Cognitive Analytic Therapy (Γνωσιακή Αναλυτική θεραπεία)
(πηγή: www.acat.me.uk)
Introducing CAT
Cognitive Analytic Therapy involves a therapist and a client working together to look at what has hindered changes in the past, in order to understand better how to move forward in the present. Questions like 'Why do I always end up feeling like this?' become more answerable.
Who is it for?
CAT is safe and user friendly, being widely applicable within a variety of settings, and across a range of disorders and difficulties - such as depression, anxiety, personal and relationship problems.
Why now?
People often wish they could change things to make life more manageable, but don't know where to start. Unhappiness, depression or anxiety can make them feel less capable of finding a way out of their difficulties. Help is needed.
People often wish they could change things to make life more manageable, but don't know where to start. Unhappiness, depression or anxiety can make them feel less capable of finding a way out of their difficulties. Help is needed.
How does it work?
CAT focuses its attention on discovering how problems have evolved and how the procedures devised to cope with them may be ineffective. It is designed to enable clients to gain an understanding of how the difficulties they experience may be made worse by their habitual coping mechanisms. Problems are understood in the light of clients' personal histories and life experiences. The focus is on recognising how these coping procedures originated and how they can be adapted and improved. Then, mobilising the clients' own strengths and resources, plans are developed to bring about change.
The work is active and shared. Diagrams and written outlines are worked out together to help recognise, challenge and revise old patterns that do not work well. Agreed insights are noted in documents, which become tools for use within, outside and beyond the duration of therapy.
In this way, clients gain skills to help them manage their lives more successfully and to continue using after therapy ends.
CAT focuses its attention on discovering how problems have evolved and how the procedures devised to cope with them may be ineffective. It is designed to enable clients to gain an understanding of how the difficulties they experience may be made worse by their habitual coping mechanisms. Problems are understood in the light of clients' personal histories and life experiences. The focus is on recognising how these coping procedures originated and how they can be adapted and improved. Then, mobilising the clients' own strengths and resources, plans are developed to bring about change.
The work is active and shared. Diagrams and written outlines are worked out together to help recognise, challenge and revise old patterns that do not work well. Agreed insights are noted in documents, which become tools for use within, outside and beyond the duration of therapy.
In this way, clients gain skills to help them manage their lives more successfully and to continue using after therapy ends.
Practically Speaking
Cognitive Analytic Therapy...
Cognitive Analytic Therapy...
is time-limited: therapy ranges from four to twenty four sessions, typically sixteen. It is designed as a brief intervention, but can also work for longer treatments.
works with individuals, but can also be used effectively with couples and groups.
works with individuals, but can also be used effectively with couples and groups.
is cognitive in that it makes full use of clients' capacity to observe and think about themselves, their assumptions, their feelings and their behaviour.
is analytic in that unacknowledged, unconscious factors are explored and worked with, and their impact is recognised. In addition, the therapist-client relationship is understood and used.
is integrated in that a cohesive body of theory has been developed with a unique understanding of personality and development. It emphasises the interplay between mental processes, feelings, actions and consequences.
is open to and already subject to research and evaluation.
is an effective way of developing self-awareness and personal development.
recruits and extends clients' capacity for self-help, and develops with them specific tools for understanding and changing their unhelpful coping procedures.
recruits and extends clients' capacity for self-help, and develops with them specific tools for understanding and changing their unhelpful coping procedures.
Theoretical Overview of the CAT approach
Cognitive Analytic Therapy aims to understand and ameliorate chronic and self limiting patterns of emotional expression/inhibition and tries, among other things, to find the main emotional patterns of relating to self and others and their connection to the client's presenting problem or apparent distress.
It looks for the bigger picture of the client's psychological world and explains it in clear, user friendly ways, which in many cases allows the person to feel less trapped, more able to care for themselves and do their own psychological self-help homework outside the session. At the heart of the bigger picture is an understanding of the importance of sympathetically identifying reciprocal emotional roles which are exacerbated or perpetuated by a variety of long established and emotionally driven coping procedures for the client. These coping procedures are maintained because despite their contribution to distress, they were once effective solutions (albeit maladaptive) in providing relief from damaging childhood and adolescent experience. These emotional roles are also prone to be enacted in the therapeutic relationship with the therapist and it is the non-collusion with and working through of these re-enactments which is at the heart of effective therapy.
CAT is most often offered in a predetermined package of usually 16 sessions.
Such an approach offers the possibility of a relatively brief intervention without losing depth of psychological engagement and insight with the client and his or her concerns. In that it also uses a more explicitly educative approach to the helping relationship than many other psychotherapeutic models, it gives the client a better chance of understanding and collaborating with the purposes and methods of helping with his or her problems. CAT offers a corrective emotional and cognitive experience through which the person takes away a stronger sense of his or her own agency in patterns of self-harm or self care.
CAT is proposed as a safe and accessible intervention for a wide variety of presenting and underlying psychological and mental health problems (Ryle, 1990). CAT in particular has been used to work with groups with hard to help problems such as eating disorders and personality disorders.
It looks for the bigger picture of the client's psychological world and explains it in clear, user friendly ways, which in many cases allows the person to feel less trapped, more able to care for themselves and do their own psychological self-help homework outside the session. At the heart of the bigger picture is an understanding of the importance of sympathetically identifying reciprocal emotional roles which are exacerbated or perpetuated by a variety of long established and emotionally driven coping procedures for the client. These coping procedures are maintained because despite their contribution to distress, they were once effective solutions (albeit maladaptive) in providing relief from damaging childhood and adolescent experience. These emotional roles are also prone to be enacted in the therapeutic relationship with the therapist and it is the non-collusion with and working through of these re-enactments which is at the heart of effective therapy.
CAT is most often offered in a predetermined package of usually 16 sessions.
Such an approach offers the possibility of a relatively brief intervention without losing depth of psychological engagement and insight with the client and his or her concerns. In that it also uses a more explicitly educative approach to the helping relationship than many other psychotherapeutic models, it gives the client a better chance of understanding and collaborating with the purposes and methods of helping with his or her problems. CAT offers a corrective emotional and cognitive experience through which the person takes away a stronger sense of his or her own agency in patterns of self-harm or self care.
CAT is proposed as a safe and accessible intervention for a wide variety of presenting and underlying psychological and mental health problems (Ryle, 1990). CAT in particular has been used to work with groups with hard to help problems such as eating disorders and personality disorders.
The three Rs of CAT
The three Rs of therapy are reformulation, recognition and revision, through which the client increasingly internalises both the person of the therapist and the conceptual tools used.
The reformulation is jointly arrived at by client and therapist and it is recorded in written and diagrammatic form.
It has both a narrative component, re-telling the patient's history and a descriptive one, describing current damaging procedures.
This reformulation is used throughout therapy as a basis for patient homework aimed at speedy recognition and also as a guide to, and description of, transference-countertransference interactions.
In addition, at termination both the therapist and client write 'goodbye' letters, reviewing what has been achieved.
The Psychotherapy File is normally given to clients at the first session and the discussion of the patient's responses contributes to the reformulation document. The reformulation describes past and present relationships, including the evolving therapeutic relationship and also the patient's relationship with him or herself, thus simultaneously attending to interpersonal and to intra-psychic processes. Within this overall understanding, particular problems may be addressed by a range of therapeutic techniques.
Evidence based
CAT is an evidence based therapy with a strong commitment to research (see Ryle, 1995).
An early comparison of CAT with Mann's approach showed that CAT produced more cognitive re-organisation, as measured with the repertory grid, than did the more purely analytic approach (Brockman et al, 1987); subsequent uncontrolled, unpublished trials have shown similar levels of change, as does the time-limited group using CAT techniques reported by Imelda Duigan and Susan Mitzman (1994). Other research includes Pauline Cowmeadow's work on deliberate self-harm (1994) and projects on CAT in non-compliant insulin-dependent diabetic subjects. Other work is addressing theoretical issues, as in the paper by Martin Marlowe (1994).
The reformulation is jointly arrived at by client and therapist and it is recorded in written and diagrammatic form.
It has both a narrative component, re-telling the patient's history and a descriptive one, describing current damaging procedures.
This reformulation is used throughout therapy as a basis for patient homework aimed at speedy recognition and also as a guide to, and description of, transference-countertransference interactions.
In addition, at termination both the therapist and client write 'goodbye' letters, reviewing what has been achieved.
The Psychotherapy File is normally given to clients at the first session and the discussion of the patient's responses contributes to the reformulation document. The reformulation describes past and present relationships, including the evolving therapeutic relationship and also the patient's relationship with him or herself, thus simultaneously attending to interpersonal and to intra-psychic processes. Within this overall understanding, particular problems may be addressed by a range of therapeutic techniques.
Evidence based
CAT is an evidence based therapy with a strong commitment to research (see Ryle, 1995).
An early comparison of CAT with Mann's approach showed that CAT produced more cognitive re-organisation, as measured with the repertory grid, than did the more purely analytic approach (Brockman et al, 1987); subsequent uncontrolled, unpublished trials have shown similar levels of change, as does the time-limited group using CAT techniques reported by Imelda Duigan and Susan Mitzman (1994). Other research includes Pauline Cowmeadow's work on deliberate self-harm (1994) and projects on CAT in non-compliant insulin-dependent diabetic subjects. Other work is addressing theoretical issues, as in the paper by Martin Marlowe (1994).
Traditional Sources of CAT Theory
The CAT approach is an integration and extension of ideas and methods used in different, conventionally opposed, traditions. The main sources are...
From Psychoanalysis concepts of conflict, defence, object relations and counter transference. However, the theory is restated in cognitive terms and the therapist's interventions are more active and various than in psychoanalytic therapies.
From Kelly's Personal Construct Theory and work with repertory grids, a focus on how people make sense of their world ("man as scientist") and on common sense, co-operative work with patients. However, more attention is paid to the organisation of action as well as to construing, and CAT does not share Kelly's polemical rejection of psychoanalysis and behaviourism.
From Cognitive-Behavioural Approaches the step by step planning and measurement of change, teaching patients self-observation of moods, thoughts and symptoms. However, attention is not confined to visible behaviours and consciously accessible thoughts.
From Developmental and Cognitive Psychology and Artificial Intelligence an information processing model of how experience and actions are organised is proposed, with emphasis on the recurrent sequences of related mental (internal) and behavioural (external) processes.
The CAT approach is an integration and extension of ideas and methods used in different, conventionally opposed, traditions. The main sources are...
From Psychoanalysis concepts of conflict, defence, object relations and counter transference. However, the theory is restated in cognitive terms and the therapist's interventions are more active and various than in psychoanalytic therapies.
From Kelly's Personal Construct Theory and work with repertory grids, a focus on how people make sense of their world ("man as scientist") and on common sense, co-operative work with patients. However, more attention is paid to the organisation of action as well as to construing, and CAT does not share Kelly's polemical rejection of psychoanalysis and behaviourism.
From Cognitive-Behavioural Approaches the step by step planning and measurement of change, teaching patients self-observation of moods, thoughts and symptoms. However, attention is not confined to visible behaviours and consciously accessible thoughts.
From Developmental and Cognitive Psychology and Artificial Intelligence an information processing model of how experience and actions are organised is proposed, with emphasis on the recurrent sequences of related mental (internal) and behavioural (external) processes.
Description of the Approach
The main features of the therapy are that it is active, integrated and focussed. A wide range of therapeutic methods may be combined, but the defining characteristic is the emphasis placed on the formulation and sharing with the patient of dense descriptions of the procedures which maintain their problems. Procedures are linked sequences of mental and behavioural processes which serve as repeatedly used guidelines for purposive action. They mostly operate outside of conciousness. They are organised hierarchically: low level procedures, like those that organise teeth cleaning, are "sub-routines" of higher order ones, like preserving health. Change at one level of the hierarchy may affect higher or lower levels. Problems are caused by the persistent, unrevised use of ineffective procedures, and therapy aims to identify and revise such procedures.
The main features of the therapy are that it is active, integrated and focussed. A wide range of therapeutic methods may be combined, but the defining characteristic is the emphasis placed on the formulation and sharing with the patient of dense descriptions of the procedures which maintain their problems. Procedures are linked sequences of mental and behavioural processes which serve as repeatedly used guidelines for purposive action. They mostly operate outside of conciousness. They are organised hierarchically: low level procedures, like those that organise teeth cleaning, are "sub-routines" of higher order ones, like preserving health. Change at one level of the hierarchy may affect higher or lower levels. Problems are caused by the persistent, unrevised use of ineffective procedures, and therapy aims to identify and revise such procedures.
What Happens in Therapy?
The therapist will usually agree with the patient a set number of sessions. This is traditionally 16, but may be more or less. After the first session, the patient may be set the task of monitoring a particular symptom or mood, and will be asked to complete the psychotherapy file which asks about typical, common problem procedures (described as Traps, Dilemmas and Snags). At around the fourth session, the therapist presents the patient with a written Reformulation. This includes a description of the client's life so far, the difficulties they have struggled with and how they have survived them, and a reformulation of their presenting complaints as Target Problem Procedures to be worked on. This will also be presented in the form of a diagram. The patient is asked to reflect on these and make changes, so that eventually a joint understanding is arrived at.
In the remainder of the therapy, any material that comes up in the course of the (largely unstructured) sessions, including current events, past history and transference, should be discussed in terms of the Target Problem Procedures. The aim is to develop the client's capacity to recognise his or her faulty procedures, so that s/he can start to control and replace them. Homework assignments may be used to confront the client with his or her procedures and open the possibility of modification. Change is seldom complete by the end of therapy but the client is left with the tools to continue working.
The last 3-4 sessions are used to look at the ending of therapy and how this may affect the client, particularly if endings have been difficult in the past. A "good-bye letter" is written by both therapist and patient to formalise this process. A follow-up appointment at 2-3 months is usually offered.
The therapist will usually agree with the patient a set number of sessions. This is traditionally 16, but may be more or less. After the first session, the patient may be set the task of monitoring a particular symptom or mood, and will be asked to complete the psychotherapy file which asks about typical, common problem procedures (described as Traps, Dilemmas and Snags). At around the fourth session, the therapist presents the patient with a written Reformulation. This includes a description of the client's life so far, the difficulties they have struggled with and how they have survived them, and a reformulation of their presenting complaints as Target Problem Procedures to be worked on. This will also be presented in the form of a diagram. The patient is asked to reflect on these and make changes, so that eventually a joint understanding is arrived at.
In the remainder of the therapy, any material that comes up in the course of the (largely unstructured) sessions, including current events, past history and transference, should be discussed in terms of the Target Problem Procedures. The aim is to develop the client's capacity to recognise his or her faulty procedures, so that s/he can start to control and replace them. Homework assignments may be used to confront the client with his or her procedures and open the possibility of modification. Change is seldom complete by the end of therapy but the client is left with the tools to continue working.
The last 3-4 sessions are used to look at the ending of therapy and how this may affect the client, particularly if endings have been difficult in the past. A "good-bye letter" is written by both therapist and patient to formalise this process. A follow-up appointment at 2-3 months is usually offered.
Other ways of working with CAT
People are constantly finding new ways of using the ideas behind Cognitive Analytic Therapy. It has been used with couples, in groups and in organisations. The concepts are being used with children, adolescents and those with learning disability. Some community mental health teams are using CAT to understand clients with particularly complex and/or challenging needs or problems.
People are constantly finding new ways of using the ideas behind Cognitive Analytic Therapy. It has been used with couples, in groups and in organisations. The concepts are being used with children, adolescents and those with learning disability. Some community mental health teams are using CAT to understand clients with particularly complex and/or challenging needs or problems.
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