Cognitive Analytic Therapy: An Innovative Psychotherapy Framework in the Indian Context

The Need for Innovation in Psychotherapy Practice

The need for systematic development in psychotherapy provision in India has been highlighted within the existing literature on psychotherapy from India. ¹ The World Health Organization (WHO) recommends a stepped care approach to ensure an optimal mix of services for mental health. ² Expanding the repertoire of psychotherapy models available in a system can support the need at every level. Worldwide, there are many innovations to make psychological interventions more available and accessible.^{3, 4} One such strategy in India that improves the availability of psychotherapy in the community is task shifting the delivery of psychological therapies to lay counselors.^{4, 5} Another example is the training of lay counselors in family therapy. ⁴

There is also a growing recognition to modify psychotherapy models to be responsive to cultural and social factors.^{6, 7} Culture can be defined as a fabric of meaning that people hold to make sense of life. ⁸ Among the various psychotherapy models being used in India, cognitive behavioral therapy (CBT) is one of the most widely used. Some authors, like Neki, describe CBT as a good fit in the Indian context as opposed to nondirective psychotherapies developed in the West. ⁹ This is because of characteristics such as being directive, problem oriented, and brief, similar to the Guru–Chela paradigm. However, there are other considerations as well. A study conducted in India found that graduate students experienced cognitive approaches to counseling as conflicting with their values and beliefs. ¹⁰ In a study conducted in Pakistan, Naeem et al. ¹¹ found that university students perceived CBT as disagreeing with their religious beliefs.

There are many systematic approaches developed with participation from persons living in that community to modify therapies to suit a particular cultural group and study the effectiveness of the same. ¹² They incorporate the need for the therapist to be aware of and to attend the common beliefs and values of that group. Other aspects, such as religion, idioms of distress, and language too, are given attention. In one such attempt of adapting CBT to suit a non-Western culture, the adaptation requires the therapist to be aware of these factors a priori and make adjustments at different levels of therapy, from engagement to the techniques employed. The adaptations include using culturally relevant metaphors, imagery, and symbolism.^{12, 13} Similar adaptations are being made in other therapy models, such as dialectical behavior therapy and interpersonal psychotherapy. For example, psychological intervention is framed as a training program for adolescents, with the view of improving acceptability in that particular community.^{13, 14}

There are a few limitations of these attempts at adapting psychotherapy models to suit cultures. One such factor is the need for flexibility in applying cultural factors at the level of the individual. ¹² For example, an assumption that individual assertiveness is inappropriate in certain cultural groups will need a more careful analysis at the level of each person.

Communities can inadvertently get classified based on rigid categories, such as individualism and collectivism. ¹⁵ At times, this approach can reduce individuals to stereotypes without space for further complexity. When taken even further, it deems some populations as not suitable for certain forms of psychotherapy. ¹⁵

This invites the need for comprehensive psychotherapeutic frameworks that offer more nuanced possibilities of including culture and social context. Verghese et al. have written about the practice of a transdiagnostic systemic model that can serve as an example of one such framework. ³ Acceptance and commitment therapy (ACT) is another example. ¹⁶

We propose that cognitive analytic therapy (CAT), an integrated model with a transdiagnostic, whole-person approach, as one that can be used within a stepped care approach at community mental health services as well as more specialist centers. Within the CAT model, every course of therapy is adapted to each person and their culture.Other ways include using the person’s own expressions in describing their experiences.

In CAT work, cultural adaptation happens as therapy proceeds with a focus on individually held meaning and without the fixed use of categories that are generalized to a community/culture.

Cognitive Analytic Therapy (CAT)

CAT was developed by Dr Anthony Ryle in the early 1980s and evolved within the publicly funded National Health Service (NHS) in the UK. It is a brief, time- limited, and effective intervention that can be appealing within pressured mental health care settings. The number of sessions can vary between 8 and 24. CAT is an integrated psychotherapy model that provides a general theory of self and psychotherapy. It proposes a comprehensive theory that integrates findings from different schools of psychotherapy as well as developmental psychology, infant observational research, neuroscience, epidemiology, and sociology.

An integrative approach in psychotherapy indicates a generally inclusive attitude toward different psychotherapy models. ¹⁷ This is motivated by the need to improve applicability and therapeutic efficacy. It has developed partly in response to the limitations of any one psychotherapy model in responding to every patient’s needs. CAT provides a larger framework within which techniques particular to the model can be used along with specific ones from other models, to address a wide variety of presenting problems across different services. ¹⁸

The model is transdiagnostic and responds to the more severe and complex needs of individuals with personality disorders, eating disorders, medically unexplained symptoms, and substance use. Individuals presenting with such complex needs are typically offered between 16 and 24 sessions. A length of 16 sessions was offered in our case example 1 to suit the complexity of the presentation. CAT also finds its application in common mental disorders, such as depression and anxiety, where 8 to 12 sessions are employed. ¹⁹ A course of eight sessions was considered appropriate in case example 2, with a less complex presentation. This affords the possibility of using the model in varying intensities depending on the presentation and the level of care (primary or secondary). Another application of the model is at an organizational level to explore the relational patterns within teams at the workplace. Within health care teams, this is known to have a significant impact on the care delivered. ¹⁸

The evolution of CAT started with the restating of traditional psychoanalytic concepts into a more accessible language using cognitive psychology. The cognitive method was employed in describing sequences of beliefs, attitude, behavior, emotion, and consequences. The perspectives of the psychologist Vygotsky and philosopher Bakhtin were important sources in CAT’s concept of a social self. The emergent theory proposes a socially constituted self that is developed and maintained through relating and communicating with others within a wider culture. The different psychological structures (thoughts, feelings, actions, beliefs, and expectations) are considered to emerge, develop, transform, and maintain within this intersubjective space.

In India, CAT was introduced in 2011 by Jessie Emilion and Hillary Brown (CAT practitioners and supervisors) through a practitioner course designed for postgraduate students of psychology in Bangalore. Subsequently, numerous training programs have been organized in different parts of the country.

Stages in the Course of Therapy

The course of therapy can be arbitrarily divided into three stages: reformulation, recognition, and revision.

The reformulation stage is focused on generating generalized descriptions of structures and processes that maintain dysfunctional procedures and their relational, developmental origins. ¹⁸ Reformulation in CAT aims to be a joint activity where the therapist and the patient attempt to develop a shared understanding of the presenting problem and associated difficulties. At times, this may begin with noticing role enactments as they occur within the therapeutic relationship and openly discussing them. Such information regarding transference and countertransference may be reflective of relationships outside of the therapy room and hence helpful in understanding them. The reformulation is expressed as a letter and through maps cocreated in the session. The maps contain the person’s procedures and reciprocal roles (described in the next section) in his/her own words or images and act as visual supplements to the reformulation. They provide a foundation for recognizing and designing exits.

By the end of the reformulation stage, there is more clarity on shared goals for therapy. The recognition of enactments of the patterns identified in the first phase marks the next stage. This involves self-monitoring both within and outside sessions. In the revision stage, the therapist and the patient work together to find exits from these recurring patterns and to manage feelings related to doing things differently. The practice of recognition and the use of alternatives can result in the revision of problematic patterns. This is comparable to the concept of psychological flexibility in ACT. However, in CAT, recognition and revision are done while keeping the patient’s zone of proximal development in perspective. The therapist scaffolds learning and change within the patient’s zone of proximal development. ¹⁸

At times, some direct techniques from other psychotherapy orientations, such as behavioral activation, exposure–response therapy, distress tolerance skills, and eye movement desensitization and reprocessing (EMDR), can be employed, within the wider understanding, to address some symptoms and maladaptive patterns that are more fixed and unyielding.

Target Problem Procedures and Reciprocal Roles

There are two theoretical constructs in CAT that facilitate the link between the presenting problems and the higher-order patterns of self.

The procedure or procedural sequence is the basic unit of the description of the presenting problem, providing repetitive circular patterns of activity (cf. CBT), including maladaptive ones that remain unrevised (target problem procedures, TPP—described further in case example 2). This is compatible with current cognitive models while being more comprehensive in including existing beliefs, values, and needs. ²⁰ These procedures are not considered in isolation but in relation to past and present relationships with others.

In the practice of CAT, these are further linked with reciprocal roles (RRs), templates through which individuals learn to relate to others and themselves (described further in case example 1). They are called RRs because they invite individuals to reciprocate the role that is being presented to them. The recognition of these roles and their enactment with oneself and others occur in the course of therapy. This further supports a systemic approach and provides opportunities to include significant family members in joint sessions where the family members can reflect on their own responses within a relationship. Procedures that emerge to maintain these RRs are known as reciprocal role procedures (RRPs). The emergence of the RRPs is considered developmentally, in response to experiences in early and later life of significant relationships. They are described as “traps,” “snags,” or “dilemmas,” depending on their configuration. These patterns are considered to occur at varying levels of awareness. CAT does not agree with the notion of an unknowable unconscious (cf. psychodynamic psychotherapy) that needs to be interpreted by an expert. It considers the expansion of one’s own awareness about the different ways of being and doing, by paying close attention to what is available to the conscious. In CAT, this activity is a collaborative undertaking by the patient and the therapist.

Case Example 1

When Sushil (name changed to protect identity) came in for the first session, he stated that he was experiencing high anxiety levels. He described his parents as being unavailable during his childhood. His father was intoxicated with alcohol most of the time, whereas his mother was busy with managing the house, multiple miscarriages, and a younger sibling. He often felt ignored and assumed that he was a burden who did not deserve to be loved and had to please others for them to love him. As an adult, he frequently felt neglected by romantic partners and friends. This reinforced his belief that he did not deserve others’ care and attention and hence struggled to get into and maintain relationships.

He felt immense guilt for being so “useless” and unable to do much for his family, despite being the older son. Individually held meaning of the role of the eldest son within his family and community was explored in therapy. Feeling useless played out in the therapy sessions where he felt guilty of “wasting” the therapist’s time talking about his difficulties, which “did not deserve so much time and attention.” Quite unconsciously, he often “forgot” or “overslept” and missed the session.

One of the RRs identified in this case was ignoring/neglecting—ignored/neglected (Figure 1). As a child, Sushil often felt ignored and neglected by others. This had become an internalized template of relating to others and himself. He would ignore his own needs and unknowingly sabotage any care extended to him as if he did not deserve it. This was recognized in his relationship with his family members, with whom he avoided any conversation despite staying in the same house. This was part of a procedure that maintained the RR in place and was mapped in later sessions.

Figure 1. An Example of Reciprocal Roles.

Source: Case example 1.

The top end of the dyad is an eliciting role, other (or parent) derived, whereas the bottom end is a responding state that is usually child derived. A habitual way of relating in that relationship can develop into a template that is applied to the world around. Either the child role or the parental role of an important RR may be enacted toward others, who may then be invited to play the reciprocal. ¹⁸

This becomes one among a repertoire of RRs that the individual holds, as derived from a range of significant relational experiences. Each role implies action that is linked with memory, meaning, affect, values, beliefs, and expectations. This automatically includes cultural values, beliefs, and hierarchies as held by that person. ¹⁸ It is a subjective experience and a state of being. A role implies a tone of voice, posture, way of acting, expectation of the other’s response, and an associated effect. These ways of relating to others are internalized as conscious or unconscious ways of relating to oneself. Although it is similar to the concept of self-schema in CBT, it is different, as discussed above. ²¹

RRs identified from this patient’s experience were drawn on paper during the session so that mapping of procedures that emerged from these RRs was possible in the upcoming sessions. The patient’s own words, with their specific meanings, are used to capture the subjective experience of that role. Images and simple drawings can be used to refer to the RRs and enable collaboration when engaging with individuals who cannot read or write.

Case Example 2

This is an example of TPP (translated from Tamil) of a patient who presented with episodic, medically unexplained physical symptoms of intense chest discomfort, involuntary swaying of the upper half of the body, breathing difficulty, numbness over hands, and dizziness. These symptoms were associated with recurring concerns about health and possible adverse consequences, such as a serious disease being missed. This is an example of an anxiously avoiding trap that maintains the presenting symptoms (Figure 2).

Figure 2. An Example of a Target Problem Procedure.

Source: Case example 2.

The description evolved using the patient’s own words, without using any technical jargon. This aspect of CAT readily enables engaging with the patients’ subjective experience in their own language, without the need to translate it into pre-existing and fixed templates. For this patient, we were able to write down the different physical sensations using her own expressions and then proceed to name the feeling of anxiety, making links between physical symptoms and emotions. The use of local expressions strengthens the truly collaborative efforts of the patient and therapist at every stage of the therapy. This takes place in the natural course of CAT without any specific adaptations. In the therapeutic process, this supported an emerging sense of agency for the patient. The dominant RRs linked with this trap included suppressed to silenced and were explored as a way of understanding the relational origins and higher-order self-processes. This includes the experience of being a girl in her family and community. The CAT model allowed both the therapist and the patient to examine a wider societal factor, such as gender, and this individual’s experience of the same, within the course of brief therapy (seven sessions).

The Therapeutic Relationship in CAT

Creating and maintaining a relationship with the patient that is authentic, empathic, noncollusive, and respectful is considered a prerequisite for therapeutic change. When using CAT, a major aim is to provide a more equal, exploratory relationship that can generate a thoughtful, accepting, and generous dialogue with oneself. ¹⁸

In CAT work, along with agreements on goals and tasks of therapy, the working alliance also includes a space for manifestation and enactment of the patient’s RRPs. One of the therapeutic tasks is to pause and acknowledge the roles being played out in the therapy room. It is a shared emotional experience for both the patient and the therapist. The therapist’s role is to stay past the point where one is likely to collude with the individual’s RRs and not reciprocate in unhelpful or damaging patterns. This explicit naming of the roles occupied by the patient and the therapist alike allows recognition of some automatic culture-bound hierarchies that may be implicit and very powerful when not named. ²² This can be extended as an invitation to the patient to relate in a new way. ¹⁸ Described below are examples of therapists’ responses within the working alliance that further demonstrate CAT’s unique contribution in including cultural aspects.

“It’s as if you wait for me to take the lead and tell you what to do. However, if I were to tell you, then you may experience me as controlling and silencing. I wonder if that’s what happens in other relationships where others decide for you and then feel upset that you don’t have a voice.”

“I feel like I’m being invited to occupy a very powerful position in our relationship; you were referring to me as God. In the see-saw, it’s as if I’m up and you are down…… I wonder what it would be like for the both of us to be more in the middle….”

Apart from using the insights gained in therapy, learning can be immediate from the therapy relationship through recognition, nonreciprocation, and exploration of alternatives. The reflection on the therapy relationship and the relationships of daily life help patients generalize from the lived experience of transference and countertransference to daily life. ¹⁸ The alliance changes throughout the course of therapy and may involve multiple transference–countertransference relationships. ²³ Early mapping and naming of the repertoire of RRs and continued use of the diagram to understand oneself during and in-between the sessions can aid in therapeutic change, provide opportunities to address potential ruptures in the therapeutic relationship, and reduce the likelihood of premature dropout from therapy.

Evidence Base for the Model

There is published literature that includes case studies, small-scale studies, and randomized controlled trials (RCTs) from different parts of the world where CAT is being practiced. A case report describing the application of the model in the Indian setting illustrates and discusses the many points proposed in this article, particularly the challenge of including culture in psychotherapy. ²²

The evidence base is currently dominated by practice-based evidence (PBE) and requires the additional weight of strictly controlled effectiveness trials. ²⁵ The effectiveness of CAT in many conditions, and particularly in more complex disorders, such as personality disorders, is demonstrable with the present evidence. It is being widely used within the UK, in the National Health Service, to treat a wide variety of conditions, without going through the phase of strictly controlled trials. ²² A recent meta-analysis on the effectiveness, durability, and acceptability of the model concluded that it is an acceptable and effective intervention with effects that last beyond the treatment period. ²⁴

Another practice-based study from the UK, conducted in routine practice settings, found an eight-session CAT showing similar levels of change as CBT in treating common mental health conditions, such as depression and anxiety. The model was tested as an alternative to CBT, particularly in patients with clinical complexity, and the dropout rate was found to be lower than CBT. In the current context, the patients allocated to CAT are those with complex relational problems, personality disorder traits, or histories of adverse childhood experiences. Therefore, the outcome matching with CBT outcomes needs to be seen in this clinical context. ¹⁹

Overall, there is a clear need to expand the evidence base.

Conclusion

There is a need for alternative psychotherapy models that meet the needs of diverse clinical presentations and suit the Indian context.^{1, 3} CAT may be one such model that needs to be considered alongside other developments in psychotherapy practice within India.

Some commentaries have expressed the limitations of the CAT model and have questioned whether the brief and time-limited aspect can suit individuals with complex needs, such as those with personality disorders. ²⁰ Some others have commented on the need for a larger evidence base that includes RCTs. ²⁰ Further practice and research studies to gather empirical evidence of the applicability and effectiveness of such a model in the Indian population are required.

In the Indian scenario, with an overall treatment gap of about 83% for mental health conditions, there is a need for innovation in services, ranging from acute care to psychotherapy services and rehabilitative efforts. ¹ The implementation of any psychological intervention, including CAT, will need to be aware of other issues within the system, such as access to psychotherapy and the availability of trained professionals. This calls for innovation in terms of capacity building and service delivery in order to meet the existing demand.