Clients' experience of change: An exploration of the influence of reformulation tools in cognitive analytic therapy

"Finding my voice again" - women's experiences of psychological therapy in perinatal secondary care settings: a qualitative study

Introduction

Although women often experience mental health comorbidities in the perinatal period, the evidence-base for psychological therapy across diagnostic boundaries in the perinatal period remains limited. As there is a need to understand experiences of therapy, irrespective of diagnosis, to inform intervention provision, the aims of this study were to explore women's experiences of psychological therapy for perinatal mental health difficulties and to identify the mechanisms that women attributed to the most significant therapeutic change for themselves and/or the mother-infant relationship.

Method

Semi-structured interviews were conducted with 16 women who received therapy within specialist perinatal community mental health settings in the Northwest of England, the UK. Interview data were analysed using reflexive thematic analysis.

Results

One overarching theme entitled participant life stories were at the heart of therapy was identified alongside three other main themes: 1.) We're in this together - therapeutic bond and establishing a coherent sense of self, 2.) Surfing the urge to 'fix' feelings - Sitting with emotions improved regulation and 3.) Seeing myself in a new light - Shifting self-blame to self-compassion enhanced self-efficacy. Theme 1 consisted of three subthemes. Participants described the quality of the therapeutic relationship as the fundamental foundation to (re)connecting with their needs, values and boundaries, which improved their sense of agency, self-esteem, therapeutic engagement and self-understanding. Shifting emotional avoidance to emotional engagement improved their self-regulation. Considering alternative factors that could have contributed to their experiences helped them to defuse self-blame and enhance self-compassion. Finally, changes in their mental health led to positive relational changes in their relationship with their infant and improved communication with partners.

Discussion

Sensitivity, engagement and responsivity experienced in the therapist-woman relationship was reported to be mirrored in the mother-infant relationship. Developing a coherent sense of self and self-regulation skills both appeared to heighten women's self-compassion and empathy for their infants, which also seemed to improve their ability to tolerate uncertainty and mixed emotions within themselves and their infants. The mechanisms of change in the perinatal period are important to consider at a stakeholder, therapist and service management level to parsimoniously and best meet the needs of women and the mother-infant relationship.

Personal reformulation during the clinical associate psychologist apprenticeship: Exploratory mixed methods evaluation

OBJECTIVES

Clinical associate psychologists (CAPs) train under the auspices of the apprenticeship programme and are a new addition to the psychological workforce. This project sought to evaluate whether a "personal reformulation" (PR) was helpful in terms of personal and professional development during the apprenticeship.

METHODS

A mixed methods evaluation containing a longitudinal quantitative element and a "Big Q" qualitative element with a single cohort of N = 18 CAPs. A PR consists of a 2-hr one-to-one session and a follow-up session with a cognitive analytic psychotherapist. During a PR, a sequential diagrammatic reformulation is produced to aid recognition and revision of potentially problematic relationship patterns at work. Two outcome measures concerning reflective capacity and professional quality of life were completed at the start of the apprenticeship, pre-PR and at 3-month PR follow-up. The semi-structured interviews (n = 11) conducted at the follow-up were analysed using reflexive thematic analysis.

RESULTS

Quantitative changes were limited to significant increases to general confidence and 8/12 apprentices had a reliable increase in confidence in communication. Qualitatively, five overarching themes were found: (1) gaining insight, (2) wellbeing, (3) nature of the space, (4) being an apprentice, and (5) moving forward.

CONCLUSIONS

PRs were generally found to be emotionally challenging, but relatively large amounts of insight are possible from a very brief intervention that can contribute to personal and professional development during clinical training. More controlled research needs to be conducted and wider applications and evaluations of PRs in different professions would be welcome.

Psychotherapeutic Change Mechanisms and Causal Psychotherapy: Applications to Child Abuse and Trauma

The study of change mechanisms in psychotherapy needs to be integrated with the causality of behavior, which leads to the concept of causal psychotherapy. Causal psychotherapy is posited as a useful adjunct to standard, evidence based psychotherapies for child and youth victims of abuse and trauma. The article illustrates six processes that could be involved in causal psychotherapy in this context, from the distal to the proximal. They include the distal mechanism of activation-inhibition coordination. The most proximal one relates to executive function. The intermediate levels include ones related to co-regulation (e.g., self control), analysis-synthesis, objectivity-subjectivity, and psychological reserve, which is a new concept in the domain of psychological change mechanisms. Each of the variables can vary from high to low, with the low end being more problematic. Psychotherapy can aim to bring the patient toward adaptive levels. The literature review focuses on psychotherapeutic change mechanisms, and standard psychotherapies for child/youth abuse/trauma, especially trauma-focused cognitive behavior therapy (TF-CBT). Then, it considers causal aspects of child/youth abuse and trauma, including PTSD. The discussion relates causal therapy to the question of unifying psychology and psychotherapy under the rubric of causality as a core integrative mechanism.

The acceptability, effectiveness, and durability of cognitive analytic therapy: Systematic review and meta-analysis

OBJECTIVES

This paper sought to conduct a meta-analysis of the effectiveness and durability of cognitive analytic therapy (CAT) and assess the acceptability of CAT in terms of dropout rates.

DESIGN

Systematic review and meta-analysis.

METHODS

PROSPERO registration: CRD42018086009. Searches identified CAT treatment outcome studies eligible to be narratively synthesized. Pre-post/post-follow-up effect sizes (ESs) were extracted and synthesized in a random-effects meta-analysis. Variations in effect sizes were explored using moderator analyses. Dropout rates were extracted. Secondary analyses synthesized between-group ES from trials of CAT.

RESULTS

Twenty-five studies providing pre-post CAT treatment outcomes were aggregated across three outcome comparisons of functioning, depression, and interpersonal problems. CAT produced large pre-post improvements in global functioning (ES = 0.86; 95% CI 0.71-1.01, N = 628), moderate-to-large improvements in interpersonal problems (ES = 0.74, 95% CI 0.51-0.97, N = 460), and large reductions in depression symptoms (ES = 1.05, 95% CI 0.80-1.29, N = 586). All these effects were maintained or improved upon at follow-up. Limited moderators of CAT treatment effect were identified. CAT demonstrated small-moderate, significant post-treatment benefits compared to comparators in nine clinical trials (ES = 0.36-0.53; N = 352). The average dropout rate for CAT was 16% (range 0-33%).

CONCLUSIONS

Patients with a range of presenting problems appear to experience durable improvements in their difficulties after undergoing CAT. Recommendations are provided to guide the further progression of the CAT outcome evidence base.

PRACTITIONER POINTS

Large pre-post reductions in global functioning and depression outcomes and moderate-large reductions in interpersonal problems are evident after CAT. The effects of CAT appear durable, and interpersonal functioning significantly improves over follow-up time. CAT produces small-moderate benefits compared to trial comparators. CAT appears to be an engaging psychotherapy that maintains patients in treatment.

An exploration of group cognitive analytic therapy for anxiety and depression

OBJECTIVES

Cognitive analytic therapy has been shown to be an effective psychological treatment for a range of differing presentations but little research to date has focused on the use of Group CAT (GCAT). The aim of this study was to explore the acceptability, feasibility, and preliminary effectiveness of GCAT for clients with mood and anxiety disorders in primary care.

DESIGN

This study utilized a mixed method design.

METHOD

A 12-session GCAT programme was developed covering key CAT concepts. The structure reflected the three phases of CAT - reformulation, recognition, and revision. Participants completed outcome measures pre- and post-treatment and at 3-month follow-up. Acceptability was reported using session attendance and participant feedback in addition to asking clients to rank the utility of CAT treatment components. A therapist interview was also completed.

RESULTS

Fifty-five per cent of clients completed the treatment, and feedback suggests that GCAT is an acceptable and feasible intervention for a primary care population. Clients also reported on the utility of specific CAT treatment components. Clients demonstrated positive change on a number of outcome measures.

CONCLUSIONS

Group cognitive analytic therapy shows promise as an acceptable and feasible treatment for clients with mood and anxiety disorders presenting to primary care services. Further larger and more controlled studies are indicated.

PRACTITIONER POINTS

The study supports the idea that GCAT is an acceptable and feasible treatment for clients with mood and anxiety disorders in a primary care setting. Clients indicated the utility of various aspects of GCAT The study provides tentative evidence for the effectiveness of GCAT in ameliorating symptoms of stress, anxiety, and depression in primary care.