1997). More recent outcome data suggests similar results are being obtained across an increasing range of patient problems, severity, and settings (see Calvert & Kellett, 2014). It may also be that CAT is more effective for some patients if undertaken over a somewhat longer time, or in separate blocks with intervals. Its combination or alternation with other interventions, such as creative therapies, psychodrama, or group work, would almost certainly be helpful for patients who are hard to engage emotionally or who need more time to explore alternatives. Further and ongoing research is of course needed, although funding and support remain in general hard to find for psychotherapies, and notwithstanding that some approaches appear more “politically” acceptable and better promoted at any given time.
Which aspects of CAT are the effective ingredients in successful therapy has not been fully demonstrated, but research summarized later in the book has shown that the reformulation process can produce accurate summaries of key issues with good inter‐therapist reliability (see Chapter 8), although its impact appears, perhaps unsurprisingly, to vary for different patients with different problems. Research has also shown that systematic linking of “transference–counter‐transference” enactments (seen as representing a sub‐set of RRs and RRPs) to the reformulation is associated with good outcome (see Chapter 8). Our belief is that the main factors associated with good outcome include: (a) the experience of a benign and collaborative, although at times challenging, therapeutic relationship; (b) as part of this and contributing to it, the joint creation and use of reformulation tools (in written and visual form) and ongoing use of them in and around therapy; and (c) the internalization of these tools and their meanings in the course of and following a collaborative and non‐collusive relationship. These factors cannot be isolated from the other features of the theory and practice that allow intense but contained connections between patients and therapists, and of course the overall systemic and socio‐cultural context of therapy.
To end this chapter, we present an abbreviated and revised account of a typical CAT therapy in order to illustrate its stages and the use of the various tools.
Case History: Bobby (Therapist Steve Potter)
Bobby, a mature student in his early 30s, presented to a lunchtime on‐call session at a student counseling service with depression and “agitation.” Since the break‐up of a 4‐year relationship, over the previous 2 years he had been sleeping badly, drinking, and smoking excessively despite having asthma, eating irregularly and neglecting his studies, while indulging in fantasies of becoming a famous musician. He had had two previous experiences of therapy and felt he would need it always.
Background
Bobby was the youngest of a large family, alternately spoiled (especially on the many occasions when he was ill) and neglected; in part this was because his mother was frequently away in hospital. He recalled frequently lying in his bed calling quietly for his mother, crying into his pillow and feeling inconsolable but afraid of a telling‐off from his brother, by whom he was frequently bullied. He was also bullied later on at school, although he had one best mate there with whom he shared fantasies of becoming a famous pop star.
Assessment and Reformulation
After two assessment sessions he was offered 16 sessions of CAT. He was given the Psychotherapy File (see Appendix 2) and he started to keep a symptom diary. The Psychotherapy File and some of his diary keeping confirmed the initial patterns he had described and also set him thinking that perhaps he was not as bad as he used to be. We identified what he wanted to change (target problems) and how his patterns of relating to others and self‐neglect and self‐comfort fed into these. By Session 4 Bobby felt much improved in morale. He had used the provisional diagram, begun self‐monitoring, and was keeping a diary.
At Session 4, a letter was read to him which is reproduced in part:
Dear Bobby,
Here, in writing, is what we have talked about in recent weeks. I hope it can help us keep on track in the weeks ahead and serve as a reminder to you of what we have been working on.
… One thing you remember of your childhood is either feeling especially loved and treasured, or being a nuisance and ignored and smacked and told to shut up and go to sleep (for example by your brother). You felt you were cared for if ill but otherwise ignored by your older brothers and sisters. You tried to please them and win them over but always felt scared.
This pattern seems to have been echoed in your close relationships with women and with a therapist previously, as well as in the way you either neglect and ignore your own needs or seek comfort through drink or smoking dope … You are usually neglectful of your body and have not seen a doctor or got proper care (for asthma and other ailments) …
We have named a number of patterns of feeling, thinking, and behaving:
1 You long for special care but fear it won’t last, so you tend to cling anxiously and alienate others (as with Elizabeth your partner), leaving you still uncared for.
2 Feeling depressed leads you to drink or smoke dope and ignore problems which then build up making you feel low and even more depressed.
3 You receive care, but only if “special,” so you strive to create special claims but feel you must suffer to deserve it and so neglect yourself and become “agitated” and drink or smoke dope.
These patterns undoubtedly arose from the ways you coped with the limited options of your childhood; they seem to have given you some intimacy and relief but they have been costly …
Already in our relationship we have seen how you push to get me to provide comfort and hold you through this difficult time when you are no longer in a relationship with a woman who will rescue you. By learning to recognize these patterns in therapy you will be better able to explore more satisfactory ways of doing things.
You have said you have been impressed with my help (a bit like the honeymoon phase in one of your relationships), but I suspect it will be hard to imagine how short and limited our relationship is (16 sessions), and how you will cope with tolerating the disappointment when I cannot meet your current pattern of neediness …
Our aims in therapy will include:
learning to be less clinging and demanding in relationships
getting help with your health
focusing on working for your degree and on more concrete “out there” activities and achievements.
With best wishes
He was moved and tearful as the letter was read out. He said he had learnt more in five sessions than in 4 years of previous therapy. He began to see his helplessness within a wider emotional narrative. The state of forlorn “agitation”—which seemed deeply part of him and just swept over him, especially at night‐time—had hitherto seemed beyond his understanding. Now it began to be seen as part of an emotional story. However, he did not like the ending being mentioned in the letter. He asked if he would be better after 16 sessions.
The Course of Therapy
Before the next session, he left a note in which he said his relationship with Elizabeth his partner was definitely over and could he have an extra session? I said I couldn't see him for an additional session and he later left a letter saying he wanted to stop the therapy:
I think I am going to have to stop the therapy for now. It has been very revealing but is too much at the moment and I must concentrate on my studies. I am