Cognitive Analytic Therapy with a young woman who has a diagnosis of borderline personality disorder and learning disabi

1. Phil Clayton R.N.M.H., R.M.N., Cognitive Analytic Therapist BSc (Hons) Clinical Nurse Specialist & Matt Edgar R.N.L.D. Staff Nurse Calderstones N.H.S. Trust 'Cognitive Analytic Therapy with a young woman who has a diagnosis of borderline personality disorder and learning disability and who lives in a medium secure environment�

2. Introduction A brief history of Susan. The approach: Cognitive Analytic Therapy. Individual therapy. Institutional responses.

3. A Brief History A personal history A life of aggression, setting expectation (reciprocal roles) Maternal deprivation and paternal loss Sibling abuse and loss

5. The Approach Cognitive Analytic Therapy - An integrative model of short term psychotherapy, the conceptual basis being found in both cognitive psychology, psychoanalysis (Ryle 1993, Leiman 1994) and activity theory (Vygotsky).

6. `The aim of the method is to identify, in a language the patient can share, those mental constructions underlying the patients symptoms and difficulties and their inability to change and to relate treatment and the evaluation of its effectiveness to those constructions� (Ryle 1979)

7.  Conceptual Tools The tools of C.A.T. provide the framework/vehicle for therapy and enable a structure which promotes collaboration. Collaboration implicit so as to focus on target problem and target problem procedures, the latter being patterns of thinking and acting that potentiate the target problem.

8. The psychotherapy file - this helps to elucidate the areas of difficulty. The reformulation letter or tape - a way of putting current problems in context of life experiences.

9. Individual therapy Reciprocal role procedures. The therapist is on the look out for what CAT therapists call enactments, the patient pushing the therapist into �roles� they want the patient to think about. Initial sessions establish a contract and focus on presenting problem(s) and emphasise collaboration. The therapist is aware of difficulties that may arise in the assessment sessions as a result of the patients early experiences which may present as threats to the therapeutic alliance. Reformulation letter or tape given after about four (to eight) sessions. This might depend on contracted sessions and presenting difficulties. Working phase - use of tools. Working with the transference. The S.D.R.,`diagram� or `map�.

11. Institutional Responses Staff responses, walking into a reciprocal role, the powerful male nurse, brothers and father. Systemic responses and splitting. Mary Dunne and C.M.H.T.�S. Training.

12. Summary  With complex cases it may be necessary to extend awareness of the psychological processes to the direct care staff. This requires a commitment from the clinician working with the individual and the service managers to resource training.