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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Introduces the principles and applications of cognitive analytic therapy (CAT)
Cognitive Analytic Therapy (CAT) is an increasingly popular approach to therapy that is now widely recognised as a genuinely integrative and fundamentally relational model of psychotherapy. This new edition of the definitive text to CAT offers a systematic and comprehensive introduction to its origins, development, and practice. It also provides a fully updated overview of developments in the theory, research, and applications of CAT, including clarification and re-statement of basic concepts, such as reciprocal roles and reciprocal role procedures, as well as extensions into new areas of expertise.
Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health, 2nd Edition starts with a brief account of the scope and focus of CAT and how it evolved and explains the main features of its practice. It next offers a brief account of a relatively straightforward therapy to give readers a sense of the unfolding structure and style of a time-limited CAT. Following that are chapters that consider the normal and abnormal development of the Self and that introduce influential concepts from Vygotskian, Bakhtinian and developmental psychology. Subsequent chapters describe selection and assessment; reformulation; the course of therapy; the ‘ideal model’ of therapist activity and its relation to the supervision of therapists; applications of CAT in various patient groups and settings and in treating personality type disorders; use in ‘reflective practice'; a CAT perspective on the ‘difficult’ patient; and systemic and ‘contextual’ approaches.
- Presents an updated introduction and overview of the principles and practice of cognitive analytic therapy (CAT)
- Updates the first edition with developments from the last decade, in which CAT theory has deepened and the approach has been applied to new patient groups and extended far beyond its roots
- Includes detailed, applicable ‘how to’ descriptions of CAT in practice
- Includes references to CAT published works and suggestions for further reading within each chapter
- Includes a glossary of terms and several appendices containing the CAT Psychotherapy File; a summary of CAT competences extracted from Roth and Pilling; the Personality Structure Questionnaire; and a description of repertory grid basics and their use in CAT
- Co-written by the creator of the CAT model, Anthony Ryle, in collaboration with leading CAT practitioner, trainer, and researcher, Ian B. Kerr
Introducing Cognitive Analytic Therapy is the definitive book for CAT practitioners and CAT trainees at skills, practitioner, and psychotherapy levels. It should also be of considerable interest and relevance to mental health professionals of all orientations, including clinical psychologists, psychiatrists, counselors, mental health nurses, to those working in forensic and various institutional settings, and to a range of other health care and social work professionals.
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Table of Contents
Cover
List of Figures
About the Authors
Preface to the Second Edition
Preface to the Second Edition
Acknowledgments
The Structure of the Book
Further Information
1 The Scope and Focus of CAT
Summary
CAT Is an Integrated Model
CAT Is a Collaborative Therapy
CAT Is Research Based
CAT Evolved from the Needs of Working in the Public Sector and Remains Ideally Suited To It
CAT Is Time‐Limited
CAT Offers a General Theory, Not Just a New Package of Techniques
CAT Has Applications In Many Clinical and Other Settings
2 The Main Features of CAT
Summary
Background
The Early Development of CAT Practice
The Theoretical Model
The Development of a Vygotskian and Bakhtinian Object Relations Theory
The Development of the Basic Model of Practice
The Development of Sequential Diagrammatic Reformulation (“Mapping”)
The Course of Therapy
Time Limits and Ending
The Clinical Aims of CAT
3 The CAT Model of Development of the Self
Summary
The CAT Concept of Self
Neuroscience Research and the Self
The Permeability of the Self
Cultural Relativity of Models of Self
Studies of Infant Development
The Contribution of Vygotsky's Ideas
Developmental Studies of Role Acquisition
Bakhtinian Contributions
Contrasts with Other Concepts of Self
Genetics and Temperament
Our Evolutionary Past
The Evolution of Cognitive Capacities and of Culture
Evolutionarily Pre‐Programmed Psychological Tendencies
4 The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy
Summary
Abnormal Development of Self and Its Consequences
Common Therapeutic Factors
Damaged or Abnormal Development of the Self and the CAT Model of Therapeutic Change
Understandings of “Transference” and “Counter‐Transference” and Avoiding Collusion
Use of Personal and Elicited Counter‐transference
Identifying and Reciprocating Counter‐transference
Self‐Esteem
The “False Self”
Who Does the Therapist Speak for?
Implications of Our Evolutionary Past for Psychotherapy
Concluding Remarks
5 The Practice of CAT
Summary
Referral
Assessment Information
The Conduct of the Assessment Interview
Other Considerations
Assessing Motivation
Combining CAT with Other Treatment Modes
Assessing the Risk of Self‐Harm and Suicide
Assessing the Potential for Violence
“Paper and Pencil” Devices and Questionnaires
Treatment “Contracts”
Concluding Remarks
6 The Practice of CAT
Summary
Case Formulation and CAT Reformulation
The Process of Reformulation
The Reformulation Letter
Diagrammatic Reformulation or Mapping
The Order and Process of Reformulation
Formal Evaluation of the Impact of Reformulation
7 The Practice of CAT
Summary
Later Sessions—General Considerations
Change and the Working Alliance in the “ZPPD”
Making Use of Transference and Counter‐transference in Enabling Change
Transference, Counter‐transference, and the Working Relationship of Therapy
Dialogic Sequence Analysis
Technical Procedures
Rating Progress
Recognizing Enactments and Procedures as they Occur
Recapitulating and Reviewing Sessions
Homework
Accessing Painful, Possibly Traumatic, Memories and Feelings
Not Recognizing Enactments and Procedures as they Occur
The CAT Model of Resistance and of the “Negative Therapeutic Reaction”
Dropping out of Therapy
Recognizing Enactments and Procedures at Termination and Ending Well
Concluding Remarks
8 The CAT Model of Therapist Activity and of Supervision
Summary
The Competence in CAT (CCAT) Measure
Therapist Activities in CAT
Supervision of Therapists in CAT
Audio‐tape Supervision
Dialogical Sequence Analysis
“Parallel Process”
Group Supervision
Reflective Practice
Distance Supervision
9 CAT in Various Conditions and Contexts
Summary
The Problem of Diagnosis
CAT in Some Specific Conditions and Settings
Concluding Remarks
10 The Treatment of “Severe and Complex”Personality‐Type Disorders
Summary
The Concept of Personality Disorder
Borderline Personality Disorder (BPD)
Aids to Reformulation
The Course of Therapy
Narcissistic Personality Disorder (NPD)
The Treatment of “Severe and Complex,” Personality‐Type Disorders: CAT and the Research Evidence
11 The “Difficult” Patient, Contextual Reformulation, Systemic Applications, and Reflective Practice
Summary
The “Difficult” Patient
Causes of “Difficult” Behavior
General Approaches to the “Difficult” Patient
Contextual Reformulation
Constructing a Contextual Reformulation
Examples of Contextual Reformulations
Broader Uses and Applications of Contextual and Systemic Approaches
Reflective Practice
Afterword
Distinctive Features of CAT
The Continuing Expansion of CAT
The Evidence Base and Research
The Implicit Values of CAT
Glossary
Appendix 1: The Psychotherapy FileThe Psychotherapy File
Keeping a Diary of Moods and Behavior
Patterns that Do Not Work, but Are Hard to Break
Different States
Appendix 2: Cognitive Analytic Therapy (CAT) Competences for Individuals with Personality DisorderCognitive Analytic Therapy (CAT) Competences for Individuals with Personality Disorder
Knowledge of CAT Theory
Knowledge of Key Features of CAT
The Psychotherapy File
Reformulation
Knowledge of the CAT Theory of BPD
Key Skills of CAT
Reformulation
Constructing the Sequential Diagrammatic Reformulation (SDR) (or “Map”)
Constructing Target Problem Procedures (TPPs or “key issues”)
Formulating Aims or Exits
Moving Between Task and Process
CAT Methods of Intervention
Ability to use CAT Skills to Manage the Ending of Therapy
Ability to use CAT‐Specific Measures to Guide the Intervention
CAT Skills of Particular Relevance for Work with Borderline Personality Disorder
Engagement
Developing the Reformulation
Sustaining and Consolidating Positive Change
Using CAT to Facilitate Work with Wider Systems (Contextual Reformulation)
Appendix 3: Personality Structure Questionnaire (PSQ)Personality Structure Questionnaire (PSQ)
Appendix 4: Repertory Grid Basics and the Use of Grid Techniques in CATRepertory Grid Basics and the Use of Grid Techniques in CAT
References
Index
End User License Agreement
List of Tables
Chapter 4
Table 4.1 List of Some Typical (Formative) Reciprocal Role Patterns and Some ...
List of Illustrations
Chapter 2
Figure 2.1a Key formative RR for Bobby.
Figure 2.1b Key RRP enactments.
Figure 2.2 Rating sheet for target problem procedure 1 for Bobby.
Chapter 3
Figure 3.1a CAT‐based sketch of normal development of the Self through healt...
Figure 3.1b Their subsequent internalisation as formative RRs within the gro...
Chapter 4
Figure 4.1 CAT‐based diagrammatic sketch of damaging and abnormal developmen...
Chapter 6
Figure 6.1 Part diagrams: sequences illustrating traps, dilemmas, and snags....
Figure 6.2 Types of cores in sequential diagrams.
Figure 6.3 (a–c) Beatrice—Self states sequential diagram. (a) Initial depict...
Figure 6.4 (a) Depicts formative reciprocal roles; (b) mapping of most commo...
Chapter 7
Figure 7.1 Self states sequential diagram for Rita showing reciprocal roles....
Chapter 8
Figure 8.1 Sequential diagram for Grace.
Chapter 9
Figure 9.1 Simplified SDR/map for Susan showing key formative RR and key RRP...
Figure 9.2 SDR or “map” for Tamara.
Figure 9.3 SDR/map for Alan.
Figure 9.4 (a) Key formative RRs for Sarah. (b) SDR/map for Sarah.
Figure 9.5 The client in the sessions.
Figure 9.6 The therapist in the sessions.
Figure 9.7 A problematic sequence (RRP) of thoughts, emotions, and behaviors...
Chapter 10
Figure 10.1 (a–d) Stages in construction of a stereotypical BPD‐type diagram...
Figure 10.2a Deborah—grid of self‐descriptions.
Figure 10.2b Deborah—grid of self–other relationships.
Figure 10.3 Narcissistic personality disorder: the two common Self states.
Figure 10.4 (a–c) Stages in constructing a stereotypic NPD‐type diagram show...
Figure 10.5 Olivia—sequential diagram (revised and simplified).
Figure 10.6 Sam—final Self state sequential diagram (revised and simplified)...
Chapter 11
Figure 11.1a Schematic patient SDR or map showing (formative) RRs and conseq...
Figure 11.1b Schematic rudimentary contextual reformulation showing patient ...
Figure 11.1c Schematic extended contextual reformulation showing added layer...
Figure 11.2a Initial description of patient's formative RRs.
Figure 11.2b Simple contextual reformulation showing patient RRPs and staff ...
Figure 11.3a Initial SDR or map for Paula showing her formative RRs.
Figure 11.3b Initial SDR or map showing subsequent RRPs and consequences.
Figure 11.3c Initial SDR or map showing additional tendencies to dissociate ...
Figure 11.3d Contextual reformulation showing (situational) reciprocal role ...
Guide
Cover
Table of Contents
Begin Reading
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Introducing Cognitive Analytic Therapy
Principles and Practice of a Relational Approach to Mental Health
Second Edition
Anthony Ryle* and Ian B. Kerr
*Deceased
This second edition first published 2020© 2020 John Wiley & Sons Ltd
Edition HistoryJohn Wiley & Sons Ltd (1e, 2002)
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
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Library of Congress Cataloging‐in‐Publication Data
Names: Ryle, Anthony, author. | Kerr, Ian B., author.Title: Introducing cognitive analytic therapy : principles and practice of a relational approach to mental health / Anthony Ryle and Ian B. Kerr.Description: Second edition. | Hoboken, NJ : Wiley, 2020. | Includes bibliographical references and index.Identifiers: LCCN 2019058760 (print) | LCCN 2019058761 (ebook) | ISBN 9780470972434 (paperback) | ISBN 9781119695165 (adobe pdf) | ISBN 9781119695134 (epub)Subjects: LCSH: Cognitive therapy.Classification: LCC RC489.C63 R955 2020 (print) | LCC RC489.C63 (ebook) | DDC 616.89/1425–dc23LC record available at https://lccn.loc.gov/2019058760LC ebook record available at https://lccn.loc.gov/2019058761
Cover Design: WileyCover Image: © Jose A. Bernat Bacete/Getty Images
List of Figures
2.1a
Key formative RR for Bobby.
2.1b
Key RRP enactments.
2.2
Rating sheet for target problem procedure 1 for Bobby.
3.1a
CAT‐based sketch of normal development of the Self through healthy early infant‐caregiver interactions (RRs) shown here in a ‘nuclear’ family type setting and in a particular sociocultural context.
3.1b
Their subsequent internalisation as formative RRs within the growing child (by permission Bevan Fidler).
4.1
CAT‐based diagrammatic sketch of damaging and abnormal development of the Self.
6.1
Part diagrams: sequences illustrating traps, dilemmas, and snags.
6.2
Types of cores in sequential diagrams.
6.3
(a–c) Beatrice—Self states sequential diagram. (a) Initial depiction of formative reciprocal roles. (b) Mapping of key reciprocal role procedures leading to a similar state of “deep sadness.” One of these involves enactment of a situational RR of ideally loved to ideally loving (c) mapping the outcome of key reciprocal role procedures which reinforce original formative RRs and depicting also two Self states (SS 1 and SS 2) and highlighting a key dialogic voice using an asterisk.
6.4
(a) Depicts formative reciprocal roles; (b) mapping of most common coping procedure (effectively a “trap”); (c) further mapping of a “dilemma” leading to a briefly enacted RRP (effectively a “snag”) undermined by a critical voice; (d) depicting possible further RRP enactments (from the parental/culturally‐derived pole of his formative RR) toward Self and/or others.
7.1
Self states sequential diagram for Rita showing reciprocal roles. B, D, and F represent childhood‐derived roles which, when activated by experiences, perceptions, or memories of A, C, or E, lead to flashpoint X followed by either rage or the dissociated alternative coping zombie state. The consequences of these would be typically “rejection” and having “needs unmet” which in turn would reinforce underlying formative RRs.
8.1
Sequential diagram for Grace.
9.1
Simplified SDR/map for Susan showing key formative RR and key RRPs.
9.2
SDR or “map” for Tamara.
9.3
SDR/map for Alan.
9.4
(a) Key formative RRs for Sarah. (b) SDR/map for Sarah.
9.5
The client in the sessions.
9.6
The therapist in the sessions.
9.7
A problematic sequence (RRP) of thoughts, emotions, and behaviors (a “trap”).
10.1
(a–d) Stages in construction of a stereotypical BPD‐type diagram. (c) illustrates likely dissociated Self states and (d) introduces a description of typical staff reactions around such patients and illustrates a rudimentary “contextual reformulation” (see Chapter 11).
10.2a
Deborah—grid of self‐descriptions.
10.2b
Deborah—grid of self–other relationships.
10.3
Narcissistic personality disorder: the two common Self states.
10.4
(a–c) Stages in constructing a stereotypic NPD‐type diagram showing (a) underlying (formative) RRs, (b) typical initial coping RRPs and typical Self states, and (c) potential Self states, defensive RRPs and (situational) RR enactments, including potentially with staff and others.
10.5
Olivia—sequential diagram (revised and simplified).
10.6
Sam—final Self state sequential diagram (revised and simplified).
11.1a
Schematic patient SDR or map showing (formative) RRs and consequent RRPs.
11.1b
Schematic rudimentary contextual reformulation showing patient SDR or map and outline possible therapist and staff team (situational) RR enactments toward patient RRPs. Some of these staff RR enactments may be derived in part from their own formative RRs.
11.1c
Schematic extended contextual reformulation showing added layers (like “onion skins”) of interactions arising from possible service context and broader social and political context.
11.2a
Initial description of patient’s formative RRs.
11.2b
Simple contextual reformulation showing patient RRPs and staff team reciprocal (situational) RR enactments and the split between these. Some of these enactments may have partial origins in formative RRs of staff.
11.3a
Initial SDR or map for Paula showing her formative RRs.
11.3b
Initial SDR or map showing subsequent RRPs and consequences.
11.3c
Initial SDR or map showing additional tendencies to dissociate or “fragment” into at least two Self states (broken ellipses).
11.3d
Contextual reformulation showing (situational) reciprocal role interactions between staff and patient with subsequent splits within staff team. Some of these situational enactments may have partial origins in staff formative RRs.
About the Authors
Anthony Ryle qualified in medicine in 1949 and worked successively as a founding member of an inner city group practice, in Kentish Town, London, as Director of Sussex University Health Service and as a Consultant Psychotherapist at St. Thomas's Hospital, London. After retiring from the NHS he worked part‐time in teaching and research at Guy's Hospital. While in general practice he carried out epidemiological studies of the patients under his care and the experience of demonstrating the high prevalence and family associations of psychological distress influenced his subsequent interest in the development of forms of psychological treatment which could realistically be provided in the NHS. Studies of the process and outcome of psychotherapy followed, and from these grew the elaboration of an integrated psychotherapy theory and the development of the time‐limited model of treatment which became cognitive analytic therapy. He died in September 2016.
Ian B. Kerr graduated in medicine from the University of Edinburgh. After several junior hospital posts he worked for many years in cancer research. He subsequently completed dual training in psychiatry and psychotherapy at Guy's, Maudsley, St. George's, and Henderson Hospitals in London, and with the British Association of Psychotherapists. He worked for several years as Consultant Psychiatrist and Psychotherapist and Honorary Senior Lecturer in Sheffield, UK, and then in NHS Lanarkshire, Scotland, UK. He has been involved in teaching and researching CAT in many settings in the UK and internationally.
Preface to the Second Edition
This revised edition is being offered given an evident need to update, expand, and clarify aspects of the first edition which appeared now almost two decades ago, and given a keen wish by Tony Ryle to do this. Our aim was to offer a summary but comprehensive overview of the current evolved Cognitive Analytic Therapy (CAT) model, its background and comparative context, and of its range of applications, that would be informative and helpful to those new to the model, to trainees and even established practitioners. Very sadly however, as many readers will be aware, not long after being commissioned to do this Tony, who was the senior author and progenitor of the cognitive analytic therapy model, developed a serious illness from which he ultimately succumbed in 2016. Summaries of his remarkable creative personality, his career and contributions to the field of psychotherapy and mental health more broadly have been published in various obituaries which are available on the internet and in a special issue published in 2018 of Reformulation the newsmagazine of the Association for Cognitive Analytic Therapy (ACAT) in the UK, also available on‐line.
One of the critical tests of the achievement of any remarkable, creative, and charismatic character, which Tony certainly was, is the way in which their achievement and any model they may have created survives and prospers subsequent to their death. In this I am very clear, as are many others, that the current CAT model described in some detail in this volume is doing just that and that, given its principles and underpinnings, it should continue to play a major creative and contributory role in the future to human mental health and well‐being in various ways. That this might occur was one of his principal passions and aims. Having said that, like many of us he was recurrently saddened and frustrated by the evident socio‐political direction of the world at large. I am sure his enthusiasm to update and publish this volume despite his illness also related to a hope that the model might in some small way contribute to ameliorating and improving this situation. Certainly, the evolved CAT model seemed to us also to address a global epidemic, including and especially in more “developed” countries, of so‐called mental disorders in a much more radical, thorough‐going, and humane manner than currently dominant, more individualistic and mechanistic paradigms. As such we were sure that if human sense, compassion, and evidence prevail (about which sadly neither author was very confident) CAT will ultimately be able to offer a great deal, including in ways far beyond its use as a model of individual therapy, important as that is, into more clearly systemic and socio‐political domains. These issues and these potential applications are discussed further in the book.
However, Tony’s death left the final task of articulating and presenting many of these revisions to myself. These have however all been based on our extended discussions—some quite animated!—and also on our deep, essential agreement about the core of the model and what sorts of revisions needed to be undertaken. These have been also based on initial drafts that we both did and discussed, and on consideration of various review articles and books containing both theoretical and clinical developments that had appeared in recent years and presented and/or approved of by himself (e.g. Ryle et al., 2014, Kerr et al., 2015, Kerr, Hepple and Blunden, 2016; Pickvance 2017; Ryle and Kellett, 2018).
Tony was very clear that he wished the revision to proceed on this basis with myself as more active co‐author despite his illness. I believe there is nothing in this volume that was not agreed and decided at least in principle with Tony, although of course its presentation, expansion, and articulation in many cases has fallen to myself notwithstanding our initial drafts. I am, therefore, wholly responsible for any serious deficiencies of content or style related to this. However, I hope that it may still represent an important “staging post” in the development and evolution of CAT in that it represents the last position and views of its creator. This should not of course be regarded as any kind of “final word”; and indeed Tony certainly did not wish this to be the aim. We were both very clear this volume could only represent a re‐statement, expansion, and clarification of Tony’s own views on the development of the model hitherto, aided and abetted in this case by myself. We were clear about the subsequent need to continue developing the model in a further integrative manner, in ways which may prove to be quite counter‐intuitive and unexpected. Nonetheless this re‐statement may be perhaps an important reference point in that process of the development and of the application of the model by others.
We agreed that there was a need for a revised and updated edition for various reasons. These include a proliferation of new understandings over the past couple of decades relating to mental health, treatment for mental health problems or disorders, understandings of psychotherapy, and in relation to the CAT model itself. These developments have occurred in fields as diverse as infant psychology, developmental neuroscience, social psychiatry, through to the social and political sciences, and also developments, for example, in understanding of factors, including common factors, relating to process and outcome in psychotherapy. Since the first edition appeared there has also been a proliferation of innovative and humane uses of CAT, some rather unexpected, for example in work with schools, refugees, police and forensic services, in consideration of broader socio‐political challenges (see e.g. Lloyd and Pollard 2018), as well as for a whole range of mental health problems (see especially Chapter 9).
Feedback from and reflection on the first edition made it clear also that some clarification of fundamental theoretical concepts was needed, as well as perhaps a clearer and in places a more helpfully didactic presentation of them. Some confusion and ambiguity have occurred, in retrospect probably largely due to the history and “archaeology” of CAT and its development over many years. This has resulted in certain key concepts like procedures, reciprocal roles, reciprocal role procedures, and even repertory grids, being more predominantly focused on and stressed at different stages in the evolution of the model, and accordingly subtly changing, with these concepts sometimes being used in ambiguous or overlapping ways for these reasons. This evolution and history has undoubtedly caused some perplexity, for example to trainees over the years, and has also undoubtedly affected the way in which practitioners and supervisors, who would have trained at different times, have understood and used these concepts and how they work with the model. Although we are clear that the underpinning, relational, core concepts in CAT have remained consistent for many years, we have therefore revisited these and, we hope, helpfully clarified, amplified, and restated these in the early chapters of this revision.
As regards the enduring fundamental core of the established CAT model, Tony clearly felt increasingly that this was still essentially embodied in the “Procedural–Sequence Object–Relations Model” (PSORM) notwithstanding various later refinements and enrichments, for example by Vygotskian activity theory and Bakhtinian concepts of a dialogical self, and by diverse, for example more “here and now,” clinical and other applications. The PSORM of course implies a clear presentation and understanding of early developmental internalization of (formative) reciprocal relationships (reciprocal roles, akin to although differing significantly from internal objects), and an understanding of and stress on how, on this basis, we subsequently develop and enact patterns of coping and responding (reciprocal role procedures). We were both rather concerned that the important interest in more recent years in systemic or “contextual” role enactments in the here and now (including also therefore more “situational” RRs) can potentially lead to loss of focus on deeper, historic internalized RRs and their consequences for the patient or client, given that these are of fundamental importance in clinical presentations and in therapy. Indeed, at times in therapy they may be the sole focus of activity. These issues are again addressed in the early and then later chapters.
I have felt rather freer to expand as I saw fit concepts or sections for which I was originally largely responsible, for example consideration of psychotic disorders, “contextual” and systemic approaches, and the clarification and presentation of “Self” as an “organizing construct” within CAT. These have appeared to be of some importance and were developments that Tony also contributed to and fully supported, both in discussion and having read and approved various publications up to 2016—where some of these various changes and clarifications were first mooted. We also both felt the section on sex and gender‐related issues (Chapter 9) needed to be expanded considerably given important developments over recent years in this challenging and complex area, and we have attempted to do this with the assistance of others who are acknowledged in the text.
We were both keen to expound clearly the importance of the socio‐cultural and political dimensions of mental health, which is implicit in the model and its applications, notwithstanding Tony’s, and my own, frustration and sadness at many socio‐political developments in the world at large. As therapists we can all too often only bear witness to these and it can feel very hard to influence them helpfully. However, we both felt that a model such as CAT can and should helpfully offer humane and compassionate, while scientifically valid, understandings of mental health and well‐being much more broadly. We have been very clear, therefore, and unapologetic about a need to locate the model in a broader context, both scientifically and clinically but also socio‐politically. We also felt it important to attempt to locate CAT broadly within the extensive field of “brand name” therapies, the distinctions between which, as discussed, are frequently spurious and appear to relate sadly more to professional narcissism, parochialism, and campanilismo. These considerations and views will be evident yet again in this edition, as they were in the first. Hence the book is, and aims to be, more than simply a summary of key features of CAT as a model of therapy and of its applications.
Having said this, Chapter 9 in this edition, which aims to overview clinical uses and applications of CAT, is considerably expanded given a considerable increase in these, and also given the continuing and often quite acrimonious debate with regard to classification and nosology in the field of mental health. Challenging currently dominant but flawed paradigms (notably those of a largely more individualistic biomedical and/or cognitivist persuasion) and reconceptualizing disorders and how we might help treat them is an important part of what any good and evolving model should offer. However, it is still avowedly not an explicitly “how to” kind of chapter giving detailed descriptions of treatments by various specialist authors. Such a volume or volumes are undoubtedly needed but this was certainly beyond the remit or feasibility of a one‐ or two‐author volume.
But even in the writing of this more summary book we have depended greatly on the work and input of others. Tony would have been the first to acknowledge and celebrate the fact that we all stand “on the shoulders of giants” and of many others, and depend on their very various contributions. In a very real, and dialogical, sense there is no such thing as completely original or independent work. Many others who are cited in the text have contributed to the model, its underpinning theory, and its range of applications over the years. By way of example the articulation and presentation of the very first specifically CAT volume was apparently greatly aided and abetted by Professor Glenys Parry, who has continued to be an active champion of the model in different ways over the years since then.
At a personal level it has been an honor and privilege to undertake the final work of this revision, although this has also felt to be, perhaps unsurprisingly, a challenging and quite arduous undertaking. In many ways it has felt a weighty responsibility to re‐state and update what was essentially Tony's life’s work, although the development of the model was assisted increasingly by various others who are cited in the text. It has also inevitably felt a rather poignant and solitary undertaking at times, despite helpful discussion with various current colleagues, in the absence of Tony’s “larger than life,” innovative, critical, and at times impatient presence and input. It would have been good at various moments to have been able to “chew things over” with him as I and many others would have done in the past.
This revised edition has unfortunately been delayed by the inevitable distractions and intrusions of life, both personal and professional. This has included, sadly, a protracted but morally unavoidable involvement in campaigning in support of “whistle blowers” in the face of some serious incompetence, victimization, and cronyism within and around the NHS in the UK. But I have also been guilty of some procrastination, a tendency to unhelpful over‐inclusiveness, and aspiring to imagined perfect outcomes; all of this Tony with his talents was much better able to transcend, to “see the wood for trees” quickly, and to express his views articulately—if sometimes very forthrightly!
As regards terminology, we have in this revision on the whole, as noted in the previous edition, referred to “patients” rather than “clients,” although we use the term interchangeably. We recognise an increasing tendency and preference among many colleagues, especially non‐clinical, to use the word “client” possibly given some of the arguably paternalistic and disempowering associations of the word “patient.” Possibly in part due to our own medical trainings and background we continue to take a view that the word patient has also an honorable history and associations implying notably a vocational and not essentially commercial responsibility to those who are in distress and are suffering. Indeed, the roots of the word lie in the Latin verb patior (I suffer). In our experience, too, people seeking help from clinicians and other health professionals are not always comfortable with the word client. However, times change and with them connotations and usages of terminology, including of diagnostic “labels” (see Chapter 9), and we recognize it is inevitably hard to know where consensus will lead.
We have also in this edition deliberately drawn back from use of the term “intervention” which we felt has become increasingly and excessively used as a synonym for “treatment” or “therapy.” While the word may make some sense as a high‐level, collective descriptive of treatment approaches, it still to our mind carries unfortunate mechanistic and militaristic echoes at best applicable in health care in, for example a “doing to” public health context, but not we suggest as a description of any collaborative, humane, relationally based treatment, far less psychotherapy. Unfortunately, in an era of increasing “commodification” of health care and of staff it also carries for us a quasi‐commercial and mechanical resonance invoked by phrases such as “delivering interventions” which we felt sat uneasily with our therapeutic position and aims. Again, however, we recognize that word usage changes and it may be our views are effectively already superceded and redundant, and that the word already means something different, perhaps regrettably, to a present generation of health care professionals.
We both sincerely hoped that this reworked and revised edition would be welcome and helpful to a range of people, both fellow mental health professionals and others, and I hope, despite its delayed and rather complicated coming into being, that this will prove to be the case. I very much hope that it may also contribute in some way to a more meaningfully relational and compassionate moving forward for us all much more broadly. This was, I am sure, another deeply felt aspiration and hope on Tony’s part.
Ian B. Kerr—Whangarei, New Zealand–Aotearoa (2020)
Preface to the Second Edition
This book offers an updated introduction and overview of the principles and practice of cognitive analytic therapy (CAT). The last such book appeared over 10 years ago and was the first systematic articulation of a new, integrative model which had been developed over a period of many years. Although there have been two specialist volumes since then (Ryle, 1995, 1997a) it is significant that a restatement of the model and its applications is now necessary. There are many reasons for this. They include the fact that as a young, genuinely integrative model (as acknowledged in the influential Roth and Fonagy report (1996)), it is still evolving and developing both in terms of its theoretical base and its range of applications. In this book, a further exposition of the CAT model of development is given, stressing in particular an understanding of the social formation of the self based on Vygotskian activity theory and Bakhtinian “dialogism.” We also outline an ever‐expanding range of practical applications of CAT as an individual therapy as well as its application as a conceptual model for understanding different disorders and informing approaches to their management by staff teams. This trend has been described (Steve Potter) as “using” CAT, as opposed to “doing” it. Newer or preliminary applications of CAT reviewed here include CAT in old age, with learning disabilities, in anxiety‐related disorders, in psychotic disorders, CAT for self‐harming patients presenting briefly to casualty departments, CAT with the “difficult” patient in organizational settings, and CAT in primary care. In part these also reflect theoretical developments of the model which are also reviewed. Its gradually expanding evidence base is also reviewed, along with some of the difficulties, both scientific and political, inherent in research in this area.
CAT evolved initially as a brief (usually 16‐session) therapy. This was partly for pragmatic reasons and related to the search for the optimum means of delivering an effective treatment to the kind of patients being seen in under‐resourced health service settings. However, it also arose from consideration and evaluation of which aspects of therapy, including its duration, were actually effective. This aspect of research is fundamental to the model and continues to be important in its continuing evolution. We suggest, incidentally, that a brief treatment like CAT, within the course of which profound psychological change can be achieved, genuinely merits the description of “intensive” as opposed to much longer‐term therapies usually described as such, which we suggest might better be called “extensive.”
Despite the effectiveness of brief CAT for very many patients, it is clear that not all patients can be successfully treated within this length of time. However, it is also evident from some very interesting work, with, for example, self‐harming patients but also less damaged “neurotic” patients, that effective work can also be done in a few, or even one session. The length of treatment has thus been modified to adapt to the needs of differing patients. Longer‐term therapy may need to be offered to those with severe personality disorder, longstanding psychotic disorder, or those with histories of serious psychological trauma. Thus, there will be some patients for whom the reparative and supportive aspect of therapy over a longer period of time may be an important requirement. Similarly, more extended treatments may be offered in settings such as a day hospital, where the treatment model may be informed by CAT, as an alternative to offering it as an individual therapy.
A further reason for the present book is the ever increasing popularity of CAT with mental health professionals and the demand from trainees and others for a comprehensive but accessible introduction to it. The rapidly increasing popularity of CAT with both professionals and patients is, we feel, a further indication of the effectiveness and attractiveness of the model. In part, we see this popularity as arising from the congruence of CAT with the increasing demand for “user participation” in mental health services; the explicitly collaborative nature of the model offers and requires active participation on the part of the client or patient. This “doing with” therapeutic position, in addition to being demonstrably effective, appears to be very much more appropriate and welcome to a younger generation of trainees and potential therapists. This “power‐sharing” paradigm has overall, in our view, radical implications for mental, and other, health services.
The CAT understanding of the social and cultural formation of the self also highlights the role of political and economic forces in the genesis of many psychological disorders. The external conditions of life and the dominant values of current society, internalized in the individual, are seen as active determinants of psychological health or disorder. Recognizing this, we suggest that, as therapists, we should strive to avoid describing psychological disorders as simply “illnesses” and should also play our part in identifying and articulating whatever social action may be called for in response.
The book is the result of the collaborative work of two authors who share responsibility for the text. Our contributions were different, in part because AR was the initiator of the CAT model and has a much longer history of writing about it. In so far as this conferred authority it also risked complacency which, he felt, needed to be challenged. IK brought a more recent experience of psychiatry and psychotherapy in the NHS, reflected in particular in the discussion of psychosis and of the “difficult” patient and contextual reformulation. He also wished to emphasize the importance of a full bio‐psycho‐social perspective. Our longest and most fruitful arguments were involved in writing the theoretical Chapters 3 and 4.
Acknowledgments
We should like to thank the many colleagues and patients who have contributed material to this book and who have been named in it. There are also innumerable others who have made important contributions to its production, directly and indirectly, both recently and over a period of many years. They are too many to name but we should like to express our gratitude to them collectively. Some of these contributions are referenced, although given editorial constraints we have been able, regretfully, only to cite books and peer‐reviewed publications, and material that was directly relevant to points being made in the book. We apologize to colleagues for omissions or oversights which will inevitably have occurred; however, our aim was not simply to undertake a comprehensive collation of all CAT‐related publications. This will be an important task for more specialist review literature and multi‐author books on CAT subsequently. We would like to acknowledge the support provided by the staff at John Wiley and, in particular, the early encouragement offered by Michael Coombs who commissioned the first edition, the subsequent support (and patience!) offered by Darren Read during the initial stages of this revision which he commissioned, and subsequently helpful assistance by freelance copy editor Caroline McPherson and, during the production stages, by Rahini Devi Radhakrishnan, under the strategic eye of Darren Lalonde overall. Finally, we should like to thank our partners Flora and Jane for making, in various and important ways, the writing of this book possible.
The Structure of the Book
Chapters 1 and 2 will give a brief account of the scope and focus of CAT and how it evolved and will spell out the main features of its practice. Most of CAT's relatively few technical terms will appear in these chapters; they and other general terms which may have a different meaning in CAT are listed in a glossary. In order to flesh out this introductory survey and give readers a sense of the unfolding structure of a time‐limited CAT, Chapter 2 also offers a brief account of a relatively straightforward therapy. Chapters 3 and 4 consider the normal and abnormal development of the self and introduce the Vygotskian and Bakhtinian concepts which are part of the basic theory of individual development and change. Subsequent chapters describe selection and assessment (Chapter 5); reformulation (Chapter 6); the course of therapy (Chapter 7); the “ideal model” of therapist interventions and its relation to the supervision of therapists (Chapter 8); applications of CAT in various patient groups and settings (Chapter 9) and in treating personality‐type disorders (Chapter 10); and the concept of the “difficult” patient and approaches to this problem, including the use of “contextual reformulation” and use in “reflective practice” (Chapter 11). Each chapter commences with a brief summary of its contents and includes suggestions for further reading and references to CAT published work, and to the work of others. In addition, Appendix 1 contains the CAT Psychotherapy File, Appendix 2 the summary of CAT competences extracted from Roth and Pilling (2013), Appendix 3 contains the Personality Structure Questionnaire, and Appendix 4 a description of repertory grid basics and their use in CAT.
Case material derived from audio‐taped sessions is used with the permission of both patients and therapists; we gratefully acknowledge their help. Other illustrative material is either drawn from composite sources or disguised in ways preventing recognition. We have, on the whole, referred to patients rather than clients, although in this book we use the term interchangeably.
Further Information
Further information about CAT and about the Association for Cognitive Analytic Therapy (ACAT) in the UK may be obtained from the website www.acat.me.uk in the UK, from local associations in other countries, and/or through www.internationalcat.org.
1The 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 a Collaborative Therapy
The practice of CAT reflects these theoretical developments. It has been suggested that, in contrast to the traditional polarization of health care professionals between those who are good at “doing to” their patients (e.g., surgeons and perhaps some behavior therapists) and those who are good at “being with” their patients (e.g., many dynamic psychotherapists or nurses involved in long‐term care), the CAT therapist aims to be good at doing with their patients (Kerr, 1998a). This highlights the fact that CAT involves hard work and commitment for both patients and therapists, and also the fact that much of this work is done together and that the therapy relationship itself plays a major role in assisting change.
The ways therapists interact with and describe their patients is important for the quality of the therapeutic relationship and transcends the “application” of any particular technique. Any techniques used, and how they are employed, must convey human compassion, acknowledgment, and value. CAT therapists therefore encourage patients to participate, possibly in ways that are challenging, to the greatest possible extent in their therapies. For many patients this may in itself represent a quite new, or previously “forbidden,” experience. Such a therapeutic approach may also feel unfamiliar and uncomfortable for many health care professionals. Therapists have usually learned helpful ways of thinking and being and are, in some sense, experts in activities that parallel parenting or teaching. But our patients are not pupils or children and their capacities need to be respected, empowered, and enlarged through the joint creation of new understandings, challenges to longstanding assumptions, acquisition of new “coping patterns,” and through a new relational experience.
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 in “psychological” terms at all. However, the concept of the socially constituted Self 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
