Cognitive Analytic Therapy 209 overactivity in therapists and passive resistance ently. She described her father as very stern and cried when describing how critical he was but in patients. added, “It was for my own good.” Later, she ver- bally attacked the psychotherapist for “making Maintenance her say bad things about him,” adding that he and Relapse Prevention was a perfect parent who, had he not died a few The maintenance and continuation of change years back, would have been very upset by the after a 16- or 24-week therapy depend on the mess her life was now in. She described how her internalization of the therapist as a corrective mother, with whom she currently shared a house, voice and on the continuing use of the tools had never sided with her against the father and develop ed in the thera py. Fo llo w-up at 3 months had never trusted her to manage anything in the usually shows that more has been retained than home. Neither parent had expressed any pleasure appeared likely during the ambivalent phase of when she graduated from college. termination. This experience of coping alone Kate “fell desperately in love” at the age of 20. is a positive one for most patients. Nonetheless, Despite episodes of mutual physical violence, she a proportion of patients, especially those with lived with the man and became pregnant by personality disorders, may need further help. choice when aged 27. No sooner was her daugh- This may take the form of further spaced ter Lily born than the couple separated, Kate be- follow-up sessions or a short spell of “top up” ing given custody. At 29, she met and married a sessions designed to reinforce what was “well-off and good looking” businessman and learned. In other cases, long-term “dilute” sup- had her second daughter, Tina. Soon after the portive therapy informed by the understanding birth, she requested a legal separation and the of the reciprocal role patterns may be appro- husband was granted custody of the child. She was priate. Patients needing a continuation of ac- currently trying to incre ase her access to Tina but tive therapy may be referred to group therapy, did not wish to take over full-time parenting and, therapeutic community, or day hospital pro- in any case, Social Services were conce rned about grams, preferably to receive various inputs her inc onsi sten t behavior toward the children. (such as other group activities, psychodrama, Kate herself described her attitude to her or art therapy) coordinated by CAT-informed daughters in strongly contrasting terms. Some- management. There may be a place for a sec- times she would be overwhelmed with longing ond CAT after a gap of a year or more, for and sadness for Tina and would describe Lily as example, with patients who, building on a first an unmanageable monster; at other times, she therapy, risk greater involvement with others would reject Tina and praise Lily. and encounter new forms of difficulty. Kate was given the Psychotherapy File. She checked traps concerned with the fear of hurting others, depressed thinking, and social isolation. She identified the following self-management di- CASE EXAMPLE lemmas: either I try to be perfect or I feel guilty, Kate, aged 33, consulted with the aim of obtain- and either I keep things and feelings in perfect order or I fear a terrible mess. Relationship dilem-ing psychiatric support for her request to be al- lowed more access to her 3-year-old daughter mas identified were: either I am involved and likely to get hurt or uninvolved, in charge butwho was in the custody of her husband, from whom she had separate d shortly after the birth of lonely; either I stick up for myself and am disliked or I give in, get put upon and feel cross and hurt;the child. She did not want psychotherapy, but agreed to attend for four asses sme nt sessions. A t and when involved with someone either I or they have to give in. Her score on the PSQ was 37.the end of this ti me, she accepted a further 20 ses - sions. Kate missed her third session, explaining at the next meeting that she had felt too upset. The ther-Kate was an intelligent and attractive woman who told her story histrionically and incoher- apist suggested that this might reflect the self- 210 Integrative Psychotherapy Models continue to work together to make sense of management dilemma of “either I keep things what, at present, is so often bewildering. and feelings in perfect order or I fear a terrible mess” and the relationship dilemma of “either I am involved and likely to get hurt or uninvolved, Kate was moved by the reformulation letter and brought it to the next session. She said it wasin charge but lonely.” At the next meeting, the provisional reformulation letter was read. perfect and needed no revision, adding that no- body had ever understood her before. Work onAfter recording how, as a child, she had had to work hard to avoid father’s criticism and how the diagram was started, but when a draft was of- fered at session 6, she said it made no sense atmother had never trusted her to be capable, the reformulation letter continued: all and tore it up. The final version (Figure 9.2), which encapsulates her borderline features, was It seems to me that, although your parents agreed on two sessions later. gave you a lot, they did not give you any se- Kate became far more aware of her idealiza- cure sense of your own worth. You experi- tion, of her slavish striving for praise, and of her enced your father as particularly rejecting switches into destructiv e anger. At session 11, she when you became adolescent, mocking your reported how she had prepared for a meetings with appearance and your normal interest in boys, and you felt too anxious to risk getting close her husband and social worker a bou t Tin a with the to people of your own age. The one way you aid of the diagra m and how this had enabled her could feel good about yourself was through to be calm and coh eren t for the firs t time. your achievement at school. It seems that it is Kate stopped her therapy after 15 sessions, still very important for you to win admiration saying it was too demanding to go on and that and praise but you still have no close friends she felt less distressed and more controlled than and often feel lonely and empty. With both the before. She had achieved more independence important men in your life you seem to have from her mother and was looking for separate ac- started by expecting too much and then, as commodation. The therapist wrote a brief good- things became difficult, you alternated be- bye letter, noting the changes that had been tween desperately striving to please them and achieved and the residual instability of mood and angry, sometimes violent, dis app oint ment . Sim- ilar switches affect how you are with your chil- emphasizing the need to continue self-reflection dren. It seems to me at this point that with Lily with the help of the diagram. At follow-up meet- you are sometimes harsh like your father was ings at 3 and 6 months, Kate reported that she to you and at other times you try to make it up now had a clearer understanding of her child- to her and be a perfectly caring parent. With hood and of how it had affected her attitude to- Tina you are facing the consequences of hand- ward her children. She also reported that her ing her over to her father; as we discussed, I mood and behavior were more even and con- wonder if this was your way of protecting her trolled. from what you feel is bad in you. Now, though Two main problems had faced the therapist in you miss her desperately, you feel unable to this case. The first stemmed from the fact that the take full care of her and can become very im- patient came seeking support for her wish for patient when she is with you, as a result of which your ex-husband and Social Services more access to Tina, rather than for help with her are only allowing you restricted access. personal difficulties. The experience of the first It seems that you can be angry, loving, de- assessment meetings was distressing, and she structive, and unhappy in extreme ways and missed the next appointment. (Normally patients that deep down you feel irrationally bad. Our lose any sessions missed without notification, but first important task will be to continue to work during assessment this rule is relaxed.) However, on the map we started as a way of understand- after completing the assessment process and re- ing the switches between these different states. ceiving the reformulation letter, she was able to It is probable that we will experience these commit herself to therapy, although she did fail states, for working at therapy may make you to attend on one subsequent occasion. The pre- feel exposed or angry or well cared for or dis- liminary understandings of the role procedures appointed at different times; our job will be to recognize and manage these changes and to derived from the history and the Psychotherapy Cognitive Analytic Therapy 211 Critical Rejecting Kate to daughters Kate to parents Rejected Guilty Deprived Placate Seek admiration perfectionist Resentful Ideally cared for Idealized care Fall in love Feel wonderful Disappointed FIGURE 9.2 Diagram of Kate. The number s in brack- ets indicate individuals with whom the procedures are clearly operating: 1 = Lily; 2 = Tina; 3 = first husband; and 4 = second husband File had helped the therapist to contain the dys- EMPIRICAL RESEARCH functional procedures that threatened therapy from the beginning. As explained above, many CAT features were originally developed in the context of research The second problem stemmed from the pa- tient’s “narrative incompetence” (Holmes, 1998). (Ryle, 1980), and smal l explorato ry studies have continu ed to i nfluenc e d eve lopments. The rap id Kate’s account of her life was full of the illogical jumps, obvious contradictions, and violent mood expansi on of CAT train ing , the fact that it takes place in a large number of center s, and the ex- swings typical of patients with borderline person- ality features. The idea that these could reflect al- treme shor tag e of rese arc h funding during the past two de cad es hav e l imi te d large-scale studies, ternating states of mind, which could be under- stood and connected, was put to Kate at the but some are now being undert ake n. The fol- lowing are the main published studies . second session. The process of identifying and describing her different states was initiated by a detailed consideration of her replies on the PSQ. Controlled Outcome Studies The development of the diagram supported the therapist in making sense of the patient’s various and at times extreme attitudes. Although Kate 1. A small, randomized comparison of CAT with focused dynamic therapy carried failed to carry out agreed self-monitoring based out by the same therapists and using on it, her use of it to prepare for her meeting with both nomothetic and ideographic (grid- her ex-husband and social worker demonstrated derived) measures showed a significantly that she had achieved more understanding and larger effect for CAT on the latter. The control through the use of it. Kate did not com- results indicated more change in the pa- plete the 24 sessions offered, and this doubtless tients’ dysfunctional self-attitudes and in reflected a persistent uncertainty about self-expo- associations between caring, depending, sure. However, her attendance for follow-up and controlling, and submitting (Brockman, her reports of continued change suggested that Poynton, Ryle, & Watson, 1987). she had achieved significant changes in personal- 2. Insulin-dependent diabetic patients with ity functioning. poor diabetic control despite nurse edu- 212 Integrative Psychotherapy Models cation were randomized between CAT Naturalistic Outcome Studies with Measured Outcomesand an equivalent number of sessions with a diabetic specialist nurse offering intensive education. The procedures as- 1. Mitzman and Duignan (1993; Duignan & Mitzman, 1994) described a CATsociated with poor self-management in- cluded depressive self-neglect (sometimes therapy group in which the patients’ re- formulation letters and diagrams, con-amounting to slow suicide), passive resis- tance to the clinic staff, and personality structed in four individual sessions, were shared in the subsequent 12 meetings offragmentation. The CAT focus on high- level procedures seemed particularly rel- the group. Five of the eight group mem- bers had Axis II diagnoses. One patientevant for such problems. HbA1 levels, in- dicating the average level of diabetic dropped out after two meetings. Mean changes in questionnaire scores and grid-control, fell in both groups at the end of 16 sessions, but this was not maintained derived measures in the remaining 7 cases were similar to those achieved inin the nurse education group, whereas in the CAT group further reductions oc- 16 sessions of individual CAT. 2. Garyfallos and colleagues (1998) as-curred. Measures of interpersonal diffi- culties improved significantly in the CAT sessed the effect of CAT in a large series of outpatient s in Greece using the MMPI.group only. 3. In a similar randomized controlled trial, They concluded that CAT offered a satis- factory approach in this setting.Cluely (perso na l communica tio n, March 2001) reported a significant effect of 3. Kerr (2001) described the use of CAT in post–acute manic psychosis and alsoCAT on increasing the quality of life and improving treatment adherence in pa- CAT treatment of a case of schizoaffec- tive disorder (Ryle & Kerr, 2002, pp.tients with poorly controlled asthma. 4. There have been two unsatisfactory ran- 167–172). 4. Ryle and Golynkina (2000) described thedomized controlled trials (RCTs) of CAT in anorexia nervosa. Treasure et al. outpatient treatment of a series of pa- tients with borderline personality disor-(1995) compared CAT with educational behavior therapy, and Dare, Eisler, Rus- der with up to 24 sessions of CAT, in most cases by trainees. Of the 31 patientssell, Treasure, & Dodge (2001) com- pared CAT with routine care, a psycho- starting treatment, 4 dropped out. The remaining 27 patients were all assesseddynamic in ter ve nti on, and family therapy. It is hard to draw conclusions from these at a 6-month follow-up, and 18 attended at 18 months posttherapy. At 6 months,studies for, though CAT was reasonably effective and patients were positive about mean psychometric scores were signifi- cantly lower, and half the sample nothe approach, in neither case were the CAT therapists trained. Further, in the longer met Diagnostic and Statistical Manual of Mental Disorders IV (DSM-latter study, the effect of a 7-month CAT was compared to 12-months of the other IV) criteria for BPD; these were catego- rized as improved. The pretherapy assess-interventions. 5. Pollock (personal communication, Octo- ments showed that the unimproved pa- tients were less likely to have been inber 2002) compared 16 sessions of CAT with a waiting list control condition in employment or in any ongoing relation- ship and were more likely to have a his-female survivors of childhood sexual abuse. CAT showed clinically and statistically tory of self-harm, violence, and alcohol abuse than were the improved group.significant treatment effects. 6. Controlled trials are currently in process Follow-up at 18 months showed further reductions in psychometric scores inwith personality-disordered patients and with seriously disturbed adolescents. both groups. Cognitive Analytic Therapy 213 clinical disorders. The approach will doubt- Studies of Phenomenology less continue to be modified and will need and Change evaluation in these various applications. It is likely to be applied more frequently to workClarke and Llewelyn (1994; Clarke & Pearson, 2000) reported studies of adult abuse survivors. with couples and families, where it is compati- ble with systems theory approaches, and toRyle and Marlowe (1995) described the clini- cal and research uses of the self-states sequen- group therapy. In the care and management of personalitytial diagram. Golynkina and Ryle (1999) used repertory grids to identify the characteristics of disorders and major mental illnesses, CAT has, I believe, an important contribution to make.the partially dissociated states of a series of bor- derline patients, and Ryle (1995) linked state It provides, in accessible language, descriptions of interactions that can be shared by patientsdiagrams t o me as ure me nts of variatio ns in trans- ference and countertransference during the and staff. The more technical contributions of CAT, notably the value of written and dia-therapies of two borderline patients. Pollock (1996) reported repertory grid studies of a group grammatic reformulation, have two parts to play: one in extending patients’ capacity forof sexually abused women who had committed violence against their partners, demonstrating self-reflection, and the other in supporting clinical workers in the creation and mainte-how it was necessary for the therapist to ac- knowledge the patients’ self-perceptions as guilty nance of a working alliance that can guard against inadvertent collusion and allow an au-abusers before the guilt irrationally associated with the victim role could be reconsidered. thentic human interchange. CAT continues to aim for integration at theSheard et al. (2000) described a CAT-derived three-session intervention for patients present- level of theory and practice, being committed to the creation of a conceptual base that ising to emergency departments with repeated deliberate self-harm. compatible with what is reliably known about human development, personality, and therapy. Such a base supports the critical evaluation Measures of Model Adherence and continuing selective assimilation of ideas and Process from other models. This should generate a continuing debate,Bennett and Parry (1998), using reliable alter- native analyses of the therapy dialogue, demon- but so far this has not been forthcoming. Expo- sitions of the differences between the idea ofstrated the accuracy of the CAT joint reformu- lation of a borderline patient. Methods for the the schema and the procedure and of the na- ture of sign-mediated internalization as op-microanalysis of audiotapes or transcripts of therapy sessions were developed (the Therapist posed to representation have not been dis- cussed; the radical critiques made of selectedIntervention Coding) with the aim of identify- ing how threats to the therapeutic alliance psychoanalytic ideas and practices have re- mained uncommented upon. The CAT dia-were managed (Bennett, 1998; Bennett & Parry, 2003). The use of an early version of this logical understanding of early development, self-processes, and therapeutic change impliesin the supervision of CAT therapists is de- scribed in Ryle (1997a). Bennett and Parry (in a challenge to common philosophical assump- tions about how humans should be thoughtpress) have also developed a method of mea- suring competence in delivering CAT. about and will, I suspect, be widely misunder- stood but I hope will eventually be construc- tively debated. Differences in language and un- derlying paradigms, even though they oftenFUTURE DIRECTIONS conceal considerable areas of agreement, make much debate as constructive as conversationsThe development of CAT is not over. As a framework for individual therapy, it is being in the Tower of Babel. However, the difficul- ties cannot be resolved by adherence to parishapplied in different contexts and to different 214 Integrative Psychotherapy Models loyalties or by bland assertions that we are all Bennett, D. & Parry, G. (in press). A measure of psychotherapeutic competence derived from doing the same thing really. In both theory and in values, CAT is insis- cognitive analytic therapy (CAT). Psychother- apy Research. tent on the need for psychotherapists to work from an understanding of the whole person. Bennett, D., Pollock, P., & Ryle, A. (in press). The States Description Procedure: The use ofReductive models of human functioning, whether by overemphasizing the role of genes, guided self-reflection in the case formulation of patients with borderline personality disorder. behaviors, cognitions, or unconscious forces, have damaging ethical implications. In its em- Clinical Psychology and Psychotherapy. Brockman, B., Poynton, A., Ryle, A., & Watson, J. phasis on the profound and subtle influence of human culture on individual personal develop- P. (1987). Effectiveness of time-limited therapy carried out by trainees: A comparison of two ment, CAT does not deny these factors. But nor should psychotherapists deny that we and methods. British Journal of Psychiatry, 151, 602–609. our patients live in, and internalize much of a world where increasing wealth is linked with Clarke, S., & Llewelyn, S. (1994). Personal con- structs of survivors of childhood sexual abuse persistent gross inequalities, increasing loneli- ness, depression, passivity, and powerlessness. receiving cognitive analytic therapy. British Jour- nal of Medical Psychology, 67, 273–289. These forces effectively diminish the individu- al’s sense of self and connection with others; Clarke, S., & Pearson, C. (2002). Personal con- structs of male survivors. Unpublished manu- we need to bear witness to this. In our relation- ships with our patients, we need to challenge, script. Coleman, P. (1999). Identity management in later not reinforce, the internalized social sources of psychological damage. life. In R. T. Woods (Ed.), Psychological prob- lems of ageing: Assessment, treatment and care (pp. 49–72). Chichester: Wiley. 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