The Procedure Tracking Form (PTF): A Possible New Tool for CAT

Kingerlee, R., 2004. The Procedure Tracking Form (PTF): A Possible New Tool for CAT. Reformulation, Summer, pp.25-27.

Clinical experience of working both with cognitive analytic therapy (CAT) and cognitive therapy (CT) is instructive in many ways. The strengths and weaknesses of each approach – while often overplayed, as false dichotomies are set up by members of both camps - are well-known (Llewelyn & Cooper, 2004; Marzillier & Butler, 1995; Ryle & Kerr, 2002). It is clear, for example, that for various reasons, CT has grown to be among the most widely empirically-supported psychological interventions; equally, that CAT has ground to make up in that area – but has original insights of its own to offer, including, among other things, the notion of reciprocal roles, and selfreinforcing procedural sequences. Happily, though, both camps seem to agree on a predominantly psychological view of the development of psychological problems (Bentall, 2003); and there is no doubt that each can learn from the other (Llewelyn & Cooper, 2004). To take one example, CT-oriented clinicianresearchers are usefully examining CAT-related self-self relationships (Gilbert, Clarke, Hempel, Miles, & Irons, 2004). In the light of working with both CAT and CT, however, I have been struck by one issue in CAT that may be easily resolved - by further developing material originating in CT.

One noted aspect and strength of CT is the Dysfunctional Thoughts Record (DTR) (e.g. Hawton, Salkovskis, Kirk, & Clark, 1989; Greenberger & Padesky, 1995; Wells, 1997). A key aspect of CT involves the client’s completion of the DTR between sessions: specific issues are targeted; (behavioural) experiments carried out; and thoughts and feelings noted. The material generated is then (ideally) brought to the next CT session, where it is (ideally) collaboratively explored. Clinical experience suggests that use of the DTR can be very useful for both client and therapist, enabling key issues to be pinpointed and, eventually, worked through. Finally, the DTR also lends itself well to the much-touted ‘scientific’, ‘empirical’ nature of CT, in which client and therapist together set out to experiment with the client’s predictions about certain situations. It is not unreasonable, I think, to suggest that this ‘scientific’ aspect of the DTR has contributed to the overall growth and popularity of CT.

CAT, however, has no clinical tool strictly comparable to the DTR. It is true that clients may keep diaries of their activities, session-to-session, and that they may note general change regarding their Target Problem Procedures on Rating Sheets; but diaries may be unsystematically kept and/or used, while Rating Sheets arguably do not allow inclusion of sufficient circumstantial detail and, as anecdotal evidence suggests, are unused by some experienced CAT therapists. Since significantly different kinds of (say) self-critical procedural sequences demonstrably exist, though (cf. Gilbert et al., 2004), preciselytargeted recording of such subtle, internal psychological movements may provide valuable clinical data. Moreover, changes generated in-session may be operationalised by the CAT client between sessions – and so accurate recording of these specific processes may again be required.

I therefore offer a possible alternative to the Rating Sheets: the Procedure Tracking Form, or PTF (see Appendix). Like the DTR, it consists of a series of columns to be completed by the client, most likely after the Reformulation stage of CAT. The columns are broadly based on the following broad stages of a procedural sequence (Fig. 1 below), mindful of the fact that ‘[a]ffect, cognition, meaning and action [are] intimately linked […]’ (Ryle & Kerr, 2002: 9; cf. Potter, 2004).

Fig. 1. The stages of a procedural sequence in CAT as a basis for the Procedure

fig 1

The five columns are as follows:

Situation. How were you feeling? What might you have been aiming to do? Asks client to note salient aspects of the situation, including where, when, with whom – as well as feeling(s) and aim(s).
What did you think? Asks the client about their cognitive, conscious perception of the situation.
What did you do? What role(s) did you adopt? Asks the client about their enactment in the situation, encouraging to them refer to any reciprocal roles noted on their SDR.
How did you feel afterwards? Asks the client to evaluate their feelings after the event.
How does this differ from what you did before? Asks the client to process the procedural sequence and its consequences in retrospect, and reflect any possibilities for change that are raised.

The final column of the PTF also uses existing knowledge of levels-of-processing theory, and (2) mindfulness and self- reflection. Regarding (1) above, in the light of classic work in cognitive psychology by Craik and colleagues (e.g. Craik & Lockhart, 1972), it is broadly the case that material is more likely to be encoded in long-term memory – and so actually remembered - if data are subject to more deep or semantic processing (processing of meaning). Regarding (2) above, increasing clinical and research evidence suggests that processes of mindfulness and self-reflection can be beneficial with a range of psychological issues, including depression (Segal, Williams, & Teasdale, 2002) and anxiety states (e.g. Kingerlee, 2003). Taking (1) and (2) together, it might be hypothesised that encouraging clients to purposefully and systematically selfreflect on completed procedural sequences between sessions would positively impact their psychological state. It might be, then, that the final column of the PTF helps nurture this process of higher-level self-reflection - which of course forms one aim of CAT (Ryle & Kerr, 2002).

In sum, in a spirit of exploration, I offer the PTF to colleagues for discussion and experimentation. The PTF is intended as a possible tool to help define, focus and sharpen what transpires between CAT sessions more effectively and even, perhaps, positively affect what transpires during those sessions themselves.

References

Bentall, R.P. (2003). Madness explained: psychosis and human nature. Harmondsworth: Penguin.
Craik, F.I.M., & Tulving, E. (1975). Depth of processing: a framework for memory research. Journal of Verbal Learning and Verbal Behaviour 11, 671-684.
Gilbert, P., Clarke, M., Hempel, S., Miles, J.N.V., & Irons, C. (2004). Criticizing and reassuring oneself: An exploration of forms, styles, and reasons in female students. British Journal of Clinical Psychology 43 (1), 31-50.
Greenberger, D., & Padesky, C.A. (1995). Mind over mood: change the way you feel by changing the way you think. New York: Guilford.
Hawton, K., Salkovskis, P., Kirk, J., & Clark, D.M. (1989). Cognitive behaviour therapy for psychiatric problems: a practical guide. Oxford; Oxford University Press.
Kingerlee, R. (2003). Preparing for war: conflict in the cognitive therapy of obsessive-compulsive disorder. Clinical Psychology 23, 35-38.
Llewelyn, S., & Cooper, M. (2004). Internal and external voices in CAT: The case of cognitive approaches. ACAT Conference, London.
Marzillier, J., & Butler, G. (1995). CAT in relation to cognitive therapy. In: A. Ryle (ed). Cognitive analytic therapy: developments in theory and practice. Chichester: Wiley. 121-138.
Potter, S. (2004). Untying the knots: relational states of mind in cognitive analytic therapy. Reformulation 21, 14-22.
Ryle, A., & Kerr, I. (2002). Introducing cognitive analytic therapy: principles and practice. Chichester: Wiley.
Segal, Z. V., Williams, J.M.G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse. New York: Guilford.
Wells, A. (1997). Cognitive therapy of anxiety disorders. Chichester: Wiley.

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The Procedure Tracking Form (PTF): A Possible New Tool for CAT

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