The experience of using Cognitive Analytic Therapy  with clients with personality difficulties

Introduction
I qualified as a Clinical Psychologist in 1990 and work in the NHS in Secondary Care Adult Mental Health services. I subsequently trained in Cognitive Analytic Therapy (CAT). I offer a number of psychological approaches for people experiencing difficulties in managing their own feelings and with their relations with others, often receiving a diagnosis of “personality disorder”. This group of people have often had very difficult experiences early on in life, and can find themselves in stressful circumstances as a result of external stressors or longstanding coping mechanisms and frequently suffer from the chronic psychological effects of trauma.

Since using CAT with people with this range of difficulties, or those given such a diagnosis, I find that I have been able to help some people more effectively both during single individual sessions and at the end of the whole course of therapy.

My experience is that using CAT allows both patients and therapists to find the process of therapy less stressful. CAT’s framework helps me to pace the therapy, and to understand what could be going on within the patient and between us. This framework gives us a structure to work together; to talk about, and closely monitor what is going on. I like the way that CAT helps the person to discuss difficult personal and often highly painful issues in a way that helps make therapy as manageable as possible.

Building an alliance
In the early meetings with a new patient, the CAT framework helps to build a therapeutic alliance and rapport relatively quickly. I have tools at my disposal to help both myself and the person jointly understand the important issues both in their life and the therapy room. Being able to convey my understanding to the patient, perhaps through drawing up with the person a preliminary draft diagram or map of internal-personal processes or states of mind/moods people find themselves in, can help deepen that engagement really quickly. Spending time writing the draft Reformulation letter for the patient helps me to get “in tune” with the person and to try my best to imagine “walking in their shoes”. Reading the Reformulation letter out loud to the patient frequently deepens the engagement we have between us, as well as providing an opportunity for any misunderstandings to be rectified, in a sensitive way. I find it gratifying that the letter allows me a way, as a therapist, to show that I have heard and taken on board what the person has told me.

Being able to convey my understanding to the patient can help deepen that engagement

Before using CAT, patients would sometimes miss appointments and then it would be hard to pick up the momentum again. My experience is that CAT enables us to predict something of how (and the ways in which) particular people may find therapy difficult. It has also has helped me to have ways to communicate with the person I am working with so that together we can trouble-shoot these potential problems to help people to continue attending appointments. I have found that my rate of missed appointments (Did Not Attend) has reduced significantly.

CAT is a time-limited therapy and is very helpful in providing clear guidelines to patients about what to expect. It also provides a clear focus for therapy, determining with the patient the main ‘target’ problem/s which will provide the focus for therapy as well as the procedures that maintain them. This is particularly important in the NHS so that people can get the maximum benefit from available services – but equally so in private practice.

The importance of personal therapy and supervision
CAT also helps me to be sensitive to and understand when things go off-track in the therapy relationship and provides a way of seeing how to discuss and work on improving it. As CAT therapists, or indeed therapists using other approaches, we use ourselves to help others. CAT helps therapists look at what they bring to the therapy interaction to make sure that their intervention is in the service of the patient. CAT therapists all undergo personal therapy for themselves as part of their training, as well as receiving regular supervision. Having personal CAT therapy and regular supervision helps therapists to be aware of their own “blind spots” which is very much needed to be able to work with sensitivity, confidence and creativity, yet in an open, transparent manner. This is especially important given the inherent power difference between the two parties; for example, the patient having to fit in with the system within which the therapist works.

Having personal CAT therapy and regular supervision helps therapists to be aware of their own “blind spots”  and be able to work with sensitivity, confidence and creativity

Helping staff involved in working with the person
Working with people with personality issues/difficulties in ways of relating (both to themselves and to other people) has highlighted to me the importance of working relationally. It is my experience that offering training in this area to staff, helps them from unwillingly contributing to the maintenance of the problems (or sometimes even making them worse).   On occasions, with the patient’s permission, sharing the Reformulation diagram or letter with the other staff involved in providing a service to the patient has been invaluable. Not only can other staff access more their feelings of empathy for the patient but they can also recognise the pull on them to respond unhelpfully, to unwittingly take up unhelpful roles and respond in an unhelpful way. Unfortunately, we have to accept that despite being well intentioned, some staff and systems can be damaging, both to the staff as well as the patients. Patients who have had very troubled lives struggle with strong feelings and often can express these feelings strongly; some staff can take this personally and have strong responses. Using a CAT Reformulation diagram, and/or thinking about it in a CAT way, can help staff to take it less personally, to respond more helpfully, to suffer less burn-out and to obtain increased job satisfaction through seeing positive changes that people can make.

Finally

I enjoy the challenge of working creatively, matching what I have to offer to each person that comes through the door. Sometimes, some patients respond more to the diagram, others respond more to the letter; either way as therapists, we must tailor ourselves to help patients be able to take up, engage and benefit from, what CAT has to offer.

Taking time to think about unhelpful patterns, to be able to recognise and find ways of weakening (and possibly breaking out of) longstanding patterns is helpful. My experience is that the tools, technique and theory have provided an anchor for both patients and myself, preventing us both from getting overwhelmed in a turbulent sea of intense feelings consisting of actions and reactions.

Jurai Darongkamas, Consultant Clinical Psychologist, Assistant Director of the West Midlands CAT Practitioner Course, July 2011.

References
Beard, H., Marlowe, M. and Ryle, A. (1990) 'The Management and Treatment of Personality-Disordered Patients The Use of Sequential Diagrammatic Reformulation', British Journal of Medical Psychology 156 pp 541-545.

Dunn, M. and Parry, G. (1997) 'A Formulated Care Plan Approach to Caring for People with BPD in a Community Mental Health Service Setting', Clinical Psychology Forum 104 pp 19-22.

Kerr, I.B. (1999) 'Cognitive Analytic Therapy for Borderline Personality Disorder in the Context of a Community Mental Health Team: Individual and Organizational Psychodynamic Implications', British Journal of Psychotherapy 15 pp 425 - 438.

Ryle, A. (1997) Cognitive Analytic Therapy and Borderline Personality Disorder. Wiley.