Recent posts
Newell, A., Garrihy, A., Morgan, K., Raymond, C., and Gamble, H., 2009. Recieving a CAT Reformulation Letter: What Makes a Good Experience?. Reformulation, Winter, p.29.
The use of a reformulation letter is central to the CAT model. We only found one study on the effect that the reformulation letter has on the process of therapy (Hamill et al, 2008). A group of IRRAPT trainees explored the experience course members had of receiving letters during training therapies. The participants reported on the experience of receiving 26 reformulation letters via an anonymous questionnaire that used a combination of 5 point rating scales and open ended questions. We hope to publish the full results later. We were surprised at the level of the variable response to the experience, with some trainees reporting the experience to be positive, but with a significant number reporting receiving the letter as having an adverse effect on the therapeutic relationship, which seemed to correlate with the overall experience of therapy (as proposed by the CAT model).
In summary while 17 of the 26 reported the experience of reformulation overall to be a positive experience, 7 out of the 26 said the experience was negative. Factors that may have contributed to a negative outcome included: insufficient time for discussion of the letter, lack of accuracy, being handed the letter to read or being told the letter would follow.
For the majority of trainees who described the experience as positive, factors associated with a positive experience were accuracy (of the content), perceived empathy of the therapist and method of delivery (e.g. read aloud to the client) with time for discussion. Yet even where the letter was well received few therapists were rated ‘very accurate’ (7/26) or ‘very empathic’ (8/26). It was also noted that 10 of the 26 trainees reported that there was insufficient time for discussion of the letter.
For the therapies that did not go so well a number of comments made by trainees suggest that poor levels of rapport between the therapist and the client persisted to the end of therapy. Comments that suggested that an intensely negative experience had occurred included: “I felt silenced”, “I felt I had failed”, “not listened to” and “I felt over whelmed”.
Considering the data as a whole we came to the following views. Firstly there was evidence to support the view that the reformulation letter had a powerful and positive effect on the therapy, with 16 out of the 26 noting that the letter had a positive effect on the therapeutic relationship. We were concerned to discover, however, that 10 of the 26 therapies (35%) assessed, reported that the letter overall had a negative effect leading to, for example, greater distance in the relationship. This led us to conclude that the powerful impact of the reformulation letter as described in CAT literature and practice is confirmed, yet in some therapies this powerful impact has an adverse effect; this requires more investigation. Some considerations may include the greater expectations that the trainees may have had of the letter as emphasised by the CAT model and how this may have been experienced as demanding or pressurising by their therapists. We felt that perhaps an interview may have helped to clarify some of these details. Further research to include interview data should also be considered. The number of adverse experiences in receiving reformulation letters needs to be taken into account during training and planning CPD for CAT Therapists.
References
Hamill, M., Reid, M. & Reynolds, S. (2008) Letters in cognitive analytic therapy: The patients experience. Psychotherapy Research. 18 (5) 573 – 583