Why do we write letters at the end of CAT?
Ending therapy can be hard, often for both client and therapist. It is only in our most intimate, real life relationships that we make a conscious decision to stop seeing each other. It brings up feelings of grief and memories of previous endings and losses.
In CAT we try to explore feelings about the ending of the therapy in the last few sessions. As part of this, we encourage the exchange of “Goodbye Letters”. These letters describe what has happened in the therapy. They can include what problem patterns were worked on, and what goals have been achieved. They can point to what still needs to be worked on too. It is also a chance to say a more personal goodbye. All of this is much easier when the therapy has made a big difference to the client, they are feeling much better and ready to end.
What if not much has changed?
It can be more difficult to end if the client is still struggling with problem patterns. I recently finished therapy with a man who came for help with angry outbursts whenever he got into conflict with people in authority. Luckily, this hadn’t caused problems in our therapeutic relationship and we had formed a good working relationship.
At session 12 (of a 16 session course of CAT) he arrived with a story of yet another example of a conflict. This had built up to the point of him shouting at his boss and walking out of work. He managed to get himself home but was unable to calm himself down. He’d had to call his girlfriend to talk him through it. “Nothing’s changed” he said “It is still as bad as ever, this therapy hasn’t made any difference”.
I felt pretty defeated myself at this point. I was sad that in spite of all the work that we had done understanding where the pattern had come from, all the CAT mapping, role playing and self soothing that we had practised, he was still unable to stay calm. However, I managed to stay curious and ask “what happened after that?”. He was thoughtful for a moment. Then he said, “well, I just took myself off to bed and had a sleep. When I woke up I was feeling better. That’s a point, in the past I would have been going over it again and again for the rest of the week, not able to let it go. Maybe things have changed a bit?”.
This is a good example of how attending to the detail of what is happening can reveal small improvements that show things are moving in the right direction. Often “getting better” does not mean that the problem pattern never happens at all. It might mean that the problem does not happen so often, or that you get back to an easier place more quickly.
What should be in a goodbye letter?
I give a list of possible headings to clients to help them think about what they want to write in their letter. The headings are:
- What has changed for you since having CAT?
- What new ways of relating to yourself and others have you found?
- What do you need to keep working on?
- Any regrets or disappointments?
- What would you like to say to your therapist?
The personal bit
That final question can trigger all sorts of comments, from a simple “thanks for trying” to “this has been the most important relationship of my life, you know more about me than anyone”. As a therapist, i genuinely feel that I learn something new from every client I see. It might be a sudden light bulb moment of thinking “oh that is true for me too” as someone is describing how they feel about something, or learning a new way of finding healthy exits to problems. This means that I am changed by each therapy relationship. I try to put something of that in my goodbye letter to the client.
Dr Alison Jenaway is a Consultant Psychiatrist in Psychotherapy in the Liaison Psychiatry Service in Cambridge. She is a CAT therapist and supervisor and has been using CAT for around 20 years. She is a past chair, and currently a trustee of the national Association for Cognitive Analytic Therapy.