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CAT Effectiveness: A Summary

Quraishi, M., 2009. CAT Effectiveness: A Summary. Reformulation, Summer, pp.36-38.

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Over the last few years a number of research projects have been carried out in CAT, which have provided increasing evidence for the efficacy of this form of therapy. However, to date there has been no one source that cites these studies. The current article is an attempt to address this issue and provide readers with a short summary of the types of papers that have formed part of this evidence base.

Full text versions of these papers are available to all ACAT members via the website. There is also an additional page citing current (i.e. unpublished) studies which may be of interest to members. Comments and/or amendments to the article are very welcome. Please contact mansur-q@hotmail.com

Cognitive Analytic therapy (CAT) is a brief focal therapy informed by cognitive therapy, psychodynamic psychotherapy and certain developments in cognitive psychology. It has a well-developed self-contained methodology backed by a fully structured theory of mental functioning and therapeutic change. It has been cited within the National Institute for Health and Clinical Excellence (NICE) guidelines as one of a number of treatments that could be used for people with eating disorders as well as those with borderline personality disorder (BPD).

Randomised Controlled Trials

Treasure et. al. (1995) compared two forms of outpatient treatment, educational behavioural treatment and CAT for adult anorexia nervosa. Thirty patients were randomly allocated to the two treatments, educational behaviour therapy and CAT. Therapy was administered by untrained and only partially supervised therapists. It was found that patients receiving CAT reported significantly greater subjective improvement (Mann Whitney U test U=41, W=119, 2 tail P=0.045 ≈ ≈-2.2). However, there were no differences in other outcome parameters. The authors conclude that outpatient treatment of adult onset anorexia nervosa leads to an improvement in two thirds of cases, but felt that larger studies would be needed to determine the most effective form of treatment in this group.

Dare et. al. (2001) compared four treatments, focal psychoanalytic psychotherapy, CAT, family therapy and ‘routine’ treatment for patients with anorexia nervosa. Results showed that at 1 year, there was symptomatic, if modest, improvement in the whole group of patients. About a third of the patients in the three specialist psychotherapies no longer met diagnostic DSM criteria for anorexia nervosa, whereas only 5% of those in the ‘routine’ treatment group escaped from this diagnostic criterion (P=0.01). Psychoanalytic psychotherapy (P=0.03) and family therapy (P=0.02) were significantly superior to the control treatment, whilst CAT (administered by untrained and only partially supervised therapists) did not reach the criterion for statistical significance (P=0.07). However, it was the shortest intervention 7 months compared to one year for all the other interventions.

Chanen et. al. (2008) compared the effectiveness of up to 24 sessions of CAT or manualised good clinical care (GCC) in addition to a comprehensive service model of care with 78 adolescents with emerging Borderline Personality Disorder (BPD). They found that CAT is an effective early intervention for BPD and is superior to both manual-based ‘good clinical care’ and treatment as usual. Their results also showed that CAT and GCC are effective in reducing externalising psychopathology in teenagers with sub-syndromal or full-syndrome borderline personality disorder. It was felt that larger studies would be required to determine the specific value of CAT in this population.

Fosbury et. al. (1997) compared CAT to diabetes specialist nurse education (DSNE) in a controlled trial of 26 chronically poorly controlled adult, type 1 diabetes patients. Results of the comparison suggested that, though there was no statistical difference between outcomes in the two types of therapy at the end of treatment, the effects of CAT produced a more prolonged effect with regard to diabetes management. This was evident in a significantly greater (P = 0 .002) reduction of blood sugar levels at 9 months, a significantly (P <0.05) increased knowledge about diabetes and an improvement (P = 0 .03) on the Inventory of Interpersonal Problems (IIP) a self-report measure related to the understanding of understanding psychological problems.

Comparative Studies

Brockmann et. al. (1987) found that CAT is a therapeutic method that provides a suitable framework for trainee therapists to offer clients effective time limited therapy. They compared CAT conducted by trainees with Mann’s brief psychotherapy (Mann & Goldman, 1982). Results, based on a statistically significant difference (t=4 .3, P<0 .02) in mean sum scores of outcome measures reflects similar effectiveness in symptom reduction and a greater effect of the CAT approach in modifying specific cognitive features.

Marriott & Kellett (2009) conducted an evaluation of outcome measures for clients receiving CAT and comparing these to similar measures for clients given person centred or cognitive behaviour therapy within the same catchment area. Results indicated that there were broad similarities between the services with comparable, clinically significant improvement across the services.

Bell (1996) compared CAT, Inter Personal Therapy (IPT) and the mode of therapy used at St George’s Hospital for people with eating disorders. She found that CAT was the most theoretically developed and well researched. She also felt that aspects of CAT, such as an understanding of reciprocal roles and the sequential diagrammatic reformulation, were particularly helpful for patients with anorexia or bulimia nervosa.

Evaluations of the Effectiveness of CAT

Ryle & Golynkina (2000) studied the effectiveness of CAT with 27 patients with BPD at an assessment 6 months after therapy. They observed a low drop-out rate and found that over half the patients did not meet the criteria for BPD, even though CAT is a much shorter therapy than usually recommended for patients with BPD. They findings suggest that CAT could contribute to any service treating personality-disordered patients.

Dunn et. al. (1997) conducted an audit of 21 CAT patients in Guy’s Hospital London and found that there was an improved adherence to treatment and satisfactory outcomes in most cases compared to a previous audit of 28 patients conducted in 1993 by Denman. The outcomes were measured using Social Questionnaire (SQ ; Corney et at, 1982), Beck Depression Inventory (BDI ; Beck et at, 1961 ; Beck & Steer, 1987), the Symptom Check List (SCL-90-R; Derogatis, 1977) and the Inventory of Interpersonal Problems
(IIP ; Horowitz et at, 1988). Significant reductions (P < 0.001) were observed on all the measures barring the SQ (P = 0.096). The observed attrition between referral and assessment
was put down to the average 6 month delay between
referral and start of therapy.

Single and Multiple Case Studies

Ryle et.al. (1992) describes 2 case studies providing evidence for the effectiveness of time limited (16 sessions) CAT with patients who had had extensive previous treatment.

In a single case study Graham & Thavasotby (1995) concluded that CAT was effective in the resolution of symptoms for a patient with dissociative psychosis.

Pollock & Belshaw (1998) highlighted the usefulness of CAT for offenders, based on two case studies. They found that CAT language and concepts helped provide an understanding of the offender’s relationship to the victim, helped with the comprehension of the offender’s motivations for committing the offence and helped focus and direct clinical input and behavioural management in such cases. They did highlight the lack of evaluation of CAT with offenders and the fact that CAT requires a certain level of verbal reasoning and sequential logical resources often not available to brain injured, psychotic or intellectually impaired patients.

Yeates et. al. (2008) present two case studies, including an outcome evaluation, of clients with dysexecutive deficits following brain injury. Differing aspects of CAT were used the clients, which included a formulation linking early and current relationships in one case and the more here and now aspects of the therapeutic relationship in the other. The authors concluded that CAT may be a helpful therapeutic framework for further cases.

Ryle & Beard (1993) present the impact of 26 sessions of CAT with a patient with BPD mainly through the account presented by the patient at a follow-up. The case presented is of a particularly effective therapy in an intelligent and committed but seriously disturbed patient. The authors discuss the importance of the written reformulation and verbal and diagrammatic representations of procedures in CAT. They acknowledge the fact that differences between theory and practice of different schools of psychotherapy can be illustrated, but nor resolved, by comparing case studies.

Cowmeadow (1994), using two cases studies, shows that there are four features of CAT, which are effective in the treatment of deliberate self-harmers. These are flexibility, type of focus, rapid engagement and the use of problem-solving techniques. She did however, note that the time limited aspect of CAT may be a limitation with this patient group, due to their increased sensitivity to the experience of separation and loss.

Kerr (1999) published a case study of a young man with a primary diagnosis of BPD who was offered CAT. The therapy was only partially successful, due in part, to the severity of the disorder but also to a lack of a shared understanding of the therapeutic model by team members. However, CAT created a reasonably robust therapeutic alliance, with the patient showing more regular contact with the therapist and no readmissions during the course of therapy.

Kellett (2005) presents a single case study of 24 sessions of CAT with a patient with dissociative identity disorder (DID). The paper presents the long-term effectiveness of the therapy illustrated by both long-term stability and continued improvement over a six month follow-up period.

Kellett (2007) conducted a single case time series evaluation of a patient with histrionic personality disorder receiving CAT. The patient showed significant clinical improvement between assessment and follow-up, which lasted till follow-up. Kellett reports on the efficacy of CAT with this particular disorder whilst highlighting the limitations of a single case methodology and the reliance on self-reporting.

Other Studies and Reviews

In her description of CAT, Llewelyn (2003) highlights the lack of a clear evidence base for CAT, citing that most examples of effectiveness are based on small case studies or uncontrolled trials. However, she does highlight the significant clinical contributions that CAT has made both to both patients and therapist and hopes for more research in the field.

Bell (1999) analysed the assessments and formulations of 30 patients with eating disorders who were treated with CAT. She found that CAT may have a more wide ranging application for some eating disordered patients than more focussed therapies.

Beard et. al. (1990) found that the methodology of CAT to be important in the management of personality disordered patients and can assist in increasing their self-understanding and control.

Duignan & Mitzman (1994) found that a CAT approach was effective in group therapy for patients with personality disorder, despite or rather due to the short-term nature of the therapy, which seemed result in an early development of a high level of commitment and activity.

Dunn & Parry (1997) formulated a care plan approach for treating people with BPD in a community mental health team setting. They found that cognitive analytic formulation and CAT seemed more relevant for the client group in comparison to a formal exploratory therapy.

References;

Beard, H., Marlowe, M. & Ryle A., (1990) The Management and Treatment of Personality-Disordered Patients The Use of Sequential Diagrammatic Reformulation. British Journal of Medical Psychology 156 pp 541-545.
Bell, L. (1996) Cognitive Analytic Therapy: its value in the treatment of people with eating disorders. Clinical Psychology Forum 92 pp 5-10.
Bell, L. (1999) The Spectrum of Psychological Problems in: People with Eating Disorders, an Analysis of 30 Eating Disordered Patients Treated with Cognitive Analytic Therapy. Clinical Psychology and Psychotherapy 6 pp 29-38.
Brockman, B., Poynton, A., Ryle, A. & Watson, J. P. (1987) Effectiveness of Time-limited Therapy Carried Out by Trainees. British Journal Psychiatry 151 pp 602 - 610.
Cowmeadow, P. (1994) Deliberate self-harm and cognitive analytic therapy. International Journal of Brief Therapy, 9, 135-150.
Duignan Imelda & Mitzman Susan (1994) Change in Patients Receiving Time Limited Cognitive Analytic Group Therapy. International Journal of Short-Term Psychotherapy, 9, 2/3, 151-160
Dunn, M., Golynkina, K., Ryle, A., & Watson, J. P. (1997) A repeat audit of the Cognitive Analytic Therapy Clinic at Guy’s Hospital, Psychiatric Bulletin 21 pp 165-168.
Dunn, M. and Parry, G. (1997) A formulated care plan approach to caring for people with borderline personality disorder in a community mental health service setting. Clinical Psychology Forum, no. 104, June.
Graham, C. & Thavasotby, R. (1995) Dissociative psychosis: an atypical presentation and response to cognitive-analytic therapy. Irish Journal of Psychological Medicine 12 pp 109-111.
Kellett, S. (2005) The Treatment of Dissociative Identity Disorder with Cognitive Analytic Therapy: Experimental Evidence of Sudden Gains. Journal of Trauma & Dissociation 6(3) pp 55-81.
Kellett, S. (2007) A time series evaluation of the treatment of histrionic personality disorder with cognitive analytic therapy. Psychology and Psychotherapy: Theory, Research and Practice 80 pp 389-405.
Kerr, I. B. (1999) Cognitive Analytic Therapy for Borderline Personality Disorder in the Context of a Community Mental Health Team: Individual and Organizational Psychodynamic Implications. British Journal of Psychotherapy 15 pp 425 - 438.
Llewelyn, S. (2003) Cognitive Analytic Therapy: time and process. Psychodynamic Practice pp 1-19.
Marriott, M. & Kellett, S. (2009) Evaluating a cognitive analytic therapy service; practice-based outcomes and comparisons with person-centred and cognitive-behavioural therapies. Psychology and Psychotherapy: Theory, Research and Practice, Volume 82, Number 1, pp. 57-72(16)
Pollock, P. & Belshaw, T. (1998) Cognitive Analytic Therapy for Offenders. Journal of Forensic Psychiatry 9, No 3 pp 629-642.
Ryle, A. & Golynkina, K. (2000) Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: Factors associated with outcome. British Journal of Medical Psychology 73 pp 197-210.
Ryle, A., Spencer, J., & Yawetz, C. (1992) When Less Is More Or At Least Enough: Two Case Examples of 16-session Cognitive Analytic Therapy. British Journal of Psychotherapy 8, 4, 401-412.
Ryle A., & Beard, H. (1993) The integrative effect of reformulation: Cognitive analytic therapy with a patient with borderline personality disorder. British Journal of Medical Psychology, 66, 249-258
Yeates, G., Hamill, M., Sutton, L., Psaila, K., Gracey, F., Mohamed, S., & O’Dell, J, (2008) Dysexecutive Problems and Interpersonal Relating Following Frontal Brain Injury: Reformulation and Compensation in Cognitive Analytic Therapy (CAT). Neuro-Psychoanalysis 10 pp 43-58.
RCTs
Chanen, A. M., Jackson, H. J., McCutcheon, L. K., Jovev, M., Dudgeon, P., Yuen, H. P., Germano, D., Nistico, H., McDougall, E., Weinstein, C., Clarkson, V., and McGorry P. D. (2008) Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: randomised controlled trial. The British Journal of Psychiatry, Dec; 193: 477 - 484.
Dare, C., Eisler, I., Russell, G., Treasure, J. & Dodge, L. (2001) Psychological therapies for adults with anorexia nervosa: Randomised controlled trial of out-patient treatments. British Journal of Psychiatry, 178, 216–221.
Fosbury, J., Bosley, C. M., Ryle, A., Sonksen, P.H., & Judd, S. L. (1997) A trial of CAT in poorly controlled type I diabetes patients. Diabetes Care, 20, 6. pp 959-964
Treasure, J., Todd, G., Brolley, M., Tiller, J., Nehmad, A. & Denman, F. (1995) A Pilot Study of a Randomised Trial of Cognitive Analytic Therapy vs Educational Behavioral Therapy for Adult Anorexia Nervosa. Behavioral Research Therapy 33 (4) pp 363-367.
Non CAT References:
Denman. F. (1993) Quality in a psychotherapy service: a review of audiotapes of sessions. Psychiatric Bulletin, 18, 80-82.
Mann, J. & Goldman, R. (1982) A Case book in Time-Limited Psychotherapy. New York: McGraw-Hill.

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Quraishi, M., 2009. CAT Effectiveness: A Summary. Reformulation, Summer, pp.36-38.

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