ICATA Journal
Therapists’ Experiences of Facilitating Cognitive Analytic Therapy Groups
Laurie Siddel & Alison Wells
Cite as: Siddel, L., & Wells, A. (2018). Therapists’ Experiences of Facilitating Cognitive Analytic Therapy Groups. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 2(1), 105-119. https://www.internationalcat.org/volume-2-6
Int. Journal of CAT & RMH Vol. 2, 2018 / ISSN2059-9919
Abstract
Background: Cognitive Analytic Therapy (CAT) is an integrative relational therapy with psychodynamic and cognitive roots, subsequently transformed by Vygotskian activity theory and Bakhtinian notions of a dialogical self. CAT groups have been described as being successful, although there is a limited evidence base. This study sought to research the views and opinions of therapists involved with CAT groups.
Methods: Ten respondents took part in an online survey to answer the question ‘what is it that you feel CAT groups offer and individuals gain that they don’t from other psychological interventions?’ Thematic analysis was used.
Results: All respondents reported positive outcomes from facilitating CAT groups, describing an environment of support and safe containment. This led to individuals being able to access deeper seated and more challenging aspects of their problems, allowing for ‘real time’ examples and active commentary on their problematic relational styles. CAT groups were described as a unique and rewarding experience for therapists and patients alike. Further research is needed and limitations are discussed.
Key words: Cognitive Analytic Therapy; groups; therapists; qualitative; relational
Introduction
Cognitive Analytic Therapy
Cognitive Analytic Therapy (CAT) facilitates the clinical integration of psychodynamic therapy and personal construct/cognitive psychology (Ryle et al, 2014). As a time-limited relational therapy with a focus on ending, it is applicable to a wide range of psychological problems seen in public mental health settings, and has recently been included in United Kingdom national guidelines for treatment of personality disorder in the NHS (Roth & Pilling, 2016). Its relational model of pathology well describes interpersonal facets of abuse, particularly disturbances of self, affect dysregulation and interpersonal behaviour (Pollock, 2001). It provides a coherent model of development and psychopathology (Ryle & Kerr, 2002). CAT’s emphasis on joint activities and procedural thinking is helpful in working with patients whose motivation and insight are ambivalent (Denman, 2001).
Kerr et al. (2003) state that CAT is based on an explicitly collaborative therapeutic position involving the active participation of the patient. They argue that therapeutic change depends on a non-collusive relationship between patient and therapist, informed by collaborative formation of letters and diagrams and contained by a phased and time-limited relationship. This supports the development of CAT from Bakhtin’s dialogic view of mental phenomena, which states we continually are exposed to dynamic, relational and ongoing re-descriptions of the world, which continually inform and are re-informed by experiences (Leiman, 1997).
Group Therapy
Group therapies are gaining recognition in the NHS, reducing waiting times and reaching large numbers of people simultaneously. Yalom and Leszcz (2005) state eleven therapeutic factors which allow change within groups. These underlying factors include: support providing psychological glue which encourages risk-taking for self-disclosure; realising that imagined negative consequences do not occur; and the group suggesting new ways of feeling, perceiving and behaving (Yalom & Leszcz, 2005; Covington & Bloom, 2007).
This viewpoint is supported by an intensive Group Cognitive Behavioural Therapy programme, finding reduced anxiety, stress and depression scores as well as increased self-esteem (Parkeret al, 2013). Dugas et al. (2003) also found that general anxiety disorder groups not only showed immediate improvement, but after a 24 month follow up were showing further gains, with worry and intolerance of uncertainty significantly decreased. Bastien et al. (2004) reported improvements in sleep for an insomnia group, again maintained at six months follow up. They argued that groups provide cost-effective alternatives to individual therapy. However, group therapies have not been found more successful for social phobia, with Kingsep et al. (2003) arguing therapy effectiveness is diminished by delivery in a group format.
Clarkson (2003) proposed a five-relationship framework for successful group integration, including working alliance; transference and countertransference relationship; developmentally needed or reparative relationship; person to person relationship; and transpersonal relationship (Wright, 2010). This focus on psychodynamic factors and the interpersonal relationships is well supported. For instance, variables such as alliance and cohesion are associated with better results for patients after group therapy (Dinger & Schuenberg, 2010). Oei and Dingle (2008) state that as well as learning and receiving feedback from group members, peers may be a more valid source for people to receive challenges to irrational thinking, than from therapists. Modelling is likely to play a key role, with people who are functioning better on a given day being able to demonstrate adaptive strategies and encourage others (Parker et al, 2013; Yalom & Leszcz, 2005).
CAT Group Therapy
Although there is a limited evidence base, CAT groups have been found to provide advantages that individual therapy cannot, including reducing feelings of stigma, isolation and shame in sexual abuse survivors, with reduced symptoms of depression, anxiety and post-traumatic stress persisting at six month follow up (Sayin et al, 2013).
Ryle et al. (2014) argue this is due to its core relational grounding, with CAT well positioned to be applied to teams for formulation and practice. This is supported by Hepple (2012), stating as CAT is a psychotherapy based on relational understanding of human development, it has much to offer in groups. Caruso et al. (2013) reported CAT based training facilitates team cohesion and patient engagement, reducing burnout levels for therapists working with ‘difficult’ patients. Mitzman and Duignan (1993) also found that written and diagrammatic reformulation of patient’s problems, when shared in the group, served to help the group process.
There is evidence of benefit for patients, including Duignan and Mitzman (1994). Completing a twelve weeks long CAT group with eight patients, they found the time-limited nature and use of sequential diagrammatic reformulations (SDR) resulted in early development of a high level of participative activity and commitment from both patients and therapists. They reported that these factors accelerated the therapeutic process whilst providing an adequate level of containment for patients. Maple and Simpson (1995) found that group interpretations were facilitated by use of the SDR; where comparisons from the diagrams were explicitly drawn from dynamics between group members and ‘real world’ relational dynamics. Calvert et al. (2015) reported that, following a 24 session CAT group for female childhood sexual abuse survivors, experiencing high levels of psychological distress, participants showed significantly improved interpersonal functioning, lower anxiety and greater well-being, with only 19% dropout. It is important to note that the structure and process in CAT groups is variable, with some therapists constructing group letters and maps, whereas others use only pre-existing individual maps, for instance, which are shared.
The process of changing relational dynamics and procedural sequences can be challenging within a CAT group context. Although participating in and witnessing peers’ experiences, can encourage others within a safe environment. However, there is still limited formal evidence to ascertain this.
Therapists using CAT
Hepple (2012) argues in order to manage the process of change, therapists need a great deal of ‘agility’, such as trying not to re-enact unhelpful reciprocal role-play and providing a human and authentic response to things that occur within the group. He states for patients with trauma, it is vital for both therapists and the group to contain any individual members in a trusting and mutually supportive environment before any technical work takes place (see Clarkson’s (2003) developmentally needed therapeutic relationship). CAT’s reciprocal roles are helpful in naming transference enactments and containing disturbance, which allow reflection and a quick return to therapeutic work (Hepple, 2012). Experiencing these processes within a group with peers can increase normalisation of individual experience and reduce stigma, allowing them to cope with the demands of the therapy and helping to accept their own feelings.
Containment and transference are challenging for any therapist working with CAT, particularly within a group setting. Furthermore, as with individual psychological therapies, group therapies may not be for everyone. Evidence for their effectiveness is relatively scarce compared to one to one therapies and the authors have found that groups are
often seen as ‘second rate’ clinical choice by patients. This is experienced across different psychological modalities, not just CAT. Therefore, more research into effectiveness, efficacy and processes of group therapies is needed to be able to compare them to individual therapies.
Rationale for the Study
As there is a limited evidence base for the effectiveness and efficacy of CAT group therapy, there is no measure for therapists’ commitment to group work. Qualitative research may be of more value, to examine the benefits of providing group therapy from those who have facilitated and experienced group processes and dynamics. This study used thematic analysis (Braun & Clark, 2006) to examine potential themes and patterns a priori. Thematic analysis also benefits questions in relation to individual’s views, experiences and perceptions (Braun & Clark, 2006).
From discussion with CAT therapists the aim of this study was to answer the following question – ‘what is it that you feel CAT groups offer and individuals gain that they don’t from other psychological interventions?’ This one question was open ended, with space for free text and the only question within the survey, apart from a section for any further comments.
Results
Overall, 10 participants responded. The email was disseminated to 850 members of the ACAT community who were on the ACAT mailing list. All responses were relevant and included in analysis.
From the analysis, 7 themes were produced, discussed below.
Accessibility
Respondents spoke of the applicability of CAT groups and how they are ‘accessible and understandable to most people’ (respondent 1) and relevant to everything brought to sessions. They discussed how reciprocal roles unfold within a group dynamic and are more easily understood, as well as how more difficult aspects of reciprocal roles are often discussed.
Respondents explained CAT groups as fully understanding group members’ stories, travelling well with each individual’s story and allowing time for their narrative to unfold. Respondent 9 stated groups ‘tend to be good at bridging between a process/analytic stance and a psycho- educational one’, highlighting that CAT groups are accessible and understandable.
Support
A shared notion from respondents was that group members were able to provide an experience that the therapist could not, often being more direct and frank with each other, helping identify problematic relational patterns quicker. The group format was described as allowing each member to support one another and to ‘provide a language each can understand so they are able to then quickly learn to become their own and one another’s therapists in the group’ (respondent 8). Using shared resources was seen as fostering this support, such as group reformulation letters, which offer commonality and universality. By being able to understand each other’s relational patterns, individuals are seen as being better able to support each other. Respondent 9 stated ‘people see others struggling with their [reciprocal roles] and procedures and are able to offer and provide exits and questioning to the group as whole’.
Safe
Respondents spoke about CAT groups being safe and containing, which facilitates group dynamics and allows individuals to discuss feelings that they may not have accessed in one to one therapies. Groups were described as having ‘potential to provide participants with a safe emotional platform’, which leads to ‘additional relational experiences from peers’ (respondent 4). The therapist was also highlighted as being a ‘safe-enough container’. By feeling safe, it was acknowledged that good rapport develops, contributing to changing problematic relational patterns. Groups were discussed as a non-threatening way to explore and understand dynamics and explore conflict safely.
Feeling safe allowed group members to ‘provide additional opportunities for feedback to one another, noticing things the therapist may not and often saying things a therapist may not be able to say – often more candidly’ (respondent 8). Respondent 3 stated ‘it feels like we get to the painful place using CAT which other models can take longer to get to, or feel clumsier accessing’. It was argued that using a scaffolded approach provides a safe experience for people who find discussing feelings difficult, allowing them to achieve it to some degree and then know it is possible in the future.
The relationship between feeling safe and interpersonal awareness was considered, stating that CAT groups provide ‘. . . a working model of thinking and feeling. . . grounding feeling in inter-relational experience, i.e. dialogue’ (respondent 10).
Relational
Being a relational model, respondents discussed helping individuals develop positive ways of relating to themselves and others. Relations were seen as ‘instrumental to the therapy, perhaps more so than with other therapeutic modalities’ (respondent 4). Relational patterns were described as being triggered more quickly, more obviously and with a much wider variety. Groups were described as making problematic patterns explicit, so individuals could work with them openly and directly within the group. Respondents then felt group members could empathically understand origins of relational patterns, on an interpersonal and intrapersonal level. Most discussed the versatility of CAT groups and how they are applicable to everything patients bring. They discussed the innate drive in people to connect with others, stating that groups allow individuals to connect with others, helping their intrinsic motivations and studying their reciprocal roles in detail. Respondent 8 cited:
‘Patients seem to understand reciprocal roles, and I’ve found that using [reciprocal roles] allows us to get to difficult aspects of a presentation in an easier way, e.g. being able to speak with patients about how their actions/reactions could be considered as controlling, abusing, neglecting etc.’
Respondents stated that group members trigger specific responses between one another, providing the opportunity to mirror and model positive relational styles. Being in a group was seen as providing new experiences relating to one another, even relationally isolated people.
The aspect of normalising was often discussed, with groups showing that other people also get caught in problematic patterns, allowing members to help shape themselves. Being able to observe and learn from others was seen as beneficial for the individual to apply to their own skillset. This included problematic and positive relational styles.
Observation
Every respondent spoke of the benefits of individuals being able to observe others in similar situations in order to benefit their own journey. The majority felt groups help facilitate self-observation and to witness their own interpersonal ways first-hand, to help encourage self- compassion and the inner self-to-self relationship, as well as a heightened clarity of understanding. Respondents stated that being in a group allowed ‘live’ examples to help facilitate understanding and practice traps, snags, dilemmas and exits in a safe space. They were called ‘tangible and visual methods’ (respondent 10), allowing reciprocal roles to be played out and changed.
Mapping
The majority of respondents referred to how mapping the individual’s relational patterns is particularly beneficial within a group format. By using a group map, more reciprocal roles were seen emerging, which were seen as ‘making clearer the cyclical nature of people’s difficulties’ (respondent 5). Respondent 8 stated:
‘A CAT group also enables identification of patterns which may never have become apparent in individual CAT therapy because the presence of other patients and their personalities or ways of relating trigger specific responses in patients that would not have come about in a one to one interaction.’
By being able to map and provide letters ‘provides containment and removes anxiety associated with a more analytical style group’ (respondent 9). Mapping was seen as allowing ‘the more difficult to speak stuff to be drawn/written onto the map’ (respondent 6).
Beneficial for the therapist
Several respondents referred to CAT groups as being special, rewarding and enriching for the therapist, creating a ‘unique experience which is highly valued by attendees and facilitators alike’ (respondent 7). CAT groups were discussed as helping therapists in being agile and the importance of this, so as not to be drawn into and enacting unhelpful reciprocal roles with the patient. However, respondents believed that when this does happen, it is useful within the group context to map the reciprocal roles in the moment with others present.
Discussion
Results overview
All respondents were unanimous that CAT groups are of great benefit to attendees and therapists alike, providing a unique source of support and understanding. The findings suggest that CAT groups are able to help a wide variety of complex disorders to gain understanding of their difficulties, in a quicker, more relevant and less intrusive way. This can provide therapists with a clinically useful format to understand and approach a range of different problems in a group setting, being able to provide support for several people simultaneously. Notably, respondents highlighted that reciprocal roles were emphasised as they were played out more frequently and could be commented upon in real time. This is in line with previously discussed literature from Duignan and Mitzman (1994).
Themes
The accessibility theme links back to Yalom and Leszcz’s (2005) therapeutic factors, specifically universality, which one respondent referred to. Most respondents discussed the relational nature of CAT, which is increased in groups when more relationships are available to be viewed and learnt from. Literature previously discussed from Hepple (2012) on CAT being a relational model of human development supports this, as well as then also reducing stigma and shame within the group, which in turn accelerates the therapeutic process (Duignan & Mitzman, 1994) and fosters a sense of alliance and cohesion, all acting as active components for understanding. Maple and Simpson (1995) highlighted the importance of real life dynamics to be able to contain and act as references, which all respondents mentioned as a powerful therapeutic tool.
The supported and safe themes were in line with literature on the use of reformulation and collaboration, making individuals actively involved in treatment. This could be argued as an active component for understanding, developing a sense of control and fostering a sense of independence; one of the aims of CAT. Hepple (2012) also argued that being agile within groups allows reflection and a quick return to positive work to help accept one’s thoughts. By being in a non-judgmental containing space, most respondents stated that this was allowed to develop naturally and encourage understanding.
Several respondents also discussed the theory of dialogism as a framework to understand relational patterns, highlighting the importance of examining in detail individuals’ communications with one another. This is consistent with CAT literature, linking problematic patterns of behaviour and communication with a range of psychological difficulties. Respondents discussed how shared experiences and support can lead to more helpful and positive relational styles and the ability to internalise new relationship patterns. This is relevant, given the need to reduce waiting times and for the UK, and no doubt internationally, to have psychological therapies offered to people with severe and enduring mental health problems (Burke et al, 2015; Department of Health, 2011). Duignan and Mitzman (1994) support this, stating that CAT groups may be an effective and economical use of scarce resources.
Another key factor was the use of mapping as another form of communication. Respondents agreed that this provided a sense of normalisation, again linking to the relational aspect of their difficulties and allowing for more difficult patterns to be approached. It could be argued that mapping keeps up to date with relational patterns between group members. It is consistent with the notion of universality from Yalom’s therapeutic factors, helping group members realise that their feelings, thoughts, impulses and problematic patterns may not be individual to them.
This research appeared to be the first to acknowledge that CAT groups are beneficial and a special and rewarding experience for the facilitator. Several respondents noted their feelings of honour at being able to experience the dynamics in the room and witnessing problematic patterns being considered differently, with patients gaining understanding and self-compassion.
Implications and Future Use
Currently, Cognitive Behavioural Therapy is suggested as the first line psychological intervention for the majority of adult mental health issues in England by the National Institute for Health and Clinical Excellence (NICE), which is also seen further across the United Kingdom and worldwide. This preliminary research, however, suggests that for more complex issues, CAT groups can often help individuals gain a thorough understanding of their difficulties, be able to discuss and formulate difficult and distressing problematic patterns, as well as providing real life examples to experience and observe what has been formulated. It could be argued that issues arising in groups can be thought through differently in group settings compared to individual work. This then provides the NHS particularly an opportunity for time-limited sessions with multiple participants.
Strengths and Limitations
This study presents preliminary results for the support of CAT groups as a valuable and unique intervention for patients. It has been helpful in examining CAT therapists’ perspectives on CAT groups, which is a currently untapped source of information.
As inclusion criteria detailed participants having experience with CAT groups, this inevitably reduced the number of potential respondents who were eligible for participation. It is a relatively homogeneous set of respondents, potentially influencing the results, as it could be argued from only receiving positive responses, that only those committed to CAT groups participated. Further research is needed with a larger sample size to assess both positive and negative experiences of CAT groups and with different cohorts of therapists.
Conclusions
This research has highlighted group leaders views that CAT groups are able to provide a forum in which to form supportive relationships, which individuals are then able to develop self to self, a greater capacity for self-reflection, leading to self-compassion. Results of this study suggest that CAT groups are a unique and rewarding experience for patients presenting with any mental health difficulty, as well as for the facilitator, giving a true and thorough understanding of their personal difficulties whilst experiencing examples in real time. This research is the first of its kind and drawn from a relatively limited sample.
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Methodology
Participants
The respondents in the study were all members in the UK of the Association for Cognitive Analytic Therapy (ACAT), community practising or having practised CAT groups. Ethical approval was obtained and guidelines adhered to.
Procedure
A survey was established using SurveyMonkey and disseminated to members of ACAT via email through the ACAT administrator. The email and link explained the purpose of the study and the question to be answered. By accessing the link and answering the question, respondents were aware they had consented to take part and they had the opportunity to withdraw at any time. It was made clear that involvement was entirely voluntary and would not affect their association with ACAT in any way.
The researcher’s contact details were included. If interested in participating, the individual then answered the question via the survey link, which the researchers could then access. Once they provided typed responses, the link took them to further information (also detailed in the original email) on who to contact if any queries arose.
Confidentiality
All participation was entirely confidential. The above process meant that all information was kept confidential with all responses being given respondent codes for identification purposes. As the question was in survey format and emailed confidentially to the ACAT community by the administrator, potential respondents therefore decided anonymously whether to participate. Thus, a consent form was not needed, as answering the question would provide consent to their taking part. Debrief was also not necessary as the study aims were clearly stated within the email.
Data collection
The email was only disseminated once, with no reminders. A leaflet containing the same details was disseminated at the ACAT Annual Conference in June 2016. Data were collected between April and August 2016.
Data Analysis
Thematic analysis was used (Braun & Clarke, 2006), which identified key concepts and themes from the written data. Primarily, the researchers read respondent’s responses and made notes about presenting themes. The responses were analysed by line, with key ideas and words highlighted. Repetitive ideas were then used as part of data analysis, informing the interpretation of remaining data and developing thematic categories. A coding scheme was developed, using In-Vivo to manage and retrieve the codes. These codes were amalgamated into categories, further discussed under results. Any results that did not fit the thematic categories were dismissed from analysis. The thematic categories were considered in relation to respondents’ responses to provide a further level of analysis. Each response was read on multiple occasions so that once the final respondent submitted their results, researcher LS was confident that thematic saturation had been reached.
Researcher LS (a trainee clinical psychologist) conducted the coding and identification of themes. They were not involved in CAT groups nor have any formal qualification in CAT in order to limit expectations from overly influencing analysis. No triangulation of data was implemented.