2011年08月21日

What’s it like to have Cognitive Analytic Therapy?

What’s it like to have Cognitive Analytic Therapy?

Here we’d like to offer you a glimpse into the practical experience of CAT. There’s a general account of the course of therapy, and some reflections on CAT from the therapists themselves. The general description is given as a guide to the process of therapy. It is likely that your experience of therapy will differ in many ways from the patterns shown below, however these are the key themes you may expect to find. Everyone’s different and so you and your therapist will also create a unique experience of therapy. If you have any questions then either email ACAT directly, or talk with a local CAT therapist.

Assessment
Starting CAT
Reformulation
Doing CAT
Endings
Cognitive Analytic Therapy

Assessment

When you contact a therapist he or she will normally arrange a meeting to talk with you about your reasons for seeking therapy, and to share with you their idea of the scope and purpose of CAT in concrete terms as it relates to you and the things you want to talk about. This initial assessment session allows you and your therapist to see if you are happy to work together in a course of Cognitive Analytic Therapy, and to answer any specific questions you may have about the therapy.

The therapist will then draw up a contract with you for a set period of time. CAT is a "brief" form of psychotherapy and normally takes 16 sessions, however the therapist may also recommend 8, 12, or 24 sessions as he or she feels appropriate, and will discuss her reasons for doing so with you. CAT therapists rarely work to an unlimited time period. The dates and times of the therapy sessions are then worked out with you at a mutually convenient time.

Starting CAT

After the first session you will be asked to complete a "Psychotherapy File" which asks about typical, common problems or patterns, described as Traps, Dilemmas and Snags. You may also be given the task of monitoring your mood, or behaviour patterns.

The early therapy sessions will be concerned with hearing your story and beginning to piece together the patterns that make up your life and to start to understand how they work.

Reformulation

At or around the fourth therapy session the therapist will work with you on a written "Reformulation" of your situation. It will give a description of your life so far as you’ve shared it with the therapist, and it will describe the problems and patterns that lead you to seek therapy. It will also illustrate the situation you are in as a series of Target Problem Procedures which may be drawn as a diagram (also known as an SDR, or sequential diagrammatic reformulation). These show how the situations you’ve experienced in the past still influence your current behaviour, and how this old pattern may be causing you problems in the present. You and your therapist then work from these Target Problem Procedures, checking that they describe your situation, and then beginning to look for Exits from these unhelpful ways of living.

Doing CAT

The following sessions of the therapy will be focused on the SDR and Reformulation as a means for helping you learn new ways of dealing with situations you face now. The therapist will work with you on the Target Problem Procedures to help to understand the choices that you have in your current situation when you find yourself acting out of the old and unhelpful patterns.

You may be asked to complete various "homework" activities, and will be encouraged to give attention to your thoughts, actions and feelings in the course of the therapy. You and your therapist will use these observations and the experiences you share in the course of the therapy sessions to give you a greater insight into how you make positive changes in your life.

Endings

In the last 3 or 4 sessions you and your therapist will work towards a good ending to the therapy. You will be given a chance to talk through the feelings and thoughts you have about ending the therapy, and will be able to consolidate the key themes that you have shared with your therapist over the previous sessions. You and your therapist will then exchange a "Good-bye" letter which allows both you and your therapist a chance to close the therapy process.

Normally you will be offered a follow-up appointment in the next couple of months to meet with your therapist and discuss how things have gone for you following the therapy.
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What Are The Origins of CAT?

What Are The Origins of CAT?

Cognitive Analytic Therapy was derived from the convergence of three personal concerns: a commitment to the development of a therapy which might be applied in the National Health Service, an involvement in psychotherapy research, and a belief that the time was ripe for a unified psychotherapy theory.

Sources

The main sources were psychoanalytic object relations theory -which had been the model with which I had most experience and supervision, and the work of George Kelly, whose Repertory Grid Technique became a major research tool and whose Personal Construct Theory introduced me to cognitive and constructivist ideas. The development of an integrated model come from the early attempt to find a common language for psychotherapy, largely by re-stating psychoanalytic ideas in cognitive terms, and was accelerated by doing research. Working with patients to find the best descriptions of what it was we were trying to change as part of outcome research, demonstrated to me the power of collaboratively arriving at such descriptions. This early joint reformulation has remained the key feature of CAT, offering both the early creation of a non-authoritarian working relationship and yielding increasingly powerful tools of understanding and change.

Further developments were accelerated by the challenge and opportunity of running the St Thomas’s Hospital Psychotherapy Service which demonstrated that a minimum sufficient intervention of - in most cases - 16 sessions, delivered by supervised trainees with variable but often little prior experience could meet the needs of most of the patients referred to the service. During my ten years there some 1% of the adult population of the catchment area were treated. Over the same period growing numbers of trainees took up the approach, enriched it with their various ideas, rapidly upgraded the quality of the training offered and went on to create and develop ACAT.

Theoretical Developments

The development of diagrammatic reformulation over this period contributed to a more detailed and radical revision of object relations theory and to the development of a model of the dissociated personality structure of patients with borderline personality disorder. The contributions of Mikael Leiman from Finland, in linking the ideas of Vygotsky and Bakhtin with the CAT model, strengthened this process. As a result of these developments the early ways of reformulating patients’ difficulties in terms of failures to revise damaging patterns, described as Traps, Dilemmas and Snags, while still of value in simpler cases, have been largely superseded by an emphasis on reciprocal role procedures. These are seen to originate in early life and to be maintained by the elicitation of the expected reciprocations from others. . Therapists need to identify but not reciprocate damaging role procedures. Role procedures derived from relationships with others are also the origin of self processes, and both interpersonal and intrapersonal enactments are frequently replaced or accompanied by dialogue making use of language and other mediating tools learned in early life. A person's repertoire of role procedures is normally more or less integrated and mobilized appropriately but in more disturbed individuals dissociated self states may operate alternately, switches between them being disconcerting to both patients and clinicians.

Despite its integrationist ideals and despite its many publications - including some polemical writing seeking to evoke debate - CAT has generated little discussion in the journals of current schools of therapy but this has not prevented a rapidly growing demand for training and the establishment of training and practice in many parts of the UK as well as in Finland - Greece and some other centers. The proof of the pudding may be in this eating, but we still need a more extensive research basis than has so far been assembled.

To the Future

Over the 25 years since CAT was formally launched it has grown in size in the UK and abroad, it has developed theoretically, it has been applied to different conditions and different contexts, it is generating an increasing volume of research and in ACAT it has an effective professional organization. These developments have been the work of increasing numbers of practitioners, therapists, supervisors and trainers. Despite the damage done to the NHS and despite the political dominance of other models, it seems destined to continue to grow.

Tony Ryle - Originator of CAT and Founder of ACAT - 2008
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