Phil Clayton

1
'Cognitive Analytic Therapy with a young woman
who has a diagnosis of borderline personality
disorder and learning disability and who lives in
a medium secure environment

• Phil Clayton
• R.N.M.H., R.M.N.,
• Cognitive Analytic Therapist
• BSc (Hons)
• Clinical Nurse Specialist
• Matt Edgar
• R.N.L.D.
• Staff Nurse
• Calderstones N.H.S. Trust

2
Introduction

• A brief history of Susan.
• The approach Cognitive Analytic Therapy.
• Individual therapy.
• Institutional responses.

3
A Brief History

• A personal history
• A life of aggression, setting expectation
  (reciprocal roles)
• Maternal deprivation and paternal loss
• Sibling abuse and loss

4
?
Genogram
?
?
?
B
D
H
G
S
T
J
J
M
Idealised
?
Unknown
Very difficult (violent)
Warm but distant
5
The Approach

• Cognitive Analytic Therapy - An integrative model
  of short term psychotherapy, the
• conceptual basis being found in both cognitive
  psychology, psychoanalysis (Ryle
• 1993, Leiman 1994) and activity theory
  (Vygotsky).

6

• The aim of the method is to identify, in a
  language the patient can share, those mental
  constructions underlying the patients symptoms
  and difficulties and their inability to change
  and to relate treatment and the evaluation of its
  effectiveness to those constructions (Ryle 1979)

7

Conceptual Tools

• The tools of C.A.T. provide the framework/vehicle
  for therapy and enable a structure which promotes
  collaboration.
• Collaboration implicit so as to focus on target
  problem and target problem procedures, the latter
  being patterns of thinking and acting that
  potentiate the target problem.

8

• The psychotherapy file - this helps to elucidate
  the areas of difficulty.
• The reformulation letter or tape - a way of
  putting current problems in context of life
  experiences.

• The sequential diagrammatic reformulation
  (S.D.R.), diagram or map.
• Goodbye letters (or not !!)
• Rating or monitoring sheets.
• Follow up(s).

9
Individual therapy

• Reciprocal role procedures. The therapist is on
  the look out for what CAT therapists call
  enactments, the patient pushing the therapist
  into roles they want the patient to think
  about.
• Initial sessions establish a contract and focus
  on presenting problem(s) and emphasise
  collaboration. The therapist is aware of
  difficulties that may arise in the assessment
  sessions as a result of the patients early
  experiences which may present as threats to the
  therapeutic alliance.
• Reformulation letter or tape given after about
  four (to eight) sessions. This might depend on
  contracted sessions and presenting difficulties.
• Working phase - use of tools. Working with the
  transference.
• The S.D.R.,diagram or map.

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S.D.R.
Attacking
STORMY ME
Idealised Care
Perfectly Caring
Disappointed
Perfectly Cared For
Attacked
Other people wind me up
Get taken care of
Cut up
Exit
Feel powerless and confused
Neglected
Empty and unloved me
Ok Place
Caring
Feel worthless or furious
Neglected
Cared for
11
Institutional
Responses

• Staff responses, walking into a reciprocal role,
  the powerful male nurse, brothers and father.
• Systemic responses and splitting.
• Mary Dunne and C.M.H.T.S.
• Training.

12
Summary

• With complex cases it may be necessary to extend
  awareness of the psychological processes to the
  direct care staff.
• This requires a commitment from the clinician
  working with the individual and the service
  managers to resource training.