Brief Overview of CAT Mark C. Ramm, NHS Lothian

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Brief Overview of CATMark C. Ramm, NHS Lothian

• Integrative
• A theory based on the integration and extension
  of ideas and methods used in conventionally
  opposed approaches
• 
  (Anthony Ryle)
• More than just Cognitive and Psychoanalytic
• Cognitive
• Behavioural
• Psychoanalytic
• Developmental
• Social

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Brief Overview of CAT

• Distinctive individual psychotherapy
• CAT accepted as a distinctive and Independent
  form of psychotherapy
• - Roth Fonagy (1996)
• An integrated theory of personality and change
• So applicability to a wide range of situations,
  problems and settings

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CAT Radically Relational
Almost everything we do is acted out in relation
to a real, imagined or anticipated other. Lev
Vygotsky Activity Theory. All higher mental
functions are internalised social relationships
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How does CAT approach it ?

• Relational
• Understands this in terms of Reciprocal Roles
  (derived from Object Relations)
• Most distress in human beings is relationship
  based
• self and others
• self and self
• Dynamic
• Understands how people can act very differently
  at different times and in different contexts

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DEVELOPMENT
Babies are born attuned to interact with
others Each baby has its own genetic
predispositions The baby interacts with carers
who are massively influential - Attachment
issues The infant internalises its
experience Forms joint understandings with others
Forms concepts about self and others
Formation of Relationship templates Formation
of Reciprocal Roles
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Developmental Psychology

• The self emerges from our experiences with
  others
• This forms our basis for our feelings about
  ourselves and for predicting how others will be
• The core premise of CAT is that the child learns
  acquires and learns to convert interpersonal
  experiences into intrapersonal processes and
  templates

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• Present interpersonal difficulties are frequently
  found to be the result of these kinds of
  developmental roots
• (Although traumas and powerful relationships
  later in life can also cause major disruption)
• A persons attempts to cope with such issues
  often leads further problems

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• 
  RECIPROCAL ROLES

Mother or Main Other (Critical demanding)




SELF (Unworthy Striving)



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• 
  RECIPROCAL ROLES

Mother or Main Other (Critical demanding)



Other (Critical demanding)
SELF (Unworthy Striving)


SELF (Unworthy Striving)
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• 
  RECIPROCAL ROLES

Mother or Main Other (Critical demanding)

SELF (Critical demanding)

Other (Critical demanding)
SELF (Unworthy Striving)
Other (Unworthy Striving)

SELF (Unworthy Striving)
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• 
  RECIPROCAL ROLES

Mother or Main Other (Critical demanding)

SELF (Critical demanding)
SELF (Critical demanding)
Other (Critical demanding)
SELF (Unworthy Striving)
Other (Unworthy Striving)
SELF (Unworthy Striving)
SELF (Unworthy Striving)
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• The self emerges from our experiences with others
• This forms the basis for our feelings about
  ourselves and for predicting how others will be.

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Reciprocal Roles are therefore

• The templates for all subsequent relationships
• Interpersonal (self - other)
• Intrapersonal (self - self )
• Are the basis of our dialogical selves. Our
  various internal voices (Implications for
  understanding psychosis)
• Are the origin of much Intra-personal conflict
  and associated distress

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• BALANCED PERSONALITY
  ORGANISATION

A Reciprocal Role is a block of procedural
knowledge about how to do a particular
relationship and what to expect from it (Denman
2001)
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RIGID PERSONALITY ORGANISATIONRestriction and
distortion of the Reciprocal Role Repertoire









Particular Reciprocal Roles have a dominance and
extreme polarization or there are a limited in
number of Reciprocal Roles.
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Dynamic state dependent functioning

• How we think feel and remember is to a large
  extent state dependent
• We move in and out of our states and prefer to be
  in some rather than others

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Procedures and the maintenance of problems

• The cause of problems in some shape or form is

Abusing Abused
Unmet needs Negative emotion Stress
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Procedures and the maintenance of problems
Abusing Abused
Ignoring problem, drinking, running away (feels
better)
Unmet needs Negative emotion Stress
Avoiding
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Procedures and the maintenance of problems
Abusing Abused
Ignoring problem, drinking, running away (feels
better)
Doesnt solve
Unmet needs Negative emotion Stress
Avoiding
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Procedures and the maintenance of problems
Abusing Abused
Ignoring problem, drinking, running away (feels
better)
Alternative Reciprocal Role Procedure
Doesnt solve
Unmet needs Negative emotion Stress
Avoiding
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Self States

• Self states connected by procedures and
  relationships

Dynamic state dependent functioning. How we
think feel and remember is to a large extent
state dependent. We move in and out of these
states and prefer to be in some rather than others
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Self State Disorders

• Disruption of integrating procedures
• Deficient and disrupted self reflection
• Dissociation of self-states
  (Multiple Self States Model)

Confused, Cant think, Unstable
Dissociation normal
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Ramm Mair 2009

• Issues disrupting Attachment
• Dismissive Avoidant Attachment Styles
• Poor Coping Skills

• Poor emotional regulation
• Interpersonal difficulties
• Poor mentalisation

PERSONALITY DISORDER PSYCHOSIS
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CAT

• Formulation use of Formulation map
• Recognition, insight self-awareness (diaries
  etc)
• Continued focus on Map
• Develop insight
• Change Methods
• Huge flexibility and range of therapeutic
  activity possible
• CBT techniques/behavioral experiments/IPT
• Mentalisation
• Occupational interventions
• Art work
• Psychodrama
• Active use of the therapeutic relationship
• Exits
• New strategies/ways of coping/relationships
  developed