Introducing Cognitive Analytic Therapy. Anthony Ryle

your money worries in times of illness” (quoted in Wedderburn, 1996.) Despite the chronic underfunding of mental health services and of psychotherapy in particular, both in the UK and elsewhere, we believe that these principles can still be fought for and that CAT can contribute to their realization.

CAT Is Time‐Limited

CAT is undertaken with an explicit focus on time limitation (not simply brevity), and on what we have previously described as “ending well” (Ryle & Kerr, 2002). “Ending” from a CAT perspective will be described more fully below in Chapters 2 and 7. Typically, however, an initial CAT therapy contract would be for 16–24 sessions, given that for many such a period is clearly clinically effective. A focus on time limitation also helps maintain focus and addresses the major problem of therapeutic “drift,” or creating an unhelpful dependency on the part of the patient, or indeed a mutual, ongoing narcissistic gratification for both therapist and patient. In CAT, “ending well” is seen, therefore, as an important aim in itself. However, therapy may need sometimes to be extended longer term in treating more disturbed and damaged patients (see, e.g., discussion of “borderline”‐type disorders, or psychosis in Chapters 10 and 9). Therapy may also be shorter (e.g., 4–8 sessions) where the threshold to consultation is low, for more focal problems, or for less distressed or less damaged patients. Some patient groups (e.g., adolescents) may find longer (or indeed any!) formal therapies hard to engage with, and contracts may need to be modified collaboratively and accordingly.

CAT Offers a General Theory, Not Just a New Package of Techniques

      The book aims to describe and illustrate the methods, techniques, and tools developed in CAT and its underlying theory. While largely concerned with individual therapy, applications and uses in other modalities are considered, as are the wider implications for psychotherapy theory. While some CAT techniques could be incorporated in other treatment approaches (and vice versa), the model and the method involve much more than simply application of a range of disparate techniques. Psychotherapy patients can make use of a great many different psychotherapy techniques and there would be no point in simply offering a new combination of these under a new label. So why do we need theory?

      One robust finding from psychotherapy research is that therapists employing some clear, credible theory generally do much better clinically (Castonguay & Beutler, 2006; Gabbard et al., 2005; Lambert, 2013; Roth & Fonagy, 1996). And in health care more generally, plausible, humane, and scientifically‐based theories are also much more likely to facilitate effective treatments, including those with a major psychosocial component. Another robust finding is that the patient's perception of the therapist as sympathetic and helpful is associated with a good outcome (Castonguay & Beutler, 2006; Gabbard et al., 2005; Greenberg, 1991; Lambert, 2013; Norcross, 2011; Roth & Fonagy, 1996; Wampold & Imel, 2015). In one important recent study, the strength of the therapeutic alliance in working psychologically with patients suffering from psychotic disorders was noted to be the key predictor of outcome, including prediction of adverse outcomes in association with a poor therapeutic alliance (Goldsmith, Lewis, Dunn, & Bentall, 2015). This being so, a major part of any therapy model must be concerned with how to achieve this and achieve a strong “therapeutic alliance,” given that the central problem for many patients is that they are often unwittingly damaging or disruptive in their personal relationships and, mostly for very good reasons, are mistrustful and possibly destructive of offers of help from others. Working successfully with these enactments is never easy but becomes increasingly important and difficult as more disturbed patients are considered. Being helpful means more than being nice, indeed it may frequently involve being very challenging. However, in CAT this would always be undertaken in a benign, non‐judgmental manner, even when clearly drawing attention to the unhelpful consequences or effects of problematic enactments on others, including on the therapist. This would be undertaken always with at least implicit reference to previously agreed reformulations (maps and letters). This also has the effect of depersonalizing and externalizing (or “defusing”) any problematic enactment beyond the immediacy of the therapy relationship and, hopefully, restoring a collaborative dialog. Such therapist “challenges” would be undertaken, therefore, in the context of, and contribute toward, a positive therapeutic alliance. This is aided in turn by working through and resolving such potential ruptures (“tear and repair” episodes) by means of the tools and the relational style of the therapy (see Chapters 2 and 8).

A crucial quality required, therefore, is to respect the patient enough to be honest. Techniques need to be understood in relation to the complex human issues that are at the heart of therapy. Those used in CAT, whether adapted from other approaches or specific to CAT, have, as their main aim, the development of the patient's capacities to know, reflect on, and ultimately control and replace unhelpful and distressing thoughts, actions, and experiences, and to benefit from the internalization of a benign, healing therapy experience. Other tools and techniques are designed to maintain the therapist's adherence to the methods and values of the approach (see Chapter 8). These provide a framework within which a sincere and often intense working relationship can flourish. Practice embedded in theoretical clarity must be combined with accurate empathy and compassion if therapists are to be able to reach and maintain an understanding of their patients' experiences and at the same time be fully aware of their own role in enabling and encouraging change. These may also assist in the inevitable dangers of collusion, whether with a patient in therapy, or with pressures imposed by the context of service provision. The latter may include, for example, pressures to get through waiting lists, avoid risks, or to achieve immediate, but frequently superficial, clinical “results.”

CAT Has Applications In Many Clinical and Other Settings

Overall, CAT by now offers, in our view, a robust, comprehensive framework within which various helpful clinical treatments may be offered, and which also offers a means of re‐conceptualizing many challenging problems (e.g., dementia, the “difficult” patient, “personality disorder,” psychosomatic disorders, psychosis, and so forth; see Chapters 2 and 9). We note that, inevitably, further major conceptual and clinical challenges exist for CAT, as for any other current model, some of which are addressed elsewhere in the book. This book is primarily addressed to those in training or already working therapeutically with psychologically distressed or disturbed individuals, but also to those colleagues who, while not “doing therapy,” have important clinical and other (e.g., managerial, judicial) responsibilities. We believe that psychological and relational understandings should play a larger part than is now the case throughout health services, such as the NHS, and beyond. This would include management of groups such as psychiatric patients with major mental disorders, forensic patients, the “mentally handicapped” or “intellectually disabled,” and also, for example, in schools and in other social settings (see Chapter 9). We believe that psychotherapists should ideally play a central role in supporting and training staff in these fields. In all these fields experience is accumulating of applying CAT, and the model appears to be accessible and useful to many patients and clinical staff (see Chapters 9 and 11). While both psychodynamic therapies and cognitive therapy have contributed historically to these fields, neither, in our view, adequately conceptualizes or mobilizes the therapeutic power of the relationship between patients and those looking after them in a way that is clear, structured, and, above all, clinically