What Are The Origins of CAT?
Cognitive Analytic Therapy was derived from the convergence of three personal concerns: a commitment to the development of a therapy which might be applied in the National Health Service, an involvement in psychotherapy research, and a belief that the time was ripe for a unified psychotherapy theory.
Sources
The main sources were psychoanalytic object relations theory -which had been the model with which I had most experience and supervision, and the work of George Kelly, whose Repertory Grid Technique became a major research tool and whose Personal Construct Theory introduced me to cognitive and constructivist ideas. The development of an integrated model come from the early attempt to find a common language for psychotherapy, largely by re-stating psychoanalytic ideas in cognitive terms, and was accelerated by doing research. Working with patients to find the best descriptions of what it was we were trying to change as part of outcome research, demonstrated to me the power of collaboratively arriving at such descriptions. This early joint reformulation has remained the key feature of CAT, offering both the early creation of a non-authoritarian working relationship and yielding increasingly powerful tools of understanding and change.
Further developments were accelerated by the challenge and opportunity of running the St Thomas’s Hospital Psychotherapy Service which demonstrated that a minimum sufficient intervention of – in most cases – 16 sessions, delivered by supervised trainees with variable but often little prior experience could meet the needs of most of the patients referred to the service. During my ten years there some 1% of the adult population of the catchment area were treated. Over the same period growing numbers of trainees took up the approach, enriched it with their various ideas, rapidly upgraded the quality of the training offered and went on to create and develop ACAT.
Theoretical Developments
The development of diagrammatic reformulation over this period contributed to a more detailed and radical revision of object relations theory and to the development of a model of the dissociated personality structure of patients with borderline personality disorder. The contributions of Mikael Leiman from Finland, in linking the ideas of Vygotsky and Bakhtin with the CAT model, strengthened this process. As a result of these developments the early ways of reformulating patients’ difficulties in terms of failures to revise damaging patterns, described as Traps, Dilemmas and Snags, while still of value in simpler cases, have been largely superseded by an emphasis on reciprocal role procedures. These are seen to originate in early life and to be maintained by the elicitation of the expected reciprocations from others. . Therapists need to identify but not reciprocate damaging role procedures. Role procedures derived from relationships with others are also the origin of self processes, and both interpersonal and intrapersonal enactments are frequently replaced or accompanied by dialogue making use of language and other mediating tools learned in early life. A person’s repertoire of role procedures is normally more or less integrated and mobilized appropriately but in more disturbed individuals dissociated self states may operate alternately, switches between them being disconcerting to both patients and clinicians.
Despite its integrationist ideals and despite its many publications – including some polemical writing seeking to evoke debate – CAT has generated little discussion in the journals of current schools of therapy but this has not prevented a rapidly growing demand for training and the establishment of training and practice in many parts of the UK as well as in Finland – Greece and some other centers. The proof of the pudding may be in this eating, but we still need a more extensive research basis than has so far been assembled.
To the Future
Over the 25 years since CAT was formally launched it has grown in size in the UK and abroad, it has developed theoretically, it has been applied to different conditions and different contexts, it is generating an increasing volume of research and in ACAT it has an effective professional organization. These developments have been the work of increasing numbers of practitioners, therapists, supervisors and trainers. Despite the damage done to the NHS and despite the political dominance of other models, it seems destined to continue to grow.
Tony Ryle – Originator of CAT and Founder of ACAT – 2008