‘Using a Specialist Cognitive Analytic
Therapy (CAT) Model for working with
People with Learning Disabilities’
Ann Bancroft and Nicola Murphy
CAT Practitioner and Trainee CAT
Practitioner,
and Clinical Psychologists
Overview
• The CAT Model
• Suitability of the Cognitive Analytic
Therapy (CAT) model for working with
People with Learning Disabilities (PLD)
• Specialising the model for PLD
• Applications of CAT in PLD Services
• Case example
• Summary and Questions
Cognitive Analytic Therapy
(CAT)
(i)
• Well-researched, flexible and effective
psychotherapy used with a range of
client groups
• Based on social model of ‘The Self’
• Key idea is that both poles of adult to
child ‘Reciprocal Roles’ experienced
during early relationships, become
internalised, and form the basis of
personality and self-management
procedures.
Cognitive Analytic Therapy
(CAT)
(ii)
• Key features - time-limitation,
collaboration, and the active use of the
therapeutic relationship.
• Aim - to identify, recognise and revise
procedural sequences (patterns of
thoughts, feelings and behaviours) that
have become problematic/unhelpful.
• Increasing diversification of use,
including indirect work & working with
teams
Standard CAT Therapy
• Individual therapy
• Fixed sessions – 16, (and 8, 24, 32)
• Standard process
–
–
–
–
reformulation phase
recognition and revision phase
ending
follow-up
Standard CAT (i)
Reformulation phase
Identification of target problem procedures –
traps, dilemmas & snags
TRAPS
‘things we cannot escape from….. vicious
circles … trying to deal with feeling bad
about ourselves, we think and act in ways
that tend to confirm our badness’
self-fulfilling prophecies
Standard CAT (ii)
Reformulation phase
DILEMMAS
‘False choices and narrow options …. If I do ‘x’
then ‘y’ will follow …. Either/or or If/then
dilemmas’
polarised choices – no middle ground
black and white thinking
SNAGS
“….when we say “I want to have a better life, or
I want to change my behaviour but…”
Hitches/ self-sabotages
things that get in the way
Standard CAT (iii)
Reformulation phase
• Target problem procedures for therapy
agreed
• Written and diagrammatic reformulation
Standard CAT (iv)
Recognition & revision phase
Oops I’m doing it again!
• Aim is to recognise recurrences of
target problem procedures
• Therapist encourages client to make
active use of reformulation tools (letter
& diagrams) to help recognise repetition
of unhelpful patterns in client’s daily life,
and within therapy sessions
Standard CAT (v)
Recognition & revision phase
Oops I’m doing it again! I could do
something different!
• Once recognition is achieved then
client and therapist work together to
develop new, more helpful procedures
• These are added to the diagrammatic
reformulation as ‘Exits’ or ‘Ways Out’
Standard CAT (vi)
Ending Phase & Follow Up
• Aim is to achieve a ‘good’ and ‘planned’
ending
• Exchange of Goodbye Letters
• Follow up session to review progress
Suitability of CAT for PLD (i)
• Flexible framework
• Emphasis on collaboration and
boundaries
• Use of ‘Zone of Proximal Development
(ZPD)
• Use of written and diagrammatic
materials to supplement verbal
communication
Suitability of CAT for PLD (ii)
•
Practical therapeutic tools
• Provides a vehicle for addressing
fundamental Learning Disability
Issues in a safe environment
• Can be modified according to client
need without losing essential
elements of the model
Specialised CAT for PLD (i)
Modifications to the course of therapy
– Pre-Reformulation period to establish relationship
– Collaborative completion of Psychotherapy File
within sessions
– Adaptation of pace of therapy – e.g. Length,
frequency and number of sessions
– Adaptation of goals of therapy – sometimes
‘Recognition’ is the most appropriate goal
– Collaborative development of goodbye letters &/or
the story of the therapeutic journey
Specialised CAT for PLD (ii)
Modifications to therapeutic tools
– Use of simplified language as appropriate
– Adapted Psychotherapy File – simplified language
version (King, 2005), diagrammatic version
(Bancroft, 2009)
– Pictorial/Symbolised diaries, rating scales, letters
– Audio-recorded therapy letters
– Creative methods, role play, story work, emotion
symbols
From this .....
‘Fear of hurting others’ Trap, Psychotherapy
File 2009 updated version
Feeling fearful of hurting others we keep our
feelings inside, or put our own needs aside.
This tends to allow other people to ignore or
abuse us in various ways, which then leads to
our feeling, or being, childishly angry. When
we see ourselves behaving like this, it
confirms our belief that we shouldn’t be angry
or aggressive and reinforces our avoidance of
standing up for our rights.
++
+
0
To this ......
‘Fear of hurting others’ Trap,
Simplified Version
Are you afraid of hurting other people’s
feelings?
yes/no
If yes
Do you hide your feelings and needs
inside when you are with other people?
yes/no
Or this ....
YES
SOMETIMES
NO
Upset Feelings Dilemma
2009 updated version
Either I keep feelings bottled up or I risk
being rejected, hurting others, or
making a mess.
+
++
0
Upset feelings Dilemma
simplified words version
I must keep my feelings inside of me.
If I do not, other people will not like me.
Yes/no
Upset feelings Dilemma
My version for people with LD
YES
SOMETIMES
NO
Snags
2009 updated version
Do you recognise that you feel limited in your
life:
1. for fear on the response of others: e.g. I
must sabotage success, for example 1) as if
it deprives others, 2) as if others may envy
me or 3) as if there are not enough good
things to go around
+ ++
0
2. by something inside yourself: e.g. I must
sabotage good things as if I don’t deserve
them.
+ ++
0
Snags
simplified words version
Do you ever feel that you are stopped from
doing good things or having good things
because you are afraid of what other people
might say or do?
yes/no
Do you ever feel that you are stopped from
doing good things or having good things by
something inside of yourself telling you that
you are not good enough to have them?
yes/no
SNAGS – things that get in the way
My version for people with LD
I want to ….
But…
Applications of CAT in PLD
Services (i)
•
•
•
•
•
•
Individual Therapy
Group Work
Working with carers and staff teams
Staff Training
Supervision
Consultancy
Applications of CAT in PLD
Services (ii)
Group Work
Add relational element to traditional group
work- e.g. Self-esteem, Angermanagement
Encouraging both participants and
facilitators to be more aware of
Reciprocal Roles in both the content
and the process of the group work
Applications of CAT in PLD
Services (ii)
Indirect Work
A questioning relational approach:
1. How did you feel?
• What did this make you want to do?
• What did you do?
• What did they do?
• What happened then?
• How did you feel?
Applications of CAT in PLD
Services (iii)
2. How do you think they were feeling?
• What do you think they wanted you to
do?
• What did they do?
• What did you do?
• What happened then?
• How do you think they were feeling?
Indirect Work (iii)
Identification of Reciprocal Roles and
unhelpful procedures/patterns of
behaviour
Recognition of repetitions of these
Revision – development of more helpful
Reciprocal Roles and procedures
Summary and Conclusions (i)
• CAT is a useful model for working with
People with Learning Disabilities
• Flexible framework allows for
Specialisation, modifications and
adaptations according to individual
client need without losing the essential
essence of CAT
Summary and Conclusions (ii)
• The model can be used for all aspects
of LD work – direct work with
individuals, group work, work with
carers and professionals, staff training
and in consultancy and supervision
Your turn
Any questions?
References (i)
Bancroft, A., Collins, S., Crowley, V., Harding, C., Kim, Y., Lloyd.
J., Murphy (2008). ‘Is CAT an island or a solar system? The
dilemmas in the therapeutic frame when working with people
with learning disabilities’. Summer edition, Reformulation
Carradice, A (2004). Applying cognitive analytic therapy to
guide indirect working. Reformulation Conference Paper, 1623.
Clayton, P. (2006). “The learning disabled offender and the
secure institution”. In P. Pollock, M. Stowell-Smith & M.
Gopfert (Eds.), Cognitive Analytic Therapy for Offenders: A
new approach to forensic psychotherapy. London: Routledge
Clayton, P. (2001). Using cognitive analytic therapy in an
institution to understand & help both client & staff. In
Landsberg, G & Smiley, A (Ed.) Forensic Mental Health.
USA: Civic Research Institute, Inc.
References (ii)
Collins, S. (2006). ‘Don’t dis me! Working with young people
who have physical and learning disabilities.’ Winter Edition,
Reformulation.
David, C. (2009). “CAT and people with learning disability:
Using CAT with a 17 year old girl with learning disability.”
Reformulation 32 (Summer) p21-25.
Fisher, C., & Harding, C. (2009). ‘Thoughts on the rebel role:
Its application to challenging behaviour in learning
disability services.” Reformulation, 32 (Summer) p4-5.
King, Ros. (2005). ‘CAT and the therapeutic relationship and
working with people with learning disability.’ Summer
Edition Reformulation
Lloyd, J. (2007). ‘Case Study on Z; Not as impossible as we
had thought.’ Summer Edition, Reformulation
References (iii)
•Lloyd, J. & Williams, B. (2003). Reciprocal roles and the
unspeakable known: Exploring CAT within services for
people with learning disabilities. Summer Edition,
Reformulation.
•Lloyd, J. & Williams, B. (2003). ‘Exploring the use of
Cognitive Analytic Therapy within services for people with
learning disabilities and challenging behaviour.’ J. Lloyd and
B. Williams (2004) Clinical Psychology and People with
Learning Disabilities 2(2) 4-5.
•Moss, A. (2007). ‘The application of CAT to working with
people with learning disabilities.’ Summer Edition
Reformulation
•Murphy, N. (2008) ‘CAT used therapeutically and
contextually for a client with learning disability and Asperger
Syndrome.’ Summer Edition Reformulation.
References (iv)
•Murphy, N. (2008) ‘CAT used therapeutically and
contextually for a client with learning disability and
Asperger Syndrome.’ Summer Edition Reformulation.
•Psaila, K. and Crowley, V. (2006). Cognitive Analytic
Therapy in people with learning disabilities; An
investigation of the common reciprocal roles found within
the client group.’ Winter Edition. Reformulation.
•Walsh, S. (1996). Adapting Cognitive Analytic Therapy to
make sense of psychologically harmful work environments.
British Journal of Medical Psychology, 69: 3-20.