In this reflection on working with people who have attracted a diagnosis of 'emotionally unstable personality disorder', Jurai Darongkamas outlines her experience of how Cognitive Analytic Therapy can be a helpful approach for both client and therapist.
I qualified as a Clinical Psychologist in 1990. I worked in NHS Secondary Care Adult Mental Health services for over 30 years. During this time I trained in Cognitive Analytic Therapy (CAT) and used this in my NHS practice for 15 years. Retiring from the NHS in 2019, I continue to work independently. I have trained and supervised other therapists.
In my NHS role, I offered a number of psychological approaches for people experiencing difficulties in managing their own feelings and with their relations with others. Patients having these sorts of difficulties often received a diagnosis of “Personality Disorder”. For many, this was specified as ‘Borderline Personality Disorder’ (‘BPD’). In more recent years this diagnosis has been redefined as Emotionally Unstable Personality Disorder (EUPD).
There are many views and strong feelings about this diagnosis. Some people feel relieved to have a clinical label which helps them explain and understand long-standing difficulties. For example, some people feel less alone when they can look this label up on the internet. However, for others, such a diagnosis can feel like a harmful label. Some feel it fixes others’ beliefs and expectations about them and leads to some staff having negative attitudes. There is a risk they then provide less compassionate care, with more pessimism about likely outcomes. (Darongkamas et al, 2020) , Hartley et al, 2022).
This group of people have often had very difficult experiences early on in life. They can find themselves repeatedly in stressful circumstances as a result of external stressors or long-standing coping mechanisms. They frequently suffer from the chronic psychological effects of trauma. If there has to be a label at all, then perhaps a more compassionate “label” could be, “People with trauma induced emotional regulation and interpersonal relational difficulties, TIERI”, (Darongkamas et al, 2020).
Since using CAT with people with this range of difficulties, or given such a diagnosis, I find that I am able to help many people much more effectively. This is both during each individual session and considering the outcome at the end of the whole course of therapy.
My experience of using CAT is that it allows both patients and therapists to find the process of therapy more manageable. CAT’s framework helps me to pace the therapy, and to understand what could be going on. By this I mean it helps me think about process, both for the patient, and between the two of us. This framework gives us a structure to work together; to talk about, and closely monitor what goes on. I like the way that CAT helps the person to discuss difficult personal and often highly painful issues in a way that helps make therapy less stressful.
In the early meetings with a new patient, the CAT framework helps to build engagement (a therapeutic alliance) and rapport relatively quickly. CAT helps both myself and the person, jointly understand the important issues both in their life and the therapy room. I could convey my understanding to the patient, through drawing up a preliminary draft diagram or map of what they report often happens between themselves and others. Or sometime the map involves states of mind/moods people found themselves in as well as their usual coping patterns. I invite comments; so the map becomes jointly worked on and agreed. Offering my understanding (and building the person’s own understanding), using the CAT tool of the map, can help deepen our engagement really quickly.
Spending time outside an appointment meeting writing the draft Reformulation letter for the patient helps me to get more on the “same wavelength”/ “in tune” with the person. I can really focus on both their history and their current struggles. I can try my best to imagine “walking in their shoes”. When I draft up my letter to the person, ready to read out in a subsequent session I am, in my mind, talking directly to them.
Reading the Reformulation Letter out loud to the patient frequently deepens the engagement between us. It also provides an opportunity for anything I have misunderstood to be changed or for my understanding to deepen as I learn more. Usually (hopefully) the letter gives me a way to show the person that I have truly heard and absorbed what they had told me. I find it satisfying when the therapy moves to a deeper level of connection between us as a result, both during and after the letter-reading session.
Before using CAT, patients would sometimes miss appointments and then it would take time to rebuild the momentum. My experience is that CAT enables us to predict how (and the ways in which) a particular person may find therapy difficult. It also helped me have more ways to communicate with the person I was working with. The result was that together we could trouble-shoot these potential problems and help the person to continue attending. I found that my rate of missed appointments reduced significantly. (This led to the unintended consequence of me having less unexpected time for admin/paperwork. However I had more time actually doing therapy which I find the more satisfying part of my work.)
Being a time-limited therapy,CAT is very helpful in providing clear guidelines to patients about what to expect. It also provides a clear focus for therapy, determining the main ‘target’ problem/s as well as the patterns that maintain them. This is particularly important in the NHS so that people can get the maximum benefit from available services. This is equally important in private practice, given the financial outlay.
CAT also helps me to be sensitive to and understand when things go “off-track” in the therapy relationship. It provides a way of how to discuss and work on improving it. As CAT therapists, or indeed therapists using other approaches, we use ourselves to help others. CAT helps therapists look at what they bring to the therapy interaction. This helps therapists to make sure that their intervention is always in the service of the patient.
CAT therapists all undergo personal therapy for themselves as part of their training, as well as receiving regular supervision. Having personal CAT therapy and supervision helps therapists to be aware of their own “blind spots”. Staying aware of these is very much needed to be able to work with sensitivity, confidence and creativity, yet in an open, transparent manner. This is especially important given the inherent power difference between the two parties. (For example, the patient often has little choice but to fit in with the system within which the therapist works.)
Working with people with personality issues, or difficulties in relating, both with other people and in how they relate themselves, highlighted to me the importance of working relationally. It is my experience that offering training in this area to staff helps them from unwittingly contributing to the maintenance of problems (or sometimes even making them worse).
On occasions, and only with the patient’s permission, I found it invaluable to share the Reformulation diagram/map or letter with the other staff involved with the patient. Not only could other staff more easily access their feelings of empathy for the patient, but they can also recognise the pull on them to respond unhelpfully. (The latter can take the form of unwittingly assuming unhelpful roles and responding in unhelpful ways.)
Unfortunately, despite being well intentioned, some staff and systems can be damaging, both to the staff as well as the patients. Patients who have had very troubled lives struggle with strong feelings and often can express these feelings in powerful ways. Some staff can take this personally and have strong responses in return. Using a CAT Reformulation diagram/map, or thinking about it in a CAT way, can help staff to take it less personally, and to respond more helpfully. Often this means staff suffer less burnout and gain more job satisfaction. Improvements may come about both through seeing positive changes patients make, and feeling better about how they do their jobs.
I very much enjoy the challenge of working creatively, matching what I have to offer to each person who comes to see me. Some patients respond more to the diagram, others respond more to the letter. Either way, as therapists, we can tailor ourselves to help patients be able to take up, engage with and benefit from what CAT has to offer.
Taking time to think about unhelpful patterns, to be able to recognise and then find ways of weakening (and possibly breaking out of) long-standing patterns is helpful. My experience is that the tools, technique and theory of CAT have provided an anchor for both patients and myself as a therapist. CAT has helped prevent us both from getting overwhelmed in a turbulent sea of intense feelings, actions and reactions. Instead we can focus on the ultimate goal of therapy, often first described as just 'to feel better'.
Jurai Darongkamas, Consultant Clinical Psychologist
Darongkamas, J., Dobel-Ober, D., Moody, B., Wakelin, R. and Saddique, S. (2020), "Training NHS staff to work with people with trauma induced emotional regulation and interpersonal relational difficulties (TIERI)/borderline personality disorder", The Journal of Mental Health Training, Education and Practice, Vol. 15 No. 2, pp. 45-58. https://doi.org/10.1108/JMHTEP-10-2019-0054)
Hartley, S., Baker, C., Birtwhistle, M., Burgess, J.L., Chatburn, E., Cobbaert, L., Howley, M., Huggett, C., MacKenzie-Nash, C., Newton, A., Parry, S., Smith, J., Taylor, C.D.J., Taylor, P.J. and Timoclea, R. (2022), Commentary: Bringing together lived experience, clinical and research expertise – a commentary on the May 2022 debate (should CAMH professionals be diagnosing personality disorder in adolescence?). Child Adolesc Ment Health, 27: 246-249. https://doi.org/10.1111/camh.12586
