Abstract
Cognitive Analytic Therapy (CAT) is a brief, collaborative and integrated psychotherapeutic approach developed by Anthony Ryle over the past 20 years. It has gained widespread acceptance in the UK, where it now has a national training scheme. Its use has spread to pockets of interest in the rest of the world. Herein lies this reviewer's declaration of interest, as I am running a randomized controlled trial of CAT in emerging Borderline Personality Disorder.
This book is a welcome addition to the literature on the practice of CAT, as it is the first major work to be written by someone other than Ryle. Pollock is assisted by specialist contributions from a range of UK-based CAT practitioners. The book is divided into three parts.
Part I describes the CAT approach to traumatic experiences in childhood. This includes a general orientation to the language and practice of CAT. Due to the complexity of CAT jargon, these descriptions can sometimes seem impenetrable to the newcomer. Fortunately, Pollock tackles this with clarity and he also gives a lucid description of Ryle's ‘Multiple Self-states Model’ of the effects of developmental trauma. This is a trauma-induced dissociation model, originally described in relation to the development of Borderline Personality Disorder [1]. Pollock also uses this section to compare and contrast the therapeutic approaches available for traumatic experiences.
One of the strengths of Pollock's approach is his knowledge of and reference to the scientific literature on the relationship between childhood trauma and adult psychopathology. This is particularly evident in his recognition of the heterogeneity of developmental pathways and outcomes for those who experience childhood adversity and the multifactorial aetiology of pathology in this group. Moreover, he provides a sensible discussion of the issue of memories of childhood abuse. However, Pollock does not resort to empty scientism. He recognizes that, whatever the scientific evidence, one of be central tasks of the therapist is to help the individual patient to construct a coherent narrative of their life experience and to bear witness to this experience. Herein lies one of the strengths of the CAT approach.
Part II describes CAT practice and illustrates this with a series of case studies of increasing complexity and severity. These cases illustrate nicely the use of reformulation letters. They also provide good examples of Sequential Diagrammatic Reformulations. This is a diagrammatic representation of the core roles adopted by the patient and the behavioural patterns that link these roles. It constitutes a core tool of therapy. The examples also illustrate the use of CAT in group settings.
Part III discusses clinical issues in applying CAT. Pollock acknowledges that there is a dearth of research evidence to support CAT and provides data from his own case series of 37 patients. This section also contains a chapter on Pollock's instrument, the Personality Structure Questionnaire (PSQ), which measures the degree of personality integration. Appendix 1 contains a number of instruments used in the practice of CAT.
Despite its title, the book has little to say about case management. This is unfortunate, as this patient group usually requires a great deal of work in addition to the therapy itself. I would have liked to see a chapter on integrating this treatment into clinical services. The book is also somewhat light on in its discussion of the suicidal patient. Perhaps the author assumes this as a basic clinical skill. However, this issue is usually poorly dealt with in clinical services and the CAT approach is a helpful one that should be spelled out in greater detail. One drawback of the book is its poor editing. The text is overly repetitive and there are misspellings and referencing errors.
This book will be of interest to all clinicians treating patients with a history of severe childhood adversity. Pollock provides an integrated, practical and flexible therapeutic model, without succumbing to the perils of unbridled eclecticism. Moreover, his approach is refreshing for its lack of zealotry and his recognition that CAT represents but one tool in the clinician's repertoire of treatments. For those readers specifically interested in the CAT approach to BPD, I suggest referring to the work of Ryle himself [2]. Those interested in a more general introduction to CAT, including its approach to less severe forms of pathology, should refer to Anthony Ryle and Ian Kerr's new work [3].