Research into CAT

There are a number of current studies being undertaken into CAT. These are listed below.

Exploring endings from the therapist's perspective in Cognitive Analytic Therapy, with a particular focus on what makes for a good ending process.

The purpose of the study:
The purpose of the research is to explore the ending process within CAT from the therapist's perspective. We know that within the CAT model emphasis is placed on the importance of the use of endings in therapy. For example, the issues and feelings raised during the ending process create an opportunity in therapy for the client to reflect on those surrounding previous, potentially unresolved endings in earlier life. A lack of opportunity to process previously challenging endings can contribute to the client's emotional distress and a tendency to re-enact unhelpful relational patterns in the here and now.  Therefore, the CAT model advocates that the ending of therapy is on the agenda from the beginning, and a set number of sessions towards the end of therapy are used to focus on it, including the use of goodbye letters.

The significance and management of endings is clearly described within CAT literature.  However, it seems that there has been little exploration of the actual experience of endings from the therapist's perspective.  It is believed that exploration in this area will enhance our understanding of the ending phase of therapy and possibly develop awareness of what can define and increase the likelihood of a positive ending.

Research method and timeline:
This research involves the use of online qualitative methodology and Thematic Analysis. The use of online interviewing has the advantage of allowing access to participants over a wide geographical area.  Computer-mediated communication has also been identified as a method that allows for enhanced self-disclosure due to the interation between reduced public self-awareness and heightened private self-awareness. Additionally, it has been found that drop-out rates in studies using similar methodology are relatively low.

A semi-structured interview questionnaire will be sent to all participants, followed up by asynchronous, individually tailored email questions based on the responses to the questionnaire. The aim of the is to explore the following areas:

o         How therapists manage the ending process in CAT, and the use of CAT tools within this process.

o         How therapists experience the ending process, and what seems to impact either personally or contextually on the process.

o         How positive endings are described by therapists, and what seems to contribute to the likelihood of this being achieved.

o         Similarly, how unsatisfactory endings are experienced, and what seems to contribute to this process.

Recruitment and data collection is currently underway and likely to extend until July. The analysis and write up of the research aim to be completed by October, 2010.

Recruitment and research inclusion criteria:

Expressions of interest would be welcome from therapists working in both the public and private sector and who meet the following inclusion criteria:

o         a minimum of one year post Practitioner level experience as a CAT therapist,

o         the completion of at least four CAT cases since qualifying,

o         currently using the CAT model.

The organisation and review of the research:

The study is sponsored by Plymouth University and has been reviewed and approved by Southmead (Bristol) NHS Research Ethics Committee. Supervision is provided by Mina Bancheva, IRRAPT Course Tutor, as the research will contribute to the fulfillment of my CAT Psychotherapy Training.

For further information:

Please contact:   Julie Wilkinson  ||  email:  psjpw@bristol.ac.uk

Do people with learning disabilities have a concept of Reciprocal Roles? 

There is insufficient understanding about the socially derived internal worlds of people with learning disabilities and an under-development of psychotherapy opportunities and applications for them. Do people with learning disabilities have a concept of Reciprocal Roles? Although there is some research eliciting what Reciprocal Roles often play a part in the lives of people with learning disabilities, (Psaila & Crowley 2005), we do not know whether they use this heuristic device in the habitual manner that most people do within their internal and social lives, as they have not yet been asked. 

Research will involve assessing consent, using the Arscott, Dagnan & Kroese

1998 protocol, British Picture Vocabulary Scale Short Form to assess verbal mental age and Ravens Coloured Progressive Matrices to assess non-verbal IQ, and using line cartoon drawings assess a basic understanding of the relationship between feelings, and actions and then explore the 9 Reciprocal Roles previous research identified from therapy transcripts as relevant to people with learning disabilities. 

These reciprocal roles are: 

• Abusing to Abused
• Rejecting to Rejected
• Rescuing/Caring to Rescued/Cared for
• Damaging to Damaged
• Abandoning to Abandoned (Unloving to Unloved)
• Special/Perfect to Learning Disabled
• Controlling to Controlled/Fragile
• Blaming to Blamed
• Overwhelming to Overwhelmed 

Using cartoons to illustrate these reciprocal roles, one pole of the Reciprocal Role will be offered together with four other cartoons. One will be the anticipated other pole, another an antonym, another a copy of the originally presented role and the fourth a distracter. I will ask verbally about each of the cards 

• What is happening?
• What does the person feel?
• What does the other person feel?
• Want?
• Do?

Participants will then be asked to select which one suits the scene best.

Expected completion: Summer 2009        
Contact: Julie.Lloyd@sabp.nhs.uk

RCT comparing empowerment intervention, psychotherapy (CAT) and requested CAT for patients with Type1 diabetes? 

A study analysing psychological morbidity amongst patients with Type 1 was conducted at the RoyalBournemouthHospital (Shaban, Fosbury et al Diabetic Medicine 2006). Part 2 of the study was a RCT randomising patients in to empowerment intervention, psychotherapy (CAT) and requested CAT. This second part has been published as part of an abstract and has been submitted to Diabetologia for review. Biochemical (HbAlc) and psychological data were measured. All groups reduced HbAlc in a way which reduced clinical risk in patients with diabetes (e.g. blindness, amputations etc) but patients who requested CAT showed the greated result in psychological and biochemical terms and significant statistical data at 2 year follow up Diabetic Medicine March 2008, Vol 25, Supplement 1, p 135). The second part is a continuation of the first RCT of CAT in diabetes published by Jackie Fosbury (Fosbury et al 1997, Diabetes Care). This study recommends that more complex therapy is effective in those reporting more severe diabetes related psychological distress. We are making a case for CAT, which goes over and above current limitations of the IAPT agenda and a case for CAT for people with long term physical conditions (commissioning process). As second author to the Bournemouth study I will be following up the part 2 study with comments about how the trial was conducted i.e. the psychotherapist was supervised by me but not CAT trained formally and was quite 'resistant' to CAT at outset. 

Contact: Jackie Fosbury
jackie@dtaylor0.wanadoo

A process study evaluating rupture repair in CAT, using an adolescent sample. 

A process study evaluating the Bennett, Parry and Ryle (1986) model of rupture repair in CAT, using an adolescent sample from Andrew Chanen's Australian study of adolescents at risk of BPD. The research is being carried out by Dr. Susan Llewelyn and a trainee clinical psychologist (Anne-Marie Daly), in conjunction with Andrew Chanen and his team.

Results and more details should be available in September. 

Contact Dr. Susan Llewelyn      
susan.llewelyn@hmc.ox.ac.uk

CAT in Groups - a dialogic approach: to be submitted for publication in 2010.

A detailed description of how CAT can be applied clinically in a group setting.

Dr Jason Hepple, Somerset Partnership NHS Foundation Trust.

The SPeDi Trial (Sheffield Personality Disorders)

One of the main activities in the Psychological Therapies strand is a randomised controlled trial of psychotherapy for Borderline Personality Disorder (BPD). The trial is being conducted in the context of a new clinical service that has been developed by Sheffield Care Trust.

People with severe & complex psychological problems referred to by the label `borderline personality disorder´ experience acute distress and multiple difficulties – such as self-harm and repeated suicide attempts, panic, depression, anger problems and trouble with relationships. Our project aims to deliver and test improvements in services for people with these difficulties (who have at times been stigmatised and marginalised in mental health services). Mental health professionals, researchers and service users are working together to achieve this.

Two different approaches are being compared. People receive either care from a Community Mental Health Team whose team members have had special training, or psychological therapy. The therapy methods (cognitive behavioural or cognitive analytic) were pioneered in the UK. People coming into the project agree to be randomly allocated to one or the other, and are carefully followed up to find out how they get on in terms of improvements in their well-being, relationships and quality of life, using standardised measures. In addition, service users are collaborating on exploring the experiences people have in these services, whether helpful or unhelpful.

As well as improving provision for these clients, the project aims to answer several important research questions to inform future NHS services. Is it beneficial to offer individual therapy over and above good quality care from a CMHT? Which treatment programmes are most acceptable to service users? People in this client group often report negative experiences of care and many drop out of therapy, so it is important to focus on their experiences. In addition to service user involvement with the randomised trial, a parallel study addresses these issues directly, through qualitative methods. Other questions include which process factors predict outcomes, such as therapist competence, therapeutic alliance and specific techniques; and which client characteristics make a difference (e.g. history of early childhood abuse & trauma). To have a chance of answering these questions we need to follow up 132 people.

The trial service has recently recruited its first participants. To get useful evidence on which to plan services, we needed to set up a randomised trial in a realistic service setting and include the perspective of service users, which is usually neglected. This requires an extensive range of partnerships between care staff, therapists, researchers and service users, and development of an organisational culture within a mental health service to meet both clinical and research requirements.

http://www.shef.ac.uk/spedi/

The Effectiveness of CAT for Borderline Personality Disorder: the Shape of Change in Routine Practice

This project is looking at how CAT is delivered under routine conditions in the NHS. It has collected a sample of therapists together and examines BPD clients' responsivity to CAT treatment and the degree to which CAT is actually being competently delivered. The methodology is a multi-site hermeneutic single case approach which establishes 5 key evidence criteria on which a case can be considered successful. The results will entail summating conclusions from each case. The project is run by Stephen Kellett, Dawn Bennett and Tony Ryle. We are nearing the point of project completion, as we have collected outcomes for over ten cases using the exhaustive evaluation methodology. In early 2009 we are planning to answer the following questions:-

• What is the rate of clinically significant change for BPD clients in CAT in terms of symptoms, personality structure and dissociation?
• Is there any evidence for sudden gains in CAT?
• Does more competent CAT produce more better outcomes?
• What do clients think of CAT?
• Is the CAT BPD model good enough and what are the training implications for working with BPD?

Requests for information can be directed to Stephen Kellett on stephen.kellett@barnsleypct.nhs.uk

A Twice−Told Ending: Goodbye Letters in Cognitive Analytic Therapy 

CAT theory proposes that the preparation and exchange of goodbye letters plays an important role in managing the ending of therapy and "ending well". However, there is very little research into patients’ experiences of goodbye letters and, so far as the researchers are aware, there is no research into therapists’ experiences of goodbye letters.

The aim of the research study is to explore and describe the experience of writing and receiving goodbye letters in CAT from the perspectives of patients and their therapists. Each patient and therapist participant will complete a short satisfaction questionnaire in relation to the therapy and its ending, followed by a detailed semi-structured interview. The interview data will be analysed using Interpretative Phenomenological Analysis (IPA), which is a qualitative method of analysis that aims to explore systematically and in detail participants' personal perspectives and experiences.

The intended sample size is four to five therapists with two patients each (i.e. a total of four to five therapists and eight to ten patients).

The research will take place in the CAT service of the adult outpatient Halliwick Psychotherapy Department at St Ann's Hospital, London N15 3TH. The study is Henry Clements’ research project for his Doctorate in Clinical Psychology and is being supervised by Shirley Akgun, Consultant Specialist in Psychotherapy at the Halliwick Psychotherapy Department, and Dr Nancy Pistrang, Senior Lecturer in Clinical Psychology at University College London.

Call for research 

So far as the researchers are aware, only two studies to date have examined goodbye letters. The first is an unpublished study (Rayner (2005)) that used grounded theory to study nine patients’ experiences of CAT tools. The second is a study by Hamill et al (2008) which examined patients’ experiences of letters in CAT. The researchers would be very interested to receive details of any other ongoing or completed studies in relation to goodbye letters.

Timescale

Data collection will start in summer 2008 and it is anticipated that the research will be completed by June 2009.

Contact Details

Further information about the study can be obtained from Henry Clements, Trainee Clinical Psychologist, University College London, tel: 07877 127863, email: henry.clements@hotmail.co.uk.

The Case Formulation Task in Psychotherapy: Validity, Reliability and Process of Evidence Gathering and Decision Making 

Coherent and accurate formulations are the hallmark of brief and time limited therapies as they enable the clinician to make informed choices about how to focus the work but there is very little research on their validity and reliability.  The reformulation is central to CAT in providing a structured understanding of the central problems of the patient and their origins.  Unlike other formulation methods it is standard practice for the therapist to share a written formulation with the patient.   While it has much practice based evidence to justify and validate its use, relatively little formal research has been conducted on the reliability and validity of reformulations or the process evidence gathering and decision making in writing them.. 

Aims

This research aims to see whether Cognitive Analytic Therapy (CAT) formulations are valid and reliable, that is, whether CAT therapists are able to produce broadly similar written reformulations when presented with the same material and whether the material that is selected is accurate and relevant to the patient.  It also aims to examine the rules therapists use to generate reformulations.

Questions

The key questions are: Are reformulations in CAT replicable or idiosyncratic? Can the formulations be validated by research tools? What evidence do CAT therapists seek in order to construct reformulations? Does the implicational knowledge of experienced therapists reveal common rules in their evidence seeking?

Method

I asked four experienced CAT therapists to tape the pre-reformulation sessions of a therapy from their routine waiting lists and to write reformulations.  They then listened to each others’ tapes and wrote reformulations from these.    I then interviewed them individually to explore with them their understanding of the reformulation process in relation to these therapies and to see whether there are common themes in the evidence they seek and the implicit knowledge they use.  In a second study I coded the therapies and reformulations using the Structural Analysis of Social Behaviour (Benjamin, L.S. 2003).  I compared the generated codes with the reformulations to gain a measure of the validity of the reformulation and the codes between reformulation for the same patient to measure reliability.   A matching exercise using independent judges was also used to test reliability.    

Estimated completion date: November 2008 

Contact details: Lawrence Welch, Psychological Therapies Service, Lea House, Whackhouse Lane, Gateway Drive, Yeadon, Leeds LS19 7XY  Email: lawrencewelch@onetel.com

A Randomised Control Trial of CAT Informed Care Planning

This trial is taking place is Barnsley PCT NHS Trust and is being coordinated by Dr Mark Wilbram and Dr Stephen Kellett. The trial concerns assessing the effectiveness of a CAT consultancy model for patients in the Assertive Outreach Team and is being supported by a local research grant. Patients in the AOT with stable psychosis are being randomly allocated to one of two possible conditions; (1) treatment as usual and (2) CAT enhanced care planning. The active arm entails providing consultancy to care coordinators to produce an SDR for the client and then developing exits for the client and the care coordinator in CAT-informed group supervision sessions. Prior to the consultancy process, the care coordinators received two days of training on CAT principles. The primary outcome measure for the project is the level of client engagement. The trial has now been completed and the service is currently receiving the feedback, which indicates the organisational effectiveness of the CAT consultancy approach. Results will be feedback to ACAT in due course.

Contact details:
Mark.Wilbram@barnsleypct.nhs.uk
Stephen.Kellett@barnsleypct.nhs.uk

Letters in cognitive analytic therapy: The patient's experience

A new research paper by Michelle Hamill, Mary Reid, & Shirley Reynolds is now online: http://www.acat.me.uk/article.php?article_id=653 You can view this if you are a current member of ACAT.

Abstract
Patient perspectives on how therapeutic letters contributed to their experience of cognitive analytic therapy (CAT) were investigated. Eight patients took part in semistructured interviews. A grounded, thematic analysis of their accounts suggested four general processes. First, letters offered a tangible, lasting framework for the assimilation of a new perspective about themselves and their relationships and facilitated coping with a complex range of emotions and risks this awareness required. Second, they demonstrated therapists' commitment to patients' growth. Third, they helped to teach participants about the therapy process as an example of an interpersonal exchange. Fourth, they helped participants consider how they wished to share personal information. These data offer a more complex understanding of this standard CAT intervention. Although some findings are consistent with CAT theory, the range of emotional dilemmas associated with letters has not received specific attention. Clinical implications are discussed.

Get in Touch...

If you are are involved in research, or planning to set up a project, that you would like to see displayed on this website please email details to either Susan Van Baars at admin@acat.me.uk or Jon Sloper on support@acat.me.uk.  Jason Hepple is Chair of the Research and Communications Committee and can also be contacted through our Who's Who page.

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