In this guest blog, Peter Taylor offers an invitation to contribute CAT-related papers to a forthcoming special issue of Psychology and Psychotherapy: Theory, Research, and Practice. He also outlines his thoughts on how the evidence base in CAT might be strengthened.
Sam Hartley and I are editing a special edition of Psychology and Psychotherapy: Theory, Research, and Practice, focussed on cognitive analytic therapy (CAT) (see the submission details here). We are hoping this special issue will help capture where CAT research is currently, and serve as an impetus to those involved in or thinking about research relating to CAT. We are also hoping this special issue will also help showcase to those outside of the CAT community what this approach may have to offer, and so generate wider interest.
We welcome submissions focused on CAT, adopting a wide variety of research methodologies. These can include reviews, small-scale clinical evaluations or studies of theoretical principles and mechanisms. Please do have a look at the call details and consider if anything you are involved in could be submitted. Let’s see if this special issue could trigger some new interest and exciting research into CAT. The deadline for submissions is 1st November 2019.
In light of this special issue I would like to share some thoughts about where CAT currently sits with regards to research. I work as a senior lecturer at the University of Manchester and have an active research interest in CAT. Whilst I am a qualified clinical psychologist I am not a qualified CAT therapist. My experience of CAT came though my clinical training, but my interest since then has been primarily about researching the CAT approach to psychological difficulties and what it may offer clients.
The CAT community is currently a thriving network, supported by the Association of Cognitive Analytic Therapy (ACAT). A myriad of local special interest groups help maintain connections and shared ventures, as do partner organisations like Catalyse. However, from a slightly outsider perspective, I feel concerned that this growing clinical interest has often not transitioned into research interest and activity.
I have been increasingly involved in research concerning CAT over the last few years. I would argue that providing robust research evidence concerning its value is essential, both to support current practice, and to make the case for additional support of CAT within services. There has been a consistent ongoing stream of CAT-focused research, much of which was helpfully summarised in the 2014 review by Calvert and Kellett. However, I believe that a concerted and collective investment in both the scale and scope of CAT research would really help us to better understand how, when, and in what way, CAT may be of value to those in health services.
I recently ran a search on PsycINFO with the keyword “cognitive analytic therapy”. (PsycINFO is probably the main online database for psychology, including clinical psychology.) Two-hundred and ninety-four articles were identified, with fifty-three having been published in the last three years. A quick screening of these identified seventeen that could be considered empirical research. There are a few where the line between an evaluative research study and something more illustrative is blurry. Given the enthusiasm for training in CAT, and adopting the approach in many clinical settings, this number of empirical studies illustrates for me that the CAT research base is more limited than it might be.
There are various possible reasons why there has not been more research on CAT. My own feeling is that CAT has been adopted and championed by individuals with predominantly clinical roles. They may have less time for doing research, or may not feel confident in their research skills. Connections with academic departments and research groups have not quite flourished, in comparison with other approaches like CBT.
A brief review of the seventeen studies I found leads to two observations worth highlighting.
First, the majority are small-scale evaluations of CAT or some aspect of this approach (n = 11). This observation highlights one characteristic of the CAT literature that I alluded to earlier. It has been very much led by clinicians and emerged from clinical contexts, where small-n designs have been embraced. What is notable though is the lack of larger-scale systematic research studies. I identified three larger studies, but still with small samples of around n = 30-50. This suggests a difficulty in the transition from smaller to larger scale studies.
Second, a large number of these studies involve the same individuals leading the research. For example, Stephen Kellett is a leading author (first or second authorship) on nine of the studies. This suggests research into CAT has not branched out beyond particular research-active individuals and groups as much as it could have. However t it also demonstrates that individuals knowledgeable in undertaking research exist in the CAT community. There is therefore potential for modelling and scaffolding of research capacity.
So how might we move ahead to encourage and support more research in CAT?
1) Focusing on the first observation, small-n studies (e.g. case series) are important. They are part of a recognised step within the MRC guidance on developing the evidence base for complex interventions. Crucially, they help answer important questions about feasibility and acceptability. The lack of CAT research outside of this area suggests to me both a challenge but also an opportunity to develop and expand the CAT research base further.
2) Larger-scale trials typically require funding, which is notoriously difficult to obtain. However there may be other ways of extending CAT research. Linking up researchers from multiple services or groups may help to establish collaborations for undertaking larger-scale research.
3) There is also potential in using routinely collected outcome data that many services hold, using common measures. I wonder if there is scope to collate this data to further evaluate the potential benefits of CAT. I recall there was some discussion of this latter possibility at the 2018 CAT research conference in Manchester.
4) Whilst much of the research concerning CAT has been understandably about the therapy, I also wonder about designing research directed at testing some of the conceptual and theoretical principles that underlie CAT. For example, we recently found that the Personality Structure Questionnaire (PSQ), a tool designed to assess mechanisms of action linked to CAT, is associated with difficulties around self-harm. Specifically, scores on this measure, which captures instability in self-concept or personality, distinguished those with recent (past year) and historic self-harm, with greater instability being apparent for those with recent self-harm.
Returning to a point in my second observation, I noted earlier my perception that CAT lacks strong links with academic departments and research institutions. It feels like currently in the UK there are a small number of academics who also have an active research interest in CAT. I would count myself in this group. My experience has been that many CAT clinicians have a real interest in research but either lack the capacity or confidence to develop research projects themselves.
Stronger links with academic departments and research-active academics is a possible solution here. Networking and collaboration with and between academic departments may help increase the spread of this interest and research activity.
We should perhaps also consider how the next generation of researchers could be involved in research about CAT. Funded PhD studentships with a CAT focus might be one option. For clinicians wishing to develop their research capacity further, clinical research fellowships such as those available through NIHR may also provide opportunities and ongoing support.
It will be interesting to see how the Catalyse practitioner training will be influenced by someone as research-active as Stephen Kellett joining the core trainer team as of this year.
I wasn’t able to make it along to the second CAT research conference organised jointly between Catalyse and ACAT in April 2019. However, following the Catalyse 25 Years conference in May, a small group of researchers and research-interested clinicians in the North arranged to meet informally this coming September. It would be great to hear of other local connections and collaborations which might be able to move forward with some of the ideas I’m proposing in this blog.
Moving beyond the submission deadline for the PAPTRAP special issue – 1st November 2019 – I look forward to seeing research confidence growing, the evidence base for CAT becoming more solid, and generated by a broader group of clinicians and researchers.
You can follow Peter on Twitter via @PJTaylorClinPsy