3. Indispensable survival guide for the thinking psychotherapist 3
Drug watch
Benzodiazepines often inappropriately
prescribed
B
enzodiazepines are prescribed disproportionately
to patients who either do not have a clear
indication or have poor indications, such as
depression, leading to higher healthcare usage, greater
health risk, and increased costs, according to researchers
at Harvard Medical School. The findings appear in the
Journal of General Internal Medicine in May, 2016.
Benzodiazepines are commonly prescribed for
anxiety and sleep disorders, but have known risks for
adverse events in the elderly, including fractures, and
among patients with substance abuse or lung disease.
The authors of the study found that, despite this, the
drugs were frequently prescribed to these patient groups,
often in high doses. Among these patients 52% were
also concurrently prescribed antidepressants.
Researchers found nearly half (44%) of the patients
who received benzodiazepine prescriptions received at
least one from their primary care physicians. Previous
studies have shown that primary care providers write
many of the prescriptions for benzodiazepine, yet there
is limited research regarding the type of patients who
receive these drugs in the primary care setting.
The study comprised 65,912 patients who had
visited one of 10 clinics in Brigham between 2011 and
2012. The findings showed that providers prescribed
at least one benzodiazepine to 15% of the patients. Of
benzodiazepine recipients, 5% were given high doses.
Compared with non-recipients, recipients were more
likely to have diagnoses of depression, osteoporosis,
chronic obstructive pulmonary disease (COPD), alcohol
abuse, tobacco exposure, sleep apnea, and asthma.
Findings regarding high-dose benzodiazepine
prescriptions were even more troubling, the
researchers said. Compared with patients receiving a
low dose, high-dose benzodiazepine recipients were
even more likely to have certain diagnoses, such
as substance abuse, alcohol abuse, tobacco use and
COPD.
The authors say, “Our finding that high-dose
prescribing was also associated with diagnoses of
COPD and substance use disorders raises special
concern. The magnitude of the association between
benzodiazepines and mortality in general appears to
be dose-dependent, and dose-dependent relationships
between benzodiazepines and mortality have been
described independently for COPD and overdose
deaths. Therefore, the disproportionate prescribing of
high-dose benzodiazepines to patients with COPD
and substance use disorders may amplify the effect of
prescribing standard-dose benzodiazepines to patients
already at risk of adverse outcomes.”
The authors also found that healthcare use was
higher among those prescribed benzodiazepine.
Specifically, they had more primary care visits per
100 patients (408 vs 323), specialist outpatient visits
(815 vs 578), emergency department visits (47 vs
29), and hospitalizations (26 vs 15; P < .001 for all
comparisons).
Lead author of the study David Kroll warns,
“Prescribers should take into account their patients'
risk factors for adverse events when considering a
benzodiazepine. For patients with COPD, substance
use disorders, osteoporosis, and advanced age—
those who appear to be the most likely to receive
benzodiazepine prescriptions and, for the two former
categories, at the highest doses—the choice of
prescribing a benzodiazepine should be made with
great caution.”
4. New Therapist July/August 20164
Drug watch
Antidepressants ineffective in the
treatment of complicated grief
I
n treating complicated grief (CG), adding an
antidepressant does not significantly enhance the
efficacy of targeted complicated grief treatment
(CGT) psychotherapy. However, it has been shown
to be effective in treating patients with co-occurring
depressive symptoms, according to researchers at Columbia
University. The research findings appeared online in
JAMA Psychiatry in June, 2016.
Lead author of the study Katherine Shear notes,
“CGT is the treatment of choice for complicated grief,
and the addition of citalopram optimizes the treatment of
co-occurring depressive symptoms.”
About 7% of bereaved individuals develop CG,
which is characterized by persistent, maladaptive
thoughts, dysfunctional behaviors, and poorly regulated
emotions that interfere with the ability to adapt to loss.
Co-occurring depressive symptoms are common, however,
the authors note that CG can be “clearly differentiated”
from major depression both in its primary symptoms and
with respect to response to treatment.
The researchers explored whether an antidepressant
would enhance CGT psychotherapy and whether it would
be effective on its own for CG. The study included 395
bereaved adults who scored 30 or greater on the Inventory
of Complicated Grief. To confirm the presence of CG,
independent evaluators completed a supplemental interview
for CG.
Two thirds of the patients met criteria for current major
depression, and more than half reported a wish die since
the loss. The median time since the loss was 2.3 years.
Patients were stratified with respect to major depression
and were randomly divided into four groups: those
receiving citalopram 40 mg, those receiving placebo, those
receiving 16 sessions of CGT plus citalopram, or those
receiving CGT plus placebo. Standard assessments were
made monthly for 20 weeks. Response was reflected by a
rating of either “much improved” or “very much improved.”
In confirmation of the efficacy of CGT, far more
patients responded to CGT than to placebo (82.5% vs
54.8%; relative risk [RR], 1.51; 95% confidence interval
[CI], 1.16 - 1.95; P = .002; number needed to treat [NNT]
= 3.6).
Contrary to expectations, adding citalopram to CGT
did not significantly improve CG outcomes (CGT with
citalopram vs CGT with placebo: 83.7% vs 82.5%; RR,
1.01; 95% CI, 0.88 - 1.17; P = .84; NNT = 84). However,
co-occurring depressive symptoms decreased significantly
more when citalopram was added to CGT (P = .04).
Rates of suicidal ideation diminished to a substantially
greater extent in those who received CGT compared with
those who did not.
ADHD prescriptions plateau in UK
T
he tendency to treat childhood hyperactivity
(ADHD) with drugs may have reached a
plateau in the UK, following a steep rise in
the number of prescriptions for these medicines over
the past 20 years, according to researchers at the
University of Geneva. However, the authors of the
study also note that among children in the UK who
do take pharmacological medication, their treatment
lasts for much longer than that of their European or
U.S peers. The study appeared online in the journal
BMJ Open in June, 2016.
The researchers based their findings on an
analysis of Clinical Practice Research Datalink
(CPRD) records, relating to children up to the age
of 16 who had been prescribed at least one drug to
treat ADHD between 1992 and 2013.
The researchers analysed the data to estimate
trends in ADHD prescribing patterns among
children between 1995 and 2013, and the length of
treatment for those diagnosed with the condition.
During this period, 14,748 children under
the age of 16 (85% of them boys) were given
at least one prescription for an ADHD drug,
with methylphenidate accounting for 94% of all
prescriptions. Over half (58%) of the children
received their first prescription between the ages of 6
and 11; around 4% were 5 years old when they were
first prescribed an ADHD drug.
The use of these drugs in this age group soared
by a factor of 35, from 1.5 per 10,000 children in
1995 to 50.7/10,000 in 2008, after which it seemed
to level off at 51.1/10,000 children by 2013. The
rate of new prescriptions rose 8-fold over the same
timeframe, reaching 10.2 per 10,000 children in
2007, but subsequently falling to 9.1/10,000 in 2013.
The researchers suggest that these patterns may
reflect the impact of National Institute for Health
and Care Excellence guidelines issued in 2008, and/
or concerns about the potential impact on the heart
of long term use.
The authors note that the UK prescribing rates
for ADHD are 10 times lower than in the US, up to
5 times lower than in Germany, and 4 times lower
than in the Netherlands. However UK rates are
twice as high as in France.
Nevertheless, the course of treatment tends to
be longer than in these countries, the published
evidence indicates. More than three out of four UK
children on stimulant medication (around 77%) were
still being prescribed ADHD drugs 1 year after
diagnosis and 60% were still on treatment 2 years
later.
5. Indispensable survival guide for the thinking psychotherapist 5
Research
While morning responsibilities like work, children and
school influence wake-time, the researchers say they're
not the only factor.
The spread of national averages of sleep duration
ranged from a minimum of around 7 hours, 24
minutes of sleep for residents of Singapore and Japan
to a maximum of 8 hours, 12 minutes for those in
the Netherlands. That's not a huge window, but the
researchers say every half hour of sleep makes a big
difference in terms of cognitive function and long-term
health.
The following trends were evident in the study:
• Middle-aged men get the least sleep, often getting
less than the recommended 7 to 8 hours.
• Women schedule more sleep than men, about 30
minutes more on average. They go to bed a bit
earlier and wake up later. This is most pronounced
in ages between 30 and 60.
• People who spend some time in the sunlight each
day tend to go to bed earlier and get more sleep than
those who spend most of their time in indoor light.
• Habits converge as we age. Sleep schedules were
more similar among the older-than-55 set than
those younger than 30, which could be related to a
narrowing window in which older individuals can
fall and stay asleep.
A recent Centers for Disease Control and Prevention
study found that across the U.S., one in three adults
aren't getting the recommended minimum of seven
hours. Sleep deprivation, the CDC says, increases the
risk of obesity, diabetes, high blood pressure, heart
disease, stroke and stress.
Sleep is more important than a lot of people realize,
the researchers say. Even if you get six hours a night,
you're still building up a sleep debt.
Co-author of the study Walch says, “It doesn't
take that many days of not getting enough sleep before
you're functionally drunk. Researchers have figured
out that being overly tired can have that effect. And
what's terrifying at the same time is that people think
they're performing tasks way better than they are.
Your performance drops off but your perception of
your performance doesn't.”
Getting enough sleep? Society versus
biology explored
A
novel study of worldwide sleep patterns
combines math modeling, data collection and
a mobile app to shed light on the role society
and biology each play in setting sleep schedules.
Researchers at the University of Michigan found that
while societal norms govern bedtime, our internal
clocks govern the time we wake up in the morning
resulting in later bedtime being linked to a loss of
sleep. The findings appeared in the journal Science
Advances in May, 2016.
The researchers examined how age, gender, amount
of light and home country affect the amount of shut-
eye people around the globe get, when they go to bed,
and when they wake up.
The authors explain that circadian rhythms—
fluctuations in bodily functions and behaviors that
are tied to the planet's 24-hour day—are set by the
suprachiasmatic nucleus (a grain-of-rice-sized cluster
of 20,000 neurons behind the eyes). They're regulated
by the amount of light, particularly sunlight, our eyes
take in. Circadian rhythms have long been thought to
be the primary driver of sleep schedules, even since the
advent of artificial light and 9-to-5 work schedules.
For purposes of the study the researchers used
a free smartphone app, called Entrain, designed
to reduce jetlag to gather robust sleep data from
thousands of people in 100 nations. The app helps
travelers adjust to new time zones. It recommends
custom schedules of light and darkness. To use the
app, you have to plug in your typical hours of sleep and
light exposure, and are given the option of submitting
your information anonymously.
They then analyzed the app for patterns and tested
correlations using a circadian rhythm simulator.
The simulator--a mathematical model--is based on
the field's deep knowledge of how light affects the
brain's suprachiasmatic nucleus. With the model, the
researchers could dial the sun up and down at will to
see if the correlations still held in extreme conditions.
Population-level trends showed that cultural
pressures may override natural circadian rhythms,
with the effects showing up most markedly at bedtime.
6. New Therapist July/August 20166
Research
Health coverage up, shrink visits down
W
hile an increasing number of individuals with mental
health problems have obtained insurance coverage,
the percentage visiting mental health professionals
has declined according to a survey from the Centers for Disease
Control and Prevention (CDC). The report was issued by the
CDC's National Center for Health Statistics (NCHS) in May,
2016.
The findings raise the question of whether more of these
patients are taking their troubles to primary care physicians
instead.
Study authors Robin Cohen and Emily Zammitti analyzed
data from the center's National Health Interview Survey on
access and utilization for adults aged 18 to 64 years with and
without serious psychological distress (SPD) in the past 30 days.
SPD is a gauge of mental health problems severe enough to
disrupt daily living and require treatment.
The survey uses the Kessler 6 non-specific distress scale
to identify individuals with SPD. The scale asks individuals
how often in the past 30 days they felt: So sad that nothing
could cheer them up; nervous; restless or fidgety; hopeless; that
everything was an effort and; worthless. Individuals scoring 13 or
higher on the 24-point scale were deemed to have SPD.
The researchers found that the percentage of adults
experiencing SPD in the previous 30 days has remained stable
in recent years, nudging up from 3.2% in 2012 to 3.8% in 2015
through September. During that same time, the percentage of
adults with SPD who lacked insurance coverage decreased from
28.1% to 19.5%, a not so surprisingly development, given the
dramatic expansion of coverage under the Affordable Care Act
(ACA) in 2014.
Likewise, the percentage of adults with SPD who needed
mental healthcare in the previous 12 months, but could not afford
it, declined from 33% in 2012 to 24.4% through September 2015.
The problem of unaffordable prescriptions also shrank.
Increased access to insurance coverage did not translate into
more crowded waiting rooms for psychiatrists, psychologists,
licensed counselors, and other mental health professionals. The
percentage of adults with SPD who reported seeing a mental
health professional during the previous 12 months decreased
from 41.8% to 34.2% during the study period.
However, the percentage of these adults visiting some kind of
healthcare professional for whatever reason held steady—87.7% in
2012 compared with 86.6% in 2015 through September. This rate
was slightly higher than the roughly 80% for adults without SPD
that prevailed during that period.
In their report, Cohen and Zammitti said that the shrinking
percentage of adults with SPD who have seen a mental health
professional in the previous 12 months could stem from a number
of factors, including a shortage of mental health professionals and
an increasing trend towards obtaining mental health care from
primary care physicians.
High fiber diet strongly tied to
healthy aging
A
high-fiber diet promotes healthy
aging, according to researchers at
Westmead Institute’s Centre for
Vision Research in Australia. The findings
appeared in The Journals of Gerontology in
May, 2016.
The authors of the study explored the
link between carbohydrate nutrition and
healthy aging using data gathered by the
Blue Mountains Eye Study, a benchmark
population-based study that examined more
than 1,600 adults aged 50 years and older
for long-term sensory loss risk factors and
systemic diseases.
They found that out of all the factors
they examined—which included a person’s
total carbohydrate intake, total fiber intake,
glycemic index, glycemic load, and sugar
intake—it was the fiber that made the
biggest impact on successful aging. Healthy
fiber can typically be found in goods such
as fruits (strawberries, raspberries, oranges,
bananas, pears and apples), grains (cereals,
breads, and pastas), nuts and seeds, and
vegetables (artichokes, green pears, broccoli,
turnip greens, corn, and brussel sprouts).
Lead author of the study Bamini
Gopinath says, “Essentially, we found
that those who had the highest intake of
fiber or total fiber actually had an almost
80% greater likelihood of living a long
and healthy life over a 10-year follow-up.
That is, they were less likely to suffer
from hypertension, diabetes, dementia,
depression, and functional disability.”
Although one might assume that the
level of sugar intake would have made
the biggest impact on successful aging,
Gopinath pointed out that the particular
group they examined were older adults
whose consumption of carbonated and
sugary drinks was already quite low.
While it is too soon to use the study
results as a basis for dietary advice,
Gopinath says, “There are a lot of other
large cohort studies that could pursue
this further and see if they can find
similar associations. And it would also be
interesting to tease out the mechanisms that
are actually linking these variables.”
7. Indispensable survival guide for the thinking psychotherapist 7
Research
Moving detrimental to wellbeing
M
oving to a new home during childhood
increases the likelihood of multiple
adverse outcomes later in life, according
to researchers at the University of Manchester, UK.
The findings appeared in the American Journal of
Preventive Medicine in April, 2016.
The study comprised 1.4 million Danish children
born between 1971 and 1997. Every residential
childhood move was documented from birth to 14
years. These individuals were then tracked from their
15th birthdays until their early forties
Each move was associated with the age of the
child so that the impact of early-in-life moves
could be contrasted with moves during the early
teenage years. The authors of the study were able to
measure and correlate subsequent negative events
in adulthood, including attempted suicide, violent
criminality, psychiatric illness, substance misuse, and
natural and unnatural deaths.
The risk of adverse outcomes due to residential
mobility during childhood was classified into three
categories: self-directed and interpersonal violence:
(attempted suicide, violent criminality), mental illness
and substance misuse (any psychiatric diagnosis,
substance misuse), and premature mortality (natural
and unnatural deaths).
Thirty-seven percent of people studied relocated
across a municipal boundary at least once before
reaching their 15th birthdays, with multiple
relocations occurring most frequently during infancy.
Across all adverse outcomes studied, the highest
risks were among individuals who moved frequently
during early adolescence.
Data analysis showed that risk increased with
multiple moves at any age versus a single move,
and that an even sharper spike in risk for violent
offending was observed with multiple relocations
within a single year. The attempted suicide risk
increased steadily with rising age at the time of the
move, and was markedly raised if multiple annual
relocations occurred during early adolescence (12-14
years of age).
Interestingly the initial hypothesis that adverse
outcomes might be more prevalent in households
with lower Socioeconomic status (SES) was not
borne out by this study, where markedly elevated risk
due to residential moves during early/mid adolescence
applied to all SES levels.
Lead author of the study Roger Webb says, “The
elevated risks were observed across the socioeconomic
spectrum, and mobility may be intrinsically harmful.”
Satisfied partners perceive single
counterparts as less attractive
I
ndividuals who are satisfied in their primary
relationships seem to downgrade the appearance
of people they perceive as threatening their
relationships, according to researchers at New York
University. The authors of the study believe that this
perceptual bias could be a non-conscious method
of self-control. The predisposition helps a person
overcome temptations and helps maintain long-term
goals of staying with a romantic partner. The findings
were published in the Personality and Social Psychology
Bulletin in May, 2016.
The first experiment showed participants images
of an opposite-sex lab partner with whom single and
coupled college students would interact extensively.
Each participant read the individual’s profile, which
included relationship availability.
Next, participants matched the individual’s
photo with one of several other images. These other
images had been manipulated, so that some were
more attractive than the original photo and some less
attractive.
Of the 131 heterosexual college participants, those
in a relationship who learned the target was single and
therefore a potential threat to their relationship viewed
the individual as less attractive than he or she actually
was. Conversely, when participants in a relationship
learned the individual was in a relationship, they
viewed the individual as slightly more attractive than
was really the case.
This downgrading bias occurred despite the fact
that participants were offered entry into a raffle
for $50 if they selected the correct face during the
matching activity, suggesting participants in a
relationship were actually perceiving the individual as
less attractive.
The researchers then replicated their study with 114
students, this time also asking participants to report
how satisfied they were in their relationships. This
second study also included an extra detail about the
availability of the individual.
Participants who were satisfied with their own
relationship partners showed the same results as those
in relationships in study one. They saw the individual
as less attractive than he or she actually was.
However, among those in less satisfying
relationships, the results appeared similar to those of
single people. Unsatisfied participants more accurately
matched the attractive faces to the provided photo.
Researchers believe the study suggests innate forces
attempt to extend relationship longevity.
8. New Therapist July/August 20168
Research
Unpacking why psychotic symptoms are more
prevalent among children in urban areas
L
ow social cohesion and higher crime in urban areas is
shown to increase presence of psychotic symptoms in
children, according to researchers at Duke University and
Kings College London. The research findings appeared in online
in the Schizophrenia Bulletin in May, 2016.
Psychotic symptoms include paranoid thoughts, hearing or
seeing things that others do not, and believing others can read
one's mind. Psychotic experiences in childhood are associated
with schizophrenia and other psychiatric disorders in adulthood.
While previous studies have shown similar findings, the
authors of the current study undertook to examine the causes
of the trends and whether certain conditions in urban areas
cultivated psychotic symptoms in children.
The study comprised 2,232 British twins from birth to age
12. Children's psychotic symptoms at age 12 were assessed
through in-home interviews.
Neighborhood features were captured by surveying local
residents and constructing high-resolution geospatial profiles
from administrative records and Google Street View images. The
long-term study controls for family history of mental illness and
for the mother's history of psychotic symptoms.
The researchers found that 12-year-olds in urban
neighborhoods were almost twice as likely to experience a
psychotic symptom than those in non-urban areas. This held true
when controlling for residential mobility, social economic status
and family psychiatric history. Around 7.4% of children living in
urban areas had experienced at least one psychotic symptom by
age 12, compared to 4.4% living in non-urban areas.
The researchers looked at four experiences at the
neighborhood level to help determine the cause: supportiveness
and cohesiveness between neighbors; the likelihood that
neighbors would intervene if problems occurred in the
neighborhood; disorder in the neighborhood, such as graffiti,
vandalism, noisy neighbors and loud arguments; and crime
victimization.
Psychotic symptoms were more common in children who
lived in areas with low social cohesion, low social control and
high neighborhood disorder and whose family had been the
victim of a crime. Low social cohesion and crime victimization
seemed to have the largest impact. That combination of factors
explained a quarter of the association between urban living and
psychotic symptoms in children.
Lead author of the study Joanne Newbury poses the following
questions for future investigation: “Do crime and threat increase
children's vigilance and paranoia? Does prolonged exposure to
neighborhood stressors undermine some children's ability to cope
with stressful experiences? Further research is needed to identify
the social and biological mechanisms underlying our findings.”
Maternal smoking linked to
schizophrenia in offspring
H
eavy prenatal nicotine exposure
results in a 38% increased risk
for schizophrenia in offspring,
as evidenced by higher maternal serum
cotinine level, according to researchers
at the University of Oulu, Finland.
The study was published online in the
American Journal of Psychiatry in May,
2016.
Lead author of the study Solja
Niemelä says, “To our knowledge, this is
the first biomarker-based study to show
a relationship between fetal nicotine
exposure and schizophrenia. Given
the high frequency of smoking during
pregnancy, these results, if replicated,
may ultimately have important public
health implications for decreasing the
incidence of schizophrenia.”
The researchers conducted a
population-based, nested, case-control
study of all live births in Finland from
1983 through 1998. Maternal serum
cotinine levels were prospectively
measured from early to mid gestation
using serum samples archived in a
national biobank.
They identified 977 cases of
schizophrenia through 2009 and
matched each case patient to a control
person. The mean age of schizophrenia
patients and control persons was 22.3
years.
A higher maternal cotinine level was
associated with an increase in the odds
of developing schizophrenia (odds ratio
[OR] 3.41; 95% confidence interval [CI],
1.86 - 6.24), the researchers report.
In unadjusted analysis, categorically
defined heavy maternal nicotine
exposure (cotinine level > 50 ng/mL)
was associated with 51% greater odds of
schizophrenia (OR, 1.51; 95% CI, 1.18 -
1.93; P < .001). The association persisted
after adjusting for key covariates,
including maternal age and parental
psychiatric disorders (OR, 1.38; 95% CI,
1.05 - 1.82; P = .02).
9. Indispensable survival guide for the thinking psychotherapist 9
Research
Witnessing parental domestic violence
during childhood heightens future
suicide risk
A
pproximately one in six children who are
exposed to chronic parental violence will
attempt suicide as an adult, according to
researchers at the University of Toronto. The findings
appeared in the journal Child: Care, Health and
Development in June, 2016.
The study comprised 22,559 community-dwelling
Canadians, using data from the 2012 Canadian
Community Health Survey-Mental Health. Parental
domestic violence was defined as “chronic” if it had
occurred more than 10 times before the respondent
was age 16.
The findings showed that the lifetime prevalence
of suicide attempts among adults who had been
exposed to chronic parental domestic violence during
childhood was 17.3% compared to 2.3% among those
without this childhood adversity.
Lead author of the study Esme Fuller-Thomson
says, “We had expected that the association between
chronic parental domestic violence and later suicide
attempts would be explained by childhood sexual or
physical abuse, or by mental illness and substance
abuse. However, even when we took these factors
into account, those exposed to chronic parental
domestic violence still had more than twice the
odds of having attempted suicide.” She adds, “These
chaotic home environments cast a long shadow.”
Co-author of the study Reshma Dhrodia
accounts, “Those who had been maltreated during
their childhood were also more likely to have
attempted suicide, with 16.9% of those sexually
abused and 12.4% of those physically abused having
made at least one suicide attempt.”
Co-author of the study Stephanie Baird says,
“A history of major depressive disorder quadrupled
the odds of suicide attempts. A history of anxiety
disorders, substance abuse and/or chronic pain
approximately doubled the odds of suicide attempts.
These four factors accounted for only 10% of the
association between suicide attempts and parental
domestic violence, but almost half of the association
between suicide attempts and childhood sexual abuse
or physical abuse. This suggests professionals working
with survivors of childhood adversities should
consider a wide range of interventions addressing
mental illness, substance abuse and chronic pain.”
Childhood adversities associated
with poor sleep in adulthood
C
hild adversities, which are known to play
an important role in mental and physical
health, including child abuse, parental
divorce and parental death, are associated with
higher rates of adult insomnia, according to
researchers at the University of Arizona. The
findings appeared in the journal Sleep in June,
2016.
The study showed that mild insomnia was
uniquely predicted by childhood abuse and
divorce, and moderate-severe insomnia was
uniquely determined by childhood abuse and
parental death.
Senior author of the study Michael Grandner
says, “Good quality sleep is an important part
of health. People who don't sleep well are more
likely to have worse physical and mental health.
In particular, insomnia can lead to decreased
quality of life, increased rates of depression, and
even increased risk of heart disease.”
Data for this study was assessed as part of the
Sleep and Healthy Activity Diet Environment
and Socialization (SHADES) study. The
Insomnia Severity Index was used to asses 1,007
adults between the ages of 22 and 60 years. The
participants self-reported psychosocial stressors
including child abuse, parental divorce, death
of a parent, or having a parent suffering from
depression or anxiety disorder.
Lead author of the study Karla Granados
says, “The fact that events that happen during
childhood can have an impact on sleep many
years later can help us to better understand
how sleep is related to health and better target
our efforts to address sleep problems in the real
world.”
10. New Therapist July/August 201610
Research
Average earnings Average earnings
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Sense of securitySense of security
Academicachievement
Positivementality
Academicachievement
Positivementality
Supportive Strict Indulgent Easygoing Harsh Average
(Left) Parenting methods (supportive, strict, indulgent) and their effects on children's success
(Right) Parenting methods (easygoing, harsh, average) and their effects on children's success
Credit: (Kobe University Center for Social Systems Innovation, Communications Division)
Parenting styles predict child’s
happiness, income and success
C
hildren who receive positive attention and care
from their parents tend to have high incomes,
high happiness levels, academic success, and
a strong sense of morality, according to researchers at
Kobe University, Japan. The findings were presented as
a discussion paper at the Research Institute of Economy,
Trade and Industry (RIETI) in June, 2016.
The authors of the study administered an online
survey to gather responses from 5,000 participants
about their relationships with their parents during
childhood. Using this data, they identified four key
factors: (dis)interest, trust, rules, and independence,
as well as "time spent together," and "experiences of
being scolded." Based on their results, the research
group divided parenting methods into the following 6
categories:
Supportive:
High or average levels of independence, high levels
of trust, high levels of interest shown in child, large
amount of time spent together
Strict:
Low levels of independence, medium-to-high
levels of trust, strict or fairly strict, medium-to-
high levels of interest shown in child, many rules
Indulgent:
High or average levels of trust, not strict at all,
time spent together is average or longer than
average
Easygoing:
Low levels of interest shown in child, not strict at
all, small amount of time spent together, few rules
Harsh:
Low levels of interest shown in child, low levels of
independence, low levels of trust, strict
Average:
Average levels for all key factors
The results demonstrated that people who had
experienced "supportive" child-rearing, where
parents paid them a lot of positive attention, reported
high salaries, academic success, and high levels of
happiness. On the other hand, participants subjected
to a "strict" upbringing, where parents paid them high
levels of attention combined with strict discipline,
reported high salaries and academic achievement, but
lower happiness levels and increased stress.
11. Indispensable survival guide for the thinking psychotherapist 11
Research
Childhood hunger linked to violence
later in life
C
hronic hunger in childhood leads to a
greater risk of developing impulse control
problems and engaging in violence,
according researchers at the University of Texas,
Dallas. The findings appeared in the International
Journal of Environmental Research and Public Health,
in June, 2016.
The researchers used data from the National
Epidemiologic Survey on Alcohol and Related
Conditions to examine the relationship between
childhood hunger, impulsivity and interpersonal
violence. Participants in that study responded to a
variety of questions including how often they went
hungry as a child, whether they have problems
controlling their temper, and if they had physically
injured another person on purpose.
The authors of the the study note that children
who often experienced hunger as children were
more than twice as likely to exhibit impulsivity
and injure others intentionally as adolescents and
adults.
Of the participants reporting frequently going
hungry as children, 37% reported involvment in
interpersonal violence. In comparison only 15% of
their study counterparts who reported little or no
hunger demonstrated involvement in interpersonal
violence. The findings were strongest among
whites, Hispanics and males.
Previous studies have shown that childhood
hunger contributes to a variety of other negative
outcomes, including poor academic performance.
The study is among the first to find a correlation
between childhood hunger, low self-control and
interpersonal violence.
Lead author of the study Alex Piquero says
“Good nutrition is not only critical for academic
success, but now we're showing that it links to
behavioral patterns. When kids start to fail in
school, they start to fail in other domains of life.”
Low maternal thyroid hormone during
pregnancy heightens risk of
schizophrenia in offspring
L
ow levels of the thyroid hormone
thyroxine during pregnancy, referred to
as hypothyroxinemia, are associated with
abnormalities in cognitive development similar to
those in schizophrenia, according to researchers at the
University of Turku, Finland. The authors of the study
note that hypothyroxinemia is also associated with
preterm birth, another risk factor for schizophrenia.
The research findings appeared in the journal Biological
Psychiatry in June, 2016.
To determine whether hypothyroxinemia is
associated with schizophrenia, the authors of the study
examined thyroxine levels in archived serum samples
from 1,010 mothers of children with schizophrenia
and 1,010 matched control mothers. The sera were
collected during the first and early second trimesters of
pregnancy.
Comprehensive Finnish registries of the population
and psychiatric diagnoses provided information on case
status (schizophrenia or control) among offspring of
mothers corresponding to the prenatal serum samples.
The authors found that 11.8% of people with
schizophrenia had a mother with hypothyroxinemia,
compared with 8.6% of people without schizophrenia.
This suggests that children of mothers with
hypothyroxinemia during pregnancy have increased
odds of developing schizophrenia. The association
remained even after adjusting for variables strongly
related to schizophrenia such as maternal psychiatric
history and smoking.
This study did not address the cause of this
association, but did find that adjusting for preterm birth
lessened the association between hypothyroxinemia
and schizophrenia, suggesting that preterm birth may
mediate some of the increased risk.
Lead author of the study David Gyllenberg notes
that the importance of this paper is that it “links
the finding to an extensive literature on maternal
hypothyroxinemia during gestation altering offspring
brain development.”
Senior author Alan Brown emphasized that, “this
work adds to a body of literature suggesting that
maternal influences, both environmental and genetic,
contribute to the risk of schizophrenia. Although
replication in independent studies is required before
firm conclusions can be drawn, the study was based
on a national birth cohort with a large sample size,
increasing the plausibility of the findings.”
13. Indispensable survival guide for the thinking psychotherapist 13
Psychotherapy integration (PI)
is an inherently paradoxical
project. Although the majority
of practicing mental health
professionals describe themselves
as ‘integrative’ (Lambert et al
2004), PI is probably the least
developed, taught, theorized and
researched of all psychotherapy
approaches. PI is a modality of
therapy in its own right, yet its
very basis rests on opposition to
the notion of modalities.
One way of thinking about
these ironies is to see them as
an example of the ‘Esperanto
problem’. Esperanto—perish the
thought Brexiters—is a language
devised with the laudable aim
of integrating the variety of
European languages, transcending
national differences, and
promoting collaboration and
cooperation. But few are fluent in
Esperanto, and for none is it a first
language. Human sociobiology
insists that we learn our ‘mother
tongue’ before we speak second
or third languages—desirable
as these later acquisitions are.
And so it is with psychotherapy.
Training as a therapist generally
starts with becoming conversant
with a primary modality of
therapy; integration comes later.
Nevertheless the leitmotiv of this
article is that awareness of the
different therapeutic modalities,
and the overlaps and differences
between them, is likely to enhance
the skillfulness of therapists at all
levels.
Dimensions of PI
Let’s focus on three distinct senses
in which PI is used.
a) Integration in practice
This is integration seen from the
perspective of the practitioner
on the ground, wanting to bring
together the best approaches and
By Jeremy Holmes
Why psychotherapy integration
trumps brand loyalty
Features The urge to integrate
14. New Therapist July/August 201614
techniques available for the benefit
of her patient. It can take one
of two forms. One is eclecticism,
where the practitioner employs
different techniques as ‘add-on’
to a basic mono-therapy. The
psychoanalytic therapist treating
an anxious patient might suggest
anxiety ratings, a CBT-derived
procedure, while remaining mainly
within a relational psychodynamic
framework; a spouse might be
invited to join on-going individual
therapy for a few session if it is
thought that systemic factors were
interfering with progress. This
eclectic ‘smorgasbord’ approach
sounds sensible, but runs the
risk of enactments on the part of
therapists who indulge in model-
hopping rather than sticking to
the task and working through
difficulties.
The second type of pragmatic
integration is ‘integrationism’.
Eclecticism is a species of ‘mezze’
in which a number of dishes
are presented separately but on
the same plate; integrationism
combines different approaches into
a novel concoction that draws on
existing ingredients but creates a
new whole. An example would be
Ryle’s (1990) Cognitive Analytic
Therapy (CAT), ‘cognitive’ in
that it is collaborative, symptom-
focused and uses rating scales
to track progress; analytic in
that the therapeutic relationship
is a primary focus of interest;
innovative (indicating ‘hybrid
vigour’) in that it uses letters from
therapist to patient, and formulates
problems in terms of ‘reciprocal
role procedures’, ingrained patterns
of interpersonal ‘dance’, an
approach unique to CAT.
b) Theoretical Integration
The focus in theoretical
integration is primarily linguistic
and philosophical. Here PI
questions whether different
therapeutic modalities reflect
real differences, or represent
different ways of describing similar
phenomena. Schema-focused
CBT (Young 1994) identifies the
fundamental assumptions about
relationships that determine a
person’s world-view; Object-
Relations psychoanalysis speaks
of ‘internal objects’ which form
the relational template driving
thoughts and actions. Here two
divergent monotherapy traditions
focus on comparable concepts.
But whatever the theoretical
overlaps, as therapies they diverge:
schema-focused therapy uses
direct cognitive challenges to
‘dysfunctional schemata’, while an
Object Relations approach targets
transferential ways in which object
relations manifest themselves.
An example of theoretical
integration is exemplified by
Ablon & Jones’ (1998) archival
outcome study of CBT and brief
psychodynamic therapy. Treatment
records were examined by an
independent group of researchers
who found discrepancies between
therapists’ espoused models,
and their actual behaviour in
sessions. Irrespective of belief,
‘psychodynamic’ factors were
best predictors of good outcome,
especially a positive working
alliance and the capacity of the
therapy to facilitate ‘experiencing’
of previously warded-off affect.
c) Common factors
The common factors approach,
initiated by Frank (1991), suggests
there is a number of general
healing processes that apply to all
effective therapies; PI’s task is to
identify, categorize and research
these. A doughty proponent of this
tack has been Wampold (2001).
He argues that the lion’s share of
the ‘effect size’ for psychotherapy
derives from common factors,
while the contribution of specific
techniques represents but 8% of
the outcome variance.
Attachment approaches
to common Factors
An evidence base for the common
factors approach derives from
attachment theory, offering a
meta-position from which to view
psychotherapy practice (Holmes
2010). Common features of all
therapies include the therapeutic
relationship, meaning-making
and mutative interventions,
all of which have attachment
ramifications.
Features The urge to integrate
‘ ’
The common factors approach,
initiated by Frank (1991), suggests
there is a number of general healing
processes that apply to all effective
therapies; PI’s task is to identify,
categorize and research these.
15. Indispensable survival guide for the thinking psychotherapist 15
The therapeutic
relationship
Sensitivity
The attachment behavioural
system triggers proximity-seeking
to a secure base in those who are
threatened, separated or ill; in
the case of children, one who is
‘older and wiser’. Once soothed
and safe, the sufferer can once
more explore his or her world,
inner or outer, in the context of
companionable interaction with
a co-participant. This model
applies to various aspects of the
therapist-client relationship: the
initiation of therapy; starting
sessions; in-session moments of
emotional arousal. Since a central
therapeutic aim is eliciting and
identifying buried feelings, there
will, in the course of a session, be
a cyclical iteration between affect
arousal, activation of attachment
behaviours and their assuagement;
companionable exploration of
the triggering feelings; further
affective arousal etc.
Attachment and empathy,
apparently abstract concepts,
are ultimately psycho-physical
phenomena—a common factors
link between predominantly verbal
therapies and body psychotherapy.
Proximity is sought—tactile
(hugging), auditory (via a
telephone), or visual (a picture,
which may be in the ‘mind’s eye’).
This lowers arousal—slowed heart
rate, less sweating, and releases
oxytocin (Zeki 2009). The physical
posture and tone of voice of the
client reveals his or her emotional
state. The therapist imaginatively
or physically (via contingently
marking and so altering their
own posture) mirrors this state,
which, in turn, via ‘mirror neurons’
triggers a version of the client’s
emotional state in the therapist’s
receptive apparatus. This can then
be introspected, identified, and
verbalised.
From an attachment
perspective, the therapeutic
relationship can be seen as the
result of two opposing sets
of forces. On the one hand,
therapists attempt to provide
secure attachment experiences—
identifying and assuaging anxieties
and despair and facilitating their
understanding. On the other,
patients approach the relationship
with prior expectations of sub-
optimal care-giving, unconsciously
assuming an unloving and/or
untrustworthy, or narcissistically
self-gratifying care-giver. The the
primary aim is for a modicum of
security.
The first step in any therapy is
the therapist’s facial, verbal and
postural ‘marked mirroring’ of
the patient’s affective states. Step
two is affect-regulatory, as the
therapist ‘takes’ the communicated
feeling and, through facial
expression, tone of voice and
emphasis, modifies or ‘regulates’
it. Softly expressed sad feelings are
amplified, perhaps with a more
aggressive edge added; manic
excitement soothed; vagueness
of tone sharpened. The security
associated with being understood
leads to enlivenment on the part of
the patient. This in turn opens the
way for companionable exploration
of the content or meaning of the
topic under discussion. Mirroring
here becomes dialogical, as the
therapist communicates to the
patient that he has heard and felt
her feelings, co-regulates their
intensity, and points to the sadness
that underlies mania, or anger as
an unacknowledged feature of
depression
An integrative approach to
psychotherapeutic work sees a
crucial component in psychic
change as the exposure to
previously avoided or warded-
off mental pain and trauma.
Co-regulating emotional pain,
past and present, in safety enables
sufferers to gain perspective on
the unexpressed feelings that
bedevil their relationship with
themselves and their intimates.
Psychoanalytic approaches here
parallel the cognitive/behavioural,
even if the methods—‘in vitro’ (i.e.
the consulting room) spontaneous
free association and transference
interpretation, as opposed to ‘in
vivo’ (i.e. everyday life) pen-and-
paper self-observation and directed
homework exposure tasks—are
radically different.
A psychotherapy, however
empathic, that merely reflects back
what the patient brings without
challenge or elaboration will fail to
Features The urge to integrate
‘ ’
An integrative approach to
psychotherapeutic work sees
a crucial component in psychic
change as the exposure to
previously avoided or warded-off
mental pain and trauma.
16. New Therapist July/August 201616
precipitate change, which depends
on the continuous interplay
of sameness and difference.
Secure therapists redress their
client’s attachment insecurities,
while insecure ones more likely
reinforce them, going along with
avoidant client’s detachment, or
colluding with an anxious patient’s
demandingness.
Finally, in order to alleviate
client anxiety, the therapist
needs not just to be empathic
and challenging, but also to
communicate ‘mastery’ (with its
‘paternal’ resonance)—a sense
that she knows what she is doing,
is in control of the therapy and
its boundaries (without being
controlling), and is relaxed
enough to be aware of her own
contribution to the interpersonal
dynamic. Mastery and empathy
are not mutually exclusive, but
denote a good ‘primal marriage’
of sensitivity and power from
which clients can begin to tackle
difficulties.
Rupture and repair
On-going proximity and
availability, together with
intimate ‘knowing’—holding
in mind through absence and
interruption that is integral to
parental (and spousal) love—are
essential ingredients in a secure
base. But, like parents and
spouses, therapists regularly ‘get
it wrong’. Being misunderstood is
anxiety-augmenting and aversive,
triggering withdrawal and
avoidance and/or defensiveness and
anger. Just as security-providing
mothers are able to repair lapses
in attunement with their infants,
providing the ‘stress innoculation’
that is a feature of resilience, so
the capacity to repair therapeutic
ruptures’ (Safran & Muran, 2000),
is associated with good outcomes
in therapy. Therapeutically, the
aim is not so much to eliminate
misunderstandings as to mark
and then talk about them and the
feelings they arouse. Therapist
‘enactments’ (e.g. starting a session
late, drowsiness, inattention or
intrusiveness etc) need to be
non-defensively acknowledged.
Reflexively thinking about them by
therapist and client strengthens the
therapeutic bond, and is a change-
promoting manoeuvre, enhancing
clients’ capacities for self-awareness
and negotiating skills in intimate
relationships.
Meaning
Meaning-making is intrinsic to
all therapies. An explanatory
framework brings order to the
inchoate experience of illness,
whether physical or mental
(Holmes & Bateman 2002). A
‘formulation’ is both anxiety-
reducing in itself, and provides a
scaffolding for mutual exploration.
A symptom or troublesome
experience is ‘reframed’ via an
explanatory system, which helps
make sense of the sufferer’s mental
(or physical) pain. The use of the
word ‘sense’ here acknowledges
that meaning transcends mere
cognition and derives from bodily
experience.
In the consulting room,
accurate verbal identification
of feelings—i.e. the emergence
of shared meanings or ‘fusion
of horizons’ (Stern 2009)—is
in itself soothing. Therapy’s
meaning-making function
picks out significance from the
unending flux and free play of the
imagination. Once verbally ‘fixed’,
meanings can be collaboratively
viewed by therapist and patient
from all possible angles: tested,
refined, held onto, modified, or
discarded. This applies as much
to the predetermined categories
of Cognitive Therapies as it does
to the free play of new meanings
generated in analytic work.
How we talk about ourselves
and our lives, as much as what
we talk about, also reveals the
architecture of the inner world.
Secure narratives are ‘fluid and
autonomous’—neither over-,
nor under-elaborated, and able
to balance affect and cognition
in ways appropriate to the topic
discussed. Insecure narratives
may be dismissive and under-
elaborated, or suffused with
confusion and logical disjunctions.
Therapeutic conversations do not
just convey information, they are
also ‘speech acts’. Insecure clients
push their therapists away with
their tendency to dismissal, or by
immediately taking back what
they have said when the therapists
attempts to mirror and mark it.
Anxious clients draw the therapist
Features The urge to integrate
‘ ’
Mastery and empathy are not
mutually exclusive, but denote
a good ‘primal marriage’ of
sensitivity and power from
which clients can begin to
tackle difficulties.
17. Indispensable survival guide for the thinking psychotherapist 17
in, but then seem impervious to
the new perspectives therapists try
to suggest. The struggle here, in its
verbal form, is between clinging
to the comparative safety of an
outmoded past, and tolerating
the uncertainty of a richer, more
complex, but potentially less
troubled future.
Successful therapy is associated
with the replacement of insecure
by more secure narrative styles
(Avdi & Georgaca 2007), towards
the acquisition of ‘autobiographical
competence’ (Holmes 2001).
Therapists will ask: “Can you
elaborate on that?”; “What exactly
did you mean then?”; “I can’t quite
visualise what you are talking
about here; can you help?”; “What
did that feel like to you?”; “I’m
getting a bit confused here, can
you slow down a bit”; “There seems
to be something missing in what
you’re saying; I wonder if there is
some part of the story we haven’t
quite heard about?”. The good
therapist is probing for specificity,
visual imagery and metaphor that
enable her to conjure up, in her
mind’s eye and ear, aspects of the
patient’s experience.
Promoting change
How then do effective therapies
bring about change?
Corrective experiences
The provision of a secure
attachment relationship with a
therapist, experiencing rupture/
repair cycles and the co-regulation
of negative affect, all constitute
new and potentially corrective
experiences for many patients.
They underpin the emergence
of ‘epistemic trust’ (Fonagy &
Allisoon 2014) in which clients
benefit not just from therapeutic
relationship itself, but turn
towards the health-promoting
aspects of everyday life, work, and
relationships. Similarly, challenge
in the context of validation,
puts clients in ‘benign binds’:
given commitment to therapy
and inhibition of flight or fight
(although both may be manifest
in ‘speech acts’ of repression or
rejection), they cannot not change.
Skill acquisition:
mentalising
According to Gustafson (1986),
psychic change invariably entails
taking a perspective at a meta-
level, or ‘higher logical type’
from the problematic behaviour
or experience that has led the
sufferer to seek help. ‘Mentalising’,
or ‘mind-mindedness’, fulfils this
criterion. It can be defined as
the capacity to ‘see oneself from
the outside and others from the
inside’. Learning to move from
automatic impulse to reflecting on
one one’s own and others’ mental
states before making authentic
responses and choices is crucial to
therapeutic action (Allen 2003).
Therapy can be thought of as a
‘school for mentalising’.
An interesting common factors
challenge is to explore the possible
overlaps between the effectiveness
of mindfulness, an aspect of
‘third-wave’ CBT in preventing
relapse in depression, and the role
of mentalising, which similarly
provides a vantage point from
which to view oneself and one’s
relationships in more detached and
imaginative ways. Clients come
away from therapy having both
learned to manage their emotions,
and, if overwhelmed, to seek
appropriate co-regulation from
parents partners or friends.
Towards a complexity
model of therapeutic
skills
As mentioned, the research
evidence shows little or no
correlation between therapy
outcomes and modality (Miller
et al 2013). Two crucial
factors however do seem to be
important. The first is duration
of therapy—on the whole, the
longer the therapy the better the
outcomes, although there may be
‘diminishing returns’, in which
gains decrease with time.
The second key determinant of
outcome is therapist skill. ‘Super-
therapists’ seem to have the knack
of getting almost all of their clients
better; a few produce little change
or even deterioration; most of us
lie somewhere in the middle. As
with proficiency in languages,
music or sport, psychotherapeutic
Features The urge to integrate
‘ ’
‘Super-therapists’ seem to have
the knack of getting almost
all of their clients better; a few
produce little change or even
deterioration; most of us lie
somewhere in the middle.
18. New Therapist July/August 201618
skilfulness rests on ‘deep domain-
specific knowledge’, acquired
through persistence; accumulated
experience; and the ability to
seek and respond to feedback.
Recent studies have confirmed
the importance of the latter;
mediocre therapists improve
dramatically when client feedback
is incorporated into their routines
(Lambert et al 2004). Similarly
secure attachment is characterised
by a dialogic relationship between
care-giver and care-seeker,
in contrast to the one-way or
distorted communication channels
typical of insecure attachment. All
told, these factors suggest a more
complex model of our work than
is typically espoused by mono-
therapy.
Psychotherapy outcome
research requires ‘manualisation’
of therapist’s procedures and
measuring ‘adherence’ in order
to determine the ‘purity’ of
what the client receives. From
a psychotherapy integration
perspective, this has major
limitations. First, many studies
show little or even negative
correlation between manual-
adherence and good outcome.
Second the model is predicated on
a simplistic, linear ‘drug metaphor’,
inappropriate for psychotherapy.
Therapy is a complex system’
(Mitleton-Kelly & Land
2004), having more in common
with weather systems or the
vagaries of economies than with
pharmacology.
One feature of complex
systems is that small variations
in initial conditions may produce
big differences in outcomes
in periods of instability—the
proverbial beat of a butterfly’s
wing in Brazil launching a
tornado in Texas. Computer-
based weather forecasting gets
round this by generating a large
number of possible climatic
scenarios, each based on minute
differences in initial conditions.
The confidence or otherwise of
predictions depends on accord
between the different picture.
Furthermore, catastrophic, albeit
unlikely, possibilities also need to
be taken into account. Accuracy
improves with continuous feedback
between predictions and real-world
outcomes.
An integrative perspective on
psychotherapy would suggest that
comparable processes go on in
consulting rooms. In any specific
clinical relationships, skilful
therapists draw on an intuitive
or preconscious array of possible
outcomes. Their interventions are
adjusted accordingly in the hope of
producing change, and outflanking
transferential ‘eternal return’, as
well as taking possible risks, such
as drop-out, suicide or violence
into account.
Conclusions
The primary integrative
psychotherapy argument holds
that psychotherapy processes are
best understood by theoretical
perspectives beyond those
immediately espoused by its
practitioners. Freeing oneself
from dogma (including dogmatic
views on attachment!) may lead to
better therapy, productive research
questions and a focus on the
common mutative ingredients of
all psychotherapeutic processes—
the ultimate goal of psychotherapy
integration.
PI is in the curious position
of being both a leading edge
in psychotherapy thinking
and research, and a nostalgic
reminder of bygone hopes that
psychoanalytic and cognitive
behaviour therapists could learn to
talk with, and value, one another.
The majority of practitioners will
continue to subscribe to one form
or another of PI. Their academic
and cultural leaders meanwhile
perseverate in promulgating their
own brands of therapy. Continuing
cross-fertilization between
different modalities, and the search
for mutative factors are continuing
tasks for our pluralistic polyvocal
Features The urge to integrate
‘ ’
PI is in the curious position of being
both a leading edge in psychotherapy
thinking and research, and a
nostalgic reminder of bygone hopes
that psychoanalytic and cognitive
behaviour therapists could learn to
talk with, and value, one another.
19. Indispensable survival guide for the thinking psychotherapist 19
profession.
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How expert clinicians’ prototypes
of an ideal treatment correlate
with outcome in psychodynamic
and cognitive- behavioral therapy.
Psychotherapy Research, 8, 71–83.
Allen, J. G. (2003). Mentalizing.
Bulletin of the Menninger Clinic, 67,
87-108.
Avdi, E. & Georgaca, E. (2007)
Narrative research in psychotherapy:
a critical review. Psychology and
Psychotherapy: Research and Practice. 78
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Fonagy, P. & Allison, E. (2014) The
role of mentalising and epistemic
trust in the therapeutic relationship.
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Frank, J. (1991) Persuasion and
Healing. 3rd Edition. Baltimore: Johns
Hopkins Press.
Gustafson, J. (1986) The Complex
Secret of Brief Psychotherapy. New York:
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Holmes, J. (2001) The Search for the
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Holmes J. (2010) Exploring in Security:
Towards and Attachment-informed
psychoanalytic Psychotherapy. London:
Routledge.
Holmes, J. & Bateman, A. (1992)
Psychotherapy Integration: Models and
Methods. Oxford: Oxford University
Press.
Features The urge to integrate
Lambert, M., Bergin, A., & Garfield,
S. (2004) Introduction and historical
overview. In: M. Lambert (Ed.)
Bergin and Garfield’s Handbook of
Psychotherapy and Behaviour Change.
5th Edn. Pp 3-15. New York: Wiley.
Miller, S., Hubble, M., Chow, D.,
& Seidel, J. (2013) The outcome of
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tomorrow. Psychotherapy. 50 88-97
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systems In: Cooper, Cary and
Argyris, Chris and Starbuck, William
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Safran, J. & Muran, J. (2000)
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relational treatment guide. New York:
Guilford.
Stern, D. (2009) Partners in Thought.
London: Routledge.
Wampold, B. (2001) The Great
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Young, J. (1994) Cognitive therapy for
personality disorders: a schema-focussed
approach. Sarsota, Fl: Professional
Resource Press.
Zeki, S. (2009) The Splendours and
Mysteries of the Brain. Chichester:
Wiley-Blackwell.
For 35 years professor Jeremy Holmes was
consultant psychiatrist and psychotherapist
in the NHS first at UCL and then in N
Devon. He was chair of the psychotherapy
faculty of the Royal College of Psychiatrists
1998-2002. He set up and teaches on
the Masters/Doctoral Psychoanalytic
PsychotherapyTraining and Research
Programme at Exeter University; where he
is visiting professor; and lectures nationally
and internationally.
He has written over 200 peer reviewed
papers and chapters in the field of
attachment theory and psychoanalytic
psychotherapy. His many books, translated
into 9 languages, include the best-selling
John Bowlby and AttachmentTheory;
TheTherapeutic Imagination: Using
Literature to Deepen Psychodynamic
Understanding and Enhance Empathy;
Attachments: Psychiatry, Psychotherapy,
Psychoanalysis and Psychiatry; Storr’s
The Art of Psychotherapy; Exploring
In Security:Towards an Attachment-
informed Psychoanalytic Psychotherapy.
He also co-edited: The OxfordTextbook
of Psychotherapy; Benchmarks in
Psychology: AttachmentTheory (A
6-volume co-edited compendium of the 100
most important papers in attachment) and
Past, Present and Prospect.
He was recipient of the 2009 NewYork
Attachment Consortium Bowlby-Ainsworth
Founders Award, and the 2013 BJP
Rozsika Parker Prize.
About the author
20. New Therapist July/August 201620
CATalytic
Exploring Cognitive
Analytic Therapy
(CAT)
Features CATalytic
21. Indispensable survival guide for the thinking psychotherapist 21
T
Introduction by John Soderlund
ony Ryle began his career in a
private general medical practice
in the UK and, in the sixties,
moved to the University of Sussex
to provide healthcare services to
students. Fueled by his socialist
and egalitarian ethics, he aimed to
provide a stripped-down, personal
approach to helping people with a
wide range of health problems. But
he was also constantly aware of the
psychological issues at play among
so many of his patients.
A growing interest in these
psychological ideas stayed with him
through his own psychoanalytic
supervision and into his gradual
transition into a more psychological
role in his practice. He found that
the work was centred on identifying
and confronting the ways in which
patients were failing to revise
manifest but unrecognised harmful
ways of thinking and acting. He
wrote:
“I have had a lifelong ambivalence
towards psychoanalysis but my
attitude was not simply negative
and I was glad of its guidance
when my listening to patients began
to evoke powerful transference
attachments and rejections, and I
welcomed the attempt it made to
understand personality in terms of
developmental processes.”
He put together a more formal
model based on his ambivalent
relationship with psychoanalysis in
the early 1980s, calling it Cognitive
Analytic Therapy (CAT). He
describes it as:
“an approach which maintains
as its core features the early
description of problem procedures
through the joint work of the
patient and therapist, the use of
these descriptions by the patient
to recognise and control damaging
ways of acting and their use by the
therapist to avoid reciprocating
and reinforcing such damaging
patterns.”
Ryle’s next career move, as
Psychotherapy Consultant at Guy’s
Hospital, allowed him to more
thoroughly test, refine and expand
the use of CAT in a public health
setting. As the only psychotherapist
serving a population of about
180,000, he clearly had to decide
where to put his energy. He focused
on training and service provision,
and while a proportion of junior
psychiatrists worked with him, it
became clear that the only way to
provide a service was to attract non-
medical trainees. Scores of social
workers, occupational therapists,
nurses and others started requesting
supervision of their work. “They
proved an excellent resource but
the rapid growth in referrals
would not have been coped with
but for the parallel accelerating
demand for CAT training which
yielded an inexhaustible supply of
trainees from outside the hospital,
prepared to see patients in return
Features CATalytic
22. New Therapist July/August 201622
‘ ’for supervision,” the Association
for Cognitive Analytic Therapy
(ACAT) website recounts (see
http://www.acat.me.uk for more).
Very few patients received
long-term treatment and the vast
majority, including those with
diagnoses of personality disorders,
received between 12 and 16 sessions
of CAT. The majority of patients
received their therapy from trainees.
Ryle retired in 1992, but retained
a role in developing CAT, training
and supervision. In 2010, he
stopped working altogether and, at
the time of writing, was 89 years of
age. He declined to be interviewed
on the approach, but Elizabeth
McCormick, a psychotherapist and
author who was involved with the
method from the early days in Guy’s
Hospital, in 1984, agreed to an
interview shown below. McCormick
is a trustee of ACAT and the author
of a number of psychological self
help books including Change For
The Better, the CAT self help book
which has been translated into
several languages.
So, what is CAT?
CAT, according to the Association
of Cognitive Analytic Therapy’s
website, aims to offer the following
to prospective clients:
1. Thinking about yourself
differently;
2. Finding out what your problems
and difficulties are; how they
started; how they affect your
everyday life—your relationships,
your working life and your
choices of how to get the best out
of your life;
3. Getting under the limitations
of a diagnosis or ‘symptom
hook’ (that is, understanding
the reasons that underlie a
symptom such as bulimia), by
naming what previously learned
patterns of thinking or behaving
contribute to difficulties and
finding new ways of addressing
them within yourself;
4. Thinking about the importance
of relationships in your
psychological life. This includes
the relationship you have with
yourself, and the relationship you
have with the therapist.
At first blush, this looks a lot
like a selection of concepts and
perspectives from psychodynamic
thinking and some that might
be understood to have their roots
in cognitive and behavioural
approaches. In a more Rogerian
tradition, the model stresses the
collaborative and egalitarian nature
of the therapist/client relationship
and the active involvement of the
client in setting the treatment
agenda. In a nod to systemic
thinking, CAT tries to locate the
client’s problems in the context in
which they are located, examining
how this might encourage
adherence to long-established
relational and affective patterns.
The more egalitarian and
collaborative flavor of CAT, it
would seem, arose at least in part
from Ryle’s disaffection with the
more formal, top-down nature of
psychoanalytic paradigms. But he
retains an analytic sensibility in
frequent references to the likelihood
that old relational patterns are
likely to manifest in the present
and in the therapy room. And
termination of therapy is singled
out as a potentially difficult process
for which special considerations
are made to ensure it is not unduly
jarring—certainly not an overriding
concern of CBT approaches.
Ryle’s move away from some
of the features of analytic therapy
are reflected in the less formal,
more common-sense approach it
adopts. Largely absent are the dark,
mysterious unconscious libidinal
and oedipal proclivities for which
classical analysts are constantly on
the prowl. Further, given the very
active involvement of the client in
setting the therapeutic agenda, one
might expect less easily manageable
or unusual unconscious material to
be largely absent from the average
CAT therapeutic encounter.
But CAT is equally non-analytic
in the more forumalaic, even
manualised, framework in which
it is wrapped. Examples of this
include:
1. A 16-24-session
recommendation.
2. The use of grid-like survey tools,
including “The Psychotherapy
File”, which invites patients to
examine their Traps, Dilemmas,
Snags, and Unstable States of
Mind, all concepts developed
by Ryle. These paper and pen
analyses, says the website, help
the patient “to focus accurately
Features CATalytic
In a nod to systemic thinking, CAT
tries to locate the client’s problems in
the context in which they are located,
examining how this might encourage
adherence to long-established
relational and affective patterns.
23. Indispensable survival guide for the thinking psychotherapist 23
on exactly what sorts of
thinking or behaving contribute
to things going wrong”.
3. Symptom monitoring from one
session to the next.
4. The use of the “Reformulation
Letter” by the therapist to make
more explicit what the patient is
seeking to address in therapy.
Essentially, CAT presents as a
thoroughly integrative approach,
incorporating some of the
most widely espoused views on
what is likely to be important
in any therapeutic endeavor.
Psychoanalysts might well
scoff at its prescriptive, paint-
by-numbers approach (which
no doubt helps when largely
untrained professionals are being
trained to use it). They might also
wonder about the extent to which
resistance and defenses are left
unchallenged, sidelined as they
might be by the heavy influence
of the client in determining the
focus of treatment. No doubt, they
would also doubt the usefulness of
so tightly restricting the focus of
treatment with a Reformulation
Letter.
By the same token, CBT
purists might eschew the value
of the meandering into the
historical origins of maladaptive
affective and behavioural
patterns, particularly when the
number of sessions is so limited.
And they would question the
value of focusing on any kind
of transferential manifestations
thereof when therapy is so short-
lived. And Rogerians might find
the sessions too heavily driven by
a didactic philosophy of writing,
assessing and staying on the
straight-and-narrow focus of
treatment.
But, notwithstanding CAT’s
tolerant attitude to such a wide
range of influences, it is of
particular interest in that it has
been used extensively in public
health settings, where resource
restraints and bureaucratic
pressures are heavily at play. The
question of arguably greatest
interest is how effective it is.
That’s also a question in much of
the psychotherapy effectiveness
research that is hard to answer
or at least begs a whole range
of other questions, such as the
countless variables—apart from
the manualised CAT treatment
protocols—that might be to
account for any changes it appears
to bring about.
ACAT lists a modest number
of research studies into CAT’s
effectiveness across a range of
conditions and, by refreshing
contrast to so many other “brands”
of therapy, is modest in its claims
about the model’s efficacy for
which there is not significant
research support.
With a view to getting a
more nuanced picture of the
current state of CAT as a widely
used therapeutic approach, we
spoke to Elizabeth McCormick,
a psychotherapist, author and
ACAT Trustee. Her responses are
complemented by selected writings
of Tony Ryle.
Kelly’s Repertory Grids
George Kelly’s Repertory Grids,
developed in the mid 1950’s, was
an interviewing technique designed
to provide a map from which
interpretations about a patient’s
personality patterns can be made.
Tony Ryle used it extensively for
around 15 years of his work prior to
developing CAT and it is credited
with informing much of his thinking.
Repertory Grids are embedded
in Kelly’s wider ranging Personal
ConstructTheory.
A grid consists of four parts:
“A topic”, which is the area of
the person's experience under
examination. A topic may be one’s
interest in attending the theatre.
A set of elements, or are examples or
instances of the topic. For example,
if I intend to go to the theatre, a
list of preferred plays for my own
preferences would constitute a set of
the elements.
A set of “constructs”, or the essential
terms by which the client makes
sense of or evaluates the elements.
These are always expressed as a
contrast.The theatre performance
may be dramatic or undramatic or
conservative or experimental.
A set of ratings of Elements on
Constructs, which would typically
be rated on a 5- or 7-point scale.
This grid-like structure is populated
repeatedly for all the constructs
that apply; and thus its meaning
to the client is captured, and
statistical analysis varying from
simple counting, to more complex
multivariate analysis of meaning, is
made possible.
Features CATalytic
24. New Therapist July/August 201624
Speaking CATology, on:
1.)Traps;
2.) Dilemmas;
3.) Snags;
4.)Target problems;
5.) Aims and
6.) Exits
Central to the theory of CAT is the use of the concepts
of traps, dilemmas and snags, all of which are outlined
to clients in their “psychotherapy file”, a document
provided at the outset of therapy that helps them to
build a conceptual picture of the mechanics of the
problems that bring them to therapy.
1.)Traps
Traps are described as cyclical patterns that tend
to become self perpetuating. They closely resemble
the negative thinking patterns of cognitive
therapy. An example is shown below (used with
permission from the ACAT web site). Traps are
tackled in therapy by first identifying their internal
dynamics and then by examining possible “exits”
from the vicious cycle.
Features CATalytic
Fear of hurting other people's feelings trap
I believe it's wrong for me
to be angry or aggresive
I am afraid that I will hurt
other people's feelings
So I don't express my own
feelings or needs
With the result that I get
ignored or abused
Which makes me feel angry
but it feels childish to be angry
25. Indispensable survival guide for the thinking psychotherapist 25
2.) Dilemmas
Dilemmas are just that. But they are cast in CAT as
absolutist, either/or dichotomies that are not unlike
the black and white thinking of CBT or the splitting
of psychoanalytic thought. Managing dilemmas
Features CATalytic
requires teasing out the ideas that lie between the
absolute extremes that clients usually present as their
only options. An example of a dilemma is shown
below.
Feeling
Upset
I feel expressing my
feelings doesn't work
Others respond by attacking
me or rejecting me
Others feel hurt, attacked,
overwhelmed, threatened
OR I express my
feelings explosively
I feel that bottling up feelings
doesn't work
EITHER I bottle up my
feelings
Others ignore me, take
advantage of me or abuse me
Others don't notice
I'm upset
Upset feelings dilemma
26. New Therapist July/August 201626
3.) Snags
Snags are at work when we present a desired change
in our circumstances but follow it with a reason why
that change is unattainable. The snags can be varied in
their origin but are usually couched in a script or logic
that needs to be unpacked before it can be overcome.
4.)Target problems
Target problems are the identified issue(s) that
gave rise to the reason(s) for seeking therapy. A
typical one might be protracted grief arising from
the death of a relative or constant anxiety about
actual or potential conflict with others at work.
Features CATalytic
They might be injunctions from one’s family of origin
or from one’s current context. But they usually don’t
stand up to the scrutiny of therapy. A typical example
might be:
I want to change snag
I want to change
the way I am
I make plans to be
different
But I don't go through with
them, or I sabotage or spoil
my plans
Because others will be upset or
deprived, or deep down I feel
I don't deserve good things
Which leaves me feeling
frustrated and miserable
5.) Aims
Clients are encouraged to set therapeutic goals
or ‘aims’ in relation to the target problems. These
usually begin as rather vague statements and are
refined into better articulated expectations and
outcomes during the course of therapy. They
might be something like an aim to feel less grief
stricken and alone following a bereavement or
to feel less crippled by anxiety over potential
conflict with others at work.
6.) Exits
Exits are the kinds of solutions that clients and
therapists craft together during therapy as ways
out of the various cycles outlined above. They
are typically alternative behaviours or logical
processes that short-circuit the cycle at one or
more points with a view to interrupting the
identified dysfunctional pattern.
27. Indispensable survival guide for the thinking psychotherapist 27
New Therapist: Can you outline the
key philosophical underpinnings of
CAT that would help us to understand
how it differs in its essential
philosophy from other integrative
psychotherapeutic approaches?
Elizabeth McCormick: The
practice of CAT is based upon a
collaborative therapeutic position,
which aims to create, with patients,
narrative and diagrammatic
reformulations of their difficulties.
The theory focuses on descriptions
of sequences of linked external,
mental and behavioral events.
Ideas drawn from Kelly’s
personal construct theory inform
CAT that patients can learn to
recognize unhelpful patterns and
learn new ones; they can be trusted
to take part in the therapeutic
work. In this way, CAT differs
from therapies where patients feel
either “done to” or their symptoms
interpreted. The cognitive
underpinning helps to make clear
and accurate descriptions of what
often in psychotherapy are complex
ideas. CAT uses the patients
own words and each therapy is
focused on what the patient can
use, thus making it available to
patients from many different
backgrounds and presentations.
Object Relations theory, largely
drawn from Donald Fairbairn and
Harry Guntrip and Thomas Ogden,
informed the early understanding
of patterns of relating in CAT
and the introduction of Vygotsky’s
understandings of the social
and historical formation of
higher mental processes and of
the key importance in human
learning of sign mediation, linked
with Bakhtin’s illuminating
understanding of the role of
interpersonal and internal dialogue,
allowed a radical restatement
of object relations ideas. CAT’s
collaborative approach and the way
the therapy seeks to get “under the
symptom hook” invite a shared
experience, and the letter writing
and diagram creating gives patients
tools and material to keep in
awareness.
Tony Ryle writes: “In practice,
generalised descriptions of past and
present relationship patterns are
developed jointly with patients and
are recorded:
1. In a reformulation letter,
offering a narrative account of the
evident sources and nature of their
difficulty, and
2. In sequential diagrams tracing
their recurrent, damaging
interpersonal and intrapersonal
patterns. Involving patients
in the joint construction of
these verbal and diagrammatic
descriptions of what needs to be
changed establishes a cooperative
relationship, sets the agenda
of therapy, enlarges patients’
psychological awareness and
supports their development of
a greater sense of responsibility
and agency. It allows therapists to
anticipate dysfunctional patterns
that may be mobilized in the
therapy relationship. The work of
reformulation is itself powerfully
therapeutic and many symptoms
and problematic behaviours fade
without being directly addressed.”
Features CATalytic
Interview with Elizabeth McCormick,
psychotherapist, author and ACAT Trustee
28. New Therapist July/August 201628
NT: In drawing a distinction between
CAT and CBT, would it be fair to say
that CAT focuses more on the here and
now of the therapeutic reenactments
of earlier relational patterns and that
these form the focus of therapy?
Tony Ryle writes: The early
description of Target Problems
resembled CBT practice but the
creation of descriptions of the
hitherto unrecognized patterns of
thought and action which therapy
would seek to modify, expressed
as Target Problem Procedures, is a
feature of CAT.
CAT seeks to offer a
comprehensive understanding of
human psychology and involves
therapists in forming real, clearly
defined and therapeutically
powerful relationships with their
patients. In this respect it is a
“psychodynamic” theory and is
clearly differentiated from CBT.
The understanding of human
psychological development and of
therapeutic change moved from the
traditional focus, characteristic of
CBT, on individual, ‘in-the-head’
processes to a radically social view
in which, on the basis of universal
and personal biological features,
individual personality is seen to be
formed and maintained through a
web of relationships and dialogue
with external and internalized
others (Ryle and Kerr, 2002).
Understanding the immense
complexity of human psychological
processes needs to be based
on an understanding of their
development. CBT provides a
model of learning but takes little
account of early development
and its effects upon psychological
structures. CAT, in contrast,
revised object relations theories
in ways that sought to eliminate
unverifiable assertions about “the
unconscious” and were consistent
with observational studies of early
development.
CAT offers a broad
understanding of the development
of personality through
relationships, consistent with
the observational studies of early
development of recent years,
and it offers a model of self and
interpersonal functions that
supports the use of the therapy
relationship to assist change.
These understandings guide the
application of a wide range of
techniques, some specific, others
derived or modified from other
models. From CBT, for example,
came the use of patient self-
monitoring to identify the events
associated with symptoms. This
technique was extended in CAT
by focusing self-monitoring on
the recognition of interpersonal
and self-management reciprocal
role procedures. Recognising
RRPs as they occur or are reported
in therapy sessions allows the
immediate discussion or initiation
of alternative understandings and
behaviours.
NT: Would CAT be encouraging of
transference and countertransference
interpretations by the therapist?
Elizabeth McCormick: CAT
theory draws upon a cognitive
revision of Object Relations
Theory, primarily Harry Guntrip
and Donald Fairbairn. The early
reformulation of patients’ histories
identifies learned patterns of
relating, which CAT calls reciprocal
role procedures (RRP’s). The
dance of relationship begins as
patients walk through the door and
both therapist and patient bring
their own repertoires of learned
relationship patterns. Naming
the patterns through accurate
description allows patients to
develop an understanding of how
they can be enacted within the
dance of relationship. CAT tends
not to use the term transference or
countertransference but uses the
understanding of the invitation to
the dance of named role procedures.
When this is shared and specifically
named on a diagram that is always
open in the room, it is possible to
remain aware of repeated unhelpful
dances and to ask the patient to look
at their diagram and ask: “Where
do you think that you and I are
right now?” This means that, rather
than relying on the therapist’s lone
position of countertransference
interpretation, the work of
understanding is shared. Usually,
in the prose reformulation, in
anticipation of the work within
therapy, therapists name how these
patterns are likely to be invited.
Their description in the prose
reformulation or in diagrammatic
form gives patients more control
over them.
Features CATalytic
’
CAT seeks to offer a comprehensive
understanding of human
psychology and involves therapists
in forming real, clearly defined
and therapeutically powerful
relationships with their patients.
29. Indispensable survival guide for the thinking psychotherapist 29
NT: What is the role of emotional
abreaction, if any, in CAT?
Elizabeth McCormick: CAT
does not specifically encourage
emotional abreaction as a form
of catharsis but the nature of the
time limit can invite an intense
“hot-house” experience. With
some presentations, patients may
allow what has previously been
disallowed, such as intense emotion,
because the ending of the work is
on the horizon from the beginning
and they know this will not go
on forever! This is one of CAT’s
strengths.
During the ending phase of a
traditional CAT there is often a
surge of difficulties and presenting
problems. This is a challenging
time but it is also an opportunity
for patient and therapist to look
together at the nature of the
chronically endured pain as it
appears in the room but which now
is shared and to see that there are
opportunities to be with this in
another way.
NT: To what extent has research into
CAT been able to determine whether
the level of training of its practitioners
received prior to CAT training has
an influence on outcome? In other
words, do qualified psychiatrists or
psychologists who are trained in CAT
achieve outcomes that are better or
worse than nurses or lay practitioners
whose only formal mental health
training is in CAT?
CAT attracts many different mental
health care professionals from
very different backgrounds. This
is one of its strengths and aligned
to the vision Tony Ryle had in
the early days for formulating a
therapy that could be learned by
people who already had a mental
health training. CAT is not a new
therapy but one that integrates
already well researched approaches.
The clear scaffolding and focus
of how to proceed within a CAT
therapy allows for many different
approaches for delivery. Art, music,
drama therapists, doctors, social
workers, psychologists, nurses,
yoga practitioners, counsellors and
psychotherapists all bring their own
different strengths into the therapy.
All CAT therapists have to have
their own therapy and supervision.
I have encouraged therapists in
training to bring themselves into
what they write and how they might
proceed when sitting in the room
with another person.
In my early days of supervision
with Tony Ryle at the Munro
Clinic at Guy’s hospital our group
playfully discussed the idea of
whether there could be what we
called Jungian, Freudian, Lacanian
CAT’s. In the 1990 Wiley edition
of Cognitive Analytic Therapy:
Active Participation in Change,
there is an account of a therapy that
was conducted only with dreams, as
the patient found the psychotherapy
file, one of the “tools” of CAT, too
dry and left it on the bus. We called
this a dream CAT.
Because the scaffolding of CAT
is so clear, it means that many
different approaches to being with a
patient may be offered. In the past
five years I have been integrating
mindfulness in CAT as the CAT
steps of stopping, noticing, standing
back and then trying something else
are a helpful structure for the steps
of mindfulness practice; stopping,
noticing, focusing, allowing kindly
whatever arises, stepping aside,
experimenting with curiosity.
NT: What is the purpose of the
“Reformulation Letter” and how is the
process of it made part of the therapy?
Elizabeth McCormick: The
reformulation letter, or prose
reformulation as it was called
originally, is a fundamental building
block in the therapeutic work. It is
offered around session four or five.
The aim is to name the patterns
that have led to things going wrong
using the patient’s own words
and in a useful and clear form,
avoiding technical terms or jargon.
The reformulation is read aloud
to the patient who is then given
a copy and invited to respond if
they wish to. This is often the first
time a patient’s struggles have been
understood in the context of their
lives and made sense of. Because it
is written by the therapist it forms
a therapeutic document with past,
present and future. It can also form
a “transitional object”, connecting
the patient with their inner life and
with the therapist as helper along
the path.
Features CATalytic
‘ ’
CAT does not specifically
encourage emotional abreaction
as a form of catharsis but the
nature of the time limit can invite
an intense “hot-house” experience.
30. New Therapist July/August 201630
NT: What does CAT mean when it
speaks of “unstable states of mind”?
Elizabeth McCormick: All of us
can recognize different states of
mind in relation to our everyday
lives—home, work, internal milieu.
When our learned response to
early care or neglect has had to be
fragmented to cope with intense
child-derived emotion, these states
can become unstable, and we may
shift from one state to another in
order to bear unmanageable feeling.
Unstable states and their equally
unstable invitations are often one
of the most challenging aspects
for the therapist. The naming and
mapping of states gives clarity to
the therapeutic work and can be
usefully shared.
Tony Ryle writes: The most
significant patterns acquired in
early life are concerned with issues
of care or neglect in relation to
need and over-control or cruelty
in relation to submission. The self
is normally multiple as individuals
acquire a repertoire of RRPs,
different ones being mobilised in
ways appropriate to the context.
“Normal” multiplicity may include
the manifestation at different
times of contradictory patterns,
but in general, links between
patterns and awareness of the
range is established. However,
this is not the case where adversity
and predisposition result in a
structural dissociation. In such
cases the sense of self is fragmented
and discontinuous. In borderline
personality disorder, which is
the most frequently encountered
type in clinical practice, patients
commonly show abrupt switches
between states and may have little
recollection between them. This
is confusing to the patient and
to those around them, including
clinicians, who as a result may
feel “de-skilled” and may become
rejecting.
Elizabeth McCormick: Many
borderline patients are prone to
switch into states of uncontrolled
anger. Rather than relying on anger
management, the CAT response
would be to trace the dysfunctional
RRPs that precede the switches into
anger with the aim of establishing
more adaptive modes. These prior
dysfunctional modes usually
represent long-term strategies
evolved in response to deprivation
and are attempts to avoid anger.
They typically involve patterns of
resentful compliance, emotional
distancing or the avoidance of
vulnerable need, all of which
maintain a sense of deprivation
and pain from which switches to
rage states may be triggered. These
states, whether expressed in hurting
self or others, are liable to provoke
rejection and hence perpetuate
deprivation. CAT would seek to
modify these preceding patterns as
well as developing recognition and
control of the switches.
Borderline personality disorder
(BPD) is characterised by the
narrow and predominantly negative
range of RRPs, including patterns
of abuse and neglect in relation to
deprived victimhood in all cases.
While BPD patients commonly
inflict abuse on, or accept abuse
from, both self and others, they may
also enact avoidant, compliant and
idealising roles. The CAT written
reformulation offers an outline of
the patient's story in a way that can
transform the often chaotic account
of events in which the person
feels subsumed. This also clarifies
responsibility and challenges
irrational guilt and acknowledges
what harm has been done. The
Self States Sequential Diagram
illustrates the process currently
maintaining the person's problems
and difficulties. These, tested within
the relationship, serve to promote
understanding of the ongoing
patterns of self states anticipate how
dysfunctional RRPs are likely to
affect the therapy relationship.
NT: CAT appears to be strongly
manualised in its prescription of length
of treatment, the various phases of
treatment and the range of exercises
that move treatment along, such as
the “Reformulation Letter”. How did
this come about and to what extent are
trainees in CAT encouraged to adhere
closely to the manualised version of the
treatment?
Elizabeth McCormick:
Information about the development
of the Reformulation Letter’ is
written earlier.
Features CATalytic
‘ ’
When our learned response to
early care or neglect has had to be
fragmented to cope with intense
child-derived emotion, these states
can become unstable, and we may
shift from one state to another in
order to bear unmanageable feeling.
31. Indispensable survival guide for the thinking psychotherapist 31
Features CATalytic
Length of treatment
CAT is designed as a brief
intervention and the traditional
CAT is 16 sessions and, with
patients presenting with a more
borderline structure, 24 sessions.
But the number of sessions is at the
discretion of the therapist and the
service in which sessions are made
available. The follow-up session is
traditionally after 3 months. But
with borderline presentations the
follow-ups take place at monthly
intervals, often for up to a year and
are then spaced appropriately. The
time limit is an important feature
of CAT and is supported by the
“scaffolding”.
The “scaffolding” of CAT is
both the theoretical basis and
also the different phases. The first
four phases are the reformulation
phase and setting goals for the
therapy. Again these goals are at the
discretion of the therapist and also
need to mirror both the needs of
the patient and also what they can
manage. Goals can be revised at any
time, or changed for other goals.
The middle phase is traditionally
the “moving-it-along” phase,
where the reciprocal roles become
more present in the room and self
monitoring each week is shared
as well as trying out revisions
of learned ways of being and
responding.
The ending phase, sessions 12-16
is traditionally when the therapist
needs to name that ending is in
sight. There are often opportunities
for intense therapeutic work during
this phase, the raising of difficult
feelings or memories that have an
opportunity to be heard and held
within the structure. The “goodbye
letter” is read at the last session
and the patient is invited to bring
and read their own letter. These
letters, with therapist and patient
retaining copies of each, is a form of
“transitional object” for the months
until follow up.
NT: Can you briefly summarise the
results of existing research into CAT
and give some idea of the conditions,
clients, personality types or diagnoses
with which is has been shown to be
most effective?
A summary of CAT-related
research is available at http://
www.acat.me.uk/page/
journal+articles+about+cat
The research will be more
thoroughly summarized in Ryle et
al (2014)
NT: If we should have asked one thing
about CAT that we failed to ask, what
is that, and what is the answer?
Elizabeth McCormick: What’s
it like to be part of the CAT
community? The answer is that
it is now a large professional
organization of over 900 people,
attracting equal numbers of men
and women, and people from
different cultures and countries.
CAT training is established in
Finland, Spain, Italy, Greece, India,
Australia, New Zealand and CAT-
informed practice is developing in
France, Nigeria and South America.
CAT has a history of continuing
development within its original
working structure or scaffolding.
Approaches based upon CAT
also extend to other professions
interested in understanding
conflict, such as lawyers and people
working with families and peace
organizations.
Further reading
Chanen AM, Jackson HJ, McCutcheon
LK, Jovev M, et al. (2009). Early
intervention for adolescents with
borderline personality disorder:
quasi-experimental comparison with
treatment as usual. Australian and New
Zealand Journal of Psychiatry 43(5):397-
408.
Clarke, S.,Thomas P., & James, K.
(2013). Cognitive analytic therapy for
personality disorder: Randomized
controlled trial. British Journal of
Psychiatry, 203, 129-134. doi:10.1192/
bjp.bp.112.108670
Ryle, A., Kellett, S., Hepple, J. &
Simmonds, R. (2014) Cognitive analytic
therapy (CAT) at thirty. Advances in
PsychiatricTreatment. Manuscript
submitted for publication.
ElizabethWilde McCormick has been
in practice as a psychotherapist for
over thirty years working in private
practice and in several NHS settings.
Her professional background is in social
psychiatry, transpersonal and humanistic
psychology, sensorimotor psychotherapy
and cognitive analytic therapy. She was
part of the initial brief psychotherapy
project with Dr Anthony Ryle at Guy's
hospital in the early 1980's, and is a
founder of ACAT, a trainer, supervisor and
currentlyTrustee.
About the author
