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Baker, J., 2003. Evaluation of CAT in GP Practice. Reformulation, Spring, pp.16-17.
Evaluation of CAT in GP Practice
I work in three GP surgeries offering cognitive analytic therapy for patients referred by their GP, others members of the primary health care team and the CMHT. During the 8 years I have been in post I have developed a short term model of working with CAT – referred to as a cognitive analytic informed therapy. Patients are offered 8 sessions of therapy over a 16 week period, using the tools of CAT to support the intervention, including a sequential diagrammatic reformulation, [the therapy does not include a written reformulation or goodbye letter]. Target problems and target problem procedures are identified together with aims and exits.
The therapy is offered to patients suffering from a wide range of psychological problems including depression, anxiety, relationship difficulties etc. The 8 session model was developed in response to my training in CAT with an aim of developing a more structured response to the referrals I was receiving, which could facilitate my practice becoming evidence based.
Although I was aware the patients I saw appeared to get better, the feedback from their GP’s was positive, and new referrals kept appearing, I had no evidence that the therapy I was offering was effective. It seemed important to find this evidence in response to recommendations from the national service framework that therapy offered must be evidenced based and to secure my post within the new primary health care structure. With minimal knowledge of Research methods or language I decided to try to find a method and measure to provide the evidence.
Measure
The CORE measure was chosen because it is financially viable – the only costs being administration and the photocopying of forms. The scoring system is simple to administer with each item having four possible responses (0- 4) The CORE measure has 34 items of measurement, which can be scored by computer of hand. It is a self reporting measure with four domains.
- Well being (4 items)
- Physical symptoms (12 items)
- Functioning (12 items)
- Risk factor (6 items)
Patients with scores of 1.29 and above are considered to have scores within a clinical range.
Method
Following discussion with the GP’s it was decided the initial core form would be given to the patient immediately before their Assessment appointment in an effort to minimise other factors, for example medication prescribed at the initial consultation could influence the therapy. A second form was given at the end of the final session to be returned by post. and the final form is sent to the patient three months after ending to be returned by post. Only one person throughout the study period refused to complete the CORE form pre-assessment.
Following assessment patients were offered:-
1. An 8 session cognitive analytic informed therapy
2. A shorter term intervention.
3. A longer term cognitive analytic therapy (16 –24 sessions) - this therapy is usually offered to patients who have a history of self harming, eating disorder, sexual abuse and have features of borderline personality disorder.
A decision was taken not to score the forms until after treatment had been completed to try to remove bias by the CORE scores on clinical decisions taken.
Results
The study included 152 referrals, 33 males, 119 females aged between 18 – 65 years referred for Assessment between the period April 00 – March 02
68 patients completed an 8 session cognitive analytic informed therapy with 48 patients completing forms at assessment, end of therapy and 3 month follow-up.
45 of the patients completing 8 session therapy had lower CORE scores at discharge than at assessment.
Patients receiving 8 sessions of cognitive analytic informed therapy showed significant improvement in the CORE scores at ending which was maintained at the three month follow-up contact.
The mean CORE score at Assessment was 1.71, the mean CORE score at ending was 1.02 (p< 0.005)
The mean CORE score 3 months after therapy ended was 1.00 (p< 0.005)
Patients offered less than 8 sessions cognitive analytic informed therapy had lower CORE scores at the pre-assessment measure and generally were within the non-clinical range as defined by the CORE measure.
Patients offered the longer term therapy 16 – 24 sessions tended to have higher CORE scores pre-assessment which were within the clinical range.
In retrospect I realise it would have been useful to have included CORE scores for patients not receiving an 8 session cognitive analytic informed therapy at the three month follow up for comparison with the CORE scores for patients who had received the short term cognitive analytic informed therapy.
Discussion
The aim of this study was to evaluate the effectiveness of a short term intervention within a primary care setting. This was a very limited study evaluating the work of one therapist, but does indicate using the CORE measure that there was some change following the intervention and good results can be achieved using a time limited cognitive analytic informed therapy. Further work is indicated looking at different lengths of treatment with therapists in different settings. An interesting comparison would be the potential difference of offering therapy at weekly intervals to two weekly intervals – i.e. the impact of a more intense intervention versus the increase in time to allow for recognition and revision within the therapy framework. I would appreciate comments from colleagues who have an interest in the area of CAT work and evaluation.
Acknowledgements
With appreciation to Alison MacDonald, for her help with the statistical analysis, Hellesdon Medical Practice, Drayton Surgery and Old Catton Surgery, Norfolk for their advice and support.
Jackie Baker