18 - Cognitive analytic therapy for borderline personality disorder

Summary

Summary Cognitive analytic therapy (CAT) is a still-evolving integrative and relational model that conceptualises borderline personality disorder as a pervasive and complex dissociative disorder of the self arising largely as a consequence of long-term, developmental psychological trauma in the context of dysfunctional formative relationships and neurobiological vulnerability. Therapy aims initially at the collaborative creation, through a benign and non-collusive relationship, of empathic and validating descriptions and understandings of current difficulties and of their background through written (narrative) and diagrammatic reformulation. These aid self-reflective capacity and integration of the self. They also serve as ‘route maps’ for the work of therapy and contribute to the therapeutic alliance and to the negotiation of often ‘difficult’ transference–countertransference enactments. Many of the contributory and perpetuating factors of problems in borderline personality disorder are social and relational and these may be addressed using systemic ‘contextual reformulation’ in multidisciplinary team-based approaches. Cognitive analytic therapy offers a robust and coherent conceptual framework within which a range of further interventions can be undertaken for various problems and symptomatic behaviours.

In this chapter we describe the conceptual framework and key features of the cognitive analytic therapy (CAT) approach to borderline-type personality disorders (Ryle, 1997, 2004; Ryle & Kerr, 2002; Kerr & Ryle, 2005). We also consider how effective these may be for different patients in different settings and implications of this for further (comparative) research and evaluation. We note some current problems with the concept of borderline personality disorder. These include, in particular, ongoing uncertainty regarding its nosological status, its heterogeneity in terms of both apparent aetiology and clinical presentation, and the range of apparently different ‘brand name’ models that have addressed it, each with its own emphases and specialist terminology. It will be a major challenge for the future to clarify which approaches do in fact effect lasting change and how they do so, and to elucidate the undoubted considerable commonalities between differing models (Roth & Fonagy, 2004; National Collaborating Centre for Mental Health, 2009).