Cognitive Analytic Therapy with Adolescents

Before starting an individual CAT therapy with an adolescent, it is important to remember that a young person is always surrounded by some system of care, usually their family. Initial assessment should always include this system as the young person may be showing difficulties because they are reacting to problems in this system. For example, there may be marital relationship problems, parental illness or parental substance misuse, and it might be better to target these problems rather than offer individual therapy to the young person. At the same time, a CAT therapy for the young person may help them to develop resilience to these problems, when they cannot be resolved.

It is important to offer both the young person, and their main carer, an explanation of the CAT model and information about how the therapy may progress. It is also important for the therapist to think about how the carer may be included in reviews of how things are going, and given information about things that they may be able to do to help. Confidentiality should be discussed and the young person reassured that it will be up to them how much of the work they want to share.

One model of CAT therapy with an adolescent might be a joint initial assessment and explanation of the therapy with both the young person and their carer, followed by eight individual sessions and then a joint review. Following this, a further eight individual sessions and then a joint review as follow up. In some circumstances, it may be appropriate to offer therapy using a CAT model to a young person and their carer together, where the relationship between the two seems to be the most pressing problem. Another model might be to offer family therapy and, at the same time, individual CAT therapy to the young person. Where the family is also having family therapy, it may be appropriate for the young person to share either their reformulation letter, or their diagram, within the family therapy at some stage.

Anyone offering CAT to adolescents should have experience of working with this age group, or be supervised by someone with such experience.

Assessment for CAT

Factors which would make one feel that an adolescent might make good use of CAT would be:

  • The ability to self-reflect and an awareness by the young person that some of the way they behave is unhelpful.
  • An acknowledgement, by the young person, that early experiences and relationships have had an impact on them and the way they feel.
  • A wish to talk about early life experiences in therapy.
  • Being able to form a good collaborative relationship.

Is CAT helpful for Adolescents?

We are starting to see evidence that CAT therapy is acceptable and helpful for adolescents. An audit carried out in a UK Child and Adolescent Mental Health service found that the tools of CAT, the Reformulation Letter and the Diagram, were helpful to adolescents. The average rating out of 10 for how helpful the therapy had been was 8 (Jenaway and Mortlock 2008). Young people often find it hard to stick with a course of therapy and drop out rates for CAT are similar to those for other types of therapy at around 40% (Jenaway and Mortlock, 2008; Wierzbicki and Pekarik, 1993).

A research group in Australia have compared CAT with intensive outreach standard care for young people with early signs of personality disorder (Chanen et al. 2006). They found that CAT was as helpful as the standard care and seemed to work more quickly. Denis Ougrin in the UK has developed a form of therapeutic assessment for young people who have self-harmed. The assessment is based on a CAT model and the development of a diagram for the young person, then thinking about alternatives to self harm. They found that the young people who had the CAT style assessment were significantly more likely to engage in the follow up treatment which was offered than those who had a standard assessment (Ougrin et al, 2008).

Chanen, A. et al (2006). A randomised controlled trial of psychotherapy for early intervention for borderline personality disorder. Acta Neuropsychiatrica, 18 (6) 319.

Jenaway, A. and Mortlock, M. (2008). Service Innovation, offering CAT in a Child and Adolescent Mental Health Service. Reformulation, issue 30, 31-32

Ougrin, D., Ng and Low, J. (2008). Therapeutic assessment based on cognitive analytic therapy for young people presenting with self harm. Psychiatric Bulletin, 32, 423-426

Wierzbicki, M. and Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24, 190-195

Alison Jenaway


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