BOOK REVIEW: Cognitive Analytic Therapy for people with intellectual disabilities and their carers

Lloyd, J,. and Clayton, P., 2014. BOOK REVIEW: Cognitive Analytic Therapy for people with intellectual disabilities and their carers. Reformulation, Summer, pp.10-11.


I was enthusiastic for this book’s emergence and was involved in the early stages of approaching publishers, but when asked to write a review for Reformulation I initially said ‘no’. This was based upon my lack of experience in working in this area. I believed I would not be able to offer as clear an appraisal as others more familiar with the work.

The latter is true objectively, but it was Julie Lloyd’s exasperation at my response that invited me in. In believingthat I would never have the special giftedness and patience that this work involves I had created a ‘special/distant’ in relation to unseen/distanced reciprocal role. Julie expressed frustration that therapists, like me, who were ‘mainstream’ CAT, had a tendency to exclude this work from critical or other attention. It is the experience of the Special Interest Group in Learning disabilities that working with what is now termed intellectual disability, is seen as separate by most ACAT members, even sometimes as the poor relation. In the Afterword to the book I read that this ‘disdain’ toward people with intellectual disability was referred to in a 1993 paper by Mike Bender called ‘The Unoffered Chair’. The authors write that they believe that twenty years on they have moved beyond this, and their book certainly illustrates how well they have done so through their careful use and adaptation of the CAT model, which offers both a chair and a voice.

My experience of reading this book has been to dissolve division and step into an unexpected richness where expressions labelled as ‘difference’ or ‘disability’ are witnessed compassionately, and looked at with shared curiosity and equality. The book brings CAT’s theoretical structure, where everything is in reciprocal relationship and in dialogue, vividly and dramatically to life, and allows felt and other experience to be expressed through many different forms. There is no division, no exclusion, no poor relation when we apply relational deep listening in our exchanges with another. And deep listening is the foundation for relationship.

The book succeeds in being moving as well as practical and engaging, and offers clear practical adaptations of CAT’s working structure with many case illustrations and descriptions of adaptations of the CAT tools. It also invites us to extend our awareness into understanding the often unhelpful limitations of using the label of intellectual disability on service users and carers; the internal dialogue of the service culture; and it also takes the complexities
of the reciprocal role repertoire of being cared for by a carer into wide social and politically constructed understandings, which returns us to Bakhtin.

The group of patients termed as having intellectual disability are more likely to have suffered abuse and neglect, mistreatment and misunderstanding. They are more likely to be operating with a restricted set of reciprocal roles, making clumsy shifts more frequent and eliciting more punitive responses from those around them. Silence, placation and compliance are often the responses in anticipation of judging/criticising/being told off. CAT’s understanding of how trauma, neglect and abuse contribute to the fragmentation of different self states that can operate in isolation makes sense of how ‘others’, particularly in the more powerful carer roles, can take control or override the wishes of the vulnerable, rather than listening and sharing collaboratively, and making sense of what is happening. The CAT model stresses that only when we are freed to ‘notice, stop and think about’ our procedures, whether they are traps, dilemmas, snags or whether we are state shifting, are we able to make decisions for ourselves based upon something stable.

The book begins by describing the journey of the LDCAT special interest group over the last fi fteen years and how they sought to fi nd creative ways to use CAT with their patient groups and, in particular, to involve whole care teams, fi nding ways of working in the available Zone of Proximal Development of each group. 

In Chapter 5 Steve Potter and Julie Lloyd describe four sources of intelligence - communal, societal, executive and emotional - which contribute to relational intelligence. In the next chapter Steve Potter’s ‘helper’s dance list’ offers colleagues and teams ways to refl ect together on their and others’ interactions. 

In Chapter 7 Julie Lloyd gives us her research examples of how people with intellectual disability can make use of visual patterns and mapping when in a side to side relationship, and can learn to recognise both ends of a reciprocal role. 

A very thoughtful chapter by David Wilberforce on ‘the problems with caring and being cared for’ challenges us all on our ‘roles’ as professional therapists, psychologists or carers in a world where identity is socially constructed and, in the words of Frantz Fanon’s The Wretched of the Earth, ‘mystery of language affords remarkable power.’ 

Part three of the book focuses on the use of CAT in different forensic settings, and this section forms one third of the entire book. Philip Clayton and Simon Crowther illustrate how CAT is well placed to complement working within a therapeutic community setting which has an established place in the treatment of offenders with Personality Disorder. The process of recognition and revision occurs within this community context, where often the process the SDR, whilst potentially exposing, can be validating, and can be helpful in fi nding appropriate exits. Nicola Murphy has chapters on working in secure services and in groups within the Brooklands offender relationship treatment programme.

All chapters illustrate how the sharing of the CAT mapping process is particularly helpful in forensic settings as different team members come to understand invitations to the ‘dance’ of reciprocal role. The detailed case studies in each of these chapters, in the chapters by Perry Morrison; by Michelle Anwyl and Pamela Mount in ‘behind the mask’, give the reader a powerful sense of the very personal and relational listening aspect of CAT. The generous inclusion in the book of reformulation and goodbye letters and diagrams/maps illustrate well the practice of CAT to name the states and roles that have led to offending behaviour, and also CAT’s conceptualisation of the offending behaviour as an exit from unbearable and unmanageable emotional pain. The discipline of the CAT structure supports the often challenging and painful relational therapeutic work in these settings.

In Chapter 12, Hilary Brown and Julie Lloyd take us through the 2005 Mental Health Act and decision-making, viewing decisions as traps, dilemmas and snags.

There are sixty pages of appendices and glossary of terms where the CAT structure has been adapted to this
patient group and so this book will have wide appeal to both CAT therapists and to non-CAT professionals. The appendices bring the side by side therapeutic work to life in a clear and relational way. 
The authors illustrate Tony Ryle’s emphasis that therapists must offer therapeutic work that is tailored to what the patient can use; that a diagram is of no use unless it is of use to the patient. His development of the theoretical structure of CAT combined with an emphasis on ‘push where it moves’ is beautifully emphasised throughout the text in this book, taking the reader through the steps of engagement with each patient and what they bring. 


I recommend all CAT therapists and other therapists to read this book.

Elizabeth Wilde McCormick

Psychotherapist and author.
Founder member of ACAT

Full Reference

Lloyd, J,. and Clayton, P., 2014. BOOK REVIEW: Cognitive Analytic Therapy for people with intellectual disabilities and their carers. Reformulation, Summer, pp.10-11.

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