Anthony Ryle - Introducing Cognitive Analytic Therapy

CAT evolved initially as a brief (usually 16‐session) therapy. This was partly for pragmatic reasons and related to the search for the optimum means of delivering an effective treatment to the kind of patients being seen in under‐resourced health service settings. However, it also arose from consideration and evaluation of which aspects of therapy, including its duration, were actually effective. This aspect of research is fundamental to the model and continues to be important in its continuing evolution. We suggest, incidentally, that a brief treatment like CAT, within the course of which profound psychological change can be achieved, genuinely merits the description of “intensive” as opposed to much longer‐term therapies usually described as such, which we suggest might better be called “extensive.”

Despite the effectiveness of brief CAT for very many patients, it is clear that not all patients can be successfully treated within this length of time. However, it is also evident from some very interesting work, with, for example, self‐harming patients but also less damaged “neurotic” patients, that effective work can also be done in a few, or even one session. The length of treatment has thus been modified to adapt to the needs of differing patients. Longer‐term therapy may need to be offered to those with severe personality disorder, longstanding psychotic disorder, or those with histories of serious psychological trauma. Thus, there will be some patients for whom the reparative and supportive aspect of therapy over a longer period of time may be an important requirement. Similarly, more extended treatments may be offered in settings such as a day hospital, where the treatment model may be informed by CAT, as an alternative to offering it as an individual therapy.

A further reason for the present book is the ever increasing popularity of CAT with mental health professionals and the demand from trainees and others for a comprehensive but accessible introduction to it. The rapidly increasing popularity of CAT with both professionals and patients is, we feel, a further indication of the effectiveness and attractiveness of the model. In part, we see this popularity as arising from the congruence of CAT with the increasing demand for “user participation” in mental health services; the explicitly collaborative nature of the model offers and requires active participation on the part of the client or patient. This “doing with” therapeutic position, in addition to being demonstrably effective, appears to be very much more appropriate and welcome to a younger generation of trainees and potential therapists. This “power‐sharing” paradigm has overall, in our view, radical implications for mental, and other, health services.

The CAT understanding of the social and cultural formation of the self also highlights the role of political and economic forces in the genesis of many psychological disorders. The external conditions of life and the dominant values of current society, internalized in the individual, are seen as active determinants of psychological health or disorder. Recognizing this, we suggest that, as therapists, we should strive to avoid describing psychological disorders as simply “illnesses” and should also play our part in identifying and articulating whatever social action may be called for in response.

The book is the result of the collaborative work of two authors who share responsibility for the text. Our contributions were different, in part because AR was the initiator of the CAT model and has a much longer history of writing about it. In so far as this conferred authority it also risked complacency which, he felt, needed to be challenged. IK brought a more recent experience of psychiatry and psychotherapy in the NHS, reflected in particular in the discussion of psychosis and of the “difficult” patient and contextual reformulation. He also wished to emphasize the importance of a full bio‐psycho‐social perspective. Our longest and most fruitful arguments were involved in writing the theoretical Chapters 3and 4.

We should like to thank the many colleagues and patients who have contributed material to this book and who have been named in it. There are also innumerable others who have made important contributions to its production, directly and indirectly, both recently and over a period of many years. They are too many to name but we should like to express our gratitude to them collectively. Some of these contributions are referenced, although given editorial constraints we have been able, regretfully, only to cite books and peer‐reviewed publications, and material that was directly relevant to points being made in the book. We apologize to colleagues for omissions or oversights which will inevitably have occurred; however, our aim was not simply to undertake a comprehensive collation of all CAT‐related publications. This will be an important task for more specialist review literature and multi‐author books on CAT subsequently. We would like to acknowledge the support provided by the staff at John Wiley and, in particular, the early encouragement offered by Michael Coombs who commissioned the first edition, the subsequent support (and patience!) offered by Darren Read during the initial stages of this revision which he commissioned, and subsequently helpful assistance by freelance copy editor Caroline McPherson and, during the production stages, by Rahini Devi Radhakrishnan, under the strategic eye of Darren Lalonde overall. Finally, we should like to thank our partners Flora and Jane for making, in various and important ways, the writing of this book possible.

Chapters 1and 2will give a brief account of the scope and focus of CAT and how it evolved and will spell out the main features of its practice. Most of CAT's relatively few technical terms will appear in these chapters; they and other general terms which may have a different meaning in CAT are listed in a glossary. In order to flesh out this introductory survey and give readers a sense of the unfolding structure of a time‐limited CAT, Chapter 2also offers a brief account of a relatively straightforward therapy. Chapters 3and 4consider the normal and abnormal development of the self and introduce the Vygotskian and Bakhtinian concepts which are part of the basic theory of individual development and change. Subsequent chapters describe selection and assessment ( Chapter 5); reformulation ( Chapter 6); the course of therapy ( Chapter 7); the “ideal model” of therapist interventions and its relation to the supervision of therapists ( Chapter 8); applications of CAT in various patient groups and settings ( Chapter 9) and in treating personality‐type disorders ( Chapter 10); and the concept of the “difficult” patient and approaches to this problem, including the use of “contextual reformulation” and use in “reflective practice” ( Chapter 11). Each chapter commences with a brief summary of its contents and includes suggestions for further reading and references to CAT published work, and to the work of others. In addition, Appendix 1contains the CAT Psychotherapy File, Appendix 2the summary of CAT competences extracted from Roth and Pilling (2013), Appendix 3contains the Personality Structure Questionnaire, and Appendix 4a description of repertory grid basics and their use in CAT.

Case material derived from audio‐taped sessions is used with the permission of both patients and therapists; we gratefully acknowledge their help. Other illustrative material is either drawn from composite sources or disguised in ways preventing recognition. We have, on the whole, referred to patients rather than clients, although in this book we use the term interchangeably.