Validating Conceptual Aspects of the Reformulation Process in CAT

Donias, S., 1993. Validating Conceptual Aspects of the Reformulation Process in CAT. Reformulation, ACAT News Autumn, p.x.

Validating Conceptual Aspects of the Reformulation Process in CAT

Stamatis Donias

Interest in psychotherapy research has shifted from outcome studies to the investigation of the therapeutic process. The outcome of any therapy cannot be meaningfully assessed without considering the complex interaction of distinct events in the particular therapy (e.g. interpretations) the various dimensions of the therapeutic relationship established, and the individual characteristics of both therapist and patient. In this sense, the clear flow of communication between therapist and patient with regard to particular events in therapy may be an issue of great importance. This may hold even more true for CAT, which defines itself as a collaborative enterprise and which, as a structured therapy, may lend itself more easily to an investigation of important steps in therapeutic work such as the Reformulation.

The present study tries to investigate the extent to which CAT patients and therapists correspond and communicate to each other their beliefs and attitudes concerning Reformulation: what the patients feel and understand from what their therapists say with the reformulation, and what the therapists perceive and understand from what their patients say and do when receiving the reformulation.

Twenty consecutive patients (16 women and four men, mean age 27.8 ± 7.2 years; mean education 14.5 ± 1.9 years) of a Community Mental Health Center in Thessaloniki (Greece) received CAT. The main DSM-JII R diagnoses were: major depression (35%), panic disorder (10%), marital problem (10%), dysthymia (5%), generalized anxiety disorder (5%), obsessive-compulsive disorder (5%), atypical or mixed personality disorder (15%), borderline personality disorder (5%), narcissistic personality disorder (5%), hypoactive sexual desire disorder (5%). No patient was on any other kind of therapy during CAT. The study included many therapists in order to dampen the confounding effect of the individual characteristics of the therapist. The thirteen therapists were: psychiatrists (70%), psychologists (15%), and social workers (15%). All except one were trainees in CAL Four of them had bad more than one CAT case.

Just after the last CAT session each patient and therapist independently completed ad hoc questionnaires regarding several aspects of all the stages of therapy. This study includes only the variables associated with the reformulation process: the patients’ accepting the validity of the reformulation, the patient’s need for additional explanations, the patients’ emotional reaction to the reformulation, the therapists’ difficulty in reformulating problems in CAT terms, the patients’ difficulty in understanding the reformulation and in accepting the suggested aims as relevant, the frequency of both therapists’ and patients’ use of the reformulation during the rest of the therapy. The statistical methods used were Chi-square tests and Spearman rank correlations.

The results show, first, that there was 100% agreement between the patients’ assessment of the reformulation as being valid for their case on the one hand, and the therapists’ assessment of their patients’ acceptance of the reformulation on the other. All patients felt that the reformulation held true for their case, and only 15% of them considered that their acceptance of the validity of the reformulation was in part influenced by their therapist’s status. It seems that the patients did become familiarized with the CAT perspective offered by the reformulation, and this was clearly communicated to their therapists and was perceived as such by the latter. This shared belief in the relevance of the reformulation i~ very important because it may be associated both with the patients’ engagement in therapy and with the positive outcome of therapy. Moreover, there was a similar agreement between patients’ and therapists’ assessments regarding the need for further explanations and clarifications accompanying the reformulation (55% of the patients felt that they needed such clarifications, and 60% of the therapists felt that their patients needed them). This is another aspect of the clear flow of communication between therapists and patients during the reformulation process.

Second, 60% of the patients acknowledged an emotional reaction to the reformulation given, and in 75% of the cases the therapists perceived correctly this emotional reaction in their patients. This correspondence of assessments between the two parties underlines the important role that the therapeutic use of the emotions amused in the patients may play as a mediating factory between reformulation and therapy outcome.

A third important finding was that the degree of difficulty the patients had in understanding the reformulation was positively correlated with the degree of difficulty their therapists had in reformulating problems in CAT terms. This difficulty on the therapists’ part may be a measure of an informational “noise” conveyed to their patients, making it hard for them to understand and accept the reformulation offered. One can only hypothesize that this difficulty on the therapists’ part may be associated either with their difficulty in integrating material coining from multiple sources during the initial phase of CAT, or with an interference from other explanatory models (e.g. psychoanalytic) in the therapists’ thinking, or with a difficulty (particularly in inexperienced therapists) in identifying problematic procedures or reciprocal role matrices. I think this is an interesting issue, calling for further investigation.

Fourth there was an agreement between the therapists’ and the patients’ assessments regarding the frequency with which patients had difficulties in accepting the aims suggested by the reformulation (25%). Moreover, the therapists’ assessment of the degree of difficulty their patients had in accepting the suggested aims correlated positively with the degree of difficulty the patients themselves reported to have in accepting the aims. These findings suggest again the existence both of a shared frame of understanding and of a clear communication between therapists and patients. Interestingly, the difficulty the therapists had in reformulating problems in CAT terms, while correlating positively with the patients’ reported difficulty in understanding the reformulation, did not correlate significantly with the patients’ reported difficulty in accepting the suggested aims. Thus, the patients’ acceptance of the aims suggested by the reformulation may be a fact relatively independent from their accepting the understanding offered by the reformulation. It would seem that reformulation is not a simple event or a uniform process, but it may consist of a sequence of operations. One of the possible mediating operations could be the offering of explanations/clarifications, which may compensate for the reported difficulty of the therapists to express problems in CAT terms and allow for a more precise patient-therapist communication.

Finally, the frequency with which therapists referred to the reformulation during the second phase of CAT did not correlate with the frequency with which patients turned to it during their everyday life outside sessions. It may be that the patients, who in their majority (80%) turned to the reformulation frequently-very frequently, retain a considerable degree of independence in their everyday functioning outside sessions, in accordance with the non-directional nature of CAT.

Making sense of one’s problems within a collaborative relationship may facilitate therapeutic work. If all therapy is essentially a communicational enterprise, the efficacy of such a communication depends on the extent to which the messages exchanged are being correctly perceived, adequately understood, and essentially accepted by both parties involved. The present theory-based study has tried to demonstrate the clear flow of communication and the correspondence of attitudes and beliefs between therapists and patients with regard to the reformulation process in CAT. Verification of the findings and further investigation of concept validity issues in CAT are badly needed.

Stamatis Donias

Full Reference

Donias, S., 1993. Validating Conceptual Aspects of the Reformulation Process in CAT. Reformulation, ACAT News Autumn, p.x.

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Validating Conceptual Aspects of the Reformulation Process in CAT