Cognitive–analytic therapy 　Chess Denman-2

Severe borderline personality disorder

Practising CAT as described above is suitable for less severely disorganised personalities and neurotic conditions. However, when the patient suffers from borderline personality disorder a piecemeal approach to individual maladaptive procedures becomes ineffective. This is because as each procedural sequence is tackled the patient takes flight into different reciprocal-role structures; in effect, patient and therapist chase each other around the patient's diagram.

Nevertheless, these diagrams are particularly useful in adapting CAT for use with patients who have borderline personality disorder. With such patients, the focus should be integration and the therapeutic aim should be to enable patients to gain an overview of the wildly discontinuous self-states they can find themselves occupying. CAT therapists conceptualise this aim as the development of an ‘observing I', who is concerned and involved but neither overwhelmed nor silenced.

Probably a key therapeutic technique in helping the development of an observing I is modelling. By watching as the therapist (more or less successfully) continues to describe what is going on for the patient without becoming drawn into enacting any of the patient's reciprocal role patterns and by trying to do this him- or herself, the patient builds up an inner state that embodies this stance. This technique of involved non-collusion is similar to a range of therapeutic modalities for borderline personality disorder. But CAT is distinctive in its use of the diagram as a guide for patient and therapist about what is going on in a session. CAT is also distinctive in combining elements of interpersonal and object relations theory in its understanding of the patient with a frank and educative model that supposes that the patient, at least in part, can be an active and cooperating partner rather than a consciously or unconsciously motivated opponent.

Let us return to Paul (case vignette 2). Despite misgivings, Paul was offered therapy. In order to help Paul's therapist, at the very first meeting the assessor drew a sketch of a tentative diagram of reciprocal roles known as a sequential diagramatic reformulation (SDR). There had not been time in the assessment to share this with Paul, but it became immediately relevant in the first therapy session when Paul, upset at seeing a different person from his assessor, began to denigrate and devalue the therapist. After the therapist had shared her version of the diagram, Paul was able to admit that he was frightened of coming to therapy because he thought the therapist would be sneering at him (Fig. 4⇓).

Comparing CAT with other therapies

As its name implies, CAT shares elements of both cognitive and psychoanalytical psychotherapies. Psychoanalytical concepts, particularly those drawn from the independent group, have been central to the phase of CAT marked by the development of the SDR. The theory of reciprocal roles and of reciprocal-role induction allows CAT to conceptualise the psychoanalytical concepts of transference, countertransference and projective identification in ways that Ryle claims are less mystifying and more practically useful (Ryle, 1994b, 1998). CAT therapists regard transference phenomena and their countertransferential responses as useful sources of information about the patient's reciprocal-role procedures. Importantly, the reformulation's specification of reciprocal-role procedures can also be used to predict the likely development of the transference–countertransference relationship and hence to anticipate difficulties and developments in therapy.

Another strand in CAT's relationship with psychoanalysis is Ryle's critical struggle with psychoanalytical thinking, especially of the Kleinian school, which has resulted in a key series of papers that engage with both Kleinian technique and theory (Ryle, 1992, 1993, 1995b). Ryle's principal argument with Kleinian theory lies in his view that in severe cases such as borderline personality disorder the symptomatic experiences and behaviours of patients are consequent on psychic “unintegration” and the formation of multiple-self states. This contrasts with the Klein/Bion perspective, in which borderline states are associated with psychic disintegration and attacks on linking (Bion, 1967). Ryle levels a similar set of criticisms at Fonagy's theory of a mind-based conceptualisation of borderline personality disorder (Fonagy, 1991). In this theory, the self turns on its own mental functions to obliterate the horror of acknowledging that the mind of the abuser conceived of and carried out abusive acts (Ryle, 1998).

In recent years, CAT theorists have shown reduced interest in the less severe psychological conditions. CAT's chief causal explanation for such conditions appeals to procedural sequences that are malformed and not revised. There is a considerable body of theory within CAT that seeks for reasons why these procedures, which are set up to be self-correcting, are not revised for the better. However, signally absent among these reasons is any appeal to defence against unconscious conflict. It is CAT's resolute rejection of defence as a major mechanism in symptom formation that marks it out from psychoanalytic perspectives.

To these theoretical differences must be added some strong views about technical issues. In relation to psychoanalytical practice, Ryle regards the long intense treatments practised by an ‘invisible' and studiedly neutral analyst as likely to generate abnormal phenomena, which themselves become the spurious basis for theory-making. A good example of these views appears in Ryle (1996), where he also sets out a key CAT distinction between interpretation and description. For Ryle, psychoanalytical interpretation risks involving the interpreter in claiming special knowledge about the interpreted that is not accessible to direct test by the interpreted subject. Description, on the other hand, he conceives of as a joint process, in which the close inspection of what is available to consciousness can reveal more and more of what is not so easily available. CAT therapists therefore characterise their activities as descriptive rather than interpretive.

CAT shares with cognitive therapy a stress on the detailed analysis of the conscious antecedents and consequences of symptoms, the production and sharing of a detailed descriptive formulation with the patient, the setting of homework and a focus on, and problem-solving approach to, difficulties. Ryle deliberately drew on Kelly's personal construct psychology (Kelly, 1955) and his concept of the individual as scientist actively construing the world. This concept chimes well with the setting of behavioural experiments used in CBT. Marzillier & Butler's (1995) review of commonalities and differences between CAT and CBT identifies these similarities among others. They show CAT's commonalities both with schema-focused CBT (Young, 1990) and with Teasdale & Barnard's (1993) interacting cognitive subsystems (ICS) model. They find few differences other than ones of emphasis in relation to these models, so that their overview of CAT is in favour of classifying it as one of the cognitive therapies.

However, Marzillier & Butler's cognitivist reading of CAT would not be shared by a significant number of CAT therapists. Ryle himself, presented with the ICS model, is sharply critical. He regards it as being far too focused on intra-individual interactions between internal automata, and in consequence inclined to neglect the crucial importance of the external world, particularly the social world, in structuring experience. Thus, for Ryle, CAT is different from CBT, and particularly the ICS model is different from CAT, because the latter emphasises social interaction rather than individual processes as the primary unit of analysis. However, this criticism of the ICS model may not be entirely warranted.

There are powerful points of similarity between schema-focused CBT and CAT, and it is probably more fair to characterise their differences as ones of emphasis. I have explored these differences with a colleague (Allison & Denman, 2001). To my eye the key differences between the two lie in the consistent CAT emphasis on interaction and on social interaction, embodied in the notion of a reciprocal role that is a block of procedural knowledge about how to ‘do’ a particular kind of relationship and what to expect from it. This can certainly be viewed as a kind of schema, although it is more complex in internal structure than a normal CBT schema. Interestingly, in an early paper Young (1986) suggested schema clusters that look very like reciprocal roles but does not seem to have followed this up in later work.

Cognitive therapists who work in the schema-focused tradition often find much to agree with in CAT. A not infrequent comment is that CAT therapists should therefore just get on with doing CBT, which is better validated – although the validation of schema-focused models is debatable. CAT therapists, however, continue to feel that the CAT perspective offers approaches to interpersonal and motivational issues that are better developed and more subtly nuanced than those used by CBT. This certainly would be Ryle's view, as expressed in his review of cognitive approaches to borderline personality disorder (Ryle, 1998).

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Who is suitable for CAT?

Traditionally, CAT therapists have taken on a very wide range of patients. As a result, CAT has been tried for many conditions, including anxiety disorders and depression, deliberate self-harm, abnormal illness behaviour (particularly in diabetes) and, most particularly, the personality disorders (Cowmeadow, 1994; Fosbury, 1994; Ryle, 1997). With all these conditions there has been some success. One contraindication is current drug or alcohol use to the point of active intoxication (Ryle, 1997: p. 86). This is to some extent a matter of degree, the main issue being the difficulty of conducting sessions with an intoxicated patient. Poor or absent motivation, resulting in failure to attend sessions, may be another contraindication, because in a brief therapy missing too many sessions nullifies any effect. Even so, it is often worth seeing whether the reformulation stage of CAT draws the patient in sufficiently to make therapy viable.

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The evidence base

There is a growing, but still far from adequate, evidence base in CAT. The current situation is well summarised by Margison (2000), who highlights the lack of randomised controlled trials (RCTs) validating CAT. Nevertheless, some studies do exist. An early paper (Brockman et al, 1987) showed that CAT conducted by trainees was as effective as Mann's brief psychotherapy (Mann & Goldman, 1982). Since then the predominantly NHS base of CAT has made funding for formal trials difficult to obtain. However, a number of promising results have been published (summarised in Ryle, 1995a), and recent uncontrolled series obtained at the United Medical and Dental Schools of Guy's King's and St Thomas' (UMDS) and at Addenbrookes using both CAT-specific and other measures are encouraging in relation to both borderline personality disorder and more general practice in a psychotherapy department. Any current assessment of the status of the evidential basis for CAT must depend on an evaluation of descriptive studies and uncontrolled series. Supporters of RCT methodologies in psychological treatments tend to be less convinced by uncontrolled studies than those who are more sceptical about the unique value RCT research methodology in psychotherapy. A good description of some of the limitations of RCT methodologies can be found in Bateman & Fonagy (2000).

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Training and development

Although there are quite severe complexities in some aspects of CAT theory, practising psychotherapists, especially those with experience in both cognitive and psychodynamic approaches, should find much that is familiar. They may be able to acheive a usable level of competence in CAT by reading the key texts and having some supervision. For those with less experience of psychotherapy, formal training programmes exist. Such formal training is usually necessary for anyone wishing to become a member of the Association of Cognitive Analytic Therapists (ACAT), which exists to promote training in and standards of CAT.

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Multiple choice questions

Procedural sequences:

were developed in an attempt to understand aim-directed action

involve only feeling and acting

contain a check step

are always revised for the better if faulty

if faulty are in the form of snags, traps and dilemmas.

Procedural sequences remain unrevised because:

the check step has been avoided in some way

the alternatives are equally unacceptable

the procedure is never enacted

opportunities for learning new procedures have been too plentiful

caregivers have given injunctions that restrict procedural learning.

In borderline personality disorder:

level-one states are more numerous than in normal behaviour

level-two switching displays a ‘hair-trigger’ response

level-three self-reflection is often weak or absent

level-one and level-two difficulties explain much of the changeability characteristic of the disorder

CAT has no distinctive explanation for the affective features.

In CAT:

treatment usually lasts either 16 or 24 sessions

the therapist gives the patient a reformulation letter at about the fourth session

the therapist avoids mentioning termination

therapist and patient exchange goodbye letters at the end of therapy

follow-up sessions are discouraged.

CAT:

is suitable only for a small range of patient problems

is contraindicated if the patient is actively intoxicated

should never be attempted where motivation is poor or absent

has a small evidence base and urgently needs randomised controlled trials

is administered by an organisation called ACAT.

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References

↵ Allison, D. & Denman, C. (2001) Comparing models in cognitive therapy and cognitive analytical therapy. In Evidence in the Psychological Therapies: A Critical Guide for Practitioners (eds C. Mace, S. Moorey & B. Roberts). Philadelphia, PA: Routledge.

↵ Aveline, M. (2001) Very brief dynamic therapy. Advances in Psychiatric Treatment, in press.

Bateman, A. W. & Fonagy, P. (2000) Effectiveness of psychotherapeutic treatment of personality disorder. British Journal of Psychiatry, 177, 138–143. Abstract/FREE Full Text

↵ Bion, W. R. (1967) Attacks on linking. In Second Thoughts: Selected Papers on Psycho-Analysis, pp. 93–109. London: Maresfield Library.

↵ Brockman, B., Poynton, A., Ryle, A., et al (1987) Effectiveness of time-limited therapy carried out by trainees. Comparison of two methods. British Journal of Psychiatry, 151, 602–610. Abstract

↵ Cowmeadow, P. (1994) Deliberate self harm and cognitive analytic therapy.International Journal of Short Term Psychotherapy, 9, 135–150.

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↵ Fonagy, P. & Target, M. (1997) Attachment and reflective function: their role in self-organization. Development and Psychopathology, 9, 679–700.CrossRefMedline

↵ Fosbury, J. A. (1994) Cognitive analytic therapy with poorly controlled insulin-dependent diabetic patients. In Psychology and Diabetes Care (ed. C. Coles). Chichester: PMH Production.

↵ Kelly, G. A. (1955) The Psychology of Personal Constructs. New York: Norton.

↵ Mann, J. & Goldman, R. (1982) A Case book in Time-Limited Psychotherapy. New York: McGraw-Hill.

Margison, F. (2000) Cognitive analytic therapy: a case study in treatment development (editorial). British Journal of Medical Psychology, 73, 145–149.

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↵ Palmer, R. (2001) Dialectical behaviour therapy. Advances in Psychiatric Treatment, in press.

↵ Ryle, A. (1990) Cognitive Analytic Therapy: Active Participation in Change. Chichester: John Wiley & Sons.

↵ Ryle, A. (1991) Object relations theory and activity theory: a proposed link by way of the procedural sequence model. British Journal of Medical Psychology, 64, 307–316.

↵ Ryle, A. (1992) Critique of a Kleinian case presentation. British Journal of Medical Psychology, 65, 309–317.

↵ Ryle, A. (1993) Addiction to the death instinct? A critical review of Joseph's paper ‘Addiction to near death’. British Journal of Psychotherapy, 10, 88–92.

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↵ Ryle, A. (1994b) Persuasion or education: the role of reformulation in CAT.International Journal of Short Term Psychotherapy, 9, 111–118.

↵ Ryle, A. (1995a) Research relating to CAT. In Cognitive Analytic Therapy: Developments in Theory and Practice (ed. A. Ryle), pp. 174–189. Chichester: John Wiley & Sons.

↵ Ryle, A. (1995b) Defensive organizations or collusive interpretations? A further critique of Kleinian theory and practice. British Journal of Psychotherapy, 12, 60–68.

Ryle, A. (1996) Ogden's autistic-contiguous position and the role of interpretation in analytic theory building. British Journal of Medical Psychology, 69, 129–138.

↵ Ryle, A. (1997) Cognitive Analytic Therapy for Borderline Personality Disorder: The Model and the Method. Chichester: John Wiley & Sons.

↵ Ryle, A. (1998) Transferences and countertransferences: the cognitive analytic therapy perspective. British Journal of Psychotherapy, 14, 303–309.

Teasdale, J. D. & Barnard, P. J. (1993) Affect, Cognition and Change in Remodelling Depressive Thought. Hove: Lawrence Erlbaum.

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↵ Young, J. E. (1990) Cognitive Therapy for Personality Disorders: A Schema Focused Approach. Sarasota, FL: Professional Resource Exchange.