title: Exploring the collaborative development of cognitive analytic therapy (CAT) sequential diagrammatic reformulations (SDRs) with patients in a high secure hospital: implications for understanding and managing risks.
Creators: name: Croft, Aimee
Publisher: name: University of Liverpool Repository
Year: 2015

description: The focus of this thesis is to explore how patients in a high secure hospital (HSH) experience the process of developing formulations in Cognitive Analytic Therapy (CAT), and whether the use of formulation has helped them to understand and manage risk. To date there is no research exploring the utility of formulation in relation to understanding and managing risks from the perspectives of high secure patients. CAT and formulation CAT is an integrated therapeutic model informed by both cognitive-behavioural and psychoanalytic models of therapy (Ryle &amp; Kerr, 2002). CAT was developed with the aim of combining the most robust elements of these different theoretical approaches (Ryle &amp; Kerr, 2002). From cognitive-behavioural models the analysis and description of sequences of behavioural actions, their outcomes, and associated beliefs and emotions, and from psychoanalysis the emphasis on the role of early relational experiences in the formation of psychological structures and psychological distress, and an understanding of how relational patterns are repeated in, and can be modified through, the therapeutic relationship (Ryle &amp; Kerr, 2002). These elements are brought together in CAT and conceptualised as reciprocal role procedures (RRPs). RRPs are the sequences of behaviour and mental processes which form our individual repertoire for relating to others, developed through our early relational experiences (Ryle, 1993). As in cognitive-behavioural approaches, RRPs stress the detailed analysis of the conscious antecedents and consequences of problematic responses (Denman, 2001), however in CAT these responses are interpersonal and are seen as eliciting particular outcomes in others (Ryle &amp; Kerr, 2002). The initial phases of CAT aim to identify the RRPs implicated in the individual’s current difficulties, and to map these out visually in a sequential diagrammatic reformulation (SDR) and develop a narrative account of their origins in the form of a reformulation letter (Ryle &amp; Kerr, 2002). The diagrammatic (SDR) and narrative (letter) formulations are developed using information about the person’s past and present relationships, as well as discussion of the therapist’s experience of the client in terms of what they impose on or seek from the therapist (Ryle &amp; Kerr, 2002). This use of the therapeutic relationship draws on the psychoanalytic concept of transference, that is the assumption that the client’s demonstration of feelings or behaviours inappropriate to the current situation are manifestations of previous relational experiences (Ryle &amp; Kerr, 2002). Accordingly transference offers insight into the client’s expectations of relationships and is invaluable in formulating RRPs (Denman, 2001). In CAT transference is also seen as providing an opportunity to address unhelpful RRPs through recognition and non-reciprocation of RRPs and exploration of alternatives (Ryle &amp; Kerr, 2002). Thus CAT shares with psychoanalytic approaches the use of the therapeutic relationship as a vehicle of change (Denman, 2001). Structure of the thesis Chapter one consists of a narrative review of the literature on the use of psychological formulation in forensic mental health settings. The review discusses three areas where formulation has the potential to contribute to the assessment, management and reduction of risk. These three areas are 1) the use of formulation to assess risk and treatment needs within structured risk assessment tools, 2), the use of formulation with multidisciplinary teams to enhance staff understanding of risk behaviours and associated systemic factors, and 3) the use of formulation with individual clients to enhance their understanding of risk and self-management capacity. Empirical evidence to support the utility of formulation is lacking, however the review describes the difficulties associated with empirically demonstrating the value of formulation and suggests potential directions for future research. The review highlights that the use of formulation with clients to help them to understand and self-manage their risks has received astonishingly little consideration in the literature, and no empirical investigation. The rehabilitative importance of this is discussed and a rationale for initial exploratory research is provided. Chapter two presents an empirical paper based upon the research study conducted as part of the author’s Doctorate in Clinical Psychology training. The research uses a social constructionist thematic analysis to explore patients’ experiences of CAT and the development of a diagrammatic formulation, particularly the perceived utility of CAT and the formulation in aiding understanding and self-management of risk. The findings suggest that participants’ ability to understand and control behaviours associated with risk was enhanced by the collaborative development and use of the CAT formulation. The findings are discussed in relation to existing theory, previous research findings, and the clinical implications for HSHs. The chapter has been written according to the author guidelines for the Psychotherapy Research journal. The scope of this journal includes process research for all psychological therapies, and research with practice implications is emphasised. Accordingly it was thought to be an appropriate target journal for a naturalistic study investigating an area which had not previously been researched and will therefore be of great interest to clinicians working in forensic mental health settings.