CAT and Cognition. A Personal View and Conference Report

Denman, C., 2002. CAT and Cognition. A Personal View and Conference Report. Reformulation, Autumn, pp.23-25.

My aim in this article is to write a purely personal piece - a response to and a meditation on one morning of the CAT conference. Consequently the views in this paper have not been restrained by the requirements of academic balance or festooned with references to the literature. I shall judge my objectives to have been achieved if readers of the news letter go away thinking a good deal harder than they usually do about the advantages and disadvantages of cognitive behaviour therapies, and of those tools which CAT has (or once) borrowed from it.

This year's CAT conference timetabled a morning that it devoted to Cognitive therapy and its relation to CAT. In doing so it corrected quite a tendency for CAT to debate with and integrate psychodynamic approaches rather better than it debates with and integrates cognitive ones. This tendency is evident in Ryle's work. While it is certainly true that Tony cannot be described as a friend to Kleinian methods he has devoted plenty of time and intellectual energy to refuting them at a level of detail which attests to intense intellectual engagement. By and large cognitive approaches have not been dealt with in the same depth or with the same intellectual passion. Indeed Tony has criticised cognitive therapy (and this criticism has some force) for being "too boring" (personal communication).

The conference morning perhaps had the aim of restarting debate in this area and for me it certainly did spark off a number of new and important (well I think they're important) thoughts. Stirling Moorey who has for a long time been an exponent of CAT able to sit in the neglected hinterland between it and CBT presented us with a salutary reminder that CBT is not the therapy we thought it was. As time has passed its conceptions of the psychological processes which underlie psychological distress have grown more complex and more interactive. For some cognitive therapists the schema concept is an important tool. Schemas are underlying patterns of information processing based on early experience. They may be more or less impervious to later contradictory input. Elements of the notion of schemata permit close analogies to the notion of reciprocal roles even though their intellectual origins (in the psychology of information processing and memory or the psychology of social behaviour respectively) are very different.

Stirling wasn't only interested in showing us that CBT was rather like CAT; he also wanted CAT therapists to learn from CBT and in particular to reclaim some of their own CAT roots. He feels that one of the main advantages of CBT is its methodical symptom focussed approach. This aspect of CBT was incorporated into CAT practice early on in the form of TPP's and our old friends, snags, traps and dilemmas. These were higher order generalisations about classes of behaviours but they were still relatively focal and offered a clear prescription for change. As CAT practice, responding to changes in NHS patient populations, moved away from treating neurotic patients to those who suffer from personality difficulties the focus on TPP's relaxed in favour of reciprocal role analysis and the use of the SDR. The therapeutic aim was no longer to help the patient to mobilise higher functions to alter procedural sequences but instead to get them to mobilise higher functions in order to gain an integrated perspective on a fragmented sense of self. This approach is powerful and convincing but Stirling feels as I do that something has been lost. After all it is not simply that TPP based work is neglected for a more powerful tool (the SDR) instead it is argued that focal symptom based interventions promote fragmentation and hinder integration. However findings from CBT work on axis I conditions in patients with axis II disorders show that symptom focussed work can be done with profit in some patients even though the axis II condition may not improve. Maybe CAT therapists struggling with the challenge of personality disorder threw the cognitive baby out with the neurotic bathwater.

Professor Sue Clark was delegated within the conference to present a newcomer to the CBT block. Dialectical Behaviour Therapy tries to combine such disparate elements as behaviour therapy, Zen Buddhism and Hegelian philosophy (in its Jungian version) into an approach to treating self harming and borderline patients. It has been sharply criticised by Ryle but it has attained a considerable credibility on the basis of a number of randomised double blind placebo controlled trials. Professor Clark is running a further trial and one in which DBT and CAT will to an extent be measurable against each other. Her enthusiasm for DBT was evident in the talk she gave as was the hostility of some members of the audience to its approach. For me an important aspect of Sue's talk was that it served to remind me that there is not a single cognitive therapy but instead a family of cognitive therapies which, rather like dissociated aspects of the personality, have yet to declare themselves as truly separate personas, (a move which would convert the world of CBT from a state of mild dissociative identity disorder to full scale multiple personality disorder!).

To someone thinking this way Laura Sutton's history lesson on the development of cognitive psychology was immensely enlightening. Her argument essentially was that we had all started to discuss the C in CAT on the basis of a misunderstanding of the school of cognitive psychology that influenced Ryle. It was not the behaviourists or the cognitive theorists but rather the exponents of an ecologically based psychology such as Brunner and constructivists whom Ryle read with pleasure and whom he cites in papers. Ecological perspectives on psychology refer to the notion that studying phenomena such as perception or learning in isolation leads to misleading conclusions because the environment in interaction with the individual is a complex system with properties not present in laboratory situations. For Laura then, the cognitive in CAT bears little relation to the Cognitive in CBT. Later in discussion the question of post-modern ideas in CAT was raised. While ecological perspectives on psychology respect and work with high levels of interaction between agnts there is still an objective state of affairs to be discerned at each level. For postmodernists and possibly some dialogical theorists (Russians whose names are hard to spell) the idea of the real becomes first a negotiated matter and then an ever illusive illusion. But, from the floor, Tony indicated that this was a step too far.

From a clinical perspective Ryle's insistence on an ecological perspective means that all phenomena must be judged from within the social setting. Thus in therapy the relationship with the therapist sets the context for the observation and evaluation of some psychological mechanisms. Outside the social realities of everyday life and the relationships that people have within it are critical. Ryle's distrust of the Interacting Cognitive Subsystems Model developed by Barnard and Teasdale derives from its almost exclusive intrapsychic focus. Similar objections lie behind Ryle's rejection of Fonagy's theory of borderline personality disorder, which relies on the notion that babies develop a theory of mind (that is the realisation that others have minds and intentions) based on their observations of other's behaviour. For Ryle the error here lies in the neglect both of the intentions and actions of the others in the baby's world and also of the relationships that the baby has with those others.

However while Ryle is strongly ecological and interactionist he is not willing to become post-modern. For Ryle the difficulty with the post-modern approach is that the reality of reality is denied. All realities become simply temporary agreements in a sea of referential activity. Clinically a post modern theorist might view the patient's account of an interaction with a spouse as being "as real" as the spouse's view of the interaction. Probably Ryle and, certainly, I would take the view that there was a "real" account of events possibly apparent neither to patient nor spouse. This real account, while present, may or may not be recoverable in the clinical situation and, recoverable or not, it makes a difference whether the patient's husband (say) is an overweening bully and abuser in which case the therapeutic question is why the patient needs to stay in such a situation, or whether the patient is very narcissistic and finds any thwarting of her will unbearable and bullying, in which case the clinical problem is to help the patient own the difficulty and become sufficiently confident to lose some battles in life without this being intolerably personally threatening.

My own talk was informal. I wanted to compare different cognitive therapies (treating CAT as one of those) as they treated borderline personality disorder. I felt this exercise would be instructive since CAT is marketed as a treatment for borderline personality disorder as distinct from other therapies. I chose to compare CAT, DBT and schema focused CBT on a number of dimensions.

Every therapy must have a theory of the illness it treats. CAT's theory of borderline personality disorder is based on a deficit or trauma model in which key elements of the personality which deal with relationships (RR's) become fragmented, harsh and maladaptive. DBT by contrast fixes on an innate difficulty in emotional disregulation backed up by later experiences of invalidation. CBT does not settle for a single theory but focuses on deficits in cognitive, affective, behavioural and interpersonal areas. The theory of illness that each therapy has then drives the strategy for therapeutic change. For DBT the aim is to improve emotional regulation and promote acceptance ( a term borrowed from Zen Buddhism involving acknowledgement that some things cannot be changed). This is done by skills training, motivational improvement, skills generalisation and crucially by frequent consultation between therapists treating the patient in a multimodal multiperson package. CBT in keeping with its theoretical view opts for a multistrategy symptom focussed approach. CAT's first aim is to promote integration and its key method is accurate description of the whole of the personality in the form of the diagram. Later (but in practice rarely) other methodologies for behavioural change may be employed.

Each of the therapies has an attitude to the therapeutic relationship. The DBT approach is both behavioural and persuasive. The therapeutic relationship becomes important to the patient and so may be used as a contingency in behaviour modification. For example it may be withdrawn if the patient becomes symptomatic. Other aspects are persuasive, the therapist being a self-disclosing role model to the patient. The relationship between the CBT therapist and the patient is rational and respectful and the therapist at least strives to maintain this stance even when the patient's behaviour seems provocative. In CAT there is an intense focus on the relationship and on its inspection for the re-enactment of damaging reciprocal role relationships. In such situations the therapist aims to avoid colluding with the patient in the damaging role but instead to promote observation and description. All three therapeutic ways of dealing with the relationship have difficulties. The DBT therapist must be at some risk of becoming coercive towards the patient in ways that may not assist the patient's autonomy. The CBT approach may fail to engage in the complexity and emotional density of the patient's relationship with the patient and too easily accept an idealising positive transference. Clearly CAT has the best-developed theoretical and practical stance in relation to the therapeutic relationship but even here there are difficulties and there is a risk of coercion which derives from the injunction against collusion. If the therapist uses this in a one sided manner then they become the sole but not necessarily accurate arbiter of therapeutic truth.

In summing up the pro's and con's of each therapy I argued that DBT has as a major advantage the fact that it works. What of course I really meant was that DBT has proven better than placebo in initial trials. Later evidence may turn out to be more mixed. CBT approaches have as a major advantage a sensible workman like approach to the problem while CAT's focus on integration and its interpersonal and theoretical coherence go a long way to make up for a current lack of evidence base. Weighing in the balance against DBT are the fact that it can feel both bitty and confusing and the high expectancy effects brought about by its enthusiastic supporters may also evanesce with time and therapeutic experience. A major CAT based criticism of CBT is that its piecemeal approach may encourage fragmentation and also fail to tackle borderline personality disorder at anything other than a superficial level. Against CAT in this area must be the fact that evidence from CBT treatments of axis I conditions in borderlines show that it is wrong to insist that specific focal interventions on limited areas are detrimental to the task of integration and doomed to fail.

There would be little point in comparing CAT with other therapies and auditing their strengths and weaknesses if we could not as a result improve CAT by judicious adoption of techniques and ideas from the other approaches. At present I am designing an intensive outpatient service for borderline patients in Cambridge. In doing so I have drawn on elements of all these therapies and also on other aspects of the evidence base. CAT will be the basis of treatment. Such evidence as has emerged points to the value of a strong focus and theoretical basis for treatments that work. CAT seems ideal for this. Like DBT our patients will receive individual and group treatment and their treatment will be coordinated by a case manager who will meet with the treaters on a regular basis. Curiously in a hybrid of CAT and DBT the content of our group treatments will be on a skills base for CAT. We will focus on the particular problem which emerges among group members at the time and the therapists will use and share both an undestanding of TPP's and Reciprocal roles and repeated examples of their operation in the group and in the lives of patients. Patients will also be encouraged to try out different ways of interacting in the group and outside it which challenge their accepted RR's or TPP's.

Sadly at present there will not be any CBT input to the group but there will be OT input and a social skills group will be offered to patients. In this the focus will be on practical living tasks as diverse as managing loneliness, money and leisure/work. Since emotional regulation is a core skill when producing good art and particularly in music, I hope to be able to offer patients an arts therapy group somewhat different from that which is appropriate to patients whose emotional expression is cramped or restricted. In this group the capacity to regulate strong feeling is often absent. Playing music and concentrating on getting the sound right so that it does express strong but also subtle feeling will, I hope teach patients about emotional regulation and containment at a level which is different from the verbal modes that they will be experiencing most of the time.

I have called our venture CAT based even though there are transmuted elements in it from many different kinds of therapies, cognitive and non cognitive. Possibly other therapists would find it difficult to give any clear label to the melange. Ultimately of course the only thing that matters is whether it works. I hope so; in a few years we will know.

Chess Denman

Full Reference

Denman, C., 2002. CAT and Cognition. A Personal View and Conference Report. Reformulation, Autumn, pp.23-25.

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