The impact of reformulation on insight and symptom change in cognitive analytic therapy

Objectives. This study aims to assess: clients’ responsiveness to the delivery of CAT-specific tools in order to gain a better understanding about which tools lead to therapeutic change; the impact of CAT upon insight; and clients’ perspectives on receiving CAT and how much they ascribe the process of change to CAT-specific tools. Design. A hermeneutic single-case efficacy design, repeated with a small number of participants, was used to assess whether CAT-specific tools stimulate therapeutic change. Mixed methods were used to generate data on change processes. Methods. The case-series comprised of six therapist/client dyads. Therapists were asked to keep a weekly record of their delivery of CAT- specific tools. Participating clients were asked to complete the recognition and revision rating scale, two corrective experience questions, the insight sub-scale of the Self-Reflection and Insight Scale and the Clinical Outcome in Routine Evaluation-10. Outcomes were supplemented with qualitative data taken from client change interviews. Template analysis was used to analyse the qualitative data. Results. For all but two participants there were no statistically significant changes on the CORE-10 in the session immediately or shortly after the introduction of a CAT-specific tool. Five themes emerged from the qualitative data: making links, breaking the links in patterns, experiences that disconfirm beliefs, working in partnership, and real world influences. CAT-specific mechanisms were identified by participants as helpful for bringing about recognition and revision of faulty patterns. Both CAT-specific and non-specific mechanisms of change were identified as being helpful. Conclusions. CAT-specific tools were seen to facilitate cognitive and emotional insight which was a necessary element of the process of CAT in bringing about behavioural change through revision. It was also found that a genuine therapeutic relationship is an important mechanism operating through, and strengthened by CAT-specific tools.