A systematic review of service user’s experience of cognitive analytic therapy (CAT)

Abstract

PurposeIt is increasingly acknowledged that understanding of the process and impact of psychotherapy is enhanced by awareness of the experience of service users. Cognitive analytic therapy (CAT) was developed as a time‐limited and integrative psychotherapeutic approach. Although reviews have been published on CAT outcome studies, no reviews are currently available on service users’ experience of CAT. This paper aims to systematically review and synthesize what is known about service users’ experience of CAT.MethodsA systematic search of HDAS, Cochrane, and Ethos databases was conducted. Following this, fourteen papers were selected for review, appraised using CASP tools, and then thematically synthesized.ResultsCAT therapy enabled service users to acquire useful knowledge and skills. Most service users found CAT tools helpful in gaining insight into their reciprocal roles and patterns. However, CAT was experienced by some service users as a painful, frightening, and upsetting process, particularly in relation to the sequential diagrammatical reformulation (SDR) and reformulation letter. The importance of the therapeutic relationship was highlighted, as well as difficulties some service users had with trusting their therapist.ConclusionsCAT is helpful in supporting service users to understand their patterns and to identify useful coping skills. However, some service users can experience strong emotions in therapy and struggle to trust their therapist. Greater attention to working within the service users’ zone of proximal development (ZPD) and engendering hope during the reformulation stage may attenuate some of these risks. Recommendations are made for future research directions.Practitioner points CAT therapy enables users to develop insight to their reciprocal roles and patterns and helpful coping skills. The service user’s ZPD should be worked with when delivering CAT to manage risk of distress and reciprocal role enactments and enhance the working alliance. CAT therapists should explore ways to engender hope by attending to any helpful reciprocal roles, patterns, and exits.

Understanding the Factors That Contribute to Creating a Collaborative Psychological Formulation: A Qualitative Systematic Review

“…In line with the earlier subtheme regarding empowerment, this empathy and understanding could lead to clients feeling more empowered: 'It's nice to have someone say it's not all your fault. There are so many contributing factors as to why we are here' (Client; Balmain et al 2021) Clinicians reflected it was important to be present with their clients and show understanding and empathy: '… be compassionate and listening attentively … just trying to, I suppose, sit with them' (Clinician; Small et al 2018). When clients experienced this understanding for themselves, this could then lead to empowerment and potentially a more collaborative relationship: 'I think if you know the reason something's happening, it automatically becomes more controllable.…”

“…Empowerment was shown when clients described challenging their therapist about their formulation's accuracy 'Yes, there was a lot of debate' (Client; Kahlon, Neal, and Patterson 2014). Also individualising the formulation process was experienced as empowering: For example, creating the diagram themselves, 'I made my own diagram of what's going on now and it was exactly the same, but I'm doing it myself' (Client; Shine and Westacott 2010), and using analogies specific to themselves, 'one of mine was I was drowning in the sea' (Client; Balmain et al 2021). Similarly, clients feeling in a position to amend the formulation indicates collaboration and could be experienced as empowering: 'I did actually ask (Therapist) to edit some bits' (Client; Shine, and Westacott 2010).…”