 years to its beginnings 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 In statistics, an effect size is a value measuring the strength of the relationship between two variables in a population, or a sample-based estimate of that quantity. It can refer to the value of a statistic calculated from a sample of data, the ...
across all studies was 0.83 (95%
confidence interval In frequentist statistics, a confidence interval (CI) is a range of estimates for an unknown parameter. A confidence interval is computed at a designated ''confidence level''; the 95% confidence level is most common, but other levels, such as ...
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 Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by underweight, low weight, Calorie restriction, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thi ...
. It has also been shown to produce significant improvements in adolescents with a diagnosis of
borderline personality disorder Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong ...
. 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. CAT has also been shown to improve patients' management of
diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
. 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.


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 psychotherapy. Case series and single case studies have also been published describing the use of CAT in: * Depression * Dissociative psychosis * The treatment of offenders * Brain injury * Deliberate
self-harm Self-harm is intentional behavior that is considered harmful to oneself. This is most commonly regarded as direct injury of one's own skin tissues usually without a suicidal intention. Other terms such as cutting, self-injury and self-mutilati ...
*
Dissociative identity disorder Dissociative identity disorder (DID), better known as multiple personality disorder or multiple personality syndrome, is a mental disorder characterized by the presence of at least two distinct and relatively enduring personality states. The d ...
* Histrionic personality disorder *
Panic disorder Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, ...
* Psychological problems in multiple sclerosis * With carers of people with
dementia Dementia is a disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease. The symptoms involve progressive impairments in memory, thinking, and behavior, which negatively affe ...
* Morbid jealousy *
Borderline personality disorder Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong ...
*
Paranoid personality disorder Paranoid personality disorder (PPD) is a mental illness characterized by paranoid delusions, and a pervasive, long-standing suspiciousness and generalized mistrust of others. People with this personality disorder may be hypersensitive, easily ...
* Survivors of
child sexual abuse Child sexual abuse (CSA), also called child molestation, is a form of child abuse in which an adult or older adolescent uses a child for sexual stimulation. Forms of child sexual abuse include engaging in sexual activities with a child (whet ...


Notes


Further reading

* Ryle, A (1990) ''Cognitive Analytic Therapy: Active Participation in Change''. Chichester: John Wiley & Sons. * Ryle, A (1995). ''Cognitive Analytic Therapy: Developments in Theory and Practice.'' Chichester: John Wiley & Sons. * Ryle, A (1997). ''Cognitive Analytic Therapy and Borderline Personality Disorder: The Model and the Method.'' Chichester: John Wiley & Sons. * Ryle, A & Kerr, I (2002). ''Introducing Cognitive Analytic Therapy: Principles and Practice.'' Chichester: John Wiley & Sons.


External links


Association for Cognitive Analytic Therapy
{{Psychotherapy Borderline personality disorder Cognitive therapy Constructivism (psychological school) Integrative psychotherapy