A randomized, controlled pilot study of cognitive analytic therapy for stressed pregnant women with underlying anxiety and depression in a routine health service setting.

A pilot study of cognitive analytic therapy (CAT) plus treatment as usual (TAU), versus TAU in stressed pregnant women with anxiety and depression, was undertaken as an essential preliminary to any definitive, randomized controlled trial (RCT). The trial was pragmatic, multicentre, parallel, randomized, controlled, and unblinded. Participants were pregnant women screened using the Hospital Anxiety and Depression Scale (HADS). Treatment was standard 16-session CAT. Main outcome measures were Spielberger State/Trait Anxiety Inventory (STAI) (primary outcome measure) at 24 weeks after randomization, therefore 1 month after therapy for the CAT group; HADS; Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM); Edinburgh Postnatal Depression Scale (EPDS); 36-item Short Form Health Survey (SF-36); and a brief Experiences of Therapy Questionnaire, completed at baseline and on average at 12, 24, 40, and 82 weeks after randomization. Thirty-nine patients (CAT + TAU, n = 20; TAU, n = 19) were randomized with mean baseline STAI State scores of 50.8 (SD 11.4) and 51.1 (SD 13.3), respectively. Sixteen patients had missing primary outcome data leaving 23 (n = 11 and n = 12) patients for analysis. The mean STAI State score was 38.5 (SD 13.8) and 45.7 (SD 16.8) in the CAT and TAU groups respectively at 24 weeks after randomization, with an adjusted difference in means of 7.2 (95% confidence interval [CI]: -7.9 to 20.6). No safety issues were reported. Patient retention for the CAT group was high (18/20; 90% of patients completed therapy). Ten out of 11 (90.9%) respondents 'agreed' or 'strongly agreed' that having CAT had been 'very helpful'. The study demonstrated the feasibility of safely undertaking CAT in this setting. Outcomes showed positive trends compatible with a clinically important effect, although statistically definitive conclusions cannot be drawn in such a study.

The 'Self' and Borderline Personality Disorder: Conceptual and Clinical Considerations.

Some concept of self has been used by many, although not all, researchers and clinicians as an 'organising construct' for borderline personality disorder (BPD). There is considerable variation in this usage and how clearly researchers have defined the self. Given this diversity, and that 'self' is often used interchangeably with parallel concepts (e.g., psyche, brain-mind, 'person') or with features of self (e.g., self-awareness, identity), unqualified use of the term is problematic. This is further complicated by the heterogeneity and 'comorbidity' of BPD and the limitations of syndromally based psychiatric nosology. Still, BPD remains in current classification systems and can be reliably diagnosed. A considerable body of research on self and BPD has accrued, including a recent profusion and confluence of neuroscientific and sociopsychological findings. These have generated supporting evidence for a supra-ordinate, functionally constituted entity of the self ranging over multiple, interacting levels from an unconscious, 'core' self, through to a reflective, phenotypic, 'idiographic' and relational self constituted by interpersonal and sociocultural experience. Important insights have been generated regarding emotional and social-cognitive dysregulation, disorder of self-awareness, relationality, identity, and coherence and continuity of the self. Many of these are shared by various trauma-related, dissociative disorders. A construct of the self could be useful as an explanatory principle in BPD, which could be construed as a 'self-state' (and relational) disorder, as opposed to a less severe disorder of aspects of the self (e.g., mood or memory). We offer a tentative description of 'Self' in this context, noting that any such construct will require a clear definition and to be evaluable.

Working with the 'difficult' patient: the use of a contextual cognitive-analytic therapy based training in improving team function in a routine psychiatry service setting.

The clinical management of 'difficult' patients is a major challenge which exposes mental health teams to an increased risk of frustration and stress and may lead to professional burnout. The aim of the present study was to investigate whether a cognitive-analytic therapy (CAT) based training undertaken by a mental health team working with 'difficult' patients reduced professional burnout symptoms, improved patients' service engagement and increased the levels of team-cohesion. Twelve mental health staff members from different professional and educational backgrounds took part in five 2-hour sessions providing a basic CAT training intervention, an integrative and relational model of psychotherapy for the treatment of borderline personality disorders. Participants were administered the Maslach Burnout Inventory (MBI), the Service Engagement Scale (SES) and the Group Environment Questionnaire (GEQ) before (T0) and after (T1) CAT training, and at 1-month follow-up (T2). A significant decrease were found, at T2, on the MBI Emotional Exhaustion scores, the SES Availability subscale, the GEQ Attraction to Group-Social and Group Integration-Social, while the MBI-Personal Accomplishment scores increased from baseline.The results of this study suggest that a CAT-based training can facilitate team cohesion and patient engagement with a service and reduce burnout levels among mental health team members dealing with 'difficult' patients.

Multidisciplinary community mental health team staff's experience of a 'skills level' training course in cognitive analytic therapy.

This study sought to explore community mental health teams' (CMHTs) experiences of receiving an innovative introductory level training in cognitive analytic therapy (CAT). CMHTs are important providers of care for people with mental health problems. Although CMHTs have many strengths, they have been widely criticized for failing to have a shared model underlying practice. Inter-professional training which develops shared therapeutic models from which to plan care delivery is, therefore, essential. We have been developing such a training based on the psychotherapeutic principles of CAT. Twelve community mental health staff (six mental health social workers and six community psychiatric nurses) were interviewed by an independent interviewer following the completion of the training programme. The interviews were analysed using a qualitative thematic analysis. The analysis revealed that the programme increased the participants' self-assessed therapeutic confidence and skill and fostered the development of a shared model within the team, although the training was also perceived as adding to workload. The results of this study suggest that whole-team CAT training may facilitate cohesion and also suggest that having some shared common language is important in enabling and supporting work with 'difficult' and 'complex' clients, for example, those with personality disorders. Further development of such training accompanied by rigorous evaluation should be undertaken.

Psychotherapy for borderline personality disorder: mentalization based therapy and cognitive analytic therapy compared.

Mentalization Based Therapy (MBT) and Cognitive Analytic Therapy (CAT) are among a small number of psychotherapy approaches offering specific methods for the treatment of Borderline Personality Disorder (BPD). They share a number of features, notably both seek to integrate ideas and methods from psychoanalysis and cognitive psychology, pay attention to early attachment experiences and see harsh and inconsistent care, in combination with biological vulnerability, as playing an important part in the genesis of BPD offer treatment based on a developmental understanding of BPD, taking account of recent developments in observational research seek to provide therapy appropriate for use in the public service. These similarities, however, conceal a number of differences in underlying assumptions and emphases and are linked with contrasting therapeutic techniques. In this paper we present a discussion of key features of our models of normal and pathological development and a consideration of the conceptual underpinnings and of how far they are compatible with what is reliably known in the general field of psychology and how far it offers a model accessible to patients and clinician. Where our views diverge significantly, the reader will have some of the evidence on which to make a personal choice.

Psychotherapy and mental health teams.

Mental health teams in different configurations and settings are under increasing pressure to offer formal psychotherapies as well as psychologically informed management to large numbers of 'difficult' patients with severe and complex presentations. This pressure has arisen variously from consumers, governmental agencies and commissioning bodies. Although these teams are an important resource, they receive limited training, supervision or support in models of psychotherapy, especially those incorporating a relational dimension and offering a coherent 'common language'. This commonly results in impairment of collective team function, including the quality and consistency of assessments, and may result in stress, splitting and 'burn out' for team members. This situation is due in part to their burden of casework and responsibility but also to prevailing, largely symptom-based and biomedical, models of mental disorder which tend to minimize the importance of psychosocial dimensions in either aetiology or treatment. Formulating and delivering appropriate, evidence-based and robust models of psychotherapy in generic team settings represents a significantly different challenge from that posed by delivery of psychotherapy in specialist settings. Approaches to this important challenge are discussed and summarized drawing on general considerations and the limited direct research evidence, and are illustrated by a cognitive analytic therapy (CAT)-based training project.

Clinical and service implications of a cognitive analytic therapy model of psychosis.

Cognitive analytic therapy (CAT) is an integrative, interpersonal model of therapy predicated on a radically social concept of self, developed over recent years in the UK by Anthony Ryle. A CAT-based model of psychotic disorder has been developed much more recently based on encouraging early experience in this area. The model describes and accounts for many psychotic experiences and symptoms in terms of distorted, amplified or muddled enactments of normal or 'neurotic' reciprocal role procedures (RRPs) and of damage at a meta-procedural level to the structures of the self. Reciprocal role procedures are understood in CAT to represent the outcome of the process of internalization of early, sign-mediated, interpersonal experience and to constitute the basis for all mental activity, normal or otherwise. Enactments of maladaptive RRPs generated by early interpersonal stress are seen in this model to constitute a form of 'internal expressed emotion'. Joint description of these RRPs and their enactments (both internally and externally) and their subsequent revision is central to the practice of CAT during which they are mapped out through written and diagrammatic reformulations. This model may usefully complement and extend existing approaches, notably recent CBT-based interventions, particularly with 'difficult' patients, and generate meaningful and helpful understandings of these disorders for both patients and their treating teams. We suggest that use of a coherent and robust model such as CAT could have important clinical and service implications in terms of developing and researching models of these disorders as well as for the training of multidisciplinary teams in their effective treatment.