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"Doing CAT" versus "Using CAT"

Jellema, A., 2001. "Doing CAT" versus "Using CAT". Reformulation, ACAT News Autumn, p.x.

I was very encouraged to read Steve Potter’s 'A Personal View of ACAT' (ACAT News no. 11) in his role as ACAT’s new Chair. Among the many interesting issues he raises, is "the difference between doing CAT and using CAT". Steve mentions the application of "doing CAT" to many types of psychological health problems, and it is good to see CAT beginning to address the particular therapeutic needs of certain groups of patients/clients; Lorraine Bell (1996) and Janet Treasure (Treasure & Ward, 1997) have already begun to address more specifically the most important reciprocal roles and procedures, and possible modifications to the therapeutic process with eating disorder patients. Under the "using CAT" heading Steve includes, using CAT as e.g. a consultative or supervisory tool, rather than as a formal model of therapy ("doing CAT"). One of my own struggles as a clinical psychologist (CAT Psychotherapy trained) in adult mental health, working in relative isolation with a very difficult population, concerns a "what works for whom?" issue (Roth and Fonagy, 1996).CAT, like all therapies, cannot be a therapeutic panacea, as Tony Ryle has indicated in providing lists of assessment and exclusion criteria (e.g. 1995). With which patients is it most appropriate for us to "do" CAT, and who will benefit more from our "using" CAT, e.g. in their case management and care planning? This is a "horses for courses" issue.

CAT And "Borderline" Patients

By way of example, I would like to address the issue of CAT with "borderlines". Obviously, it is most important that we can establish that CAT is a successful treatment for such patients, via e.g. RCT’s. However, "borderlines" are very heterogeneous, no matter what diagnostic criteria we use (Berelowitz and Tarnopolsky, 1993; Paris, 1994). When we consider the therapy of individual patients in routine clinical practice, those whose terror of relationships predominates may be harder to treat than those who experience more rage, for example. Dr Ryle (1997, pp. 157 - 160) has begun to address the clinical scope of CAT for borderline patients, and when other or additional treatments might be called for. In future, can we devote more attention to the issue of which borderline patients are most likely to benefit from "doing CAT"?

A related concern of mine is to protect CAT in a time of growth and upheaval. New centuries throw up hopes for a "new age", and a new millennium even more so! CAT is spreading fast from its relatively "secure base" in London to the greater isolation of the regions and abroad. Things can be different "out in the sticks"; organic models of mental illness are widespread, and there seems little understanding of the concept of personality disorder, so referrers can cast around frantically for a "magic solution" for acting-out patients, this solution being "doing CAT".

Talking to other therapists of various persuasions working with borderlines in different areas of the country confirms to me how different borderline-style presentations can be. I work in an area with high indicators of economic and social deprivation, where geographical and social mobility is very low, and patterns of extreme family enmeshment are common. Overall, my current patients seem to have a weaker sense of "self" than other populations I have worked with. Such patients, who often have contact with abusive relatives on a daily basis and regard this as the norm, may require treatment that differs from the CAT borderline protocol treatment being developed in London, e.g. longer time frames, possibly systemic work in addition. It was good to see the recent article by Cherry Boa in the ACAT Newsletter (Sept. 1998) addressing the issue of time boundaries and contracts in CAT. Many patients may be able to benefit from "doing CAT", but might need more prolonged treatment, and it would be extremely helpful to us if we can develop our evidence base as to which these patients might be, to draw on when discussing treatment contracts and goals with referrers.

We could look at "borderline" patients in adult mental health settings in terms of three broad groups:

(a) Patients who could be described as showing "borderline personality organisation" (Kernberg, 1967) but who do not meet full DSM-IV criteria for borderline personality disorder. (Research by Fonagy et al (1996) shows that the BPO concept is a broader, more inclusive one than the BPD concept). Kernberg’s criteria for BPO include non-specific manifestations of ego-weakness, and a predominance of more primitive psychological defences, associated with very split object relations. The vast majority of so-called "neurotic" patients referred to me for CAT meet Kernberg’s BPO criteria.

(b) Patients meeting e.g. DSM-IV criteria for borderline personality disorder, and who are likely to be treatable with CAT.

(c) Patients fulfilling criteria for borderline personality disorder who are unlikely to be currently treatable, but who require management, "using CAT" either prior to or instead of therapy. This is described by Dunn and Parry (1997) in a discussion of CMHT clients who may be unsuitable for psychotherapy, in view of their uncontained acting out, or extremely suicidal behaviour.

The Northumberland Tiered Approach

Guidelines developed by clinical psychologists in Northumberland (Cameron and Maunder, 1998) can serve as a useful starting point for thinking about grouping patients, whatever their Axis I or II diagnosis. They are not "classifications", more clinical guidelines and "rules of thumb", as to whether "doing" or "using" CAT might be the better bet. In the Sunderland Clinical Psychology Department (Adult Mental Health) we have found them useful in looking at our workloads, case allocation and offers of therapy versus case management.

The Northumberland "tiered approach" suggests that adult mental health/primary care patients/clients can be roughly grouped into four broad tiers, reflecting the severity of problems. In considering allocation to the tiers, symptoms, chronicity, effects on functioning and service requirements are all taken into account:

People experiencing mild to moderate mental health problems, often stress-related, who are distressed but generally functioning reasonably well. Such patients are usually treatable by e.g. support, counselling, self-help groups within a primary care setting.

Examples might be mild depression following bereavement, first onset moderate depression.

Those with moderate mental health problems, not preventing most day to day coping, but which are unlikely to improve without specialist therapy. Such therapy may be short-term and focal. The risk of self-harm in various forms is higher in this group.

Examples in this tier might be: a person with suicidal thoughts through feeling chronically inadequate at work; a person with panic attacks who is developing agoraphobia, putting work and/or relationships at risk.

People with complex mental health problems, usually long-standing or recurrent, and significantly affecting functioning and quality of life. They will usually require long-term or episodic care, and probably liaison with other agencies. (Often associated with sexual/physical/emotional abuse). Risk of harm to self/others is moderate to high.

Examples here might be: severe and chronic OCD, more stable schizophrenia, and some personality disordered patients (e.g. schizoid and dependent patients).

Those with severe mental health problems with significant impairment of functioning in many areas of life, very high distress, significant risk of harm to self and/or others, and likely risk of deterioration. In-patient care and intra-agency approach frequently required.

Examples here might be: active schizophrenia with difficulties in self-care, manic-depressive psychosis with risk of self-harm.

Work with those in tier 3 and especially tier 4 is typically not containable within a "therapeutic hour", (however long or short that "hour" may be). CAT therapy in my experience is most appropriate for patients in tiers 2, and 3 (especially the "episodic" patients). Dunn and Parry’s CAT approach to case management would seem appropriate for tier 4.

Where "borderlines" fit, however, is a moot point. Cameron and Maunder put them in tier 4; they describe the kind of patient who regularly self-harms and is admitted via casualty. Yet CAT therapy can clearly be effective with many such patients; the question is which? Can we predict in advance, and if so, what might the criteria be? Do we need some more explicit measures of ego strength, or the degree of integration of personality? At present there are no very clear-cut indicators as to the overall treatability of borderline patients (Higgitt and Fonagy, 1993), but some research attention could be devoted to looking at the question of who is likely to respond best to CAT. Data from past and current borderline CAT patients could be analysed to identify the best predictors of therapeutic success. Can we validate our clinical "hunches" with hard data?

It may be that the extent of external trauma and loss that patients have suffered, abuse dating from very early age, or organised abuse, may be powerfully predictive factors. Recent literature (e.g. van der Kolk, 1994) drawing on experimental evidence indicates that prolonged traumatic experiences may result in possibly permanent changes in neurotransmitters and brain structuring, so that trauma is "engraved" in the brain. The implications of this for relatively brief therapies such as CAT, may be that certain procedures may be very resistant to neutralisation, containment or alteration.

If we allow ourselves to be seen in the "magic rescuer" role, we will inevitably disappoint, and so face attack and possible "abandonment". For the benefit of patients, the credibility of CAT and its future growth and development, it is important to "do CAT" with those patients most able to profit from it; this will also help us as CAT therapists to avoid burn-out and disillusionment on our own parts. "Using CAT" can be invaluable in consultation and case management, and has the potential to help us be highly influential with other professionals; we should not see it as "second best".

References

Bell, L (1996) Cognitive Analytic Therapy: Its value in the treatment of people with eating disorders. Clinical Psychology Forum, no, 92, June.

Berelowitz, M. and Tarnopolsky, A. (1993) The validity of borderline personality disorder: An updated review of recent research. In: P. Tyrer and G. Stein (eds.), "Personality Disorder Reviewed". London: Gaskell/RCP.
Boa, C. (1998) The creative use of time in CAT: How long: how short? ACAT Newsletter, no. 10, (September).

Cameron, L. and Maunder, L. (1998) The Northumberland Tiered Approach. Northumberland Mental Health NHS Trust.

Dunn, M. and Parry, G. (1997) A formulated care plan approach to caring for people with borderline personality disorder in a community mental health service setting. Clinical Psychology Forum, no. 104, June.

Fonagy, P., Leigh, T., Steele, M., Steele, M., Kennedy, R., Mattoon, G., Target, M. and Gerber, A. (1996) The relation of attachment status, psychiatric classification, and response to psychotherapy. J. Consult. Clin. Psychol., v. 64, pp. 22-31.

Higgitt, A. and Fonagy, P. (1993) Psychotherapy in borderline and narcissistic personality disorder. In: P. Tyrer and G. Stein (eds.), "Personality Disorder Reviewed". London: Gaskell/RCP.

Kernberg, O. (1967) Borderline Personality Organisation. J. Amer. Psychiat. Assoc., v. 15, pp. 641-685.

Potter, S. (1999) A personal view of ACAT. ACAT News, no. 11, (February).

Roth, A. and Fonagy, P. (1996) What Works For Whom? A Critical Review of Psychotherapy Research. London: Guilford.

Ryle, A (ed) (1995) Cognitive Analytic Therapy: Developments in Theory and Practice. Chichester: Wiley.

Ryle, A (1997) Cognitive Analytic Therapy of Borderline Personality Disorder: The Model and the Method. Chichester: Wiley.

Treasure, J. and Ward, A. (1997) Cognitive Analytical Therapy in the treatment of anorexia nervosa. Clinical Psychology and Psychotherapy, v. 4, pp. 62-71.

Van der Kolk, B. (1994) The body keeps the score: Memory and the evolving psychobiology of post-traumatic stress. Harvard Review of Psychiatry, Jan/Feb., pp. 253-265.

Full Reference

Jellema, A., 2001. "Doing CAT" versus "Using CAT". Reformulation, ACAT News Autumn, p.x.

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