Main ideas and methods

The essentials of CAT


It is helpful to offer a summary description of how CAT works in its essential elements so that a comparison can be made between it and other approaches.

Shared reformulation

At the heart of CAT is the shared and emotionally engaging activity of making meaning through reformulation and through the creative and collaborative use of a therapeutic, educational and emotional relationship involving making maps and writing heartfelt and accurate descriptions of past and present patterns of interaction that give the person their place(s) in the world.    The key conceptual tools for this are:

Reciprocal roles: a simple looking but deceptively complex and rich idea that asserts that all that we know we have learnt in relation with another and the internalised memory of this relationship shapes how we relate to ourselves and others.  In listening to client’s and their own thoughts, feelings, desires and actions the CAT therapist is figuring out the process of reciprocation or call and response involved.  Sometimes these reciprocations are direct and immediate like smiling to smiling back.  Other times they are indirect and part of an orchestration of reciprocation and these are mapped in CAT through tracking out the details of the procedures of response.

Reciprocal role procedures: are the interactive patterns of intention, feeling, thinking, action and response or consequence that keep us in particular reciprocal role positions.

Joint making of sketches, life maps and therapy maps (called the SDR in the CAT literature): The shared (reparative and validating) activity of mapping and tracking difficult or therapeutic moments helps towards fostering a therapeutic attitude to self and others.

Reformulation involves linking therapy goals dynamically to target problems and  the procedures which maintain them which in turn open a many-voiced conversation with emotional and social history.  With all this come moments of shimmering, resonance, linking and realisation often through the choice of words, the power of recognition of patterns and the power of registering feelings in detail and more generally across several life stories and current problems or concerns.

Reformulation comes to a focus with the timely use of the prose description often in the form of a letter is followed by work of recognition and revision of patterns: in session, through homework of monitoring and rating and through conflict and trauma ‘recollected in the relative safety and tranquillity of therapy’ and with previous unformulated and unmanageable feelings brought within the reach of self-acceptance and newly internalised compassion through the strength, versatility and sensitivity of the therapeutic scaffolding.

The key final process of therapeutic work is the preparation for and collaborative use of, an active ending of therapy to accurately review progress, set-backs and set out the road ahead. It is linked to a period of self-help therapy in which the client seeks to become his or her own therapist or demonstrates some understanding to other mental health professionals within a care plan or group.  Involvement ends with direction to a group, or other involvement, or to the end of contact.

For well over thirty years CAT has been centrally concerned with the deeply interactive nature of human experience, meaning making, health and disturbance. The pioneering work of Tony Ryle in trying to find a common language for psychotherapy combining behavioural, cognitive and psychoanalytic components and his concern for linking therapy process to outcome led to short descriptive accounts in writing of problematic patterns. These became a heartfelt, empirically grounded, accessible and shared focus for brief structured therapy and a platform for thinking about past influences that shaped these patterns, their possible enactment in the therapy and the work of modifying them. In the process of this much more open relational process, it became clear that links between problem patterns and whole self, identity and agency, more general interactions with others could be mapped out on paper in ways which were memorable and transferable.

CAT has proved to be a good way of working to formulate complex cases, work collaboratively in teams and teach the skills of working mutually in the therapeutic or helping relationship. In particular the simple process of sketching out how problem patterns arise and are maintained or poorly handled works well to foster a therapeutic and problem-solving alliance between client and therapist. In my work I have adapted CAT’s methods of making diagrams to help teach basic skills in empathic communication rather than do therapy. These rough and ready sketching skills seem to work well as the scaffolding for speed supervision and are very briefly described below with reference to three diagrams.  (taken from speed supervision).

Six different applications of the CAT model:

It might be a useful if crude simplification to classify the versatile range of uses of CAT into six areas.

1. Brief, focused relational therapy:  is where CAT began and still has its main interest.  The structure of therapy and the main methods are described in the methods section.  CAT can be any length the importance being in the active and collaborative reformulation at the beginning to shape and hold the therapy and the active and therapeutic use of the ending to hold and define the limits of the therapy and sustain its main focus on developing the capacity in the client to be their own therapist. CAT is sixteen sessions long most typically but can be twenty four sessions long for more complex cases or shorter for straight forward forms of personal help.

2. Consultation: CAT can be used as a consultative aid whether in the development of care plans, risk management, teams working together with one client or a consultant formulating the dynamics associated with one team.

3. Therapeutic Communication Skills: refers to how the cognitive analytic approach can be used to develop relational awareness, relational skills and enhanced communication skills  Through mapping the moment and internalising the relational properties of the maps

4. Specialist applications cover the variety of ways in which the diagrammatic element of CAT can be harnessed to develop an off the peg map of a particular condition, personality or treatment approach or setting.  Examples can be found in the work of Tim Sheard in relation to self-harm and attendance at A and E; Karen Shannon and colleagues in describing the narcissistic and borderline formulations of certain patterns of male violence.

5. Hybrid CAT sums up those mixed interventions which fit well with a cognitive analytic approach including combined work with mindfulness, mentalisation based therapies, dialectical behaviour therapy, acceptance and commitment therapy, compassionate mind and a whole host of similar approaches which can be given more relational support through combination with CAT.  Similar CAT lends itself to a multi modal approach of combining individual and group therapy such as doing a short reformulation with the client individually and then bringing that to share in a group.

6. Umbrella CAT is a catchphrase for thinking about the model as a general understanding and an over-arching relational framework for sensitive and skilled versatile practice.