There is a long history of therapists who work in the field of learning or intellectual disabilities making use of Cognitive Analytic Therapy. They have used CAT as a direct therapy with individuals. In addition they have made much use of the CAT framework to help support families, teams and services working with this group of people.
Julie Lloyd is a founder member of the CAT and Intellectual Disability Special Interest Group. In this article she describes two recent research projetcs that supplement pubications in this area available over the last decade.
In the CAT and Learning Disability group we wanted to find out whether and how Cognitive Analytic Therapy could be adapted usefully for our client group and their carers and staff. We already have a body of single case studies and reflective accounts. One of our group, Craig Hallam, with support from myself and Beth Greenhill, interviewed 10 clinicians who use CAT in the community and in forensic settings with people with intellectual disability (ID) . His aim was to explore the main themes which emerged from
He found that clinicians were particularly keen on addressing disempowerment for people with ID, seeing this as a core aspect of their work. They were generally pragmatic about their understanding of the nature of ID and held a non-reductionist, relational view of the nature of change within CAT.
In the following diagram, Craig placed the main themes around the adaptations clinicians reported making in their CAT practice.
He noticed that clincians held pragmatic and flexible approaches to intellectual disability, constantly placing their clients within a relational world. They captured effectiveness via the following themes.
This meant using a multitude of methods for capturing evidence of change and using idiosyncratic adaptations to the structure and process of therapy. For example, clinicians made changes to the length and format of sessions and how they utilised follow-ups.
The LD CAT group uses specific adaptations of CAT tools which are theoretically understood in terms of how CAT uses Vygotsky’s Zone of Proximal Development (1978) to guide accessibility. These tools are available in the book ‘Cognitive Analytic Therapy for people with intellectual disabilities and their carers’ (2014) edited by Julie Lloyd and Phil Clayton. This publication also included a piece of research into how adults with severe learning disabilities were able to understand CAT’s central relational concept of Reciprocal Roles through their ability to see patterns. This was despite being assessed as having language levels of 2-3 years.
There are also papers on working with the client’s support networks to increase understanding by emphasising the relational and systemic aspects of a client’s difficulties rather than locating them solely within the individual.
Rowena Russell (2024) explored using CAT formulations with eleven participants from staff teams. Team formulation is very popular within ID services. Referrals are often initially framed as being about ‘challenging behaviour’ presented by a person. In CAT we aim to understand the relational aspects of the problem, between people, rather than seeing a difficulty being located solely within the client.
Rowena found that CAT therapists working with teams bringing complex presentations to discuss were able to use CAT tools such as mapping. This made it possible for staff to develop a shared language for understanding what was going on. Uderstanding was further enabled by validating staff distress and exploring the emotional impact of their work. This approach promoted a meaningful intervention, more consistent care, offering a model of helpful relating. Benefits included proficient carers, effective management and staff support, and supporting an effective organisational context.
Hallam, C., Lloyd J., & Greenhill, B. (2024) "“Owning our positions and thinking our way through it”: A Thematic Analysis exploring how Clinicians using Cognitive Analytic Therapy construct ID, adapt practice and understand effectiveness when working with people with intellectual disabilities". Submitted to Journal of Applied Research in Intellectual Disabilities
Lloyd, J., and Clayton, P. (eds), 2014. Cognitive Analytic Therapy for people with Intellectual Disabilities and their Carers. Jessica Kingsley.
Russell, R.B., Theodore, K. and Lloyd, J. (2022), "“You’re changing the pattern”: cognitive analytic team formulation with learning disabilities care staff", Advances in Mental Health and Intellectual Disabilities, Vol. 16 No. 1, pp. 53-66. https://doi.org/10.1108/AMHID-05-2021-0024
