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Measurements of change and their relationship to each other in the course of a CAT therapy

Gallagher, G., Inge, T., McNeill, R., Pretorius, W., Oâ€™ Rourke, D. and Wrench, M., 2009. Measurements of change and their relationship to each other in the course of a CAT therapy. Reformulation, Winter, pp.27-28.

Introduction

The development of a good therapeutic alliance or therapeutic relationship is deemed “an obvious primary component of effective psychotherapy” (Beck, Shaw, Rush & Emery, 1979) and is central to working collaboratively and dialogically in CAT. Several studies have confirmed a positive association between the therapeutic alliance and outcome and have also shown that the ratings by the patient provide a more accurate prediction of outcome than ratings by the therapist (Horvath and Symonds). In CAT there are three clear stages during which there can be marked variations in the relationship from session to session. It is possible for the therapist to collude or enact a reciprocal role in response to the patient’s role. Learning to recognise ruptures and developing competence in resolving alliance threats and ruptures are essential to prevent premature dropping out of therapy, provide opportunities for experiential learning and therapeutic change. (Bennett, Parry & Ryle 2006).

We were interested in investigating whether there were typical changes in ratings over the course of a CAT therapy with particular reference to the impact of reformulation and termination on scores. We wanted to evaluate the relationship between the patient’s therapy experience and their scores on the CORE at each session and evaluate whether it was possible to predict threats to the therapeutic alliance and subsequent dropout from changes in scores on the various scales.

Methodology

Patients were asked to complete the Clinical Outcomes in Routine Evaluation (CORE 34), the Personality Structure Questionnaire (PSQ) and the Therapy Experience Questionnaire (TEQ) at each session. Each member of the research group is administering these questionnaires to their patients. We plan to publish the results when we have collected data from 20 patients.

For this article we have extracted the dataset for a patient who presented for therapy with a diagnosis of Borderline Personality Disorder and a PSQ of 28. The patient was offered 24 sessions of CAT with 3 follow-ups. The patient attended for all sessions and completed the CORE and TEQ at each session and completed the PSQ at the start and end on therapy and at follow up.

Results

We have plotted the results of the 24 session therapy on a graph to illustrate the variation in scores across the 24 session therapy. The session number is located on the x axis and the scores for the questionnaire are represented on the y axis. The total CORE score shows the greatest variation and is at the upper part of the graph.

Reformulation took place at session 4 when the draft reformulation letter was read out by the therapist. Diary keeping was diligently conducted with collaborative working on target problems over several sessions. Increasing recognition of the target problems and the enactment of reciprocal roles led to a greater self awareness of the difficulties and this is reflected in the scoring of the CORE. Over the course of sessions 5 to 8 she started connecting with her sadness and anger and spoke about experiencing anger towards her therapist and expressed fear that it would result in self destructive behaviour. Working together and naming her emotions and exploring “where did the emotions go if it did not lead to the path of destruction” provided containment and understanding. This led to a period of perceived progress and change with perception of ideal care and solving recurring problematic behaviour. The patient phoned after the session to change the session time.

At session 13 the therapist was late and the patient became self critical for changing the time. The impact of self to other and on the relationship was explored. At session 14 the patient disclosed the absence of diary keeping and feeling criticised by the therapist at session 13. This was acknowledged and explored during the session as well as the procedures involved on the map and exits were explored. The patient then became physically unwell and expected perfect care and became angry and distressed with good enough care. Diary keeping was suspended at session 16 and the session was spent exploring emotions, the relationship in the room and the enactment of the critical controlling reciprocal roles. This was explored and looked at in the diagram. During sessions 17 and 18 she felt confused, disconnected and unable to recall the content of the sessions. She received the audiotape of the sessions and reconnected with the work at session 19. Session time changed at therapist’s request before session 20 and this and the ending of therapy was explored. Gains acknowledged during session 21 and preparation for ending became the focus of the last few sessions. Both therapist and patient read out their goodbye letters at session 24.

The graph of her CORE ratings seem to confirm the impression of reduced general functioning over sessions 17 and 18. It is tempting to see the gradual improvement from session 10 to 14 as evidence of therapy starting to take effect, and further challenges (and possible rupture issues) in her progress in the middle phase of therapy as a transient worsening of distress, with perhaps another period of emotional adjustment of less severity towards the end, with a final improvement in the last few sessions. There is a suggestion that the Therapy Experience Questionnaire mirrors the CORE, so that in sessions where there is improvement in the CORE there is a deterioration in the TEQ. As expected the TEQ gradually improves with time. The changes in the TEQ are at first sight quite minimal which suggests a possible ceiling effect with this instrument for this client.

Conclusion

It would be helpful to have scores from several therapies and therapists to see the similarities and compare the differences across sessions and therapists. The impression from this case is that change is not gradual and predictable but a more complex affair with periods of calm and periods of heightened emotions, and the therapy relationship changing in unpredictable ways. The measurements in this case support the clinical view of improvement, but also highlight the danger in seeing a straightforward relationship between improvement and improved psychometric ratings. Our hope is to find patterns of change during therapy that could be measured and to inform future outcome research in terms of methodology.

Charts

References

Beck, A., Rush, A., Shaw, B., & Emery, G (1979) The therapeutic relationship: Application to cognitive therapy. In A. Beck, A. Rush, B. Shaw, & G Emery, Cognitive therapy of depression. New York: Guilford Press. Page 220.
Bennett, D., Parry, G., & Ryle, A. (2006) Resolving threats to the therapeutic alliance in cognitive analytic therapy of borderline personality disorder: A task analysis. Psychology and Psychotherapy: Theory, Research and Practice, 79, 395-418.
Horvath, A. O., & Symonds, B.D (1991) Relation between working alliance and outcome in psychotherapy: a meta-analysis. Journal of Consulting and Clinical Psychology, 38, 139-149

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Generating Practice-Based Evidence for CAT
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