Introducing Cognitive Analytic Therapy. Anthony Ryle

example, unresolved grief or losses, remembered experiences of severe relational adversity, or overt trauma and abuse). Some of these may possibly not have emerged in the early sessions and reformulations, or may have been provoked and facilitated by them. This phase represents an opportunity to discuss, process, and “work through” these various issues. During this phase, it is important that the therapist maintains focus and activity on the agreed aims of therapy (e.g., identifying and working on TPPs), but is also able to be receptively open, rather than always actively directive, and able to tolerate “not knowing” and uncertainty about what may or may not still emerge or require attention. This may also involve an ability to tolerate and facilitate productive (rather than persecutory) silences. For many trained in the more proactive, problem‐solving type approaches typical of most health services, this can be an unfamiliar and difficult capacity to acquire and may be a major challenge in training. This may also be a phase in which more “existential,” or for some patients, even “spiritual” issues arise and need to be responsively and respectfully addressed. Some of these may be related to the different (from the therapist) cultural or religious backgrounds of patients. These may play an important role in their lives and difficulties, and may occupy an important place on the “map.” All of these issues arising and brought by the patient, as well as inevitable ongoing “transference–counter‐transference” issues would be reflected upon jointly and always, ultimately, related back to the prior joint reformulations. This may greatly assist and enable “meaning‐making,” understanding, and processing in a non‐judgmental way, and, in the case of therapy‐threatening enactments, may help to identify and resolve them (see above and also Chapters 6, 10, and 11). This work may subsequently helpfully contribute to the further development and revision of the reformulations. These should always be seen as provisional “works in progress,” and as representing a formal expression of the dialog of therapy. As such they are understood to constitute “psychological tools.” Therapy during this phase may be productively enabled by and may require use of various adjuvant “techniques” depending on the issues arising, the skills of the therapist, and the context of therapy. This might include “empty chair” work, use of “no‐send” letters, creative or body therapies, or more formal trauma processing work. Some of these may require input from specialist colleagues either during or subsequent to a course of CAT. The phase of uncomplicated commitment to and hopefulness about therapy may fade out sometime subsequent to the reformulation phase and as the end of therapy becomes a more real prospect, and also as disappointments in the limits of what may be achieved begin to be thought about. It is important to identify and name both the early commitment and cooperation, and possible later emergence of negative feelings (including in relation to the therapist), and to link them to the reformulation. Failure to discuss and accept “transference” feelings and link them to the reformulation represents a missed opportunity and is likely to associated with dropping out and poor outcome. On the other hand, the matter‐of‐fact acceptance, description, but non‐reciprocation of hostility or emotional withdrawal—and equally of idealization—may be powerfully healing. Throughout this phase an eye should be kept on the fact that therapy will aim to be time‐limited, and this should be helpfully raised and noted in discussion at least intermittently, if not every session.

Time Limits and Ending

      The time‐limited nature of CAT owed a lot to the work of James Mann (1973), and his emphasis on the importance of naming the session number, especially as the ending approaches, as a part of CAT practice. Working to predetermined time limits is not the same as using long‐term techniques for a short time. The process is intensified and most of the problems addressed in long‐term dynamic psychotherapy can be satisfactorily dealt with. Indeed, some patients with more severe disorders are more responsive and appear more safely helped in time‐limited work where the dangers of over‐dependence are much reduced and where the realistic disappointment which allows separation is clear from the beginning. For these and other reasons, “ending well” is seen in CAT as an important aim of therapy in itself. Nonetheless, it is recognized that for some more damaged and distressed patients longer‐term, supportive, and reparative work may be required. For many such patients, depending on context, complementary or consolidating approaches such as group therapy can be extremely helpful. However, longer term work should only be undertaken following discussion and reflection in a supervisory context (see also Marx, 2011; Pickvance, 2017), and should always maintain focus on ultimately “ending well,” and ideally moving on from therapy.

Termination is inevitably an issue, however, and the last sessions are seldom easy for the patient or the therapist. Almost no therapist (including the authors!) will ever feel that enough has been done and that “a bit more” might not be helpful. In CAT, the practice was introduced of exchanging “goodbye letters” at the penultimate (probably preferable to enable subsequent discussion), or last session. The aim of the therapist's letter is reflect on and to offer an ideally accurate (not blandly optimistic) account of the course of therapy and on what has and has not been achieved (jointly) in terms of modifying problem RRs and RRPs and relieving problems, to look to the future, and to identify where further work may be helpful. The tone of the letter should aim, as ever, to be collaborative and dialogical, and be informed by a genuine relational involvement (but not collusion) on the part of the therapist. The letter should stress that this is simply the view of the therapist. Feelings of disappointment, anxiety, or possibly anger by the patient, despite what may have been achieved, are expressly noted or predicted and thereby, incidentally, also “allowed.” This letter gives the patient a reminder of the unidealized person of the therapist (assisting the “withdrawal of transference”) and of the tools of the therapy, and is intended to help the internalization of the experience overall. In the same way, the letter from the patient (always suggested but not always produced!) invites thoughtful reflection and open expression of feelings, including about the therapy relationship. For many this represents a new experience (a new RRP), and an important change from previous coping patterns (RRPs), for example of “disempowered and silently soldiering on at great personal cost.” These exchanges are seen as an important aspect of “ending well.” Follow‐up at about 3 months is usually arranged. In many cases, change is maintained or expanded more thoroughly than either therapist or patient expect. If this is not the case, further follow‐up or “top up” sessions may be arranged or possibly treatment through another modality (e.g., group therapy or trauma processing work). Decisions about further treatment of whatever kind are best postponed until the effects of the therapy have become stabilized and the experience of termination has been completed. They should always occur in the context of reflective discussion in supervision (see Marx, 2011; Pickvance, 2017).

The Clinical Aims of CAT

      The aims of CAT therapists are, in a sense, modest. We seek to remove the “roadblocks” that have maintained restriction and distress and have prevented the patient's further growth, and we aim to assist in the development of more adequate “route maps” and of ways of being and of living life. This occurs partly through the experience of a new, benign, therapeutic relationship. In so doing we also aim to engender some hopefulness where previously there may have been little or none. But we do not offer to accompany the patient along the road. Obstacles to change are various and in CAT are seen to include: self‐reinforcing ineffective procedures; restricted, avoidant, or symptomatic procedures; sabotaging inner critical “voices”; and disconnected, dissociated Self processes. We do not believe we should seek to explain, let alone claim to share or replace, the wisdom and creativity of artists, writers, and philosophers. CAT also developed as a pragmatic model. In the inner‐city London out‐patient service where CAT developed, it appeared to be a satisfactory treatment for over two‐thirds of patients and of some benefit to many of the remainder. Similar outcomes are reported in naturalistic studies in other countries (e.g., Garyfallos, Adamopoulou, & Mastrogianni, 1998) and in more recent comparative studies in the UK (e.g., Marriott & Kellett, 2009). Some of these went on go on to further treatment, such as more CAT, group therapy, or cognitive‐behavioral work on unrevised