Reformulation in cognitive analytic therapy: Effects on the working alliance and the client's perspective on change

Objectives. The study aims to investigate whether the reformulation process in cognitive analytic therapy has an impact upon a measure of working alliance, and to explore the client's perspective of the reformulation process. Design. A single-case mixed methodology was used as it is argued that both quantitative and qualitative knowledge are essential for the understanding of change processes in psychotherapy. It is also preferable to gain information from both paradigms within a single investigation. A time-series analysis was used for quantitative data and pragmatic theory, incorporating Yardley and Bishop's composite analysis, provided a rationale for the use of a mixed methodology. Methods. The case series included five clients. The Working Alliance Inventory Revised Short-Form and Simplified Personal Questionnaire were given on a weekly basis and the session in which the written reformulation was presented provided a marker. To address the second research question a qualitative approach was used. Template analysis was used to analyse interview transcripts. Results. Quantitative data showed no significant impact of the reformulation process on a measure of working alliance, either as a step-change or slope-change. Template analysis, however, identified seven themes within the qualitative data: feeling heard, understanding patterns, space to talk, feeling accepted, having something tangible, working together, and feeling exposed. Conclusions. It is proposed that elements of the reformulation process may have impacted upon the clients outside of the reformulation session, and as such had a more cumulative, longitudinal impact upon the working alliance. The use of template analysis in this study has presented an analysis of the data that enables readers to learn something about the people that clinicians work with. Theoretical implications and suggestions for future research are also discussed.