Jane Hamilton (formerly SCT now NHS Lothian) Ian Kerr (formerly SCT/ScHARR now NHS Lanarkshire)

1. A randomised controlled pilot trial of CAT for stressed pregnant women with underlying anxiety and depression. • Jane Hamilton (formerly SCT now NHS Lothian) • Ian Kerr (formerly SCT/ScHARR now NHS Lanarkshire) • Hilary Beard (SLAM) • Vivette Glover (Imperial College) • Dave Saxon (ScHARR) • Stephen Walters (ScHARR).

2. A controlled pilot trial of CAT for stressed pregnant women - acknowledgements • Funding: NHS R&D, ACAT, Stanley Johnson Foundation. • Therapists: Valerio Falchi, Paul Firth, Laura Hill, Dan Tully, Glenys Parry, Anne Sutherland, Sarah Wallis, Lawrence Welch.

3. CAT in pregnancy - background • Increasing recognition that mental health problems in pregnancy are very common and are distressing and disabling. • Are frequently a precursor to post-natal problems. • Stress in pregnancy is recognised to damage the developing foetus and cause problems with subsequent emotional, cognitive and physical development.

4. CAT in pregnancy - background • Focus hitherto has principally been on treatment of overt post-natal mental health problems. • Pregnancy is currently an exclusion criterion for most psychological treatment services in the UK. • Very few studies have aimed at early detection, intervention or prevention by targeting pregnant women despite recognition of importance of such measures in field of public (mental) health.

5. CAT in pregnancy - background • Previous studies using mixed psychoeducational and/or supportive approaches have shown slight or mixed results (Elliot et al, Barnett and Parker). • Encouraging early studies of treatment for ante- natal depression using interpersonal therapy (IPT) (Spinelli et al, O’Hara et al) and light therapy (Oren et al ). • No formal intervention studies so far aimed at stress in pregnancy.

6. CAT in pregnancy - background • Anecdotal evidence of effectiveness of standard (16 session) CAT for mixed (non-psychotic) mental health problems in pregnancy using mixed outcome measures (Hamilton et al). • General evidence of effectiveness of CAT for a range of conditions.

7. Pilot RCT of CAT for stressed pregnant women: study design • Essentially pragmatic, controlled study with ‘intention to treat’ analysis. • Stressed pregnant women recruited from perinatal outpatient clinic – preliminary consent. Offered participation if appeared to meet entry criteria (score of >10 on HAD) – full consent. • Randomisation to ‘enhanced’ clinical care plus brief (16 session) CAT vs ‘enhanced’ (multiple follow-ups) clinical care alone.

8. Pilot RCT of CAT for stressed pregnant women: outcome measures • Spielberger State/Trait Anxiety Inventory • CORE; EPDS; SF36 • Salivary cortisol levels • Video evaluation of post-natal mother-baby interactions. • Incidence of post-natal problems. • Experience of therapy questionnaire. • Health economic analysis.

9. Pilot RCT of CAT for stressed pregnant women: assessment schedule. • i) initial assessment (c. 12 weeks pregnancy) • ii) twelve weeks post assessment (c. mid pregnancy and c. mid therapy) • iii) 24 weeks post assessment (c. end of pregnancy/end of therapy) • iv) 8 week post-partum (c. three months post therapy). • v) 11 months post-partum (c. one year post therapy).

10. Cognitive Analytic Therapy • Increasingly popular integrative therapy developed in the UK by Ryle aiming to integrate the valid and effective elements of cognitive therapy and psychoanalytic ‘object relations’ theory. • Subsequently influenced by Vygotsky’s ‘activity theory’ and Bakhtinian concepts of the dialogic self to stress a more radically social model of self.

11. Cognitive Analytic Therapy • The ‘self’ seen as fundamentally constituted by internalised, socially-meaningful, interpersonal experience and described in terms of a repertoire of reciprocal roles and their procedural enactments.

12. ‘Reciprocal role’ - complex of implicit relational memory, affect and perception (including beliefs and values) - often associated with a dialogic voice . Repertoire of reciprocal roles seen to underpin all mental ‘activity’ whether conscious or unconscious.

13. ‘Reciprocal role procedure’ - stable pattern of interaction originating in early internalised relationships which determine current patterns of relations with others and of self-management. Enactment of a role always implies another, whose reciprocation is sought or expected.

14. Cognitive analytic therapy (CAT) • Essentially time-limited (usually 16-24 sessions). • Pro-active, collaborative (‘doing with’), highly structured. • Aims through extended assessment phase over first few sessions at joint description of key problem (reciprocal) role procedures by means of written (narrative) and diagrammatic reformulations.

15. Cognitive analytic therapy (CAT) • Subsequent work focuses on the enactments of these both outside and during sessions. • Use of transference and counter-transference understood as enactments of repertoires of reciprocal role procedures. • Final summary (‘goodbye’) letters by therapist and patient. • Labour intensive!

16. CAT – case vignette (fictionalised) • ‘Alison’ - late thirties, first pregnancy. Presents to GP with increasing anxiety abut coping with pregnancy (about which she has mixed feelings) and about coping with baby. Feels she ‘ought’ to be able to cope but is increasingly exhausted by trying to keep working (administrator in HR) and cope at home. Feels she ‘can’t’ burden her (second) husband or her mother with whom she has a wary relationship. At times feels hopeless and gloomy about future.

17. Alison - Background • ‘Alison’ - elder of two sisters brought up in impoverished background. Father frequently away from home with work – distant and intimidating figure. Mother probably depressed herself, emotionally unavailable and highly critical. Expected to look after herself and younger sister. Naturally ‘sensitive’. Did reasonably well at school (felt ‘safe and good’) but also experienced some teasing due to late development. Met first BF/husband at college whom she tolerated for 10 years despite his being very critical and at least verbally abusive towards her. Committed to her work in HR where she has reputation for ‘going out of the way for others’ but sets high standards and can be very critical of colleagues.

18. Simplified diagrammatic reformulation for Alison criticise others, e.g. work put self down, don’t seek or deserve help, ‘ought’ to cope they don’t like it, get rejected and alienated, ‘something wrong’ intimidating, criticising, ‘putting down’ can’t keep it up, exhausted, ‘stressed out’, depressed, confirms original experiences get ‘stressed out’, depressed, confirms original experiences intimidated, criticised, ‘put down’ (‘not good enough’, ‘ought to cope’, ‘something wrong’) feels ‘safe and good’, but, own needs unmet, emotionally isolated. put up with work, mother, Robert go out of way for others, ‘can’t’ burden others, keep feelings to self (e.g. in therapy) anticipate and expect ‘put downs’ and criticism

19. Alison – ‘Key Issues’ (Target Problem Procedures) and Aims (1). • TPP: Because of having been put down and criticised and told you ought to cope, tending then to keep things to your self and to go out of your way for others, which leaves you however isolated, ‘stressed out’ and hopeless. • Aim: Try out communicating your emotional needs to trusted others (e.g. in therapy or with your husband), and see what happens.

20. Alison – ‘Key Issues’ (Target Problem Procedures) and Aims (2). • TPP: Accepting the ‘criticising’ and ‘putting down’ voice and so tending to put your self down and to feel that you don’t deserve help. • Aim: Try to identify this ‘voice’ and consider, as we have discussed, whether it is valid and whether you really accept it.

21. Alison – Progress in Therapy. • Attends regularly despite initial ambivalence and gradually begins to be more confident in opening up. Is moved and obviously engaged by reformulation (summary) letter. Seemed ‘strange’ to have this pulled together although she knew most of its contents already. Eventually encouraged to work on key issues and aims despite feeling of not deserving it! Confides in husband and returns with big smile stating that he had been sympathetic and encouraging and had responded by talking about how he felt about things. Became more adept at recognising the ‘criticising’, ‘putting down’ voice but finds challenging it much harder.

22. Alison – Termination of Therapy. • Becomes more anxious and reports feeling stressed again as ending approaches and reverts at times to old coping procedures such as keeping things to herself and feeling she ought to cope alone. However feels she now recognises these and their costs much better. Writes a grateful brief farewell letter herself acknowledging the work achieved in therapy and the changes made, even if they often feel often fragile.

23. Alison – Follow Up • At three month routine follow up (two months post partum) she reports that she is doing well despite initial anxiety after finishing therapy. She feels she is much more ‘in dialogue’ with people (including with her baby) and less stressed out - despite sleepless nights! Significant reductions on routine questionnaires (both anxiety and depression). Referred back to routine follow up in primary care.

25. Clinically apparently-stressed pregnant women invited to undergo screening for trial N=36 Women identified as ‘stressed’ (HAD >10) offered participation in trial after full consent N=35 TAU + CAT N=16 TAU N=19 non completers T3 (term) N=2 T4 N=2 T5 N=3 non completers T3 (term) N=2 T4 N=2 T5 N=4

27. Therapy feedback questionnaire You have recently had a course of brief cognitive analytic therapy (CAT)as part of a study evaluating its effects on stress in pregnancy. We would be very interested to obtain feedback on your experience of This treatment and would be grateful if you could answer the questions below by circling the most appropriate response. [Agree strongly; Agree; Unsure; Disagree; Disagree Strongly.] 1. My experience of this treatment was essentially what I had expected.  2. The treatment seemed too long.  3. The treatment seemed to be very helpful.  4. The style of the therapy seemed appropriate to my needs. 5. I would recommend this form of therapy to other stressed pregnant women if it were routinely available.   6. The therapy felt very supportive.

28. Therapy Feedback Questionnaire 7. The therapy stirred up unpleasant emotions or memories which were unwelcome. 8. The reformulation letter was particularly helpful. 9. The reformulation diagram was particularly helpful. 10. Attending weekly for therapy was a considerable strain. 11. I feel more confident about the future having had this course of therapy. 12. I think a female therapist would be more helpful in working with pregnant women. 13. I feel that my psychological difficulties have not changed significantly as a result of therapy. 14. Any other comments?

29. Therapy Feedback Questionnaire: N=11 Q3: The treatment seemed to be very helpful. agree strongly: agree : unsure: disagree : disagree strongly 7 3 0 1 0 Q5: I would recommend this form of therapy to other stressed pregnant women if it were routinely available. agree strongly: agree : unsure: disagree : disagree strongly 7 3 0 1 0 Q8: The reformulation letter was particularly helpful. agree strongly: agree : unsure: disagree : disagree strongly 2 4 4 1 0

30. Therapy Feedback Questionnaire: N=11 Q10: Attending weekly for therapy was a considerable strain. agree strongly: agree : unsure: disagree : disagree strongly 0 4 1 5 1 Q11: I feel more confident about the future having had this course of therapy. agree strongly: agree : unsure: disagree : disagree strongly 5 3 2 1 0

32. CAT in pregnancy - conclusions • Delivering therapy in pregnancy is feasible and welcomed by patients – should be routinely available? • Provisional limited initial outcome data are encouraging. Needs further extended evaluation. • Positive outcomes could have important implications both in terms of the (long-term) well being of pregnant women but also of minimising the (long-term) effects of stress on the developing foetus.

33. Thank you! • ajane.hamilton@tiscali.co.uk • ian.kerr@lanarkshire.scot.nhs.uk