Cognitive analytic therapy: The multiple roles of a reformulation letter

Jinny McDonald 
Elizabeth Raybould Centre, Dartford

Background

Cognitive Analytic Therapy (CAT) is a mode of psychotherapy which has been derived from a strong theoretical and evidence-based background.  It is unusual in that this potentially rigid background is combined with high levels of flexibility and patient collaboration within the consulting room.  It is my belief that the CAT reformulation process links these seemingly opposing characteristics and is thus key to the nature of the therapy.  Reformulation is defined as ‘formulating again’ or ‘formulating in a different way, altering or revising’.  Virtually all psychotherapy schools anticipate an early formulation of a patient’s situation.  This distils detail of the patient’s circumstances to a coherent narrative and anticipates ways in which therapy may offer improvements to those circumstances via a more or less generalised approach to their indicated problems.  Most schools of therapy see this as offering a guide for work in future sessions and research suggests that therapy is often more effective if deviations from this broad plan are minimised.  (1)

Ryle, the founding father of CAT, examined psychodynamic formulations in some detail and established that the majority of perceived problems were identified within the first few sessions and tended to be recurrent themes through the remaining sessions.  He also noted (2) that the traditional role of ‘expert therapist’ to ‘naïve client’ accentuated dependence and failed to recruit patients’ potential to participate in their own recovery.  Ryle (3) examined the use of written documents in dynamic psychotherapy and remarked that written communication from the therapist could speed up the process of communication in time-limited therapy while offering patients a useful bridge between sessions.  He added that such communications could maximise objective distance from problems and extend patient’s participation in the therapy.  It is unsurprising, considering these views, that Ryle started to share his written formulations with patients.  These documents were not initially written with this aim in mind and so shortfalls became clear which primarily reflected a lack of empathy-developing warmth and a distance from the patients’ own perspective which limited potential collaboration.  This led to the development of the ‘reformulation letter’ which carries much of the information of a traditional formulation but is written from an empathic and provisional perspective so as to become a shared document with the patient. (1)

CAT is a short-course treatment, generally 16-24 sessions, which calls for speedy identification of a collaborative description of the patient’s sources of difficulty.  These are identified from the perspective of non-functional relationship patterns and the procedures that continually reinforce these patterns.  The patterns are described in narrative form in a ‘reformulation letter’; the aim is to reach this point in around 3-4 sessions.  This is a tentative document that should show empathy towards a patient’s experiences while suggesting possible primary relational causes of problems, their possible impact on future sessions and offer a realistic summary of the progress that could be made during the course of therapy.  This is followed by the shared construction of a diagram that summarises these relationship and procedural problems.  Thereafter the therapy can move towards ‘recognition’ of these patterns within the patient’s daily life and then ‘revision’ of the problems by establishing alternative patterns of behaviour which would cease to reinforce the patient’s difficulties.  The final (or penultimate) session sees a further exchange of letters between the patient and therapist which summarises the progress that has been made and offers signposts to the future.  A follow-up session is generally offered three months later. 

This describes a tight framework which is necessary due to the short nature of the course – wandering ‘off-piste’ into psychodynamic realms is not a real possibility within such a time period.  It indicates the central role of the reformulation as a means of recognising a shared presentation of problem behaviours which serves as a source for finding solutions.  However, within this structure, the patient and therapist can choose any appropriate means to fulfil their aims of exploring current practices and their modification.  This gives CAT an extraordinarily free-flowing nature for a short term treatment – I feel that the reformulation is key to this nature as it offers a vital starting point for recognition and revision within a very adaptive format.  (4). 

The key role of the reformulation letter means that there are a number of important functions and characteristics that should be considered when writing the document.  These are discussed below.

Early Orientation for a Patient

A CAT reformulation is a descriptive process (4) rather than the therapist’s interpretation of the patient’s circumstances.  This places the patient firmly in the role of ‘expert’ while the therapist is effectively translating the patient’s descriptions to a coherent and generalised format.  The reformulation is developed as a partnership where the patient offers information and has responsibility for confirming or correcting the accuracy of the resulting document.  The reformulation is then used as a shared starting point for future sessions and updated or modified as necessary.  This openness to modification means that reformulation can be started at an early stage of therapy and helps the patient to feel more in charge of proceedings rather than leaving him ‘afloat without a destination’ for a long period.   This allows movement into the ‘recognition’ of behavioural patterns and thus their revision. 

Expressing Empathy with the Patient

The primary recipient of a reformulation is the patient.  However, just as Bakhtin, as cited by Evans (5) describes the fact that ‘every utterance has an addressee’, there is a further audience of invisible addressees in the therapist’s mind.  This reflects the fact that the letter is addressed to the patient but still retains some of the functions of a traditional formulation.  This adds a ‘self-to-self’ role for the document where the therapist is structuring his own perspective to find clear narratives within the patient’s detailed story.  Similarly it helps him to develop a direction of treatment and consider possible obstacles that may arise.  A third addressee of the reformulation letter may be the therapist’s supervision group.  This introduces a potentially ‘judgemental’ view of the reformulation which can have an inhibitory effect on the writer.  It also means that the letter must be comprehensible to individuals who have not been present within sessions.  This multiple audience is challenging but discussion within a supervision group prior to presentation of the letter can lead to a more thoughtful product which bears better witness to the patient’s emotional experiences (6).  Ideally this is couched in simple and reflective language within the patient’s zone of proximal development, as noted by Vygotsky and later cited by Ryle (7).  It supports the therapist in his recognition of the patient’s emotions – both painful and joyous.

Accurate Communication

Reformulation is a non-judgemental process that appreciates the patient’s narrative from his personal perspective.  It is written to be read to the patient which leads to a number of potential problems.  The therapist may be ‘overly gentle’ in such letters, aiming to avoid psychological pain to the patient, and thus fail to fulfil the traditional requirements of a formulation to move a patient forward along a therapeutic pathway (1).  Alternatively the letter may be written in a harsh but accurate style which can be painful to the patient.  This then leaves the patient in a hurt and powerless state where they flounder, unable to think.  It is, however, important to realise that communication transcends the words that are used.  The nuance that is carried within phrases can have a powerful effect even if the words deny its existence (4).  An example of this would be the statement that a patient ‘not boring or needy’ which would lead to him being imbued with those attributes despite the clear negative.  This emphasises the importance of reading a letter aloud beforehand, ideally to others, to try to understand the ‘non-verbal’ messages that are implicit in its presentation

Tentative Nature (4)

Beyond the collaborative and empathic nature of a CAT reformulation is the potential for demonstration of an inquiring and reflective viewpoint.  This requires the reformulation to have a provisional and overviewing character.   The reformulation relates the patient’s past experiences to his current problems.  This is not a ‘known’ relationship but relies on standing back and wondering about possible patterns in behaviour and emotions.  This viewpoint models the metacognitive process that CAT seeks to develop (8) to help the patient to construct a ‘meaningful story from incoherent distress’.  It demonstrates, similarly, an uncertainty that is often counter to a patient’s black-and-white modes of thought (4).  It reinforces the role of the patient as sharing or owning the therapeutic process rather than being a passive subject.  This perspective, of wondering reflection, is therefore a vital tone to convey throughout the letter so as to reinforce flexibility in both emotional and cognitive terms.    

Identification of target problem (1)

The patient’s target problem is different to his described symptoms as it is more pertinent to address the unifying underlying cause of these symptoms.  Generally it is found that a number of problems will resolve if a few deep drivers are modified.  This enables a narrower treatment focus and their identification ensures that the therapist and patient are in agreement as to the treatment target.  It is vital that the patient and his therapist work together to develop a clear and simple target that underlies his daily difficulties.  Thus, feeling continually low in mood and angry may, on discussion, provide a target problem of ‘difficulty in making good enough relationships’.   

The source of target problems (1)(4). 

Establishing the aetiology of target problems in CAT has developed from evidence-based studies of psychodynamic therapy.  Ryle noted that a limited number of procedures were repeatedly observed through courses of therapy.  This led him to the concept of ‘target problem procedures’ represented by snags, dilemmas and traps.  Thus early reformulations concentrated on these procedures, examining them from the perspective of a sequential chain of appraisal, emotional response, aim, action, consequences and re-appraisal (2).  Ryle’s use of Kelly’s Repertory Grid techniques (7) then led him to realise that the effects of therapy could be observed through changes in relationships with both others and self.  He thus added dyadic ‘reciprocal roles’ as another potential source of psychological problems.  He proposed that both inappropriate reciprocal roles and target problems are maintained by procedures that continually reinforce them so that they are not revised to more productive endpoints.  Both poles of reciprocal roles (eg abuser and abused) are learned through experiencing one pole of such a relationship (9).  Children can be observed internalising relationships as they first ‘quote’ the words of carers, eg ‘all better now’ and later develop this as a template for self-soothing.  This thus becomes an internalised ‘self-to-self’ relationship (7).  A limited range or dearth of positive reciprocal roles can lead to psychological difficulties and the formation of unsatisfactory relationships in adulthood.  

Predicting therapy (1)

The reformulation letter is of value as a point where the initial therapeutic direction is considered as well as anticipation of potential obstacles.  This helps to minimise inappropriate ‘therapy drift’ which has been observed to have a negative effect on treatment.  It is also an opportunity to detoxify potential therapist-patient difficulties.  It is a point where the period of treatment required for a pragmatic level of improvement can be considered.  This tends to range between eight, sixteen or twenty-four weeks.

Conclusion

This essay tries to show the central role of reformulation in CAT therapy and the challenges of expressing the requirements in the reformulation letter.  CAT is unusual in having extended the nature of the psychotherapy formulation to play a part in the shared space between the therapist and the patient.  This has led to a degree of internal conflict which has been largely solved by the recognition that honesty and collaboration outweigh any requirement for formal and dogmatic evaluation of the patient’s situation.  Thus reformulation becomes the skeleton of a short-course therapy allowing adaptive flexibility and continuous modification of shared understanding within sessions.  My personal experience has helped me to observe the effects of reformulation on the patient and our therapeutic relationship.  The recognition of the patient’s perspective in such an empathic and supportive manner appears to foster the therapeutic alliance.  The presentation of the letter often leads to a relaxation in tension as it confirms the shared nature of the therapy and trust is engendered as it becomes clear that that the therapist does not have a hidden and suspect agenda.  The letter should set the scene and offer a plan for future sessions allowing the recognition of a common goal.  In all, the exchange of letters offers a transitional object to the patient which appears to cement the therapeutic bond between patient and therapist within an act of care and shared generosity.

Bibliography

  1. Denman, C. What is the point of a formulation? In Mace, C (ed.) The art and science of assessment in psychotherapy. London: Routledge. 1995 p159-174
  2. Ryle, A. Consciousness and psychotherapy. British Journal of Medical Psychology 1994; 67: 115-123
  3. Ryle, A. The value of written communications in dynamic psychotherapy. British Journal of Medical Psychology 1983; 56: 361-366
  4. Ryle, A & Kerr I B. Introducing cognitive analytic therapy principles and practice. Chichester: John Wiley & Sons Ltd 2002. Chapter 3,4, 6.
  5. Evans, M. A trainee’s guide to terms and concepts in standard CAT . [internet] 2013 Available from: http://catalyse.uk.com/index.php/training-supervision/cat-glossary/ [Accessed 2nd February 2015]
  6. Kerr, IB & Ryle, A. Cognitive analytic therapy. In Bloch, S (ed.) An introduction to the psychotherapies. Oxford: Oxford University Press; 2006. p267-285
  7. Ryle, A. Cognitive analytic therapy: developments in theory and practice. Hoboken; John Wiley & Sons Ltd. 1995.
  8. Ryle, A. Cognitive analytic therapy and borderline personality disorder: the model and the method. Hoboken, John Wiley & Sons Ltd. 1997
  9. Ryle, A. (1975) Self-to-self, self-to-other: the world’s shortest account of object relations theory. New Psychiatry, 1975 April: 12-13