Introducing Cognitive Analytic Therapy. Anthony Ryle

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СКАЧАТЬ through another modality (e.g., group therapy or trauma processing work). Decisions about further treatment of whatever kind are best postponed until the effects of the therapy have become stabilized and the experience of termination has been completed. They should always occur in the context of reflective discussion in supervision (see Marx, 2011; Pickvance, 2017).

The Clinical Aims of CAT

      The aims of CAT therapists are, in a sense, modest. We seek to remove the “roadblocks” that have maintained restriction and distress and have prevented the patient's further growth, and we aim to assist in the development of more adequate “route maps” and of ways of being and of living life. This occurs partly through the experience of a new, benign, therapeutic relationship. In so doing we also aim to engender some hopefulness where previously there may have been little or none. But we do not offer to accompany the patient along the road. Obstacles to change are various and in CAT are seen to include: self‐reinforcing ineffective procedures; restricted, avoidant, or symptomatic procedures; sabotaging inner critical “voices”; and disconnected, dissociated Self processes. We do not believe we should seek to explain, let alone claim to share or replace, the wisdom and creativity of artists, writers, and philosophers. CAT also developed as a pragmatic model. In the inner‐city London out‐patient service where CAT developed, it appeared to be a satisfactory treatment for over two‐thirds of patients and of some benefit to many of the remainder. Similar outcomes are reported in naturalistic studies in other countries (e.g., Garyfallos, Adamopoulou, & Mastrogianni, 1998) and in more recent comparative studies in the UK (e.g., Marriott & Kellett, 2009). Some of these went on go on to further treatment, such as more CAT, group therapy, or cognitive‐behavioral work on unrevised procedures, assisted by prior reformulation (Dunn, Golynkina, Ryle, & Watson, 1997). More recent outcome data suggests similar results are being obtained across an increasing range of patient problems, severity, and settings (see Calvert & Kellett, 2014). It may also be that CAT is more effective for some patients if undertaken over a somewhat longer time, or in separate blocks with intervals. Its combination or alternation with other interventions, such as creative therapies, psychodrama, or group work, would almost certainly be helpful for patients who are hard to engage emotionally or who need more time to explore alternatives. Further and ongoing research is of course needed, although funding and support remain in general hard to find for psychotherapies, and notwithstanding that some approaches appear more “politically” acceptable and better promoted at any given time.

Which aspects of CAT are the effective ingredients in successful therapy has not been fully demonstrated, but research summarized later in the book has shown that the reformulation process can produce accurate summaries of key issues with good inter‐therapist reliability (see Chapter 8), although its impact appears, perhaps unsurprisingly, to vary for different patients with different problems. Research has also shown that systematic linking of “transference–counter‐transference” enactments (seen as representing a sub‐set of RRs and RRPs) to the reformulation is associated with good outcome (see Chapter 8). Our belief is that the main factors associated with good outcome include: (a) the experience of a benign and collaborative, although at times challenging, therapeutic relationship; (b) as part of this and contributing to it, the joint creation and use of reformulation tools (in written and visual form) and ongoing use of them in and around therapy; and (c) the internalization of these tools and their meanings in the course of and following a collaborative and non‐collusive relationship. These factors cannot be isolated from the other features of the theory and practice that allow intense but contained connections between patients and therapists, and of course the overall systemic and socio‐cultural context of therapy.

      To end this chapter, we present an abbreviated and revised account of a typical CAT therapy in order to illustrate its stages and the use of the various tools.

      Case History: Bobby (Therapist Steve Potter)

      Bobby, a mature student in his early 30s, presented to a lunchtime on‐call session at a student counseling service with depression and “agitation.” Since the break‐up of a 4‐year relationship, over the previous 2 years he had been sleeping badly, drinking, and smoking excessively despite having asthma, eating irregularly and neglecting his studies, while indulging in fantasies of becoming a famous musician. He had had two previous experiences of therapy and felt he would need it always.

      Background

      Bobby was the youngest of a large family, alternately spoiled (especially on the many occasions when he was ill) and neglected; in part this was because his mother was frequently away in hospital. He recalled frequently lying in his bed calling quietly for his mother, crying into his pillow and feeling inconsolable but afraid of a telling‐off from his brother, by whom he was frequently bullied. He was also bullied later on at school, although he had one best mate there with whom he shared fantasies of becoming a famous pop star.

      Assessment and Reformulation

      After two assessment sessions he was offered 16 sessions of CAT. He was given the Psychotherapy File (see Appendix 2) and he started to keep a symptom diary. The Psychotherapy File and some of his diary keeping confirmed the initial patterns he had described and also set him thinking that perhaps he was not as bad as he used to be. We identified what he wanted to change (target problems) and how his patterns of relating to others and self‐neglect and self‐comfort fed into these. By Session 4 Bobby felt much improved in morale. He had used the provisional diagram, begun self‐monitoring, and was keeping a diary.

      At Session 4, a letter was read to him which is reproduced in part:

       Dear Bobby,

      Here, in writing, is what we have talked about in recent weeks. I hope it can help us keep on track in the weeks ahead and serve as a reminder to you of what we have been working on.

      … One thing you remember of your childhood is either feeling especially loved and treasured, or being a nuisance and ignored and smacked and told to shut up and go to sleep (for example by your brother). You felt you were cared for if ill but otherwise ignored by your older brothers and sisters. You tried to please them and win them over but always felt scared.

       This pattern seems to have been echoed in your close relationships with women and with a therapist previously, as well as in the way you either neglect and ignore your own needs or seek comfort through drink or smoking dope … You are usually neglectful of your body and have not seen a doctor or got proper care (for asthma and other ailments) …

       We have named a number of patterns of feeling, thinking, and behaving:

      1 You long for special care but fear it won’t last, so you tend to cling anxiously and alienate others (as with Elizabeth your partner), leaving you still uncared for.

      2 Feeling depressed leads you to drink or smoke dope and ignore problems which then build up making you feel low and even more depressed.

      3 You receive care, but only if “special,” so you strive to create special claims but feel you must suffer to deserve it and so neglect yourself and become “agitated” and drink or smoke dope.

       These patterns undoubtedly arose from the ways you coped with the limited options of your childhood; they seem to have given you some intimacy and relief but they have been costly …

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