CAT 1 (CAT Key Concepts
Procedural Sequence Model
Target Problems -…
Origions of CAT
- It was created and developed by Anthony RYLE in England, from the mid-1970’s.
- Ryle aimed to develop a therapy, and a language, which would be a meeting point for psychotherapies in general.
- The name Cognitive Analytic Therapy was coined in 1990.
- Psychoanalysis – especially Object Relations British School (D Winnicott etc)
- Cognitive BehaviourTherapy (“2nd wave”)
- Personal Construct Psychology (George Kelly)
- James Mann’s Brief Psychodynamic Model
- Lev Vygotsky (Activity Theory; social formation of mind)
CAT is effective
- It works faster than many other therapies
- It works with difficult clients who tend to do badly with other types of therapy
- It works well, and fast, even in the hands of trainees
if they are receiving supervision which is adequate in quantity and quality
Note: for evidence base please see www.acat.me.uk
- Primary care
- Secondary care
- Private practice
- Addictions (in recovery)
- Eating Disorders
- Learning disabilities
- Psychosis (not during acute phase)
- Children and adolescents
- Psychogeriatrics (including mild and moderate dementia)
- Couple therapy
- etc., etc.
CAT Key Concepts
- Procedural Sequence Model
- Target Problems - TPs
- Target Problem Procedures – TPPs
- Reciprocal Roles – RRs
- Reciprocal Role Procedures – RRPs
- Core Pain
- Self-States and State Shifts
- Integration/Fragmentation and Metashifts
- Zone of Proximal Development (ZPD)
Procedural Sequence Model
- Human beings engage in aim-directed activity. (tend to do things for a purpose)
- Our aims, and possible means to achieve them, are based on our beliefs and values, thoughts, feelings, memories of previous attempts and their outcomes, “side effects” of our behaviour, etc.
- The outcomes of our activity feed back into the above, so that we may modify our aims, or means to achieve them.
- Much of our activity becomes automatised sequences (i.e. they require little conscious attention). This enables us to save time, energy and “mental space”.
- Though we have the capacity to modify our Procedures, sometimes we get “stuck” and continue to repeat Problem Procedures, in spite of the harm they cause us.
- Problem Procedures are often a formerly adaptive response which has become inappropriate and unhelpful – for example suppressing negative feelings to avoid enraging a violent parent may be adaptive during childhood, but not in adulthood.
- Usually, we can only change sequences by bringing them into conscious awareness.
Target Problems (TPs)
Difficulties or symptoms which the patient wants to address or resolve during this therapy They may be:
- specific (eg. “recent conflicts with my teenage son”; “shyness”; “bulimia”)
- general (eg. “anxiety and depression for many years”; “no point in being alive”)
Automatised procedures which underlie Target Problems.
- In the CAT Psychotherapy File, common examples of Problem Procedures are listed as Traps, Dilemmas and Snags.
Problem Procedures: Trap
- Vicious circle, which is self-reinforcing
- usually arises from a negative belief about oneself, the world, or other people
- An attempt to avoid painful failure (including rejection, etc) which backfires, so the negative belief is reinforced
Problem Procedures: Dilemmas
It is as if
- only two polarized alternatives are possible
- both are problematic and have adverse consequences
- the consequences of each polarised alternative reinforce the polarised thinking
Problem Procedures: Snag (Self-Sabotage)
Snags = “Subtle Negative Aspects of Goals”.
- Arises from the fear of success – which may feel undeserved, or one may fear envy, or abandonment by one’s family.
- May be conscious or unconscious
- May be reality based, or the result of faulty thinking
Target Problem Procedures (TPPs)
- Problem Procedures cause, intensify, or maintain TPs.
- TPPs are the Problem Procedures which the client and therapist decide to focus on during this therapy
- They may be taken from the Psychotherapy File, but almost always they are “tailor-made” for each client. The diagrams are done jointly within sessions.
- We need to find out for EACH client, which TPPs underlie each TP.
- Each TPP may underlie, or influence, more than one TP.
- Human beings relate from birth (Winnicott: “there is no such thing as an infant; only a mother-infant pair”)
- We internalise aspects of parental figures – especially their ways of being with another and our own reciprocation (eg Bully to Victim; Critical to Inadequate)
- We learn both Roles
- We may enact the parent-derived Role in relation to others, and in relation to ourselves (eg. I care for myself, I neglect myself, I harshly criticise myself)
- The various sets of Reciprocal Roles (ways of being with another) which we have experienced are a large part of our “mental/emotional map” of what is possible and expected.
- We might even say that our Reciprocal Roles are a large part of our personality, or who we are.
Each Role may be:
- Enacted towards another or towards oneself
- Avoided (usually by projecting it onto others and/or enacting its Reciprocal)
- Expected from others (if we expect someone else to be critical of us, we might experience it as if that is the case, even though they might not actually be critical)
- Attributed to others [cf. transference]
- “Recruited” from others, [cf. projective identification or induced counter-transference]
- Fantasised/Imagined (eg. Ideal Care)
Reciprocal Role Procedures
Procedures - both healthy/adaptive, and problematic/unhealthy/maladaptive which arise from Reciprocal Roles.
- The most painful Reciprocal Role(s) of each person.
- Contains Child-derived Roles – most commonly Abused, Empty, Needy, Powerless, Ignored, Neglected, Rejected, Humiliated, Deprived.
- Is a very painful “place” for all of us.
- Most people are able to acknowledge the pain, and try to soothe themselves or seek comfort from other people.
- Poorly integrated people (e.g. those with diagnosis of “Borderline Personality Disorder”) usually find it intolerable, and “exit” from it impulsively - e.g. through substances, self-harm, gambling, violence, maladaptive sex
(promiscuous-and-later-regretted, unprotected, relationshiprisking)
- We internalise aspects (Roles) of parental figures, and the resulting Reciprocal Roles,
- A fragmented (poorly integrated) person… Functions in a “split” way, i.e.
- When they are in one Self-State, they often lose touch with the rest of their Self, so their reactions tend to be extreme and unmodulated.
- Often reacts “automatically” rather than respond thoughtfully and appropriately
- Often has little capacity for self-reflection or for reflecting on other people’s minds
- A well-integrated person...
- Is in touch with their various Self-States, so that feelings, reactions and changes of State are understandable, appropriate and modulated.
- Is able to choose how to behave appropriately to the situation from among their various self states.
- Is self-aware, and able to reflect on themselves and on others, and make necessary changes.
- To be a well-integrated person we need...
- To experience (especially in childhood) more benign and positive interactions (i.e. ways of being with another, or RRs) than harmful ones.
- An absence of very traumatic experiences (which encourage dissociation and splitting) – or the capacity to make sense of these with the help of others
- At least one person who has helped us process and make sense of our feelings (especially strong difficult and confusing ones)
- Sudden (sometimes inexplicable) shifts from one Self State to another.
- Are often a response to someone’s Core Pain being triggered – especially in people who are poorly integrated and cannot tolerate it.
- The Shift is often to a less painful “parental” role (e.g. Controlling; Contemptuous; Rejecting) which feels “stronger” and more tolerable
- May happen to any of us, but are especially frequent, intense and confusing in people with a diagnosis of Borderline Personality Disorder (Emotionally Unstable PD)
- These people (and their relatives, friends and professional carers) find their State Shifts confusing and disorienting
- Metashift is a shift not from one Self-State to another, but rather
from one degree of integration to another i.e. from well integrated to fragmented/poorly integrated Or viceversa
Zone of Proximal Development (ZPD)
(from Lev Vygotsky)
- What a learner (person) cannot yet do on his own, but can do with the help of a “teacher” (e.g. teacher, parent, therapist, sibling) Eg. Johnny, age 10, doesn’t need any help to do subtraction. (This is no longer in his ZPD)
- With help, he can manage long division (i.e. this is in his ZPD)
- Even with help, he cannot manage nuclear physics (this is outside his ZPD)
- Teachers should always work within the ZPD.
- So should therapists!
- Within the CAT model, a patient’s “resistance” is considered to be due to the therapist operating outside the patient’s ZPD
CAT: Key Tools
- Psychotherapy File
- Reformulation Letter (therapist to client)
- Goodbye Letters (client to therapist, and therapist to client)
CAT Psychotherapy File
- Includes examples of common Problem Procedures (i.e. Traps, Dilemmas and Snags), as well as examples of split-off States
- Is usually given at the end of Session 1, to be done by client at home and discussed in Session 2 (and perhaps subsequent ones)
- It starts the patient thinking in terms of patterns or procedures, but the patient’s own patterns will be “tailor-made” rather than just copied out of the File.
CAT Psychotherapy File
- It’s a shared tool for patient and therapist – not just something for the therapist’s benefit.
- Patient keeps his copy ; therapist makes her own version by writing down patient’s responses – not just the “tick answers” but the comments, anecdotes, etc.
- It’s used flexibly – e.g. something else may take precedence that session; it’s not used at all if patient doesn’t like it; it may be completed in the session rather than for homework if patient has poor literacy; etc
- Target Problems which brought them to therapy
- The underlying Target Problem Procedures
- An empathic biography, which links their experiences with their RRs and RRPs (“to avoid your father’s anger, you learned to be Submissive and fear expressing your feelings”)
- Their goals and Aims or “Exits” from TPPs
- Something about the therapeutic relationship (especially if this has been difficult)
- It is produced as a draft – the client may add or change things, so that it becomes a jointly elaborated document (this may take a few minutes or a few sessions)
- This mutually respectful collaboration can be internalised by the client (for whom this may be the first such experience) – i.e. They start to internalise a new, healthier set of Reciprocal Roles
- Are very powerful tools for increasing self-understanding, and integration of the personality.
- They are best done collaboratively, in session.
- They may take different forms:
- Simple procedural loops (e.g. trap)
- Sets of Reciprocal Roles or Self States
- Reciprocal Roles and Procedures - Sequential Diagrammatic Reformulation (SDR)
- Client writes one to therapist; therapist writes one to client.
- These letters summarise the experience of therapy – what has taken place, what changes did the client make, what did he learn, what are his new reflections and behaviours, what happened in the therapeutic relationship (especially if this had moments of difficulty). What has not changed. Highlights; disappointments; memorable moments. Etc.
The process of CAT
- Ask about present problems, aims for therapy, and history: Listen out for RRs and patterns (both healthy and problematic)
- Psychotherapy File – usually given at the end of first session. Client brings it back completed, and one or more sessions are spent going through it. It is a stimulus to the patient’s reflection about themselves, especially their repetitive patterns.
- Prose Reformulation
- Goodbye Letters –These encourage reflection and help to “consolidate” gains.
- Though Procedures are automatised, i.e. they tend to happen “without thinking”, they are available for conscious reflection if the client starts paying attention.
- So the client is encouraged to observe occurrence of TPPs – or even keep a diary of them, noticing what triggered them – what were their thoughts and feelings.
- Problems and symptoms no longer seem to happen at random, but rather with Antecedents and Consequences (cf. Cognitive Behaviour Therapy). Noticing and reflecting on these is usually the first step which enables change
(Exits, i.e. healthier alternative procedures)
- The patient decides (in conversation with the therapist) which Target Problems to focus on during therapy.
- The therapist collaborates with the patient, in a process of shared discovery and creation of meaning and narrative
- The therapist collaboratively describes and diagrams the patient’s behaviour and ways of relating:
- In his everyday life
- In relation to the therapist (cf. “transference”)
- The therapist points out links between a) and b) – i.e. the repetition of patterns of relating acquired in the past (mainly in childhood)
- The therapist does not interpret what the client “really” means, thinks, feels, etc. (This is an important difference from traditional psychodynamic therapy).
- The therapist pays attention to her own counter-transference in order to make sense of the patient’s Reciprocal Role Procedures, moments of “stuckness”, the meaning of silences, etc.
- Thanks to the above mentioned factors, the patient usually does not show “resistance”
- When the therapist notices “resistance”, she does not interpret, but rather realises she is going too fast for this patient (she is outside the patient’s Zone of Proximal Development).
The danger of “recruitment”…
- A client may “recruit” us into split and inappropriate Reciprocal Roles (eg. Rejecting; Ideal Protector; etc) This constitutes collusion with the patient’s “mental map”, and is harmful (as it confirms their pathological “mental map”, instead of questioning it, amplifying it and improving it (by enabling them to internalise good Reciprocal Roles from our way of being with them)
- Anybody (not only clients!) may “recruit” us in this way. It happens more frequently and intensely with people who function in “split” ways (eg. Personality Disorders)
Preventing and addressing “recruitment”…
- The Reformulation and Diagram are produced in collaboration with the patient. They help to predict and avoid “recruitment” (in psychodynamic parlance “Projective Identification”), because forewarned is forearmed).
- And when we are recruited (for the above is not foolproof), the Reformulation and Diagram allow us to notice, make sense of it, and discuss it with the patient in a descriptive, “digestible” way, which is not experienced as persecutory.
- Of course, Supervision is essential, as even experienced therapists may not notice “recruitment”.
“Recruitment” can be…
- into a particular Self-State
- Into a level of Integration or Fragmentation (see the slide on Metashifts/Universal Diagram in Part 1 of this lecture)
- We can be recruited into someone’s poor level of
Integration – or they can be recruited into our (usually) higher level of integration. (I.e. we can help them integrate, by staying integrated ourselves)
Process of Therapy and Therapeutic Relationship
Hopefully lead to:
- Internalisation of (new) healthy benign Self-States (Reciprocal Roles)
- Greater integration (less fragmentation) of personality
- Greater capacity to choose Roles appropriately
- Greater capacity to reflect
Addressing “recruitment” and “splitting” in teams
- “Splitting” refers to members of teams reacting to a patient in “split” ways, e.g. One of them feels protective; another angry and dismissive; a third indifferent. This often leads to staff turning against each other
- CAT offers a shared understanding, easily conveyed to staff and patients
- CAT diagrams may be shared by all staff (plus perhaps also the patient, carers, professionals not in the Team, such as the GP, etc.)
- This helps to prevent, understand, and redress enactments and “splitting”
CAT is more than a modelog psychotherapy. It is also...
- A theory of how personality develops, how psychopathology arises, and how to enable positive change.
- a tool for understanding people who have a diagnosis of Borderline/Emotionally Unstable Personality Disorder [and other challenging individuals], and the complex effects they may have on professionals and teams involved in their care.
- a tool for teaching psychological understanding quickly and accessibly to all Mental Health staff, helping us to reflect on the effects that the behaviour of others have on us, and on the effects that our behaviour has on other people.
CAT is not a panacea
- Many clients find that 16 (or 24) sessions is enough.
- Some patients do not improve
- Some patients do improve, but need more therapy:
- a. Another course of CAT (not necessarily inmediately; probably focusing on other problems and aims)
- b. A different form of therapy (many patients who would have been too fragile for individual or group psychodynamic therapy will be able to handle these after a course of CAT)
To be taken into account...
- CAT requires more supervision per hour of therapy than many other therapies – even for experienced therapists, especially when dealing with “difficult” patients
- CAT requires “homework” (i.e. Work between therapy sessions) by the therapist – producing the Reformulation and the Goodbye Letter requires 2 to 4 hours of the therapist’s time.