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EFPT Guidebook • EFPT Psychotherapy Guidebook Cognitive Analytic (CAT)

Ewa Debska, Karel Wildschut, Theodoros Koutsomitros

Published on: Jul 07, 2019 Updated on: Jul 09, 2019 EFPT Psychotherapy Guidebook • EFPT Psychotherapy Guidebook Cognitive Analytic Therapy (CAT)

Historic overview Cognitive Analytic Therapy (CAT) developed as a form of individual therapy in the 1980s at Guy’s and St Thomas’ Hospitals in London. The founder of the model, Dr. Anthony Ryle, proposed the integration of cognitive theory (particularly ideas from information processing, personal construct theory and the collaborative nature of the therapeutic relationship) and psychodynamic tradition, mainly object relations theory, introduced by the concept of ‘reciprocal roles’. CAT was formalized in 1984 as an independent (separate) form of psychotherapy.

The early days of CAT reach back to the 1960’ when National Health Service, warranting the equal and free access to healthcare for all people in the United Kingdom, was still a young institution. Dr. Ryle working as a GP in London observed, that many of his general practice patients suffered from non- psychotic psychological difficulties, but there was no provision to address their suffering. Whilst not having any formal training in or psychiatry, but having shared egalitarian values of the NHS, he commenced the development of the type of treatment suitable to public healthcare provision - a time-limited and easily accessible talking therapy.

Initially, CAT focused on people with neurotic symptomatology, later on it has attended to patients with more complex psychopathology, especially personality related difficulties, as a pragmatic and collaborative model.

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Cognitive Analytic Therapy grew out of a need to formulate patient problems in terms that were psychodynamically relevant but, at the same time, accessible to the patient and also permitted the assessment of aim achievement in therapy (Ryle, 1979). CAT has developed as a transdiagnostic model of therapy.

Theoretical developments

On the theoretical level, some of the early influences into CAT include George Kelly (repertory grid), Jerome Frank (common factors), (object relations), (). Dr. Ryle revised psychoanalytic ideas and eliminated assertions about unconscious processes. He proposed that the unconscious can be understood and shared with the patient in a non- threatening way in the process of Reformulation.

The influence of Vygotsky helped to describe the social formation of individual self-processes, and observational studies of early infant–caretaker interactions allowed adding the social and cultural context into the understanding of psychopathology (sign mediation theory by Vygotsky)

Ryle integrated the cognitive terms and developed three types of procedures (patterns) which drive patients’ thinking, feeling and behaving called traps, dilemmas, and snags. Interestingly these three patterns provided a conceptual synopsis of four traditions of psychotherapy. Trap descriptions represented a reformulation of problem descriptions that had been used in and . Dilemmas were a direct derivation of repertory grid studies when applied to psychotherapy clients. Snags represented a useful way of illustrating unconscious guilt and problems with envy, commonly discussed in the psychoanalytic tradition. Snags in current relationships were again events that systemic family therapists were interested in.

Ryle proposed a model of the self and relationships influenced by Klein’s object relations theories, with the understanding of how interpersonal development and personality structure share a common origin. With the evolution of ideas, more emphasis has arisen on the development of CAT as a dialogic therapy, incorporating ideas of the social formation of self after Vygotsky and the dialogical concept of the self by Bakhtin. CAT has been driving away from the psychodynamic idea of internal mental apparatus as the drive to the functioning within the relationship, to arrive at the stance, where the dialogue is a root to the development of self and a base to the patterns of interactions with other people (reciprocal roles) but also within the person (self to self, self to other). Both the person's structure of personality and the patterns of his interpersonal behavior and experience are seen in CAT to be shaped by the same early infantile experience (Ryle, 1990)

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In 1989 Arabella Adamopoulou, Georgios Garyfallos and Stamatis Ntonias were the first that introduce CAT outside British NHS. They have established CAT services in Greece at two public community mental health services with great success. A few years later they also create a comprehensive CAT training programme for trainees at Thessaloniki, Greece. On the other end of

Europe, in Finland, Mikael Leiman used Guy’s & St Thomas Hospital NHS Foundation CAT for the first time in private sector. Trust

In the 1990’ the influence of Mikael Leiman, from University of Eastern Finland, have further established a dialogical perspective on the self by emphasizing the interplay of biological and social influences on development. The nature-nurture controversy has been largely resolved by an understanding of the way in which human biological evolution, occurring in an evolving social context, has resulted in the person’s extreme openness to the social formation and in the adverse environment of early childhood can result in developing the pathological patterns resistive to revision and causing psychological suffering.

Description of CAT practice What does the practice of Cognitive Analytic Therapy have to offer in addition to common therapy factors?

Cognitive Analytic Therapy, a brief, time-limited therapy, is delivered over 16 or 24 50-minute sessions, plus up to three follow-up sessions, with the first follow-up taking place at 3 months after completion of the contracted sessions. Establishing the therapeutic alliance is of utmost importance, as it is highly influential in the outcome of therapy.

CAT is first and foremost a relational therapy, with a distinct collaborative style between client and therapist. It is a transdiagnostic intervention suitable for problems such as Depression, Anxiety disorders (e.g. OCD, GAD, PTSD...), personality disorders and to help someone cope with significant life changes brought on by illness (e.g. Obesity, Diabetes, Cancer, life-changing Surgery) or ageing.

Together, the client and CAT therapist explore the patient's life experiences, with the aim to discover the main problems in relationships (self-to-self and/or self-to-other) - the traps, snags and dilemmas.

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These problems can result in suspended or delayed decision-making or self-defeating attempts to solve their problems.

These impairments in relationship patterns repeat over time, which can lead to unhappiness and frustrations.

New insights gained in the process of therapy present an opportunity for change and improved self- compassion.

As an example, someone might struggle with either/or decisions or feel trapped between a rock and a hard place, and then end up not making decisions, which in turn may lead to regret and frustration.

The 3 types of problems are:

a) Snags (avoiding appropriate choices or action despite knowing what is the right thing to do), because of feared consequences.

b) Traps (going round in circles), where the client uses a strategy that leads to consequences which confirm faulty beliefs.

c) Dilemmas (false dichotomies; either/or problems).

d) Significant shifting mood states may also contribute to relationship problems.

A uniquely CAT tool, the Psychotherapy file, is used as an aid in identifying them. It consists of lists of simple questions with a corresponding rating. It is available in its standard (ACAT) format, or in alternative versions adapted to clients with intellectual disabilities or acquired language problems.

There are three distinct phases in CAT therapy: a) Reformulation, b) Recognition and c) Revision. a) In the Reformulation phase, a history is taken, and a genogram constructed, and a timeline of significant life events is drawn and annotated.

An initial rating scale is often applied, such as the CORE-34. This will be repeated at the end of therapy and at follow up, to gauge therapeutic changes.

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This stage is done in a curious and collaborative way, with no pressure to know absolutely everything, thereby creating tolerance for knowledge gaps and errors, and maintaining the opportunity for refining of information as they emerge in the course of therapy. Some forms of information may well be suppressed or merely unavailable in this phase, as in some cases the client may not remember or yet be ready to make certain disclosures.

CAT therapists are mindful of working within the client's area of competence, the so-called zone of proximal development, or ZPD.

Bringing forth unpleasant or suppressed information may elevate arousal; therefore it is essential to try to stay within the client's window of tolerance. Over-arousal is countertherapeutic and worth avoiding if possible. In addition to establishing and maintaining a safe holding environment, the therapist may need to use grounding techniques, mindfulness or de-escalation strategies to help the client return to their window of tolerance.

CAT uses the evolving client/therapist relationship actively as a tool by which a more sustainable and compassionate relationship could be templated, for application outside of the therapy setting. , unrevised reciprocal roles and role procedures are likely to manifest in this relationship, and the therapist will bring this into focus, to aid insight and learning.

At the end of the Reformulation stage, the therapist will aim to integrate the relevant information gained via questioning, reflecting and mapping -the process of making relational diagrams with circles, boxes, and arrows. The link between early life relational patterns and current relational problems are highlighted and clarified, by mutual agreement. Arrows are used to indicate processes, as well as exits from unwanted outcomes.

The client is actively encouraged to engage with the map.

The integration of these elements is expressed through the reformulation (RF) letter; a candid, honest and sensitive letter in which the therapist aims to state the problems and relational patterns and procedures. A response letter from the client may be invited, and although potentially helpful, is not absolutely essential.

The Reformulation letter will form the basis of constructing a grand diagram of the impaired relational roles and the procedures which maintain them. An observing eye is drawn on the map- this serves as a prompt for the client to pause and adopt a helicopter view, or outsider's perspective to what they're currently experiencing in the moment: thoughts, feelings and mood states. This grand map is referred to as the Sequential Diagrammatic Reformulation (SDR), and the client is encouraged to participate in its evolvement, in a clear demonstration of the collaborative nature of CAT.

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Throughout therapy, there will be exits clearly marked by using arrows. b) During the Recognition phase, the client will be encouraged to notice the problem patterns. The SDR will help guide insights here. c) In the Revision stage, based on the RF and SDR, the client is encouraged to identify target problem procedures ( TPP) for change and weekly revision.

Rating sheets and compassionate diaries can help to inform the process.

In the penultimate session, a goodbye letter from the therapist is given, and responses noted and discussed, once again using the SDR for guiding context. The client may wish to write a letter in response.

Endings may evoke strong responses in the client, especially if this is something they have grappled with before.

The client and therapist meet again after three months for one session of revision.

At this stage hopefully, the client continues to use and perhaps internalised the SDR for the continuous revision of the TPP's.

Indications Initially CAT was used mainly for patients with personality disorders particularly borderline type. However as CAT evolved over the years it proved its efficacy in nearly every psychiatric disorder. Therefore we strongly recommend to use CAT in every adult that does not meet the criteria for a substance use disorder or psychotic spectrum disorders. Nevertheless, there are several CAT subtypes that are being developed that can even be used in these disorders.

Efficacy In comparison to CBT, there is a limited but growing evidence base for the effectiveness of CAT.

There are several high-quality small studies which demonstrate the effectiveness of CAT in Depression and BPD, and there are a few systematic reviews.

The well-defined structure of CAT accommodates the use of other therapeutic modalities without necessarily impairing its effectiveness or obscuring its character.

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Comments from expert “Change is a personal matter. I freely choose my action taking responsibility for it, in a context of parity and reciprocity with the other.” Anthony Ryle , founder of Cognitive Analytic Therapy

Comments from trainee “So far I have been trained in seven different psychotherapeutic approaches and I have seen the biggest difference between sessions after I share the reformulation letter to my very first CAT case. I would strongly recommend CAT training especially to new therapists because it provides them with a cognitive template but also a psychodynamic point of view.” Theodoros Koutsomitros, EFPT Psychotherapy guidebook project leader

Books &Manuals 1. Hepple, J. and Sutton, L. (2004). Cognitive Analytic Therapy and Later Life: A New Perspective on Old Age. Routledge.

2. McCormick, E (2017). Change for the Better: Self Help Through Practical Psychotherapy 5th Ed. SAGE Publications Ltd.

3. Ryle, A. (1991). Cognitive Analytic Therapy - Active Participation in Change: New Integration in

4. Ryle, A. and Kerr, I. (2002). Introducing Cognitive Analytic Therapy: Principles and Practice.

5. Allison, D. and Denman, C. (2001). In Mace, C., Moorey, S. and Roberts, B. (eds) Evidence in the psychological : A critical guide for practitioners. Comparing models in and cognitive analytic therapy. (pp 141-153). London Routledge

6. Wilde McCormick E. (2000). In Wellings N. and Wilde McCormick E. Transpersonal psychotherapy: theory and practice. The Therapeutic Relationship. (pp 20-51). Continuum

7. Pollock, P. (2001). Cognitive analytic therapy for adult survivors of .... https://www.worldcat.org/title/cognitive-analytic-therapy-for-adult-survivors-of-childhood-abuse- approaches-to-treatment-and-case-management/oclc/50745273

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Journals recommendations *Reformulation, published by 1984 - to date, quarterly

*International Journal of Cognitive Analytic Therapy and Relational mental health - published by ICATA Vol 1 2017, Vol 2 2018 - annually

Associations International :

International Cognitive Analytic Therapy Association

National societies:

Finland: Kognitiivis-analyyttinen psykoterapiayhdistys: Greece: Πανελλήνια Εταιρεία Γνωστικής Αναλυτικής Ψυχοθεραπείας

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New Zealand: New Zealand Cognitive Analytic Therapy Spain: Asociación de Psicoterapia Cognitivo-Analítica de España Italy: L’associazione italiana per la CAT United Kingdom: Association for Cognitive Analytic Therapy

Contact practitioners for other countries, where the society has not been established

India: [email protected]

France: [email protected]

References 1. Kellett S, Bennett D, Ryle T, Thake A. Clin Psychol Psychother. 2013 May-Jun;20(3):216-25. doi: 10.1002/cpp.796. Epub 2011 Nov 23. 2. Br J Psychiatry. 2013 Feb;202:129-34. doi: 10.1192/bjp.bp.112.108670. Epub 2012 Dec 6.CAT for PD: RCT 3. Clin Psychol Psychother. 2017 Nov;24(6):1263-1272. doi: 10.1002/cpp.2090. Epub 2017 May 3 Change & EXITS 4. Wampold BE. How important are the common factors in psychotherapy? An update. World Psychiatry. 2015;14(3):270-7. 5. Cognitive analytic therapy for adult survivors 6. “ Integrative Systematic Review of Psychotherapy Research: Trends and Methodological Implications.” PLoS One, vol. 14, no. 2, Public Library of Science, Feb. 2019, p. e0212575. 7. Fosbury, J. A., Bosley, C.M., Ryle, A., Sonksen, P. H., & Judd, S. L. (1997). A trial of cognitive analytic therapy in poorly controlled type I patients. Diabetes Care, 20, 959–964. doi:10.2337/diacare. 20.6.959 8. Garyfallos, G., Adamopoulous, A., Karastergious, A., Voikli, M., Zlatanos, D. and Tsifida, S. (2002). Evaluation of cognitive-analytic therapy (CAT) outcome: A 4-8 year follow up. The European Journal of Psychiatry, 16/4, pp 197-209 9. Dare, C., Eisler, I., Russell, G., Treasure, J., & Dodge, L. (2001). Psychological therapies for adults with anorexia nervosa: Randomised controlled trial of out-patient treatments. British Journal of Psychiatry, 178, 216–221. doi:10.1192/bjp.178.3.216 10. Hepple, J (2012). Cognitive Analytic Therapy in a Group: Reflections on a Dialogic Approach. British Journal of Psychotherapy, 28 part 4, pp 474-495. 11. Kellett, S. (2005). The treatment of Dissociative Identity Disorder with cognitive analytic therapy: Experimental evidence of sudden gains. Journal of Trauma & Dissociation, 6, 55 –81. doi:10. 1300/J229v06n03_03

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12. NICE clinical guideline 78 (2009). Borderline personality disorder: Treatment and management. London, UK: National Institute for Health and Clinical Excellence. 13. Ryle, A., & Golynkina, K. (2000). Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: Factors associated with outcome. British Journal of , 73, 197–210. doi:10.1348/000711200160426 14. Yeates, G., Hamill, M., Sutton, L., Psaila, K., Gracey, F., Mohamed, S., & O’Dell, J. (2008). Dysexecutive problems and interpersonal relating following frontal brain injury: Reformulation and compensation in cognitive analytic therapy (CAT). Neuro-, 10, 43 –58. 15. Garyfallos G., Adamopoulou A.,Mastrogianni A. et al. Evaluation of Cognitive Analytic Therapy (CAT) outcome in Greek psychiatric outpatients. Eur. J. Psychiatric,12:167-179,1998 16. Mikael Leiman Manuscript of the paper published in the International Journal of Short Term Psychotherapy, 9, 67-81, 1994. 17. Anthony Ryle, Frames and cages: The repertory grid approach to human understanding Unknown Binding – 1975 18. Jerome David Frank and Healing: Comparative Study of Psychotherapy ISBN 10: 0805204709 ISBN 13: 9780805204704 Schocken Books, 1975 19. Hepple, J., The witness and the judge, Cognitive Analytic Therapy in later life: the case of Maureen. The British Journal of Psychotherapy Integration. 2006 2(2): 21-27 20. Anthony Ryle, Stephen Kellett, Jason Hepple, Rachel Calvert Cognitive analytic therapy at 30 Advances in Psychiatric Treatment, Volume 20, Issue 4 July 2014 , pp. 258-268

Affiliations Ewa Debska, London, UK Karel Wildschut, London UK Theodoros Koutsomitros, London UK and Thessaloniki, Greece

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