Research into CAT
There are a number of current studies being undertaken into CAT. These are listed below.
1. Cognitive Analytical Therapy & Cognitive Behavioural Therapy for affective disorders: A feasibility randomised controlled trial
Background information
Chanen et. al. (2008) – This RCT investigated CAT for adolescents at risk of developing borderline personality disorders. They found CAT had a more rapid benefit as an early intervention treatment than standardised good clinical care.
Fosbury et. al. (1997) – Compared CAT and diabetes specialist nurse education (DSNE) for adults with poorly controlled type 1 diabetes. CAT produced a more long term improvement on glycemic control and interpersonal difficulties.
Marriott and Kellett (2009) – Compared CAT with CBT and Person-centered therapy (PCT) for adults with anxiety and mood disorders. All three therapies were found to be equally effective. However, this study was limited because participants were not randomly allocated to therapy and there was also no effort to standardise assessment procedure or therapy delivery.
Research Rationale
- Access to Psychological Therapies is limited in the National Health Service (NHS), despite this being a top priority.
- CBT is the most commonly used therapy and has the largest evidence base. However, it not suitable for everyone and many drop out (Churchill et. al., 2001).
- The National Institute of Clinical Excellence (NICE) endorse alternative therapies to CBT for affective disorders but as yet there is limited evidence for these.
- CAT is used extensively in the NHS despite having a limited evidence base. This feasibility study aims to discover whether an RCT of CAT and CBT is possible.
Research Questions
- Can CBT and CAT therapists work together to identify clients whom they consider can be effectively treated by either therapy and thus randomly allocate them to CAT or CBT?
- Will clients consent to randomisation and co-operate with research interviews?
- Can the therapies be conducted within a research framework, including structured follow up?
- What would be the requirements for effective trial?
Methodology
Design: Feasibility Randomised Controlled Trial (RCT) in a clinical NHS Psychological Services.
Sample: 40 participants referred to Oxford Health Psychological Services.
Inclusion Criteria:
- Diagnosis of Anxiety, Depression or both.
- 18 years or over (adult and older adult)
- Assessed as being suitable for short term psychotherapy
- Equally suited to CAT and CBT in the assessor’s opinion
Eleven CAT and CBT therapists in Oxford Health NHS FT are committed to the trial and will conduct clinical assessments and deliver therapy to study participants.
Research Measures – A number of research measures are administered in an hour long interview conducted by an trained independent researcher.
Self-rated – Medical Outcomes Scale, Social Adjustment Scale, Beck Anxiety & Depression Scales, Clinical Outcomes in Routine Evaluation.
Interviewer rated – Mini-International Neuropsychiatric Interview, Hamilton Anxiety and Hamilton Depression Scales.
Update
Since the end of October 2010 we have recruited seven participants. We also have eleven therapists from Oxford Health Psychological Services committed to the study. So far all those recruited by therapists during assessments have agreed to meet with the Research Assistant and have consented to take part in the research. Two participants have been had their T2 interview and have begun their therapy.
Catriona Anderson1, Ksenija Yeeles1, Tom Burns1, Glenys Parry2, John Geddes1, David Westbrook3, Eva Burns-Lundgren3, Yvonne Taylor3.
Social Psychiatry Group, Department of Psychiatry, University of Oxford, 2School of Health and Related Research, University of Sheffield and 3Oxford Health NHS Foundation Trust
For more information contact Cate Anderson at Catriona.anderson@psych.ox.ac.uk
April 2011
2. Therapists’ Construction and Application of the Reformulation Diagram in Clinical Practice
Comparatively little research has been conducted to understand therapists’ construction and application of the Reformulation Diagram in clinical practice. Permission was obtained from Staffordshire University Peer Review and NHS Ethics Committee to conduct a research study. Seven CAT therapists were interviewed during 2010 in a Grounded Theory study. Results will be publicised when available.
Do contact Jurai Darongkamas, Consultant Clinical Psychologist, at jurai.d@nhs.net for more informat
ion.
March 2011 | Jurai Darongkamas
3. Understanding Sequential Diagrammatic Reformulations (SDRs) in CAT.
CAT diagrams or SDRs are developed in the course of CAT therapy to guide therapists and clients on the therapy journey (Ryle, 2003). They are used to illustrate problem procedures and are referred to throughout the therapy to aid recognition and identify exits. SDRs are unique to CAT and central to the process of the therapy. However there is little research of clients’ experience of SDRs and no systematic research of therapists’ experience.
The aim of this research is to explore both clients’ and therapists ‘experience of using SDRs in CAT therapy. Clients and their therapists will be interviewed separately using semi-structured interview protocols. The data will be analysed using Interpretative Phenomenological Analysis (IPA, Smith, Flowers & Larkin, 2009) to explore the lived experience of the participants.
The intended sample size will be 3-6 therapist-client dyad pairs. The research will take place in the Psychotherapy Department and the South Hackney Community Mental Health Team in City and Hackney. The study is being conducted as Jessica Osborne’s thesis for her Doctorate in Clinical Psychology at Royal Holloway, University of London. It is being supervised by Maxine Sacks, Consultant Clinical Psychologist at the Hackney Psychotherapy Department and Michael Evangeli, Lecturer in Clinical Psychology, Royal Holloway University of London.
Data collection started in December 2010 and will be completed by July 2011.
Further information about the study can be obtained from:
Jessica Osborne, Trainee Clinical Psychologist, Royal Holloway University of London
Jessica.Osborne.2008@live.rhul.ac.uk.
Jessica Osborne || February 2011
4. Do people with learning disabilities have a concept of Reciprocal Roles?
What aspects of intelligence are needed to understand the concept of Reciprocal Roles?
If RRs are descriptions of a fundamental component of how people live their lives, then is the acquisition of this device linked to specific aspects of intellectual capacity?
Why conduct this research with people who have severe learning disabilities?
• Many people with learning disabilities are willing to participate in research.
• Psychological treatments are seriously under-developed in services for people with learning disabilities. Would CAT be relevant and useful?
• Little is known about the socially derived internal worlds of people with learning disabilities.
• Direct observation of people with learning disabilities indicates they do have patterns of behaviours that elicit reciprocations from staff.
• As CAT works through the therapeutic relationship, involving activity and emotion, this approach may be more useful than the type of psycho-e
ducational therapy that depends on verbal skills.
• Psaila and Crowley, (2005), elicited 9 common RRs for people with learning disabilities, from CAT practitioners’ notes.
• This research asks, can people with severe learning disabilities match up pictures to make both poles of these RRs and if so, what intellectual capacities is this ability related to?
Is the capacity to match pairs of RRs related to verbal mental ability?
British Picture Vocabulary Scale Short Form was used to assess verbal mental age. This is a test designed to measure receptive vocabulary in children aged 3-16. The child indicates which of a set of line drawings best illustrates the meaning of a stimulus word pronounced by the researcher. When assessing adults, this scale is used to produce a verbal mental age.
Can participants match feelings to events?
Is this capacity related to recognising pairs of RRs?
Makaton symbols depict the five main emotions, disgust, happiness, anger, sad and fear, and five black and white line drawings depict events; dog faeces, a Christmas Tree, a man hitting a dog with a stick a grave, and a ghost.
Is the capacity to match pairs of RRs related to perceptual relationships?
Ravens Coloured Progressive Matrices (1947) was used to assess non-verbal IQ, aimed at 5-11 year olds. It aims to assay the ability to infer rules, to manage a hierarchy of goals, and to form high-level abstractions and is believed to be a ‘‘paradigmatic’’ measure of fluid intelligence. Recommended uses include measurement of a person’s ability to form perceptual relations and reason by analogy in research settings
The 9 RRs explored are:
- Abusing to Abused
- Rejecting to Rejected
- Rescuing/Caring to Rescued/Cared for
- Damaging to Damaged
- Abandoning to Abandoned (Unloving to Unloved)
- Special/Perfect to Learning Disabled
- Controlling to Controlled/Fragile
- Blaming to Blamed
- Overwhelming to Overwhelmed
Using cartoon-style drawings to illustrate these reciprocal roles, the stimulus pole of the Reciprocal Role was offered together with three other cartoons. One was the anticipated response pole, another was an antonym and the third a distracter. Participants were then asked to select which of the three possible response cards fitted the stimulus scene best. Using the five emotion pictures, they were also asked how the responding person might feel.
Results using linear regression
From BPVS to RR identification
There were no significant associations between scores on the BPVS and recognition of RRs.
From feeling-action matching to RR identification
There was no relationship between the ability to assign feelings to action pictures and the ability to spot RRs from the pictures.
Linear Regression from matrices score to RR identification
Overall, there was a highly significant contribution made by scores on Matrices to the ability to spot RRs (p = .01) and to assign feelings correctly to those RR (p = .001).
Furthermore, scores on Matrices highly significantly predicted the overall tendency to assign an antonym to the stimulus pole of the RR (p = .004)
Discussion
Results show the ability to recognise drawings representing both poles of RRs draws on fluid intelligence, general reasoning and the capacity to form abstractions, as assessed by Matrices.
Recognising RRs is not dependent on language ability, but on the capacity to observe and synthesise image patterns. This makes sense as we relate pre-linguistically via gestures, mime, tone, posture and facial expression which we abstract into felt relationships.
The significance of antonyms may be because they are related to both poles of a RR as the other side of the coin; as positions around one central RRP.
People with learning disabilities report that SDRs assist internalisation better than prose (Wells 2009). Perhaps this is because as a visual map drawing the sequence of difficult roles being explored in therapy; it taps into the cognitive resources they use to appreciate intuitively RRs.
Julie Lloyd || August 2010
5. Exploring endings from the therapist's perspective in Cognitive Analytic Therapy, with a particular focus on what makes for a good ending process
The purpose of the study:
The purpose of the research is to explore the ending process within CAT from the therapist's perspective. We know that within the CAT model emphasis is placed on the importance of the use of endings in therapy. For example, the issues and feelings raised during the ending process create an opportunity in therapy for the client to reflect on those surrounding previous, potentially unresolved endings in earlier life. A lack of opportunity to process previously challenging endings can contribute to the client's emotional distress and a tendency to re-enact unhelpful relational patterns in the here and now. Therefore, the CAT model advocates that the ending of therapy is on the agenda from the beginning, and a set number of sessions towards the end of therapy are used to focus on it, including the use of goodbye letters.
The significance and management of endings is clearly described within CAT literature. However, it seems that there has been little exploration of the actual experience of endings from the therapist's perspective. It is believed that exploration in this area will enhance our understanding of the ending phase of therapy and possibly develop awareness of what can define and increase the likelihood of a positive ending.
Research method and timeline:
This research involves the use of online qualitative methodology and Thematic Analysis. The use of online interviewing has the advantage of allowing access to participants over a wide geographical area. Computer-mediated communication has also been identified as a method that allows for enhanced self-disclosure due to the interation between reduced public self-awareness and heightened private self-awareness. Additionally, it has been found that drop-out rates in studies using similar methodology are relatively low.
A semi-structured interview questionnaire will be sent to all participants, followed up by asynchronous, individually tailored email questions based on the responses to the questionnaire. The aim of the is to explore the following areas:
o How therapists manage the ending process in CAT, and the use of CAT tools within this process.
o How therapists experience the ending process, and what seems to impact either personally or contextually on the process.
o How positive endings are described by therapists, and what seems to contribute to the likelihood of this being achieved.
o Similarly, how unsatisfactory endings are experienced, and what seems to contribute to this process.
Recruitment and data collection is currently underway and likely to extend until July. The analysis and write up of the research aim to be completed by October, 2010.
Recruitment and research inclusion criteria:
Expressions of interest would be welcome from therapists working in both the public and private sector and who meet the following inclusion criteria:
o a minimum of one year post Practitioner level experience as a CAT therapist,
o the completion of at least four CAT cases since qualifying,
o currently using the CAT model.
The organisation and review of the research:
The study is sponsored by Plymouth University and has been reviewed and approved by Southmead (Bristol) NHS Research Ethics Committee. Supervision is provided by Mina Bancheva, IRRAPT Course Tutor, as the research will contribute to the fulfillment of my CAT Psychotherapy Training.
For further information:
Please contact: Julie Wilkinson || email: julie.wilkinson@awp.nhs.uk
6. RCT comparing empowerment intervention, psychotherapy (CAT) and requested CAT for patients with Type1 diabetes?
A study analysing psychological morbidity amongst patients with Type 1 was conducted at the RoyalBournemouthHospital (Shaban, Fosbury et al Diabetic Medicine 2006). Part 2 of the study was a RCT randomising patients in to empowerment intervention, psychotherapy (CAT) and requested CAT. This second part has been published as part of an abstract and has been submitted to Diabetologia for review. Biochemical (HbAlc) and psychological data were measured. All groups reduced HbAlc in a way which reduced clinical risk in patients with diabetes (e.g. blindness, amputations etc) but patients who requested CAT showed the greated result in psychological and biochemical terms and significant statistical data at 2 year follow up Diabetic Medicine March 2008, Vol 25, Supplement 1, p 135). The second part is a continuation of the first RCT of CAT in diabetes published by Jackie Fosbury (Fosbury et al 1997, Diabetes Care). This study recommends that more complex therapy is effective in those reporting more severe diabetes related psychological distress. We are making a case for CAT, which goes over and above current limitations of the IAPT agenda and a case for CAT for people with long term physical conditions (commissioning process). As second author to the Bournemouth study I will be following up the part 2 study with comments about how the trial was conducted i.e. the psychotherapist was supervised by me but not CAT trained formally and was quite 'resistant' to CAT at outset.
Contact: Jackie Fosbury
jackie@dtaylor0.wanadoo
7. A process study evaluating rupture repair in CAT, using an adolescent sample.
A process study evaluating the Bennett, Parry and Ryle (1986) model of rupture repair in CAT, using an adolescent sample from Andrew Chanen's Australian study of adolescents at risk of BPD. The research is being carried out by Dr. Susan Llewelyn and a trainee clinical psychologist (Anne-Marie Daly), in conjunction with Andrew Chanen and his team.
Results and more details should be available in September.
Contact Dr. Susan Llewelyn
susan.llewelyn@hmc.ox.ac.uk
8. CAT in Groups – a dialogic approach: to be submitted for publication in 2010.
A detailed description of how CAT can be applied clinically in a group setting.
Dr Jason Hepple, Somerset Partnership NHS Foundation Trust.
9. The SPeDi Trial (Sheffield Personality Disorders)
One of the main activities in the Psychological Therapies strand is a randomised controlled trial of psychotherapy for Borderline Personality Disorder (BPD). The trial is being conducted in the context of a new clinical service that has been developed by Sheffield Care Trust.
People with severe & complex psychological problems referred to by the label `borderline personality disorder´ experience acute distress and multiple difficulties – such as self-harm and repeated suicide attempts, panic, depression, anger problems and trouble with relationships. Our project aims to deliver and test improvements in services for people with these difficulties (who have at times been stigmatised and marginalised in mental health services). Mental health professionals, researchers and service users are working together to achieve this.
Two different approaches are being compared. People receive either care from a Community Mental Health Team whose team members have had special training, or psychological therapy. The therapy methods (cognitive behavioural or cognitive analytic) were pioneered in the UK. People coming into the project agree to be randomly allocated to one or the other, and are carefully followed up to find out how they get on in terms of improvements in their well-being, relationships and quality of life, using standardised measures. In addition, service users are collaborating on exploring the experiences people have in these services, whether helpful or unhelpful.
As well as improving provision for these clients, the project aims to answer several important research questions to inform future NHS services. Is it beneficial to offer individual therapy over and above good quality care from a CMHT? Which treatment programmes are most acceptable to service users? People in this client group often report negative experiences of care and many drop out of therapy, so it is important to focus on their experiences. In addition to service user involvement with the randomised trial, a parallel study addresses these issues directly, through qualitative methods. Other questions include which process factors predict outcomes, such as therapist competence, therapeutic alliance and specific techniques; and which client characteristics make a difference (e.g. history of early childhood abuse & trauma). To have a chance of answering these questions we need to follow up 132 people.
The trial service has recently recruited its first participants. To get useful evidence on which to plan services, we needed to set up a randomised trial in a realistic service setting and include the perspective of service users, which is usually neglected. This requires an extensive range of partnerships between care staff, therapists, researchers and service users, and development of an organisational culture within a mental health service to meet both clinical and research requirements.
10. The Effectiveness of CAT for Borderline Personality Disorder: the Shape of Change in Routine Practice
This project is looking at how CAT is delivered under routine conditions in the NHS. It has collected a sample of therapists together and examines BPD clients' responsivity to CAT treatment and the degree to which CAT is actually being competently delivered. The methodology is a multi-site hermeneutic single case approach which establishes 5 key evidence criteria on which a case can be considered successful. The results will entail summating conclusions from each case. The project is run by Stephen Kellett, Dawn Bennett and Tony Ryle. We are nearing the point of project completion, as we have collected outcomes for over ten cases using the exhaustive evaluation methodology. In early 2009 we are planning to answer the following questions:-
- What is the rate of clinically significant change for BPD clients in CAT in terms of symptoms, personality structure and dissociation?
- Is there any evidence for sudden gains in CAT?
- Does more competent CAT produce more better outcomes?
- What do clients think of CAT?
- Is the CAT BPD model good enough and what are the training implications for working with BPD?
Requests for information can be directed to Stephen Kellett on stephen.kellett@barnsleypct.nhs.uk
11. A Twice−Told Ending: Goodbye Letters in Cognitive Analytic Therapy
CAT theory proposes that the preparation and exchange of goodbye letters plays an important role in managing the ending of therapy and "ending well". However, there is very little research into patients’ experiences of goodbye letters and, so far as the researchers are aware, there is
no research into therapists’ experiences of goodbye letters.
The aim of the research study is to explore and describe the experience of writing and receiving goodbye letters in CAT from the perspectives of patients and their therapists. Each patient and therapist participant will complete a short satisfaction questionnaire in relation to the therapy and its ending, followed by a detailed semi-structured interview. The interview data will be analysed using Interpretative Phenomenological Analysis (IPA), which is a qualitative method of analysis that aims to explore systematically and in detail participants' personal perspectives and experiences.
The intended sample size is four to five therapists with two patients each (i.e. a total of four to five therapists and eight to ten patients).
The research will take place in the CAT service of the adult outpatient Halliwick Psychotherapy Department at St Ann's Hospital, London N15 3TH. The study is Henry Clements’ research project for his Doctorate in Clinical Psychology and is being supervised by Shirley Akgun, Consultant Specialist in Psychotherapy at the Halliwick Psychotherapy Department, and Dr Nancy Pistrang, Senior Lecturer in Clinical Psychology at University College London.
Call for research
So far as the researchers are aware, only two studies to date have examined goodbye letters. The first is an unpublished study (Rayner (2005)) that used grounded theory to study nine patients’ experiences of CAT tools. The second is a study by Hamill et al (2008) which examined patients’ experiences of letters in CAT. The researchers would be very interested to receive details of any other ongoing or completed studies in relation to goodbye letters.
Timescale
Data collection will start in summer 2008 and it is anticipated that the research will be completed by June 2009.
Contact Details
Further information about the study can be obtained from Henry Clements, Trainee Clinical Psychologist, University College London, tel: 07877 127863, email: henry.clements@hotmail.co.uk.
12. The Case Formulation Task in Psychotherapy: Validity, Reliability and Process of Evidence Gathering and Decision Making
Coherent and accurate formulations are the hallmark of brief and time limited therapies as they enable the clinician to make informed choices about how to focus the work but there is very little research on their validity and reliability. The reformulation is central to CAT in providing a structured understanding of the central problems of the patient and their origins. Unlike other formulation methods it is standard practice for the therapist to share a written formulation with the patient. While it has much practice based evidence to justify and validate its use, relatively little formal research has been conducted on the reliability and validity of reformulations or the process evidence gathering and decision making in writing them..
Aims
This research aims to see whether Cognitive Analytic Therapy (CAT) formulations are valid and reliable, that is, whether CAT therapists are able to produce broadly similar written reformulations when presented with the same material and whether the material that is selected is accurate and relevant to the patient. It also aims to examine the rules therapists use to generate reformulations.
Questions
The key questions are: Are reformulations in CAT replicable or idiosyncratic? Can the formulations be validated by research tools? What evidence do CAT therapists seek in order to construct reform
ulations? Does the implicational knowledge of experienced therapists reveal common rules in their evidence seeking?
Method
I asked four experienced CAT therapists to tape the pre-reformulation sessions of a therapy from their routine waiting lists and to write reformulations. They then listened to each others’ tapes and wrote reformulations from these. I then interviewed them individually to explore with them their understanding of the reformulation process in relation to these therapies and to see whether there are common themes in the evidence they seek and the implicit knowledge they use. In a second study I coded the therapies and reformulations using the Structural Analysis of Social Behaviour (Benjamin, L.S. 2003). I compared the generated codes with the reformulations to gain a measure of the validity of the reformulation and the codes between reformulation for the same patient to measure reliability. A matching exercise using independent judges was also used to test reliability.
Estimated completion date: November 2008
Contact details: Lawrence Welch, Psychological Therapies Service, Lea House, Whackhouse Lane, Gateway Drive, Yeadon, Leeds LS19 7XY Email: lawrencewelch@onetel.com
13. A Randomised Control Trial of CAT Informed Care Planning
This trial is taking place is Barnsley PCT NHS Trust and is being coordinated by Dr Mark Wilbram and Dr Stephen Kellett. The trial concerns assessing the effectiveness of a CAT consultancy model for patients in the Assertive Outreach Team and is being supported by a local research grant. Patients in the AOT with stable psychosis are being randomly allocated to one of two possible conditions; (1) treatment as usual and (2) CAT enhanced care planning. The active arm entails providing consultancy to care coordinators to produce an SDR for the client and then developing exits for the client and the care coordinator in CAT-informed group supervision sessions. Prior to the consultancy process, the care coordinators received two days of training on CAT principles. The primary outcome measure for the project is the level of client engagement. The trial has now been completed and the service is currently receiving the feedback, which indicates the organisational effectiveness of the CAT consultancy approach. Results will be feedback to ACAT in due course.
Contact details:
Mark.Wilbram@barnsleypct.nhs.uk
Stephen.Kellett@barnsleypct.nhs.uk
14. Letters in cognitive analytic therapy: The patient's experience
A new research paper by Michelle Hamill, Mary Reid, & Shirley Reynolds is now online:http://www.acat.me.uk/article.php?article_id=653 You can view this if you are a current member of ACAT.
Abstract
Patient perspectives on how therapeutic letters contributed to their experience of cognitive analytic therapy (CAT) were investigated. Eight patients took part in semistructured interviews. A grounded, thematic analysis of their accounts suggested four general processes. First, letters offered a tangible, lasting framework for the assimilation of a new perspective about themselves and their relationships and facilitated coping with a complex range of emotions and risks this awareness required. Second, they demonstrated therapists' commitment to patients' growth. Third, they helped to teach participants
about the therapy process as an example of an interpersonal exchange. Fourth, they helped participants consider how they wished to share personal information. These data offer a more complex understanding of this standard CAT intervention. Although some findings are consistent with CAT theory, the range of emotional dilemmas associated with letters has not received specific attention. Clinical implications are discussed.
Get in Touch…
If you are are involved in research, or planning to set up a project, that you would like to see displayed on this website please email details to either Susan Van Baars at admin@acat.me.uk or Jon Sloper onsupport@acat.me.uk. Jason Hepple is Chair of the Research and Communications Committee and can also be contacted through our Who's Who page.
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