Introducing Cognitive Analytic Therapy. Anthony Ryle
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else but if you would like to see me I am on the phone. If not, then I ‘d like to thank you for all your hard work and for helping me to see so many things about myself which need to be changed.
On the telephone I said I felt strongly that we should have one session to review how his wish to end fitted into the patterns we had already identified. At the next session he said that he had felt very relieved by my telephone call. He wanted to continue and had had a “breakthrough” by seeing all the places on the diagram where he could do different things. In particular he had made a feature of having 15 minutes' self‐care time when he felt most agitated. He had other plans of self‐care such as going to the gym and not smoking at night. He described what he called his third‐person perspective as a way of standing back and looking at himself: not being in a state but looking at the state he was in. A simplified version of the diagram showing a key RR (Figure 2.1a) and the enactment of a key RRP (Figure 2.1b) is shown in Figure 2.1.
From session 4, Bobby had rated his progress on his aims of recognizing and revising his identified problematic procedures (TPPs). Figure 2.2 shows a rating sheet for the first of these.
Termination
In session 11, he noted he had five more sessions and asked if I could spread them out to make them last. We talked about his continuing health problems (a recurring theme) and wondered if he might now seek medical help. We looked at it in terms of the diagram and linked this to the old pattern of having to suffer to achieve or get love. We discussed how he could continue to work after therapy on how my “abandonment” might be a helpful experience. He seemed helped by the idea of asking for realistic care from self and others. We wondered what a realistic “okay” relationship with Elizabeth might be like. He talked about me abandoning him and how maybe he could learn from it. He paid detailed attention to his not sleeping pattern and noted that the “agitation” was provoked by thoughts about how forlorn and neglected he was. We wondered what he could do to change his going to bed routines and how to promote self talk whenever he did wake in the night so as to dispute the forlorn feeling.
Figure 2.1a Key formative RR for Bobby.
Figure 2.1b Key RRP enactments.
Figure 2.2 Rating sheet for target problem procedure 1 for Bobby.
Bobby rang 2 days before the final session asking if it had to be the last. I restated that it was tough, but asked how he would learn about managing on his own, using what he had learnt with me, if he did not end the therapy. In the final session, as he read out his goodbye letter, he was in tears and had to stop several times. He wrote:
I can see how I throw myself in and expect too much. I don't know how to hold back. I tried to rope you in to make it impossible for you to reject me, but you were having none of it and I appreciate that. I can't give my whole self to people and expect to be looked after. I have to look after myself. I am beginning to look after myself. The few months we have been seeing each other have seen possibly the biggest changes in me, at least in my way of thinking. I have worked hard at it and will continue to do so because I have seen that it is possible to change. I'm feeling more able to live in the “external reality” and this seems to have come from protecting my “self” a bit more.
Follow‐Up
In the follow‐up session after his final exams, Bobby said he could now see the revised diagram in his head and use it. He could now tolerate shifts in mood, which still came but were now less extreme. There had been some tough times and he had rung Samaritans once just to talk to someone. Things were not all resolved and there were still times of despair, but he felt he could survive and work his way out of, or into, relationships with more mutual understanding.
He had seen his GP and was seeing the asthma nurse regularly. He had resumed a more balanced relationship with Elizabeth, was sleeping better and living a more healthy, self‐caring lifestyle. He had been able to sustain academic work with a more normal sleep pattern, obtained a degree, and had a more realistic career goal not based on fame. He no longer thought he needed long‐term therapy and was on better terms with his mother, brother, and sisters.
Concluding Remarks
This chapter has aimed to give a summary account of the theory and practice of the CAT model and its prior development. It is clear that the model will need to continue to evolve in the light of further developments and advances, both in background disciplines and in the light of research and experience in various clinical and other applications. Some of these currently ongoing developments are outlined subsequently elsewhere in this book, although inevitably some may be unpredicted, surprising, or counter‐intuitive; for example, CAT as basis for a “self help” tool (Meadows & Kellett, 2017). Further discussion and a largely sympathetic critique of the model from more explicitly socio‐political perspectives has been offered, for example, by Fozooni (2010) and more recently by various authors in Lloyd and Pollard (2018). While acknowledging the strengths of CAT, some of this critique has centered on the evolution and role of the model within established Western mental health care systems, the extent to which the model may collude with their predominantly biomedical, arguably largely apolitical, character, and an alleged uncritical acceptance within CAT of conventional diagnostic systems. Such critiques have much in common with those properly articulated by critical psychologists and psychiatrists such as Ingleby (1980), Johnstone and Dallos (2013), Hobson and Leonard (2001), Bracken and Thomas (2005), Lowenthal (2015), and Middleton (2015a, 2015b). These debates represent important aspects of a struggle toward more meaningful and humane conceptualizations of and responses to “mental disorder.” In our view, the CAT model, as outlined above and subsequently detailed below in this book, can make a significant and critical contribution to this struggle given that it is clearly predicated on a fundamentally, although not entirely, relational and socio‐cultural model of the Self (see Chapters 3 and 4) and correspondingly of the origins and character of mental health problems. Notwithstanding these important debates, the core of the CAT model and its clinical style as outlined in this chapter has, in our view, remained essentially constant and scientifically valid over a number of years now and should, we hope and anticipate, continue to inform and support a range of further developments both as a model of therapy and beyond.
3
The CAT Model of Development of the Self
Summary
Cognitive Analytic Therapy (CAT) is based upon a fundamentally relational and social concept of the Self that has important implications for psychotherapy. This concept is based on clinical research and, to varying extents, on consideration of emerging understandings from the fields of developmental