Cognitive Analytic Therapy for Offenders

A New Approach to Forensic Psychotherapy

Philip H. Pollock, Mark Stowell-Smith, Michael Göpfert, Philip H. Pollock, Mark Stowell-Smith, Michael Göpfert

• Editorial: Routledge
• Año: 2020
• ISBN:
  9781135191153
• Edición: 1
• Categoría: Medicina
• Categoría: Psichiatria e salute mentale

Cognitive analytic therapy (CAT) is an established form of integrated psychotherapy, which has been applied in a variety of clinical settings to a diversity of disorders with promising outcomes. In Cognitive Analytic Therapy for Offenders, the authors describe the application of CAT to forensic settings, illustrating the use of this type of therapy with a range of offence types and clinical disorders.

CAT is presented as a new form of forensic psychotherapy which can enhance the understanding, conceptualisation, treatment and management of offenders. The book offers a novel description of clinical practice and describes the innovative application of cognitive analytic therapy to forensic work in a variety of contexts and settings for numerous offence types and clinical disorders, including:

• CAT in the treatment of child sex offenders in secure forensic settings
• the use of CAT with women in secure settings
• CAT for parents within prisons
• CAT for borderline and psychopathic personality disorder
• CAT for a stalking offender
• community-based CAT with perpetrators of domestic violence
• CAT for homicide perpetrators (rage-type, serial sexual, dissociative homicides)
• the application of CAT for Court reporting and managing boundary violations.

This book provides an account of a fresh, new approach to conceptualisation and treatment in forensic psychotherapy, and offers the first description of CAT presented in the form of a compilation of illustrations of practice. It will be essential reading for clinical psychologists and psychiatrists, occupational therapists, and anyone who works within services for offenders.

Chapter 1

Cognitive Analytic Therapy applied to offending

Theory, tools and practice

Philip H. Pollock & Mark Stowell-Smith

Forensic psychotherapy as a specialism

Forensic psychotherapy is the offspring of forensic psychiatry and psychoanalytic psychotherapy, and aims to provide a psychodynamic perspective to the understanding, management and treatment of the offender. The overarching aim of forensic psychotherapy is to help offenders understand, and take responsibility for, their actions in order to reduce the likelihood of reoffending (Cordess, Riley & Welldon, 1994). In this respect, a central focus is maintained on the criminal act, the psychoanalytic understanding of which can be traced at least back to Freud’s (1957) hypothesis that certain criminal acts may have an unconscious meaning and motivation, representing, for example, a means of expressing and discharging unresolved guilt. Within the discipline of forensic psychotherapy, a useful differentiation can be made between careerist criminals, for whom the cost-benefits of the offence may be carefully calculated, and the offender for whom the offence may be the equivalent of a neurotic symptom, the expression of a severe, underlying psychopathology or a defence against underlying depression. Conceptualised in this way, the therapist may address the offence with the offender as, for example, an attempt to gain ’symptom relief’ or as an attempt to resolve an internal conflict.

Away from direct clinical work, McGauley & Humphreys (2003) also note how forensic psychodynamic psychotherapy has a role in providing psycho-dynamically informed consultation which enables a dynamic understanding of, for example, the offender in the context of the ward or the institution as a whole. The application of some of these concepts under the heading ‘forensic psychotherapy’ has been comprehensively detailed by Cordess & Cox (1996) and Welldon & Van Velsen (1998). Other forms of psychological therapy, such as cognitive-behavioural therapy (CBT) in particular, have proved beneficial for offenders, Maden, Williams, Wong & Leis (2004) claiming, ‘the evidence shows that, on the balance of probabilities, completion of a suitable CBT programme will decrease the risk of recidivism’ (p. 379). The ‘what works’ debate (McGuire, 1995), which considers the effectiveness of programmes and psychotherapies for offenders, continues to flourish, and it is into this forum that we introduce Cognitive Analytic Therapy (CAT) as a new form of forensic psychotherapy.

The origins of CAT

From the early theoretical developments of the late 1970s, CAT has matured into a form of time-limited psychotherapy that draws together a range of ideas from psychoanalytic, cognitive and personal construct theory. More recently, ideas from Vygotsky (1978) and Bakhtin (1984) have been increasingly emphasised. Both in spirit and in practice, CAT is best represented as a form of integrative, relational psychotherapy. The theme of integration is expressed in Ryle’s early attempts to utilise cognitive concepts as the basis for a ‘common language’ for psychotherapy (Ryle, 1978) and persists in the idea of CAT as a ‘comprehensive theory which aims to integrate the more robust and valid findings of different schools of psychotherapy as well as developmental psychology and observational research’ (Ryle & Kerr, 2002; p. 2).

The emergence of CAT owes much to the zeal and innovation of its creator, Anthony Ryle, whose exposition of CAT as a form of generic psychotherapy can be traced through various texts (Ryle, 1990; 1995; Ryle & Kerr, 2002). While the popularisation of CAT clearly has much to do with the conceptual and practical innovations which Ryle and his co-workers have contributed to psychotherapy, its evolution has also been stimulated by a variety of economic and cultural influences (such as the growing movement in the public mental health sector toward the implementation of differing forms of brief psychotherapy, and financial accountability). Van Schoor (1996) has also noted the way in which technique-oriented forms of brief therapy appear to have taken precedence in the technologically saturated culture of the late twentieth century. According to Van Schoor, this culture involves ‘regimentation, specialisation and standardisation’, qualities that are reflected in brief psychotherapy’s use of standardised procedure, its manipulation of time and its use of technical procedure. CAT is a brief, time-limited and focused integrative psychotherapy which has found its place within this evolving culture.

CAT for offenders: The history so far

The application of CAT to offenders can be traced to the initial work by Brockman & Smith in Ryle’s first book in 1990. Very little work was reported until 1994, with the publication of an article titled ‘Women who stab: A personal construct analysis of sexual victimization and offending behaviour’ by Pollock & Kear-Colwell (1994). This paper described a combination of repertory grid analysis and CAT for two female offenders who had histories of severe childhood sexual abuse, and who had stabbed their male partners. In a follow-up paper, Pollock (1996a) reported the changes achieved through the use of CAT for an additional seven women who had similarly sexually abusive histories and interpersonal, intimate offences, with improvements noted for dissociation, psychological symptoms and abuse resolution. An explicit link between personality disorder and interpersonal crime was made within these works. In 1997, Pollock further reported the relevance of CAT in an illustrative case study of a male sexual offender who was diagnosed with borderline personality disorder, incorporating the use of diagrams into the reformulation process and highlighting the importance of deciphering the underlying roles of the offender-to-victim relationships. Pollock & Belshaw (1998) described two cases of offenders who completed CAT with good outcomes, this paper considering the significance of locating risk potential within the offender’s personality. A paper which described the benefits of CAT for a female stalker, deemed to exhibit an obsessional form of pathological relating (borderline erotomania), who attempted to kill her therapist was also published (Pollock, 2001a & b); it presented the management of a destructive therapeutic relationship.

Although this series of case studies cannot be displayed as a significant evidence base within forensic psychotherapy practice, CAT for offenders has produced interesting advances in terms of psychological formulation as a means of scaffolding the therapy process, the changes achievable and enhancement of the prediction of risk potential. The works described in the following chapters further illustrate the applications of CAT to a variety of offence categories (e.g. homicide), clinical disorders (e.g. psychopathic personality disorder), settings (e.g. community-based domestic violence services) and contexts (e.g. gender issues).

What follows is a description of CAT theory and therapy and its essential components and facets. The reader is directed to the work of Ryle & Kerr (2002) for a comprehensive review of the evolution in theory and practice of CAT with a diversity of disorders, populations and settings.

The theoretical basis: The language of CAT

For clients, it is necessary that their problems are described to them in a clear, simple and portable form. If we acknowledge that clients enter therapy with a lack of personal insight, and unformulated ideas about their thoughts, feelings, behaviours and tendencies, the importance of providing tools to think about and reflect on internal and external processes can be considered of paramount importance. As a theoretical model and psychotherapy modality, it has been refined over a 20-year period to date and offers the client a clear, succinct set of methods to enhance insight (i.e. through letters, diagrams, etc.) and improve self-knowledge, self-monitoring and self-control.

As an integrative model of psychopathology and therapy, CAT blends and revises several concepts from, in particular, psychoanalytic and object relations thinking. The theory synthesises features from personal construct theory (Kelly, 1955), cognitive-behavioural practice and object-relations perspectives. A thorough account of the origins, history and features of CAT is provided by Ryle (1995; 1997).

Basic concepts in CAT

In developmental terms, the core premise of CAT theory is the assertion that the child acquires and learns to convert interpersonal experiences into intrapsychological processes and structures. Learning is achieved through the internalisation of higher-order language and goal-directed action units, referred to as procedures in CAT. The fundamental process in CAT is that interpsychological processes occurring between parent (or others) and child become intrapsychological experience, evident within structures forming the substance of the child’s personality. This occurs during play, when learning skills and even during a parent’s explanation of events in terms of logic and cause-effect relationships in the real world.

Differences between psychotherapies can be traced to the level of inference and ’structures’, which represent this internalisation. CAT is founded on this specific model of learning that describes how the client internalises portable, psychological ‘tools’ to understand, reflect upon and negotiate the developmental tasks of life and relationships. In CAT, the basic structures of the self and relationships (relationships with others, ways of relating to oneself) are referred to as reciprocal role procedures (RRPs). The model suggests that the transition from inter- to intrapsychological learning occurs between parent and child and similarly between therapist and client in ‘tool-mediated, goal-directed’ action (Ryle, 1990). Ryle describes how a child learns to internalise a parent’s actions as a sign-mediated tool (a Vygotskian idea).

The proposal in CAT is that, through internalisation of our interactions with others, particularly our parents, a range of RRPs structure the self and guide our repertoire of actions toward others and toward ourselves. For example, the soothing, comforting, nurturing role provided by a caring parent is internalised and will guide the client’s actions toward, perhaps, a family pet and also toward him/herself when emotionally upset. The ‘voice’ of the parent may be ‘heard’ in an inner dialogue such as, ‘There there, everything will be OK, you will be all right. I’m here for you.’ The nature of the roles of self and other (and the inner dialogue experienced) reflects the child’s encounters with others and the repertoire of RRPs internalised. Of course, unhealthy and negative RRPs are internalised similarly, and a unique repertoire of relating can be observed with a spectrum of harmful (to self and others) and healthy RRPs.

The sequence enacted between parent/teacher/significant other and child is, in substance, a blueprint for the interaction sequence between therapist and client during CAT. The process of learning is sequenced through a range of factors and processes (the parent-to-child and therapist-to-client parallels). The sequence includes the consideration of the child’s cognitive readiness (i.e. the client is orientated to focus on the tasks of therapy), the parent transfers agentic responsibility to the child (the therapist explicitly shares and facilitates the client’s use of the tools of therapy), the adult helps the child to reflect on the task (the therapist focuses attention on the processes and work of therapy), the adult prescriptively directs the child about what to do (the therapist scaffolds the process of therapy and directs the client), the child incorporates and masters the relational, dyadic sequence in dialogical structure from outside to inside (the offender internalises the new learning and the internal image and ‘voice’ of the therapist as an introject), and emphasis is given to the shared, collaborative internalisation of learning, self-understanding and acquisition of language-based tools or skills. The capacity to reflect and observe oneself in relation to others (and oneself) is developed through external, real-life learning’s becoming an internalised ‘dialogue’, which influences thinking, affects feeling and guides acting.

Therefore, as the parent encourages and guides the child, the therapist uses similar processes and actions in the relationship to scaffold the client’s changes. Both scenarios facilitate change through internalisation of portable knowledge and skills in the form of procedures promoting growth and change.

Reciprocal role procedures (RRPs)

A rudimentary description of this process of internalisation is here described (readers interested in the theoretical underpinnings of these concepts should refer to Ryle, 1990; Leiman, 2004).

The concept of a procedure was introduced as a fundamental unit of analysis and level of inference within CAT (Ryle, 1982) to describe intentional acts or enactment of roles in relationships, similar to yet also different from object-relations thinking. These procedures are sustained by repetitive sequences of mental, behavioural and environmental processes. The procedural sequence occurs as follows: (1) mental processes (perception, appraisal of knowledge, action planning, prediction); (2) the effective enactment of an action or role; (3) evaluation of the consequences of the action or enactment, particularly the response of others; and (4) confirmation or revision of the aim or the means attempted to achieve this aim. The central procedures underlying the client’s difficulties are termed RRPs, which represent, theoretically, a direct incorporation of object-relations concepts into CAT theory. RRPs are the core, relational units within the theory.

RRPs are derived from early care-taking and care-receiving relationships. Gradually and by repeated experiences, the child acquires a repertoire of RRPs, forming the structures of the self. During human development, the sequence whereby a child learns about possible options for relating to another person and himself are evident in the unique repertoire of RRPs. Learning occurs through socially derived meaning (e.g. language, sy...