Ford, T.J., Roberts, J. and Pound, A., 1997. Outcome of Cognitive Analytic Therapy. Reformulation, ACAT News Summer, p.x.
Ford, T.J., Roberts, J. and Pound, A.
Department of Psychotherapy, The Royal London Hospital - St Clements, Bow Road, London E3.
Research into the outcome of Cognitive Analytic Therapy (CAT) has shown that it is as effective as other brief therapies. Some studies illustrate greater internal change as measured by repertory grids in CAT patients whilst others suggest larger subjective gains (Brockman et al 1987,Treasure et al 1995, Clarke and Uewelyn 1994 and Pollock and Kear-Coiweil 1994). These gains are maintained at follow up and there is evidence that positive change can continue after active therapy has ended (Ryle 1995). CAT has been offered at The Royal London, St Clements Hospital since 1990. The therapists have a variety of backgrounds, including psychology, psychiatry, nursing and social work. An accredited CAT psychotherapist offers group supervision. We decided to review the outcome of ail the cases who had completed CAT to date.
One of the authors (TF) reviewed the casenotes. Demographic data, diagnosis and past psychiatric history were obtained from the referral letter and the psychotherapy assessment. Outcome was measured by attendance, the therapist's and client's opinions expressed in the "Goodbye letters" and the therapist's correspondence at termination.
Forty out of forty four sets of notes were traced. Given that therapists
worked from different sites and departments the loss of some notes, though regrettable, is not unexpected. There is no evidence that these cases differed significantly from those for which files were found. The age of clients ranged from 20 to 58 years, with a mean of 34. There were 16 men and 24 women. Most patients were either single or separated, while 14 were married. Thirty five percent were unemployed.
Seventy two per cent had at least one prior contact with psychiatric services. Fifty per cent had previously received psychotherapy, with a further twenty per cent having seen a counsellor. Forty five per cent had been prescribed psychotropic medication, and twenty three per cent had a history of deliberate self harm. Most (67.5%) were diagnosed as having mood disorders, especially_. mixed anxiety and depression, 13 (32.5%) were diagnosed as suffering from a personality disorder.
This study did not have the benefit of standardised diagnostic criteria or objective outcome measures. However attendance for, and disposal after, therapy are real events from which some conclusions can be drawn. It is possible to comment on outcome and case mix, but these impressions should be accepted only as interesting observations. The notes were mostly complete and, as there was often more than one source of each piece of data, no information was missing.
The impression obtained was of a population with chronic anxiety, depression and interpersonal problems. Most had tried several kinds of treatment, often over several years, without relief. The fact that thirty per cent required no further therapy at follow up suggests that for these people CAT was a turning point. In terms of the allocation of scarce resources, this would support the use of CAT as a first line therapy.
Approximately thirty per cent dropped out after 1 or 2 sessions. A correspondingly high early drop out rate was reported in the Guys and St Thomas' audit (Ryle 1995). CAT demands the client's active participation in change and these early dropouts may. represent those who are less motivated. Both this study and the Guys and St Thomas' audit (Ryle 1995) were unable to predict those who would drop out.
Once engaged, premature termination was uncommon, though fifteen percent failed to attend at follow up. This did not seem to be linked to outcome. Over sixty per cent completed their sessions and it would be interesting to compare this with the numbers engaging successfully in other brief therapies.
No patient was felt to be worse off and only ten per cent seemed not to benefit, in the opinions of both therapist and client. The Guys and St Thomas' audit (Ryle 1995) suggested that negative and ambivalent feelings were often avoided in the "Goodbye letters" with obvious implications for the validity of these results. However, these were checked against the therapists correspondence at termination, wherever possible, which might be expected to be less conciliatory. The results suggest that the therapists views on outcome coincided with those of their clients in most cases, even if acknowledged problems remained.
Two patients became angry at termination feeling that CAT amounted only to an assessment. Both were middle aged, with a diagnosis of a personality disorder, and both had been offered many previous interventions with little success. Such cases illustrate the need for standardised diagnostic criteria and objective outcome measures. As CAT gains a reputation for the treatment of Borderline Personality Disorder, more such severe and entrenched cases are likely to be referred. Such clients might be expected to make modest changes, and without objective measures of severity and outcome, both referrers and therapists may become discouraged.
All eight patients referred on to further psychotherapy were . felt to have benefited from CAT. Two went on to individual therapy, four went into groups and two were seen with their families. Although CAT did not prove to be the definitive treatment in these cases, its positive effects may have facilitated the further therapy. Given the long past psychiatric histories illustrated by this. group, the evidence that only twenty per cent were referred for further psychotherapy, and that seventy per cent were discharged from psychiatric services, suggests that CAT is highly effective.
Although not rigorous by design, this case note review indicates that sixty per cent of those offered CAT were able to engage, of whom ninety per cent were felt to benefit. This suggests that CAT is a powerful first line psychotherapy. Further research should employ standardised diagnostic criteria to try to identify those most likely to benefit, as well as objective measures of change.
Brockman B, Poynton A, Ryle A and Watson JP. (1987) Effectiveness of time limited therapy carried out by trainees; comparison of two methods. BRITISH JOURNAL OF PSYCHIATRY 151, 602-609
Clarke S and Liewelyn S. (1994). Personal Constructs of survivors of childhood sexual abuse receiving Cognitive Analytic Therapy. BRITISH JOURNAL OF MEDICAL PSYCHOLOGY 67, 273-289.
Ryle A. (1995). Cognitive Analytic Therapy: Developments in Theory and Practice. John Wiley and Sons, Chitchester.
Treasure J,, Todd G, Brolly M, Tiller J, Nehmed A and Denman F. (1995). A pilot study of a randomised trial of Cognitive Analytic Therapy versus educational behaviour therapy for adult Anorexia Nervosa. BEHAVIOUR RESEARCH AND TREATMENT 33(4), 363-367.
Dr Ford is now based at the Child Guidance Clinic, Water Lane, Brixton, SW2.
T J FORD, J ROBERTS, A POUND
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