CAT and its Relationships to Non-CAT - Preliminary Thoughts About Annalee's Diagram

Nehmad, A., 1993. CAT and its Relationships to Non-CAT - Preliminary Thoughts About Annalee's Diagram. Reformulation, ACAT News Winter, p.x.

The diagram below is a copy of an overhead produced by Annalee for the CAT Introductory weekend. My only addition to it was to call the columns A, B, and C.

The overhead was intended for absolute beginners, but I think it is a useful tool for organising our thinking around the teaching and supervision of CAT. Before I saw Annalee's diagram I had a much vaguer idea about this subject, and tended to think only of "CAT" and “non-CAT’ (two columns rather than three, as it were). I feel this diagram can be used for several purposes, e.g.:

a) as a basis for discussion about what we are aiming to teach our trainees and what we expect them to have grasped at each stage of their training;

b) to help us and our trainees understand the general (i.e. non-CAT-specific) therapeutic factors. It also helps to answer the question, “If my cases have been failed by the supervisor and/or Training Committee, how come my patients get better?

c) as a “mental crib” for the aspects we should or could be covering in Supervision, at different stages.

d) as an aid to discussion and debate about what is, and what isn’t, a CAT therapy as opposed to a more non-specific therapy with bits of CAT added on.

e) as an aid to discussion and debate about what the Advanced Course could or should be covering. (Most of us have no idea about what is covered and how, especially in relation to the C column. Perhaps this is best left to the Training Committee’s idiosyncrasies. Problems might arise, however, if there were a major change of personnel from one year to the next. Also, the components of C may well be very different in London and in the provinces (and of course outside Britain!). Does this matter?

I feel that the diagram will help discussion on these topics o be clearer and therefore more fruitful. At this stage I will offer only a few preliminary thoughts of my own - hopefully the rest of you can improve on this or constructively disagree with it. I apologise if some of what I am saying here seems terribly obvious and hardly worth saying.

Column B is CAT-specific. Our introductory weekend is aimed at people who have no knowledge or experience of B; their knowledge and experience of A and C is very variable. As trainees embark on their first eight cases, we expect them to become competent at B. If they do not achieve this competence, they will not be accredited. We also expect them to achieve a certain level of understanding of A (the “ordinary psychodynamic” column).

How much we expect from column C has never really been discussed (except perhaps by the Training Committee, but the rest of us haven’t heard); my impression is that it doesn’t seem to matter much. It is certainly the least important column; adequate CAT can take place without it, though it is far enriched by using some of its elements.

Where does Counter-transference fit in? I would suggest it is part of A, but also in some ways part of C (sometimes it’s the only means of “keeping it moving”.)

Empathy, listening skills, respect and regard for the patient belong mostly in A (therapeutic relationship), yet without these one is unlikely to achieve probably the most important element in C: use of patient’s own language, images, metaphors (as opposed to those of the therapist or supervisor. One trainee even told me they looked for appropriate phrases for their patient’s reformulation in Tony’s blue book but couldn’t find any!).

The Introductory Thursday evening course at Guy’s seems to me to have the wrong sort of emphasis. It concentrates on B, plus the theory of A, when in fact many of the participants (in the past at any rate) seemed to be lacking any experience of A - even simple skills like empathic listening had never been imparted to them (because they did not have a “caring profession” background). Some of them are naturally good at it, of course. But I feel a greater part of this year-long course should be spent on this, and rather less on B, since in any case I understand that most of them under current rules wont even have CAT patients until after they complete the Introductory Course, and they will get plenty of B during the Basic Course.

What is the Advanced Training supposed to be about? Obviously getting even more competent at B, with more difficult patients, and new situations (e.g. couple therapy). Also a reasonably sound grasp of theory relevant to CAT. (This doesn’t appear in Annalee’s diagram because by and large it doesn’t affect the therapy directly, and is not necessary as such for adequate CAT.

How much of column C are we aiming to teach Advanced Trainees (in terms of broadening their “toolbox” of different techniques? To what degree are some of the latter counter to CAT, rather than complementary to it?

If a therapy were to be audited by listening to tapes, what minimum proportion of session-time needs to be spent on B for it to count as a CAT therapy? (I know that this is pretty controversial stuff - our Letters Page would welcome your opinions).

To what degree should Supervisors who are competent in, or partial to, different C elements use the supervision to impart these? (This can be enriching, but also confusing, in terms of What is CAT? However, armed with Annalee’s diagram, supervisors and trainees will be better able to share useful elements of C while understanding that it is not part of CAT as such.)

For trainees who are well versed in A before they start CAT training, our job is not simply to teach them B, but also to understand A in terms of B (and to a large extent to transmit it to the patient in terms of B). Completely “raw” trainees need to learn not only about A and B, but also about how they relate to each other.

In Annalee’s diagram all the arrows point from A and C towards B. In reality of course we use information from B to understand and deal with A (as well as to guide our use of C). So the diagram could include (paler?) arrows going in opposite directions.

These preliminary thoughts will suffice, I hope, to start a discussion.

Annie Nehmad

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Full Reference

Nehmad, A., 1993. CAT and its Relationships to Non-CAT - Preliminary Thoughts About Annalee's Diagram. Reformulation, ACAT News Winter, p.x.

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