Blending Cognitive Analytic Therapy With a Digital Support Tool: Mixed Methods Study Involving a User-Centered Design of a Prototype App

Background Patients can struggle to make good use of psychotherapy owing to deficits in awareness, and digital technologies that support awareness are at a premium. Currently, when patients participate in cognitive analytic therapy (CAT), the technology supporting relational awareness work involves completion of paper-based worksheets as between-session tasks. Objective We aimed to design, with therapists and patients, a prototype digital mobile app. This was to help patients better engage in the “recognition” phase of the CAT treatment model by providing an unobtrusive means for practicing relational awareness with dynamic feedback on progress. Methods A national online survey was conducted with CAT therapists (n=50) to determine readiness for adoption of a mobile app in clinical practice and to identify core content, functionality, and potential barriers to adoption. A prototype mobile app based on data and existing paper-based worksheets was built. Initial face-to-face user testing of the prototype system was completed with three therapists and three CAT expatients. Results Among the therapists surveyed, 72% (36/50) reported not currently using any digital tools during CAT. However, the potential value of a mobile app to support patient awareness was widely endorsed. Areas of therapist concern were data security, data governance, and equality of access. These concerns were mirrored during subsequent user testing by CAT therapists. Expatients generated additional user specifications on the design, functionality, and usability of the app. Results from both streams were integrated to produce five key changes for the reiteration of the app. Conclusions The user-centered design process has enabled a prototype CAT-App to be developed to enhance the relational awareness work of CAT. This means that patients can now practice relational awareness in a much more unobtrusive manner and with ongoing dynamic feedback of progress. Testing the acceptability and feasibility of this technological innovation in clinical practice is the next stage in the research process, which has since been conducted and has been submitted. The important challenges of data protection and governance must be navigated in order to ensure implementation and adoption if the CAT-App is found to be acceptable and clinically effective.

Correction: Evaluation of a Mobile App to Enhance Relational Awareness and Change During Cognitive Analytic Therapy: Mixed Methods Case Series (Preprint)

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What you see is not what you get: multiple states and dialogues in borderline presentations

The recently revised NICE guidelines on treatment and management of borderline personality disorder (BPD) (NICE, 2018) presents new evidence on psychological therapies being effective treatments for patients diagnosed with BPD. This article will describe some of the challenges we face as clinicians working with complex co-morbid presentations in a healthcare setting. It will briefly discuss the different modalities as suggested by NICE guidelines and expand on the implications of this guidance in relation to service development and constant restructuring, often acted out as an organisational procedure to avoid the harsh reality of limited resources within the NHS. The impact of this on patient care, organisational dynamics, the need for joined-up thinking, and contextual formulations will be discussed using case scenarios. Clinical examples will be used to highlight that pseudo hallucinations, core thoughts, self-to-self dialogues, which trigger "state shifts", can be understood and formulated using dialogic sequence analysis (Leiman, 1998) and concepts from cognitive analytic therapy (CAT). This article will offer some pointers as to how we as clinicians can build resilience, survive the powerful projections and countertransference reactions, recognise the importance of self-care, supervision, and personal therapy in order to be effective, minimise harm, and develop compassion for our patients.

Evaluation of a Mobile App to Enhance Relational Awareness and Change During Cognitive Analytic Therapy: Mixed Methods Case Series

Background There has been a lack of technological innovation regarding improving the delivery of integrative psychotherapies. This project sought to evaluate an app designed to replace previous paper-based methods supporting relational awareness and change during cognitive analytic therapy (CAT). Objective We aimed to assess patients’ and therapists’ experience of using the technology (ie, the “CAT-App”) and to evaluate the relationship between app usage and clinical outcome. Methods The design was a mixed methods case series. Patients completed the Clinical Outcomes in Routine Evaluation-Outcome Measure pre- and post-CAT. Mood data plus the frequency and effectiveness of relational awareness and change were collected via the app. Therapists and patients were interviewed about their experiences using the app. Results Ten patients (treated by 3 therapists) were enrolled; seven completed treatment and 4 had a reliable improvement in their mental health. App usage and mood change did not differ according to clinical outcome, but there was a statistically significant difference in app usage between completers and dropouts. The qualitative themes described by the therapists were (1) the challenge of incorporating the technology into their clinical practice and (2) the barriers and benefits of the technology. Clients’ themes were (1) data protection, (2) motivation and engagement, and (3) restrictions versus flexibility. Conclusions The CAT-App is capable of supporting relational awareness and change and is an upgrade on older, paper-based formats. Further clinical evaluation is required.