1. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Brief Overview of CAT Mark C. Ramm, NHS Lothian Integrative “A theory based on the integration and extension of ideas and methods used in conventionally opposed approaches” (Anthony Ryle) More than just Cognitive and Psychoanalytic Cognitive Behavioural Psychoanalytic Developmental Social

2. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Brief Overview of CAT Distinctive individual psychotherapy CAT accepted as a distinctive and Independent form of psychotherapy - Roth & Fonagy (1996) “An integrated theory of personality and change” So applicability to a wide range of situations, problems and settings

3. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health CAT Radically Relational Almost everything we do is acted out in relation to a real, imagined or anticipated other. Lev Vygotsky – Activity Theory. ‘All higher mental functions are internalised social relationships’

4. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health How does CAT approach it ? Relational: Understands this in terms of Reciprocal Roles (derived from Object Relations) Most distress in human beings is relationship based self and others self and self Dynamic: Understands how people can act very differently at different times and in different contexts

5. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health DEVELOPMENT Babies are born attuned to interact with others Each baby has its own genetic predispositions The baby interacts with carers who are massively influential - Attachment issues The infant internalises its experience Forms joint understandings with others Forms concepts about self and others Formation of Relationship templates Formation of Reciprocal Roles

6. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health

7. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health

8. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Developmental Psychology The ‘self’ emerges from our experiences with others This forms our basis for our feelings about ourselves and for predicting how others will be The core premise of CAT is that the child learns acquires and learns to convert interpersonal experiences into intrapersonal processes and templates

9. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Present interpersonal difficulties are frequently found to be the result of these kinds of developmental roots (Although traumas and powerful relationships later in life can also cause major disruption) A person’s attempts to cope with such issues often leads further problems

10. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health RECIPROCAL ROLES Mother or Main Other (Critical & demanding) SELF (Unworthy & Striving)

11. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health RECIPROCAL ROLES Mother or Main Other (Critical & demanding) SELF (Unworthy & Striving) Other (Critical & demanding) SELF (Unworthy & Striving)

12. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health RECIPROCAL ROLES Mother or Main Other (Critical & demanding) SELF (Unworthy & Striving) SELF (Critical & demanding) Other (Unworthy & Striving) Other (Critical & demanding) SELF (Unworthy & Striving)

13. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health RECIPROCAL ROLES Mother or Main Other (Critical & demanding) SELF (Unworthy & Striving) SELF (Critical & demanding) Other (Unworthy & Striving) SELF (Critical & demanding) SELF (Unworthy & Striving) Other (Critical & demanding) SELF (Unworthy & Striving)

14. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health  The self emerges from our experiences with others  This forms the basis for our feelings about ourselves and for predicting how others will be.

15. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Reciprocal Roles are therefore The templates for all subsequent relationships Interpersonal (self - other) Intrapersonal (self - self ) Are the basis of our dialogical selves. Our various internal voices (Implications for understanding psychosis) Are the ‘origin’ of much Intra-personal conflict and associated distress

16. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health BALANCED PERSONALITY ORGANISATION A Reciprocal Role is a block of procedural knowledge about how to ‘do’ a particular relationship and what to expect from it (Denman 2001)

17. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health “RIGID” PERSONALITY ORGANISATION Restriction and distortion of the Reciprocal Role Repertoire Particular Reciprocal Roles have a dominance and extreme polarization or there are a limited in number of Reciprocal Roles.

18. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Dynamic state dependent functioning How we think feel and remember is to a large extent state dependent We move in and out of our states and prefer to be in some rather than others

19. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Procedures and the maintenance of problems The cause of problems in some shape or form is: The person develops strategies or procedures to cope Abusing Abused Unmet needs Negative emotion Stress

20. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Procedures and the maintenance of problems Abusing Abused Unmet needs Negative emotion Stress Avoiding Ignoring problem, drinking, running away (feels better)

21. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Procedures and the maintenance of problems Abusing Abused Unmet needs Negative emotion Stress Avoiding Ignoring problem, drinking, running away (feels better) Doesn’t solve

22. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Procedures and the maintenance of problems Abusing Abused Unmet needs Negative emotion Stress Avoiding Ignoring problem, drinking, running away (feels better) Doesn’t solve Alternative Reciprocal Role Procedure

23. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Self States Self states connected by procedures and relationships Dynamic state dependent functioning. How we think feel and remember is to a large extent state dependent. We move in and out of these states and prefer to be in some rather than others

24. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Self State Disorders Disruption of integrating procedures Deficient and disrupted self reflection Dissociation of self-states (Multiple Self States Model) Confused, Can’t think, Unstable Dissociation normal

25. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health Ramm & Mair 2009 Issues disrupting Attachment Dismissive Avoidant Attachment Styles Poor Coping Skills Poor emotional regulation Interpersonal difficulties Poor mentalisation PERSONALITY DISORDER PSYCHOSIS

26. Quality Education for a Healthier Scotland Psychology SoFMH School of Forensic Mental Health CAT Formulation & use of Formulation map Recognition, insight & self-awareness (diaries etc) Continued focus on Map Develop insight Change Methods Huge flexibility and range of therapeutic activity possible CBT techniques/behavioral experiments/IPT Mentalisation Occupational interventions Art work Psychodrama Active use of the therapeutic relationship Exits New strategies/ways of coping/relationships developed