CAT in Later Life

Grandchildren with grandparents, flowers and kisses

In this article, clinical psychologists Stephanie Davis Le Brun (CAT Practitioner) and Ailsa Lord (trainee CAT Practitioner, awaiting accreditation), offer an account of Cognitive Analytic Therapy as applied with people in their older years.

Why consider CAT?

You might wonder what therapy, specifically Cognitive Analytic Therapy (CAT), has to offer to someone in their older years. People often ask us, “is it not too late?”, to which we always respond “no!”. While none of us can change the past, we have found CAT to be an empowering therapy for those navigating the changes that older age can bring.

For many older people in the UK right now, therapy was not available or accessible in their earlier years. For some, the experience of psychological support may have been very different. Many people we have worked with held fears related to memories of the old institutions and outdated ways of understanding psychological distress. With this, beliefs and misconceptions can develop about opening up to a therapist and what this might mean for you, or about you. The idea of therapy can be a bit of a mystery. However, evidence tells us that therapy for people in their later life can bring many benefits.

'I don't know yet what the future holds but that we have both worked very hard to achieve an improvement in therapy. I also appreciate your work in mental health (and later life), where so many need help - quite often help they do not get. This is such a difficult area to work in, so thank you'. (P, late 70's, offered with permission via Michelle Hamill, CAT Practitioner)

CAT was pioneering in its development as a collaborative therapy that aimed to build a shared understanding of problems. CAT should be done with you, never done to you. It was also one of the first therapies available in the NHS in the UK to shine importance on how a person’s social world contributes to the development of self-identity. CAT therefore aligns well with considering a person’s whole lifespan and the many changes and transitions encountered over time. If you are curious about the benefits of therapy for yourself or a loved one, or you're a therapist considering working with an older person, we would encourage you to consider CAT as an approach.

What might CAT with older people look like?

For an overview of CAT as a therapy model, you can find a helpful summary here. There is also a longer description here.

'CAT has taught me that my life does matter and that I am worthwhile and important as a person. I didn't know what to expect when we started and I did not think that it would make much difference. However, as the time went on, I could see things more clearly and where I could start to make different choices, helping me to feel better about myself and caring for (my husband)' (R, mid 80's, offered with permission via Michelle Hamill, CAT Practitioner)

A flexible approach, tailored to you

No matter who we are working with, CAT is very much tailored around the individual and the problems they struggle with. This makes CAT a helpful fit for many older people. It gives space to consider issues that often arise as we get older, and how these might help or hinder their relationships with themselves and others. What this means is that a CAT therapist is not trying to fit you into a therapy. Instead, you and your therapist work together to figure out what patterns are keeping you stuck. There is no one-size-fits-all.

Terms and tools we use in therapy

What many older people find helpful is that in CAT we try to use your words and metaphors instead of therapy jargon. We can creatively use a range of tools to help you find a way forward and better understand yourself. You might like some tools better than others, or you may find them all useful.

The structure of CAT

While it is flexible enough to be tailored to you, CAT is also structured. This means that there will be a fixed number of sessions, helping you and your therapist stay active as you work towards meaningful change.

The relationship between you and your therapist

Perhaps it may feel unusual in CAT to think about your relationship with your therapist. However, this is an important part of the therapy too. Being open and transparent in talking about what is happening between you in the room can be a valuable chance to learn about how patterns may play out in relationships outside of therapy. This can open up new opportunities to playfully practice trying different ways of being, or interacting, in the safety of the therapy room.

Approaching the end of therapy

For some people, coming to the end of therapy can feel hard. CAT therapists raise this early on and try to make sure there is space to talk about the ending throughout the therapy. There is time to consider how other endings and losses in your life might impact on the therapy relationship drawing to a close too. We usually mark the end of CAT with the exchange of goodbye letters. This provides a chance to work through the ending together, reflect on what you’ve achieved, and what might be useful going forward.

Adapting CAT for older people

CAT traditionally takes place in a clinic setting, but CAT with older people may require consideration of adaptations necessary to make therapy accessible, such as:

considering home visits

ensuring any CAT tools are accessible (e.g. enlarging print or images, or providing them in other formats)

adapting the pace of therapy to account for longer life histories and to help build a safe and collaborative therapeutic relationship

pausing therapy if needed, for example for illnesses, hospital appointments or hospital admissions

considering any physical health issues, mobility issues, or changes to memory and cognitive functioning

What sort of things do people use CAT for in later life?

CAT can be effective for a wide range of difficulties. In CAT, it doesn't matter what diagnosis you may have been given. Instead, it focuses more on the patterns of thoughts, feelings and actions people can struggle with.

We have commonly found that there are certain themes our older clients think about and move forward with, using CAT. For example:

Loss and bereavement

Adapting to being older

Life review and regrets about the past

Considering the future, and the end of life as this moves closer

Changes in health and care needs

Making links between current problems and experiences from your earlier life

Difficulties forming, maintaining and navigating relationships with others, particularly changes in relationships that come with ageing.

Losing confidence in the context of retirement and changes in your social networks

Hopelessness and thoughts that life is not worth living

Struggling with frequent or abrupt shifts in how you feel or behave

”Since starting this…at first I found it very difficult, but I do…mentally if that’s the right word to use…I do mentally feel a lot better, a lot calmer, and a lot of it is feeling more relaxed, even though all these bad things are happening.” (G, CMHT client, 60s, offered with permission via Ailsa Lord)

Other applications of CAT in older adult services

While CAT is typically applied as one-to-one therapy, there are other, ‘indirect’ applications of CAT in older adult services. CAT can help to make sense of the system around a person and to ensure their needs are adequately considered and met. For example, we sometimes might help those supporting a person with dementia, or people in care settings.

Sometimes an older person supported by a mental health team does not want a one-to-one therapy. In this case, we can instead help the person's care team to think in a CAT way about the most helpful approach for their needs. CAT can also support organisational staff teams by understanding unhelpful patterns that may get in the way of team functioning.