CAT is an integrative model of human development and of psychotherapy drawing on ideas as mentioned below.

It is a fundamentally relational model, both in its view of human development and in its practice of psychotherapy. At its heart is an empathic, respectful and collaborative, meaning-making relationship between the client and therapist within the therapeutic boundaries.

What are the origins of CAT?

CAT was developed in the early 1980s by Dr Anthony Ryle at Guys and St Thomas Hospital in London. CAT developed as a public health response to the mental health needs of a busy inner London area, and this concern with access and equity remains at the heart of the model. He felt it important to offer a short-term focussed therapy for use in the health service; a therapy that integrated the best of different approaches to peoples problems and that could be researched and refined with the growing experience of clients and therapists. Theoretically, CAT draws on:

Psychoanalytic concepts of conflict, defence, object relations and counter transference (particularly from Donald Winnicott). Ideas from activity theory and dialogism introduced by Lev Vygotsky and Mikhail Bakhtin. (Dialogism is a particularly kind of dialogue, not limited to two people speaking to each other, but to the whole way in which we act towards each other and expect each other to act towards us.) George Kelly's Personal Construct Theory and work with repertory grids; a focus on how people make sense of their world ("man as scientist") and on common sense, co-operative work with patients. From cognitive approaches involving step by step planning and measurement of change; teaching patients self-observation of moods, thoughts and symptoms.

What sort of problems can CAT help with?

CAT tries to focus on what a person brings to the therapy (target problems) and the deeper patterns of relating that underlie them. It is less concerned with traditional psychiatric symptoms, syndromes or labels.

CAT has been widely used to help people who have experienced childhood physical, emotional or sexual abuse, neglect and trauma, including people who self-harm. CAT is also used with people with eating disorders, addiction problems (like drugs and alcohol), obsessional problems, anxiety, depression, phobias, psychosis and bipolar illness. CAT therapists also work with adolescents, older people and people with learning difficulties, and in forensic settings. CAT is mostly offered to individuals, but it can also be used effectively with couples, in groups and to help teams understand the system in which they work an approach called contextual reformulation.

What's the difference between CAT and CBT?

CAT stands for Cognitive Analytic Therapy and CBT for Cognitive Behavioural Therapy. There are similarities between these therapies both are brief therapies with a limit on the number of sessions; both will offer a focus on a limited range of goals and may use similar ways of helping you keep track of your difficulties, e.g. keeping a diary of a particular problem you want to tackle or how you are making changes. Both are collaborative approaches working actively with the therapist on your difficulties. People referred for CBT may have been diagnosed with disorders such as anxiety, panic, depression, obsessive compulsive disorder etc. CBT has specific, research proven ways of working with such clients using different techniques appropriate for their presentation. People who want to work with their therapist on actively changing their problems tend to do well here. On the other hand, CAT works more interpersonally on relevant, jointly identified issues by creating a working relationship between client and clinician where together they:

describe the issues affecting the client aim to understand their origins in previous relationships and experiences, and importantly, use the relationship between the client and therapist to reflect on how those learnt ways of being take place both in and out of the therapy room: the aim here is to practise both recognition (awareness) and change, both in and out of the room then work focuses on changes that the client wants to make now that they feel they have a description and an understanding that makes good sense to them

CAT offers a safe and clinically effective therapy intervention for people who wish to work through these underlying issues. Sometimes, people who have symptoms of, for example, anxiety or depression, have a history of abuse, trauma or neglect underlying their symptoms. A relationally focussed therapy like CAT can be helpful as it accesses and reflects on how the difficulties come up in normal life, and that includes the relationship between therapist and client: the goal here is to respectfully and progressively understand and name the difficulties together, as safely as possible. The description below gives more detail about what is involved in CBT and CAT.

What is CBT?
It is a way of talking about:

how you think about yourself, the world and other people How what you do affects your thoughts and feelings CBT can help you to change how you think ('Cognitive') and what you do ('Behaviour'). These changes can help you to feel better. Unlike some of the other talking treatments, it focuses on the 'here and now' problems and difficulties. Instead of focusing on the causes of your distress or symptoms in the past, it looks for ways to improve your state of mind now

What does CBT involve?

You can do CBT individually or with a group of people, or even a self-help book or computer programme Individually, you will usually meet with a therapist for between 5 and 20, weekly, or fortnightly sessions. Each session will last between 30 and 60 minutes

The therapist will also ask you questions about your past life and background. Although CBT concentrates on the here and now, at times you may need to talk about the past to understand how it is affecting you now You decide what you want to deal with in the short, medium and long term With the therapist, you will look at your thoughts, feelings and behaviours to work out:

if they are unrealistic or unhelpful How they affect each other, and you

The therapist will then help you to work out how to change unhelpful thoughts and behaviours After you have identified what you can change, your therapist will collaboratively works out with you what self help assignments might be helpful between sessions. Depending on the situation, you might start to:

Question a self-critical or upsetting thought and replace it with a more helpful (and more realistic) one that you have developed in CBT Recognise that you are about to do something that will make you feel worse and, instead, do something more helpful

At each meeting you discuss how you've got on since the last session. Your therapist can help with suggestions if any of the tasks seem too hard or don't seem to be helping They will not ask you to do things you don't want to do - you decide the pace of the treatment and what you will and won't try. You can continue to practise and develop your skills even after the sessions have finished. This makes it less likely that your symptoms or problems will return

To find out more about CBT, go to http://www.rcpsych.ac.uk/expertadvice/treatments/cbt.aspx

What is CAT?
In order to bring about change, CAT offers a way of:

Thinking about yourself differently 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 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. 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

What does CAT involve?

You can do CAT individually, sometimes as a couple, and sometimes in a group. A CAT therapy is time-limited, usually between 16-24 sessions this is discussed and agreed with the therapist at the start of therapy. Each weekly session is for 50-60 minutes. Between one and five follow-up sessions are offered after the end of regular therapy. Again this is discussed and agreed with the therapist The first few sessions are the reformulation phase. You have the opportunity to speak openly and in confidence about what is happening in your life, about your own personal history and life experiences. As well as things going wrong in your life there are always some things that have gone right. The therapist will encourage you to name what works well and what areas have given you happiness and satisfaction so that you do not feel you are the sum total of the parts where things havent gone well You may be asked to complete a questionnaire called The Psychotherapy File which divides commonly experienced difficulties into Traps, Dilemmas, Snags, and Unstable States of Mind. Examples are given within each grouping such as: I act as if either I keep feelings bottled up or I risk being rejected, hurting others or making a mess. There may be other questionnaires to help you look at mood shifts or symptoms. All these papers are ways of helping to focus accurately on exactly what sorts of thinking or behaving contribute to things going wrong After the first session you may agree with the therapist to monitor a particular symptom or mood At around session 4/5 the therapist may share with you a Reformulation letter which is a written account of the understanding shared between you and the therapist about the problems that have brought you into therapy, how you have tried to cope with them, and what you are trying to change by coming into therapy The therapist will work with you to map out your problem patterns on paper. This can help you further develop your capacity to think about yourself and understand why you may repeat patterns which cause you distress but find hard to stop The active therapy that continues works towards helping you build recognition of the patterns of relating, thinking, acting and feeling that you want to change. The therapist might suggest ways of monitoring these patterns in between sessions, and you and he or she will look out for these patterns happening within therapy itself. CAT is an open and up-front form of therapy, where the therapist shares their thinking with you explicitly. There are no hidden theories or secrets in CAT. The therapist is actively involved in treatment, and will encourage you to be the same The therapist will work with you on looking at how you revise your patterns but they will understand the difficulties involved in change. One of the strengths of CAT is that the letters and maps will help you continue working after the regular therapy sessions have finished CAT recognises that finishing therapy can be difficult, especially if endings in your life have been difficult in the past. The last three or four sessions are used to think back over the course of therapy and at the ending of this therapy relationship. The therapist will write a goodbye letter and will invite you to do the same You will usually be offered a follow up appointment two-three months after the end of your regular appointments

Relationships and CAT

Kimber-Rogal, N., 2008. Relationships and CAT. Reformulation, Winter, pp.28-29.

An adult relationship does not begin the day two people meet; it starts in the childhood of each partner Armstrong (2002) What is a relationship? It is a connection, a link and involves (at least) two separate entities. Human relations require selfawareness and self-disclosure (mutual self-disclosure in the case of intimacy). Whilst a discussion of the constituent parts of the self may be relevant here, it is beyond the scope of this article. Suffice it to say that the psychological self develops in childhood and exists in relation to the other. This process involves language, dialogue, behaviour, cognition and affect, together with the metaphysics of spirituality and cultural transmission. It is not necessary to be physically present to have a relationship. The other may be absent or even dead, and the converse is also true: people may be physically proximate but unable (or unwilling) to relate. Relationships require openness, imagination, projection and the ability to internalise aspects of another. Preclusions to good relationships include syndromes where the patient can be too remote, preoccupied or fragmented to relate; for example, Generalised Anxiety Disorder (GAD), Obsessional Compulsive Disorder (OCD), depression and personality disorder. Moreover, paranoia, delusion or persistent and intractable fixedness in relation to another is the antithesis of an openness which enhances human affiliation. Relationships or the interconnectedness between two people has been significant in all healing since the time of Hippocrates and Galen. It seems to be one of the significant features in any major

change or `metanoia in peoples lives, whether this happens as a result of falling in love, being in crisis, educational development, religious conversion or effective psychotherapy. Notably, meta-analyses comparing models of therapy show that relational or non-specific factors are the strongest indicator of therapeutic outcome. Results of therapy are notoriously hard to measure even though attempts are often made through rating scales, return-to-work rates, degree of cognitive shift via repertory grids etc, on both long and short-term bases. Given that so many non-specific factors are thought to affect outcome and that similar outcomes may be obtained not only from different types of therapy but also from alternative measures such as exercise or religious healing (see eg Frank), a perennial problem remains as to how the process of psychotherapy can be shown to be effective.

Psychotherapy
The idea of talking to relieve distress is not a new one. Although Freuds particular form of talking heralded the beginning of psychotherapy as we know it, it is an age-old tradition that has been practised across countries, religions, cultures and communities, helping people who are confused about their lives and consider themselves to be ineffectual or weak. Throughout mankinds history, various shamans, priests, sages, mystics, saints, psychologists and psychiatrists have tried to point out the best ways to live with suffering so as to live beyond it. Indeed, many patients symptoms have been improved by the so-called `bed-side manner of the medical doctor a skill historically under-taught in psychiatric training. Some say it should be called the listening cure since the psychotherapist listens and, most importantly, recognises - without judgement the individual and their problems. Nowadays therapy is more directive and conversational, with therapist and patient often actively engaging on problem-solving tasks.

The word psychotherapy refers to the treatment of mental disorders by psychological rather than biological or physical means. Any treatment that does not use drugs or other physical methods could be called psychotherapy. The most important element is talking. It is the ideas behind the therapy, the way it is applied, and the nature of the relationships that develop between the patient and therapist which differentiate the types of therapy available. Suitable clients for psychotherapy are predominantly those with so-called neurotic problems. However, psychotic disorders may be further alleviated by psychotherapy when combined with other forms of treatment, such as drugs. In general, there is no reason why medication and psychotherapy should not be used together. Some therapies emphasise feelings of helplessness or the processes by which the child identifies with the parent or primary caretaker. Others focus on the importance of loss (of loved ones or cherished ideas) when considering how, for example, depression develops. Notably, the formation of attachments (relationships) and strong attachment bonds seem to be especially important and valuable when people are faced with adversity and stress. The opposite of the talking cure could be seen as the silent treatment. Isolating prisoners (solitary confinement) or ignoring friends (`sending to Coventry) remains a form of punishment and control. Interestingly, silence or disengagement on the part of a patient may be signs of mental illness, with the experience of isolation often central to depression. Although the benefits and virtues of solitude have been extolled by Storr, healthy man, in general, is not an island. Lack of communication with others is central to experiences of depression and anxiety and supports Kleins assertion that loneliness is an integral part of illness. Depression involves a lack of spontaneity related to the repression of affect associated with reciprocal roles (see Cognitive Analytic Therapy, below) and is thus consistent with Millers assertion that the true

opposite of depression is not gaiety or absence of pain, but vitality: the freedom to experience spontaneous feelings. Depression is seen to involve a separation from the true self and paradoxically, an experience of isolation may be only communicated retrospectively when levels of anxiety or depression have subsided. Since the mid 1990s demand for the talking cures of psychotherapy and counselling has continued to increase and a large proportion of patients attending GPs surgeries present with problems considered best treated by psychological rather than physical means. Reasons for this may include the break-up of the nuclear family, break-down of community living and values and a lack of religious involvement.

Cognitive Analytic Therapy (CAT)

One of the most complicated issues in the study of close relationships is whether a supportive relationship leads to better psychological well-being (`the protection hypothesis), or whether it is just those with good psychological health who are able to form close relationships (`the selection hypothesis). It seems likely that there would be an interaction which compounds good relationships for those with some ability to form them; and that, in the capacity to form good - that is, rewarding and close - relationships are based on the taught rolerepertoire in childhood. Avoidance and conflict is inherent to people who had painful experiences of chronic parental criticism and rejection. The need to bond with the rejecting parents makes the person hungry for relationships, but their longing gradually develops into a defensive shell of self-protection against repeated parental criticisms. Loss and rejection are so painful, patients will choose to be lonely rather than risk trying to connect with others.

CAT is a short-term therapy that explains the connections between early patterns of relating and present problems. It aims to help people to co-exist with aspects of the self more peaceably. The (relational) self is established through reciprocal roles - internalised aspects of the primary caretaker - and idiosyncratic responses to these. These are called, respectively, adult and child-derived reciprocal roles. For example, the child may develop a rejection role in response to a critical parent or an anxious attachment in relation to a psychologically remote carer. The extent to which these selves or part-selves are accentuated and integrated determines the psychological wellbeing of the individual. Fixed and polarised roles (eg bully/victim) predict mental ill-health or dysfunction. Role pairs are experienced as the self and others are invited to reciprocate a known and predictable way of being in the world. Unfortunately, this does not always work well for the individual and poses questions regarding human natures apparent desire for pleasure and avoidance of pain: we seem to elicit roles in another with we are familiar, regardless of the difficulties inherent in this role re-enactment. Role responses (or repertoires) involve behavioural, affective and cognitive components. Therapy aims to identify and positively adjust maladaptive responses (called reciprocal role procedures) played out transferentially during sessions. As stated earlier, an adult relationship, be it romantic, platonic or in a doctor-patient setting, does not begin the day two people meet; it starts in the childhood of each partner. One approach to conflict or irreparation in relationships suggests that individuals harbour a desire to maintain a righteous indignation at unmet demands from the past. For example, there are situations some of them central to the experience of childhood in which we cannot avoid suffering. These would include small things regarding gratification of impulses by, typically, the mother or father - for example, to be given presents, to stay up late, and so on. How can a pleasure-seeking creature cope with this? One

way depending on severity of deprivation - may be through dissociation; another by taking unconscious satisfaction in deprivation. Righteous indignation is a simple example of this kind of pleasure; it allows one to indulge, with supreme justification, in aggressive feelings. The pain of being denied what one longs for becomes mixed with the pleasures of superiority and justified anger. These expectations or patterns of being become unconscious and can be played out later in a number of settings. Like an addict, we get attached to someone with whom we can repeat a self-harming, but familiar (and therefore relatively safe) pleasure. We learn to love as children. Or more accurately, we learn a style of relating which governs our adult behaviour when it comes to love. Central to this thesis is the disturbing contention that we are generally unaware of this underlying style of relating it governs our adult behaviour without our noticing. In a romantic setting, and sadly, the exciting thought `this is the one for me may be ironically true in that we have identified a potential source of our preferred misery: the suffering which love gives rise to is often connected with the roots of love itself. Nicola Kimber-Rogal