Cognitive analytic therapy

As the name implies, cognitive analytic therapy (CAT) evolved as an integrative therapy based on ideas from cognitive and analytic therapies. CAT was also influenced in part by George Kelly's constructivism. Kelly had developed personal construct theory and the repertory grid method, and Kelly's approach to therapy "offered a model of nonauthoritarian practice" that psychotherapist Anthony Ryle found appealing.{{cite book |last=Ryle |first=Anthony |author-link=Anthony Ryle |date=2005 |chapter=Cognitive analytic therapy |editor1-last=Norcross |editor1-first=John C. |editor1-link=John C. Norcross |editor2-last=Goldfried |editor2-first=Marvin R. |title=Handbook of psychotherapy integration |edition=2nd |series=Oxford series in clinical psychology |location=New York |publisher=Oxford University Press |pages=196–217 |isbn=978-0195165791 |oclc=54803644}}{{rp|197}}

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.{{rp|196}} However the slow, exploratory nature of traditional analytic therapy meant that these were not always addressed early and assertively, with the result that therapy, while effective, took a long time to produce results. In a 1979 paper, he proposed a shorter, more active form of therapy which integrated elements from cognitive therapy practice (such as goal setting and Socratic questioning) into analytic practice.{{cite journal |last=Ryle |first=Anthony |s2cid=5017697 |author-link=Anthony Ryle |date=January 1979 |title=The focus in brief interpretive psychotherapy: dilemmas, traps and snags as target problems |journal=British Journal of Psychiatry |volume=134 |pages=46–54 |doi=10.1192/bjp.134.1.46 |pmid=760923}} 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.{{cite journal |last=Leiman |first=Mikael |date=April–July 1994 |title=The development of cognitive analytic therapy |journal=International Journal of Short-Term Psychotherapy |volume=9 |issue=2–3 |pages=67–81 |url=http://psycnet.apa.org/psycinfo/1995-14359-001}}

Subsequently, CAT has been influenced by ideas from the work of Soviet psychologist Lev Vygotsky and Russian philosopher Mikhail Bakhtin. From Vygotsky come concepts such as the zone of proximal development (ZPD) and scaffolding.Vygotsky, L. S. (1987). Thinking and speech. In L. S. Vygotsky, Collected works (vol. 1, pp. 39–285) (R. Rieber & A. Carton, Eds; N. Minick, Trans.). New York: Plenum. (Original works published in 1934, 1960). The ZPD implies that new tasks set for the patient (for example, tolerating anxiety about social situations) should extend what they do beyond their current capabilities, but only by a small and achievable amount. Scaffolding involves the therapist providing support for the patient's efforts to change, but varying this level of support as the patient's needs change.

Bakhtin provided concepts such as dialogism from which come techniques such as Dialogical Sequence Analysis. This is a structured attempt to identify and visually display sequences of behaviour, thinking, and emotions so that the patient becomes more aware of these and can start to modify them.Leiman, M. (2004). Dialogical sequence analysis. In: H. J. M. Hermans & G. Dimaggio (eds.), The dialogical self in psychotherapy (pp. 255–270). London: Brunner-Routledge.

File:Reciprocal Roles.jpg

File:Cognitive Analytic Therapy (flowchart).jpg

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.{{rp|247}}

In the second half of the therapy work moves into the Revision phase, where patient and therapist identify and practice "exits" from the procedural diagram established in the previous phase. For example, a problematic procedure might move a patient from feeling angry to taking an overdose. An exit might involve expressing the anger in some way as an alternative to self-injuring behaviour.

At the end of the therapy, patient and therapist each write "goodbye letters" which they exchange, summarising what has been achieved in the therapy and what remains to be done. After the end of the agreed number of weekly sessions, planned follow-up sessions take place to monitor and support the changes that have been made. Typically, a 16-session CAT might be followed up by a single session one month after the end of therapy, and a final one three months later.{{rp|248}}

CAT has been the subject of a number of research studies published in peer-reviewed journals. These include randomised controlled trials (RCTs) and other kinds of study. The approach is too new for any systematic reviews of RCTs to have been conducted, and therefore is not yet explicitly recommended by name by the UK National Institute for Health and Clinical Excellence (NICE). However NICE has recommended that there should be further research of CAT, for example in borderline personality disorder.NICE (January 2009). [http://www.nice.org.uk/guidance/cg78 Borderline personality disorder: Treatment and management], NICE guidelines [CG78], p. 30. 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.{{cite journal | last1 = Calvert | first1 = R | last2 = Kellett | first2 = S | year = 2014 | title = Cognitive analytic therapy: A review of the outcome evidence base for treatment | url =http://eprints.whiterose.ac.uk/102724/5/CAT%20outcome%20review.pdf | journal = Psychology and Psychotherapy: Theory, Research and Practice | volume = 87 | issue = 3| pages = 253–277 | doi=10.1111/papt.12020| pmid = 24610564 }} A review of CAT looking back over the 30 years to its beginnings{{cite journal | last1 = Ryle | first1 = A | last2 = Kellett | first2 = S | last3 = Hepple | first3 = J | last4 = Calvert | first4 = R | year = 2014 | title = Cognitive analytic therapy at 30 | url = http://eprints.whiterose.ac.uk/102723/2/CATat30.pdf| journal = Advances in Psychiatric Treatment | volume = 20 | issue = 4| pages = 258–268 | doi = 10.1192/apt.bp.113.011817 }} contains a meta-analysis of 11 outcome studies of CAT. The overall number of patients treated in the studies was 324 and the average effect size across all studies was 0.83 (95% confidence interval 0.66–1.00). This is a large effect and suggests that CAT is efficacious in treating mental health problems.

CAT has been shown to lead to subjective improvement in people with anorexia nervosa.{{cite journal | last1 = Treasure | first1 = J | last2 = Ward | first2 = A | year = 1997 | title = Cognitive analytical therapy in the treatment of Anorexia nervosa | journal = Clinical Psychology and Psychotherapy | volume = 4 | issue = 1| pages = 62–71 | doi = 10.1002/(SICI)1099-0879(199703)4:1<62::AID-CPP114>3.0.CO;2-Y }}{{cite journal | last1 = Dare | first1 = C. | last2 = Eisler | first2 = I. | last3 = Russell | first3 = G. | last4 = Treasure | first4 = J. | last5 = Dodge | first5 = L. | year = 2001 | title = Psychological therapies for adults with anorexia nervosa: Randomised controlled trial of out-patient treatments | journal = British Journal of Psychiatry | volume = 178 | issue = 3| pages = 216–221 | doi = 10.1192/bjp.178.3.216 | pmid = 11230031 | doi-access = free }} It has also been shown to produce significant improvements in adolescents with a diagnosis of borderline personality disorder.{{cite journal | last1 = Chanen | first1 = A | last2 = McCutcheon | first2 = LK | last3 = Germano | first3 = D | last4 = Nistico | first4 = H | last5 = Jackson | first5 = HJ | last6 = McGorry | first6 = PM | year = 2009 | title = The HYPE clinic: an early intervention for borderline personality disorder | journal = Journal of Psychiatric Practice | volume = 15 | issue = 3| pages = 163–172 | doi = 10.1097/01.pra.0000351876.51098.f0 | pmid = 19461389 | s2cid = 17115003 }} 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.{{cite journal | last1 = Clarke | first1 = S | last2 = Thomas | first2 = P | last3 = James | first3 = K | year = 2013 | title = Cognitive analytic therapy for personality disorder: randomised controlled trial | journal = British Journal of Psychiatry | volume = 202 | issue = 2| pages = 129–134 | doi = 10.1192/bjp.bp.112.108670 | pmid = 23222038 | doi-access = free }} CAT has also been shown to improve patients' management of diabetes.{{cite journal | last1 = Fosbury | first1 = J | last2 = Bosley | first2 = C | last3 = Ryle | first3 = A | last4 = Sonksen | first4 = P | last5 = Judd | first5 = S | year = 1997 | title = A trial of cognitive analytic therapy in poorly controlled type 1 diabetes patients | journal = Diabetes Care | volume = 20 | issue = 6| pages = 959–964 | doi = 10.2337/diacare.20.6.959 | pmid = 9167106 | s2cid = 26113327 }} 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.{{cite journal | last1 = Ougrin | first1 = D. | last2 = Zundel | first2 = T. | last3 = Ng | first3 = A. | last4 = Banarsee | first4 = R. | last5 = Bottle | first5 = A. | last6 = Taylor | first6 = E. | year = 2011 | title = Trial of therapeutic assessment in London: randomised controlled trial of therapeutic assessment versus standard psychosocial assessment in adolescents presenting with self-harm | journal = Archives of Disease in Childhood | volume = 96 | issue = 2| pages = 148–153 | doi = 10.1136/adc.2010.188755 | pmid=21030367| s2cid = 5637686 }}

Comparative studies have suggested CAT to be at least as effective as other forms of brief psychotherapy,Mann, J & Goldman, R (1982). A casebook in time-limited psychotherapy. New York: McGraw Hill. person-centred therapy and cognitive behavioural therapy,{{cite journal | last1 = Marriott | first1 = M | last2 = Kellett | first2 = S | year = 2009 | title = Evaluating a cognitive analytic therapy service: practice-based outcomes and comparisons with person-centred and cognitive behavioural therapies | journal = Psychology and Psychotherapy: Theory, Research and Practice | volume = 82 | issue = Pt 1| pages = 57–72 | doi = 10.1348/147608308X336100 | pmid = 18759998 }} and interpersonal psychotherapy.Bell (1996){{Full citation needed|date=August 2015}}

Case series and single case studies have also been published describing the use of CAT in:

• Depression{{cite journal | last1 = Bennett | first1 = D | year = 1994 | title = Readiness to change—the impact of reformulation: a case example of cognitive analytic therapy | journal = International Journal of Short-Term Psychotherapy | volume = 9 | pages = 83–91 }}{{cite journal | last1 = Dunn | first1 = M. | last2 = Golynkina | first2 = K. | last3 = Ryle | first3 = A. | last4 = Watson | first4 = J. P. | year = 1997 | title = A repeat audit of the Cognitive Analytic Therapy Clinic at Guy's Hospital | journal = Psychiatric Bulletin | volume = 21 | issue = 3| pages = 165–168 | doi = 10.1192/pb.21.3.165 | doi-access = free }}
• Dissociative psychosis{{cite journal | last1 = Brockman | first1 = B. | last2 = Poynton | first2 = A. | last3 = Ryle | first3 = A. | last4 = Watson | first4 = J. P. | year = 1987 | title = Effectiveness of time-limited therapy carried out by trainees: Comparison of two methods | journal = British Journal of Psychiatry | volume = 151 | issue = 5| pages = 602–610 | doi = 10.1192/bjp.151.5.602 | pmid = 3446303 | s2cid = 28993830 }}{{Cite journal|last1=Graham|first1=Candida|last2=Thavasotby|first2=Rijan|date=September 1995|title=Dissociative psychosis: an atypical presentation and response to cognitive-analytic therapy|url=https://www.cambridge.org/core/journals/irish-journal-of-psychological-medicine/article/abs/dissociative-psychosis-an-atypical-presentation-and-response-to-cognitiveanalytic-therapy/162A6B74DE5362A21A32D0AE9ACA3D07|journal=Irish Journal of Psychological Medicine|language=en|volume=12|issue=3|pages=109–111|doi=10.1017/S0790966700014555|s2cid=71030624 |issn=0790-9667|url-access=subscription}}
• The treatment of offenders{{cite journal | last1 = Pollock | first1 = P | last2 = Belshaw | first2 = T | year = 1998 | title = Cognitive analytic therapy for offenders | journal = Journal of Forensic Psychiatry | volume = 9 | issue = 3| pages = 629–642 | doi = 10.1080/09585189808405378 | s2cid = 143317743 }}
• Brain injury{{Cite journal|last1=Yeates|first1=Giles|last2=Hamill|first2=Michelle|last3=Sutton|first3=Laura|last4=Psaila|first4=Kate|last5=Gracey|first5=Fergus|last6=Mohamed|first6=Shemin|last7=O’Dell|first7=Juliette|date=2008-01-01|title=Dysexecutive Problems and Interpersonal Relating Following Frontal Brain Injury: Reformulation and Compensation in Cognitive Analytic Therapy (CAT)|url=https://doi.org/10.1080/15294145.2008.10773571|journal=Neuropsychoanalysis|volume=10|issue=1|pages=43–58|doi=10.1080/15294145.2008.10773571|s2cid=143497350|issn=1529-4145|url-access=subscription}}
• Deliberate self-harm{{cite journal | last1 = Cowmeadow | first1 = P | year = 1994 | title = Deliberate self-harm and cognitive analytic therapy | journal = International Journal of Short-Term Psychotherapy | volume = 9 | issue = 2–3| pages = 135–150 }}
• Dissociative identity disorderKellett (2005)
• Histrionic personality disorder{{cite journal | last1 = Kellett | first1 = S | year = 2007 | title = A time series evaluation of the treatment of histrionic personality disorder with cognitive analytic therapy | journal = Psychology and Psychotherapy: Theory, Research and Practice | volume = 80 | issue = 3| pages = 389–405 | doi = 10.1348/147608306X161421 | pmid = 17877864 }}
• Panic disorder{{cite journal | last1 = Tzouramanis | first1 = P. | display-authors = etal | year = 2010 | title = Evaluation of cognitive-analytic therapy (CAT) outcome in patients with panic disorder | journal = Psychiatrike | volume = 21 | issue = 4| pages = 287–293 | pmid = 21914611 }}
• Psychological problems in multiple sclerosisAdamopoulou, A (2006). An evaluation of cognitive analytic therapy for psychological problem in patients with multiple sclerosis. Multiple Sclerosis, vol. 12, supplement 1, p. S106.
• With carers of people with dementia{{cite journal | last1 = Hamill | first1 = M. | last2 = Mahony | first2 = K. | year = 2011 | title = 'The long goodbye': cognitive analytic therapy with carers of people with dementia | journal = British Journal of Psychotherapy | volume = 27 | issue = 3| pages = 292–304 | doi = 10.1111/j.1752-0118.2011.01243.x }}This study has also been incorporated into the NICE guidance for dementia: NICE (January 2011), [http://www.nice.org.uk/savingsAndProductivityAndLocalPracticeResource?ci=http%3a%2f%2fsearch.nice.org.uk%2fsl_413 Psychotherapy Service Provision for Carers of People with Dementia] {{Webarchive|url=https://web.archive.org/web/20150522175458/http://www.nice.org.uk/savingsandproductivityandlocalpracticeresource?ci=http%3A%2F%2Fsearch.nice.org.uk%2Fsl_413 |date=2015-05-22 }} (website).
• Morbid jealousy{{cite journal | last1 = Kellett | first1 = S. | last2 = Totterdell | first2 = P. | year = 2013 | title = Taming the green-eyed monster: temporal responsivity to cognitive behavioural and cognitive analytic therapy for morbid jealousy | journal = Psychology and Psychotherapy: Theory, Research and Practice | volume = 86 | issue = 1| pages = 52–69 | doi = 10.1111/j.2044-8341.2011.02045.x | pmid = 23386555 }}
• Borderline personality disorder{{cite journal | last1 = Kellett | first1 = S. | last2 = Bennett | first2 = D. | last3 = Ryle | first3 = T. | last4 = Thake | first4 = A. | year = 2013 | title = Cognitive analytic therapy for borderline personality disorder: therapist competence and therapeutic effectiveness in routine practice | journal = Clinical Psychology and Psychotherapy | volume = 20 | issue = 3| pages = 216–225 | doi = 10.1002/cpp.796 | pmid = 22109975 }}{{cite journal | last1 = Ryle | first1 = A. | last2 = Golynkina | first2 = K. | year = 2000 | title = Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: factors associated with outcome | journal = British Journal of Medical Psychology | volume = 73 | issue = 2| pages = 197–210 | doi = 10.1348/000711200160426 | pmid = 10874479 }}{{cite journal | last1 = Wildgoose | first1 = A. | last2 = Clarke | first2 = S. | last3 = Waller | first3 = G. | year = 2001 | title = Treating personality fragmentation and dissociation in borderline personality disorder: a pilot study of the impact of cognitive analytic therapy | journal = British Journal of Medical Psychology | volume = 74 | pages = 47–55 | doi = 10.1348/000711201160795 }}
• Paranoid personality disorder{{cite journal | last1 = Kellett | first1 = S. | last2 = Hardy | first2 = G. | year = 2013 | title = Treatment of paranoid personality disorder with cognitive analytic therapy: a mixed methods single case experimental design | url = http://eprints.whiterose.ac.uk/102728/3/paranoid%20case%20study.pdf| journal = Clinical Psychology and Psychotherapy | volume = 21| issue = 5| pages = 452–464| doi = 10.1002/cpp.1845 | pmid = 23733739 }}
• Survivors of child sexual abuse{{cite journal | last1 = Clarke | first1 = S. | last2 = Llewelyn | first2 = S. | year = 1994 | title = Personal constructs of survivors of childhood sexual abuse receiving cognitive analytic therapy | journal = British Journal of Medical Psychology | volume = 67 | issue = 3| pages = 273–289 | doi = 10.1111/j.2044-8341.1994.tb01796.x | pmid = 7803319 }}{{cite journal | last1 = Clarke | first1 = S. | last2 = Pearson | first2 = C. | year = 2000 | title = Personal constructs of male survivors of childhood sexual abuse receiving cognitive analytic therapy | journal = British Journal of Medical Psychology | volume = 73 | issue = 2| pages = 169–177 | doi = 10.1348/000711200160408 | pmid = 10874477 }}{{cite journal | last1 = Calvert | first1 = R. | last2 = Kellet | first2 = S. | last3 = Hagan | first3 = T | year = 2015 | title = Group cognitive analytic therapy for female survivors of childhood sexual abuse | url = http://eprints.whiterose.ac.uk/102719/5/Group%20CAT%20paper%20-%205th%20submission.pdf| journal = British Journal of Clinical Psychology | volume = 54| issue = 4| pages = 391–413| doi = 10.1111/bjc.12085 | pmid = 26017051 }}

{{Reflist|2}}

• 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.

• [http://www.acat.me.uk Association for Cognitive Analytic Therapy]

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