Letter from the Chair of ACAT

Hepple, J., 2011. Letter from the Chair of ACAT. Reformulation, Summer, pp.4-5.

It is an honour to be the new Chair of ACAT, and I hope that I can serve the Association half as well as my predecessor, Mark Westacott, who has steered us through times of great challenge and change. I hope the next three years will be a time of consolidation and continued growth for ACAT, despite the current ‘Cold Climate’.

I would like to open a dialogue about our medium term strategic aims, which I hope can be firmed up at the ACAT Trustees’ Awayday in the Autumn. In the meantime I would welcome your thoughts and ideas. Please feel free to e-mail me (through the ACAT website) about this.
I would like to consider two broad strategic areas as a starting point.

1. Consolidation and presentation of the evidence base for CAT

This is essential to ensure that we retain our place in the Public Sector in the UK. CAT is in a bind with respect to the way that evidence for Psychological Therapies is evaluated by the National Institute for Health and Clinical Excellence (NICE). CAT does not have a starting point of diagnostic categories. Instead, it sees symptoms such as anxiety, depression and behavioural disturbance as manifestations of developmental and relational patterns that can be unravelled with the help of its dialogic and collaborative model and method. This is not in opposition to a neurobiological model, but rather it seeks to complement other paradigms for treatment, while being true to its relational heart (much as CBT for depression is not against the use of antidepressants). The problem for CAT, however, is that the diagnostic systems have grown up around biological and cognitive developments in psychiatry in a way that is self-perpetuating and exclusive. If a case of ‘panic disorder’ doesn’t respond to the cognitive model of treatment for panic, is it ‘panic disorder’ at all, or is it something else? It is ‘something else’ that CAT uses as its starting point, treating each person, their symptoms and their clusters of symptoms as unique occurrences explored in a unique setting - the relationship between that client and that therapist. CAT specialises in ‘mixed dysphoria disorder’ which, so far, doesn’t have NICE guidance!

NICE looks for evidence of efficacy for each diagnostic category, established before treatment starts. This puts CAT at a disadvantage, as what we offer does not distinguish between people based on their DSM or ICD diagnoses. In addition, NICE applies a “medical model” to evaluation of research, so it is usually dismissive of qualitative, practice-based, non-randomised controlled research. This also is to CAT’s disadvantage.
Research favoured by NICE has poor generalisability to clinical populations, which is why CAT services get increasing numbers of referrals of “treatment-resistant” patients, but usually no extra funding.

It is beyond the power of ACAT to turn this tide, but I have confidence that this trend will start to ebb in favour of more realistic practice-based research. In the meantime, we need to make the best of what we have so far: a moderately NICE-acceptable evidence base for Borderline Personality Disorder (which we can enhance with several pieces of work in the pipeline, in time for the NICE review of BPD in January 2012); some merit in Eating Disorders; a groundswell in Learning Disabilities; and an idea that CAT may be a suitable approach for clients who, despite diagnoses of “mild to moderate anxiety or depression”, do not respond to “step 3 interventions” at Increasing Access to Psychological Therapies (IAPT) services.

If CAT can establish itself firmly in the NICE guidance for BPD, then it has a good case for marketing itself as a suitable model for ‘complex cases’, including clients who do not fit neatly into neurotic or personality disorder categories.

An example of this type of study is the small randomised controlled trial taking place in Oxford with IAPT clients. Steve Kellett in Yorkshire is also planning research on this client group, in collaboration with IAPT.

We also have on-going work in the area of Manic Depression and on the interface between mental and physical illness (particularly diabetes), and I see this interface as a potential big growth area for CAT, as GPs particularly are concerned about their patients with ‘unexplained physical symptoms’.

With the aim of ‘playing the game’ as well as we can, I hope to involve our many excellent researchers in devising a five year research strategy to be taken forward by the Research and Communication Committee.

2. Broadening the dialogue around CAT

CAT survives, and in many places flourishes, because it is based on a really good idea and is delivered by enthusiastic and clinically accomplished therapists who believe in supervision, training, Continuing Professional Development and the on-going development of the practice of CAT. We now need to venture out of the ‘CAT village’ more, to market ourselves confidently to those who might use or purchase our therapy. The best form of marketing, I think, is to engage people in dialogue - which is already the CAT project. To this end, Maddy Jevon, Jon Sloper and several others have been completely redesigning our website to make it more meaningful, informative and accessible to users of CAT, purchasers and ACAT members and friends. There are a series of factsheets covering ‘What is CAT?’, ‘What is it like to have CAT?’, ‘Training in CAT’ and ‘The Story of Research in CAT’ that will be available to print out from the website (all beautifully designed and formatted!).

Armed with these materials, we need to start talking about CAT in every hospital, clinic, GP consortium, PCT and national setting available to us. (We must not forget the private insurers who are looking for evidence-based time-limited therapies to put on their lists of approved/acceptable therapies). Most importantly, we need to consider how we involve past and future users of CAT in the dialogue and in the structure of ACAT.

To these ends I hope to establish both a marketing strategy and a user-involvement strategy for ACAT - looking forward to the next five years.

There - that is what I have in mind, so let’s hear what you think. Please feel free to contact me and/or Susan Van Baars at ACAT Administration so that we can collect all your thoughts for the Trustees’ awayday.

Finally, I would like to thank Alison Jenaway, Rosemary Parkinson and the Conference organisers for a really good day in London on 1st April. I also hope to have a chance to catch up with some of you in Krakow (Cracow) in September, which is going to be a really memorable International CAT Association Conference.

Best wishes
Jason Hepple

Full Reference

Hepple, J., 2011. Letter from the Chair of ACAT. Reformulation, Summer, pp.4-5.

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Evidence submitted by the British Association for Counselling and Psychotherapy (NICE 92)
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