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CAT and CFT - Complementary in the treatment of shame?

Jameson, P., 2014. CAT and CFT - Complementary in the treatment of shame?. Reformulation, Winter, pp.37-40.

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Having recently completed the academic component of the CAT Practitioner Course, I have been impressed at how responsive patients have been to the model. The collaborative nature of CAT, the development of a shared reformulation of the patient’s difficulties, and how these are maintained, empowers both patient and therapist. Most patients are responsive to the model and, by being helped to understand their patterns of relating, they begin to find exits, developing or building on healthier forms of relating. However, I have found that there are a small proportion of people who, despite understanding the nature of their difficulties, how they are being maintained, and the benefits of healthier reciprocal roles, are unable to feel any different. They either cannot move into, or cannot remain in, a healthier reciprocal role (particularly self-to-self relating). These patients tend to be extremely self-critical (at times self-loathing), and experience significant feelings of shame. People who have not had positive experiences cannot generate positive self states (Gilbert, Baldwin, Irons, Baccus and Palmer, 2006), and in fact are often fearful of compassion directed towards themselves because in the past compassion has been linked with abuse or withdrawal of affection (Gilbert 2006; Gilbert, 2010). If a child experiences abuse or neglect from the person who also provides compassion or soothing (i.e. the main care giver), compassion becomes conditioned to the threat-based emotions, so that when the patient experiences compassion it also triggers his threat system (Gilbert, 2010). 

Highly sensitised to threat, with little experience of compassion, these patients find it very difficult to connect or to feel safe with empathic feelings (Gilbert, 2003), making the therapeutic relationship uncomfortable and difficult to trust. In my experience these people believe themselves to be bad or toxic, often describing urges to destroy themselves or parts of themselves. In CAT terms, this could be understood as a snag (e.g. I must sabotage good things as if I do not deserve them), or an abusive, destructive self-state (such as annihilating to destroyed). It is almost as if compassion is beyond their zone of proximal development (ZPD) ( Vygotsky, 1978), and people shift self state when the therapist offers some form of compassionate reframing. An example of this would be patients who move into a cut off/dismissing self state to listen to their reformulation letter. 

Gilbert (2010) developed a therapy for people with chronic mental health problems linked to self-criticism and shame, which he called Compassion Focused Therapy (CFT). CFT developed from Cognitive Behavioural Therapy (CBT). As CBT began to be used as a therapy with people with more complex and co-morbid difficulties, it was recognised that thought challenging was less effective. “A gap opened up between the logical appraisal and emotional conviction, so that the individual might be able to agree with the reasonable explanation but still be governed by the emotional reaction” (Clarke, 2009). Research suggests that we have different processing systems within our minds. Implicit processing is fast, emotional, non-conscious and subject to classical conditioning. Explicit processing is slow, conscious and reflective (Clarke, 2009; Gilbert, 2010). As far as we know there is no simple connection between these systems; so we can know something, but not feel it. 

The CFT model aims to help people to build up a compassionate self, and use this to regulate more threat-based emotions (Gilbert, 2010). Therapists provide education on how the brain has evolved, why it is focused on threat, and how we can become trapped in loops between our older, more threat/survival focused brain, and our newer brain which has the ability to think, worry and ruminate on our experiences and emotions. 

Therapists then use mindfulness and imagery based practices to build compassion, addressing blocks to compassion during the process. This compassionate self is then used to dialogue with the more threat-based aspects of the self, allowing integration of these different self-states. Please refer to Gilbert (2010) for a more detailed explanation of the model. 

There are many similarities between CAT and CFT, and as CAT allows therapists to utilise techniques they feel would be useful to the patient during the recognition stage, I began to experiment with integrating CFT with CAT for those patients who seemed to have difficulty with compassion. I’ll explain this below in the CAT structure of reformulation, recognition and revision.

Reformulation
Both CAT and CFT emphasise the importance of early attachment relationships in how difficulties develop (Ryle, 1975; Jellema, 1999; Gilbert, 2003) and produce a compassionate reformulation (in letter and diagrammatic form) to aid the patient’s understanding, thereby reducing some self-blame (Hamill, Reid and Reynolds, 2008). Both also stress the importance of the development of a mindful, observing self to allow previous automatic behaviours to be brought into the consciousness, thought about and revised (Ryle, Spencer and Yawetz, 1992; Ryle, 1997; Gilbert, 2010). 

CAT makes active use of the therapeutic relationship, using reformulation tools to predict and understand reciprocal role enactments that occur within therapy (Beard, Marlowe and Ryle, 1990). This offers an obvious advantage in understanding the patient and the therapeutic relationship, and enabling this to be brought into the dialogue of therapy, allowing patients to experience a healthy form of relating (understanding and validating to heard and validated) (Beard, Marlowe and Ryle, 1990).
In addition to helping patients to reformulate their own difficulties, CFT offers psycho-education about evolution and the development of the brain, with the intention of providing a wider context and reducing self-blame (Gilbert and Procter, 2006).

Although diagrammatic formulations are usually done early in CFT, the written reformulation (which is a letter the patient writes to himself in CFT) is produced later within therapy, once the compassionate self has been developed. This allows self-critical people to hear and own their compassionate reformulation, rather than experiencing this as overwhelming (beyond their ZPD), and retreating into a cut off state (overwhelming to cut off and numb). 

Recognition
In CAT the mindful observing self is used to recognise and begin to integrate the fragmented self states (Wilde McCormick, 2011). This use of a mindful observing self is becoming more frequently used in third wave CBT therapies such as Mindfulness

Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT) and CFT (Clarke, 2009). Mindfulness allows enough distance from the overwhelming affect so that it can be moved into the explicit processing system, and thought about. While there are a lot of therapies designed to understand, tolerate and reduce threat based issues (e.g. anxiety, depression, panic, etc.), there are very few therapies designed to actively increase the compassion system. There is now an abundance of evidence that compassion increases wellbeing, and affects brain function, particularly in areas of the brain known to be associated with emotional regulation. I refer the reader to Gilbert (2010) for a review of this evidence. “The ability to generate powerful, warm and accepting images seems significantly protective of depression symptoms” (Gilbert, Baldwin, Irons, Baccus and Palmer, 2006, p. 197). 

CAT uses the therapeutic relationship as a model for healthy reciprocal role relating, allowing patients to experience this within the session (Beard, Marlowe and Ryle, 1990). This other-to-self relating hopefully progresses into a healthy self-to-self relating for the patient. For those people who have little or no experience of compassion, or those who fear compassion, experiencing this within the therapy can be extremely challenging. Research suggests that relying on the therapeutic relationship to do this is not sufficient. The “therapist needs to help build up and practice experiencing internal scripts and role relationships based on warmth, compassion and forgiveness” (Gilbert, Baldwin, Irons, Baccus and Palmer, 2006, p.197). “Although a supportive therapeutic relationship may aid this . . . and elaborate innate schemas for feeling supported and cared for, it is also the case that people can be encouraged to practice warm and compassionate forms of self-evaluation by focusing on compassionate attention, thinking, feeling, and behaviour, and generating compassionate imagery to themselves” (Gilbert, Baldwin, Irons, Baccus and Palmer, 2006, p. 198). 

The benefits of being able to generate positive and compassionate imagery has long been known and used in Buddhism (Gilbert, Baldwin, Irons, Baccus and Palmer, 2006), and research has shown that learning to generate compassionate imagery and the repeated practice of this helps stimulate the soothing/compassionate system, which can help to combat the threat/self-critical system (Gilbert and Irons, 2005, cited in Gilbert, Baldwin, Irons, Baccus and Palmer, 2006). 

Revision
Revision occurs when a patient begins to find exits from his unhelpful Reciprocal Role Procedures (RRPs) (Ryle, 1994). In both CAT and CFT this stage of therapy involves exploring healthier ways to relate to the self and others. This needs to be maintained and further developed once therapy is complete if therapy is to be successful for the patient. Although CAT patients experience a new way of relating within the therapeutic relationship, non- deserving snags can drag patients back into their old ways of relating. A healthy self-to-self compassion system can be slow and difficult to establish and patients from more damaged backgrounds can have difficulty trusting in the therapeutic relationship, questioning whether the therapist really cares for them or is just there because it is her job. “To feel different requires the ability to access affect systems that give rise to our feelings of reassurance and safeness” (Gilbert, 2010, p. 6). 

Simply put, in order to feel safe and trust this new way of relating, the patient needs to feel the therapist’s compassion. For the patient who is self-critical, shameful or non-deserving, if the therapeutic relationship is not trusted then this new compassionate way of relating to the self may not be internalised (Gilbert, 2003). 

CFT offers both patient and therapist, a model for understanding why these patients find compassion so hard to accept and internalise, whilst CAT offers a framework in the written and diagrammatic reformulation for understanding how this relates to the individual patient, predicting switches in self-states and allowing for this to be discussed, understood and contained. If therapists do not understand why some patients fear or reject compassion, there is a danger that therapy becomes stuck and the therapist frustrated. “Shame triggered in either therapist or patient can be a source of therapeutic ruptures” (Gilbert and Procter, 2006, p. 353) and patients who are highly sensitised to threat may potentially perceive this as blaming and further shaming, reinforcing unhealthy RRPs. Blindly offering compassion to those patients who find it threatening may put us in danger of repeating unhealthy RRPs (Wilde McCormick, 2011), or pushing the patient beyond his ZPD. 

Conclusion
Both CAT and CFT aim to collaborate with patients to reach a new understanding of the development and maintenance of their difficulties. Both aim to cultivate the development of mindful self-reflection, which will allow integration of different self-states with their accompanying distressing emotions. Both also aim to help patients develop healthier ways of relating to the self and others. CFT offers education about evolution and the importance of early relationships in brain development which can help client’s increase their understanding of the wider context and decrease self-blame. Therapist and patient understanding of why compassion can be so threatening for some patients can prevent therapeutic ruptures and reduce shame and self-blame. In CAT the collaborative production of the SDR and the active use of the therapeutic relationship can help therapists and clients to recognise re-enactments thereby increasing self- awareness and self-reflection. 

In our current climate of payment by results, the NHS values short-term evidence-based therapies, and there is pressure to produce quick outcomes (Rizq, 2012). Even though CAT was developed as a short-term therapy for use in the NHS (Beard, Marlowe and Ryle, 1990), for those patients with little experience of compassion, or for those who find compassion frightening, is the CAT model of 16-24 sessions enough to allow change? Ryle acknowledges that CAT may be the first step, with the patient moving onto further intervention to help internalise what has been learnt in therapy (Ryle and Fonagy, 1995). While undoubtedly this is the case for some, I also wonder whether an integration of CAT and CFT may allow us to work more effectively and efficiently with people whose early experiences make accepting and internalising compassion difficult. 

References
Beard, H., Marlowe, M., Ryle, A. (1990). The management and treatment of personality disordered patients: The use of sequential diagrammatic reformulation. British Journal of Psychiatry, 156, 541-545.
Clarke, I. (2009). Coping mechanisms: Strategies and outcomes. Coping with crisis and overwhelming affect: employing coping mechanisms in the acute inpatient context, http://www.isabelclarke.org [Accessed 27th January 2014]
Gilbert, P. (2003). Working with shame. Reformulation, Summer 2003, 13-15.
Gilbert, P. (2006). Old and new ideas on the evolution of mind and psychotherapy. Clinical Neuropsychiatry, 3 (2) 139-153.
Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy, 13, 353-379.
Gilbert, P., Baldwin, M., Irons, C., Baccus, J., & Palmer, M. (2006). Self-criticism and self-warmth: An imagery study exploring their relation to depression. Journal of Cognitive Psychotherapy: An international quarterly, 20 (2), 183-200.
Gilbert, Paul (2010). Compassion Focused Therapy. London: Routledge.
Hamill, M., Reid, M., & Reynolds, S. (2008). Letters in cognitive analytic therapy: The patient’s experience. Psychotherapy Research, 18 (5) 573-583.

Hanson, R. (2013). Hardwiring Happiness: The practical science of reshaping your brain and your life. Croyden: Rider.
Harris, R (2008). The Happiness Trap. London: Robinson. 
Jellema, A. (1999). Cognitive analytic therapy: Developing its theory and practice via attachment theory. Clinical Psychology and Psychotherapy, 6, 16-28.
Ritq, R. (2012). The perversion of care: Psychological therapies in a time of IAPT. Psychodynamic Practice, 1-18.
Ryle, A. (1975). Self-to-self, self-to-other: The world’s shortest account of object relations theory. New Psychiatry, April, 12-13.
Ryle, A., Spencer, J., & Yawetz, C. (1992). When less is more or at least enough: Two case examples of 16-session cognitive analytic therapy. British Journal of Psychotherapy, 8 (4) 401-412.
Ryle, A. (1994). Persuasion or education? The role of reformulation in cognitive analytic therapy. International Journal of Short-term Psychotherapy, 9 (2/3), 111-118.
Ryle, A., & Fonagy, P. (1995). BJP annual lecture 1994: Psychoanalysis, cognitive-analytic therapy, mind and self. British Journal of Psychotherapy. 11 (4) 567-574.
Ryle, A. (1997). The structure and development of borderline personality disorder: a proposed model. British Journal of Psychiatry. 170, 82-87.
Wilde McCormick, E. (2011). Compassion in CAT. Reformulation, Winter, 32-38.
Vygotsky, L.S. (1978). Mind and society: The development of higher psychological processes. (p86). Cambridge, 
A: Harvard University Press.
Pam is a Counselling Psychologist and trainee CAT Practitioner working in a secondary care psychosis team within Tees, Esk and Wear Valleys NHS Foundation Trust. 
pamelajameson@nhs.net 

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