CAT: You Gotta Have a Map

Julie has been doing something called CAT - cognitive analytic therapy - at the hospital.  She has had three or four months of sessions, and is responding very positively to it; this is the first time she has taken to any therapy.

Lack of time and limited sources of information means I haven't found out much about CAT.  I know a bit about CBT and from what Julie brings home, there are some similarities, but it's clear there must be some differences too. Julie never got on very well with CBT, and when we talked about it I could see why it didn't work for her.  CBT is rooted in the thoughts-feelings-behaviour triangle. Julie struggled to identify her own feelings with any accuracy, many automatic thoughts seem to be assigned to the voices she hears, and she wasn't mature enough to look at her own behaviour objectively.  Besides which, she has big significant blanks in her memory around her self-harm incidents which makes it nearly impossible to reconstruct the chain of thinking around these critical events.  Being a smart kid, she would pick up what she was supposed to fill out on the CBT forms she was given, so it would look as if she was making progress.  But when you asked her to talk through the steps that led up to any given decision, she had not the faintest idea.

Julie brought home no forms for CAT, but she did bring home a CAT diagram, which she had worked on for several weeks with her therapist.  Her care coordinator is very enthusiastic about CAT diagrams, and has been encouraging her to share it with people around her.  So far, I have found it very useful, without knowing much about CAT.  It is a large A3 piece of paper, with a map of Julie's mental states, as seen by Julie.  There is a big reassuring green area in the middle of the page representing the state of "OK".  Ringing the central area, in a sort of racetrack, there are various areas representing problem states, like fear or anxiety.  There are links between the problem states - presumably because she does move between them - but critically there are exit routes out of these states back to the central area.  The exits identify what she needs to do to move back to the state of "OK": take time out to focus on what she needs for herself, for example.

At regular intervals, I pull out the map and ask Julie where she is, especially if I think she might not be in an OK state.  It has been a revelation to find out where she is on that map!  If I had to guess, I would get it wrong almost every time.  As she gets further away from "OK", her communication nose-dives - it is virtually impossible to get her to express in words what is happening for her - but she can immediately point to the visual representation on the map.  Once we have a grid reference, I look at the bits of writing in the area to decode what it means - "afraid of rejection" for example - and explore it with her.  Then I prompt her to look at the exit routes and we change  what we were doing to take account of that.  She was just about to watch television?  No, she needs something more active to distract her, so let's go to the gym or get out the Scrabble board.

So if as a layperson I had to sum up what CAT means to me so far, I would say: it's visual, it works (where nothing else did), it improves communication and coping strategies, it's individual and it's fairly intuitive.

Yay!