The effectiveness of cognitive analytic therapy for borderline personality disorder: Utilizing a withdrawal experimental design to improve sensitivity to abandonment
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Objectives: A primary methodological weakness of the single‐case experimental design (SCED) outcome studies conducted of the treatment of personality disorder with cognitive analytic therapy (CAT) is that they have failed to employ a withdrawal phase or cross‐over design and so are deemed quasi‐experimental. This study sought to implement a withdrawal design, in order to improve the internal validity of the study to make it a true SCED, and also in order to enable the patient to explore abandonment dynamics. Design: The study employed an A 1 /B 1 /A 2 /B 2 with extended follow‐up SCED with a female patient treated with CAT meeting diagnostic criteria for borderline personality disorder (BPD). Following the 6‐week baseline period ‘A 1 ’, treatment occurred in two phases (21 sessions ‘B 1 ’ and 24 sessions ‘B 2 ’) sandwiching a 12‐week treatment withdrawal phase (‘A 2 ’) and a 24‐week structured follow‐up phase. Seven idiographic daily measures were collected that created a N = 698 day timeline. Nomothetic outcome measures were collected at baseline and at the end of each phase of the study, and the Session Impact Scale was completed after each treatment session. Results: There was a significant increase in the task focus of treatment sessions. Ideographically, CAT was an effective treatment for improving the participant’s self‐to‐self relationship, as their self‐hate reduced and their sense‐of‐self increased. There was a broad pattern of deterioration during the second treatment phase (B 2 ) and follow‐up phase across the ideographic measures, and CAT was ineffective for BPD ideographic emotional or self‐to‐other measures. Reliable change occurred on the primary BPD nomothetic outcome measure from baseline to end of first treatment phase. Conclusions: The study suggests that the CAT intervention was partially successful and that it is possible to integrate good research practice with clinical innovation. The methodological strengths and limitations of the design and the clinical implications of the results are discussed. Practitioner points: Cognitive analytic therapy was partially effective in the treatment of BPD in a case that had been unresponsive to other psychological interventions. Therapists need to complete lengthy and structured follow‐up to capture any emerging relapse. Therapists need to discuss the patient’s thoughts and feelings about termination regularly in a relationally informed manner.
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Psychotherapy cannot be as cleanly withdrawn as some behavioural interventions.
“Because psychotherapy aims for internalization and positive change that is maintainable, it clearly cannot be as cleanly withdrawn as some behavioural interventions can be (Kellett et al., 2021; McMillan & Morley, 2010).”
From Effectiveness of cognitive analytic therapy for bipolar affective disorder: A co‐produced single subject cumulative treatment design with extended follow‐up (A <sup>1</sup> /B/A <sup>2</sup> /C‐FU) (2022) · cites this paper as Kellett et al., 2021
Treatment withdrawal can be an authentic aspect of the phasing of clinical interventions.
“this shows that treatment withdrawal can be an authentic aspect of the phasing of clinical interventions (Kellett et al., 2021)”
From Effectiveness of cognitive analytic therapy for bipolar affective disorder: A co‐produced single subject cumulative treatment design with extended follow‐up (A <sup>1</sup> /B/A <sup>2</sup> /C‐FU) (2022) · cites this paper as Kellett et al., 2021
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Cites
Diagnostic and Statistical Manual of Mental Disorders
American Psychiatric Association (2013) · doi:10.1176/appi.books.9780890425596 · Cited by 116,369 · see citing works
Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Carter, M. J. (2014) · Therapeutic Recreation Journal · Cited by 15,154 · see citing works
Jacobson, N. S., & Truax, P. (1991) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.59.1.12 · Cited by 7,770 · see citing works
Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients
Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. F. (1996) · Journal of Personality Assessment · doi:10.1207/s15327752jpa6703_13 · Cited by 5,965 · see citing works
Assessment of suicidal intention: The Scale for Suicide Ideation.
Beck, A. T., Kovacs, M., & Weissman, A. (1979) · Journal of Consulting and Clinical Psychology · doi:10.1037//0022-006x.47.2.343 · Cited by 3,419 · see citing works
(1997) · American Psychiatric Press eBooks · Cited by 3,056 · see citing works
Single Case Experimental Designs: Strategies for Studying Behavior Change
Barlow, D. H., Nock, M. K., & Hersen, M. (1976) · Cited by 3,036 · see citing works
Testing for Serial Correlation in Linear Panel-data Models
Drukker, D. M. (2003) · The Stata Journal Promoting communications on statistics and Stata · doi:10.1177/1536867x0300300206 · Cited by 1,574 · see citing works
Schmider, E., Ziegler, M. D., Danay, E., Beyer, L. M., & Bühner, M. (2010) · Methodology · doi:10.1027/1614-2241/a000016 · Cited by 1,300 · see citing works
Single case experimental designs: Strategieṡ for studying behavior change
Matson, J. L. (1985) · Applied Research in Mental Retardation · doi:10.1016/0270-3092(85)90012-8 · Cited by 1,193 · see citing works
Single-Case Experimental Designs
Hersen, M. (1985) · Springer eBooks · doi:10.1007/978-1-4615-7278-7_4 · Cited by 1,002 · see citing works
Brown, M. Z., Comtois, K. A., & Linehan, M. M. (2002) · Journal of Abnormal Psychology · doi:10.1037//0021-843x.111.1.198 · Cited by 780 · see citing works
The borderline diagnosis I: psychopathology, comorbidity, and personaltity structure
Skodol, A. E., Gunderson, J. G., Pfohl, B., Widiger, T. A., Livesley, W. J., & Siever, L. J. (2002) · Biological Psychiatry · doi:10.1016/s0006-3223(02)01324-0 · Cited by 769 · see citing works
Bohus, M., Kleindienst, N., Limberger, M. F., Stieglitz, R., Domsalla, M., Chapman, A. L., Steil, R., Philipsen, A., & Wolf‐Arehult, M. (2008) · Psychopathology · doi:10.1159/000173701 · Cited by 738 · see citing works
Handbook of personality disorders : theory, research, and treatment
Livesley, W. J. (2001) · Cited by 638 · see citing works
Social Desirability Response Bias in Self-Report Choice Situations.
Arnold, H. J., & Feldman, D. C. (1981) · Academy of Management Journal · doi:10.2307/255848 · Cited by 479 · see citing works
Mechanisms of change in mentalization‐based treatment of BPD
Fonagy, P., & BATEMAN, A. W. (2006) · Journal of Clinical Psychology · doi:10.1002/jclp.20241 · Cited by 448 · see citing works
The IIP‐32: A short version of the Inventory of Interpersonal Problems
Barkham, M., Hardy, G. E., & Startup, M. (1996) · British Journal of Clinical Psychology · doi:10.1111/j.2044-8260.1996.tb01159.x · Cited by 430 · see citing works
Borckardt, J. J., Nash, M. R., Murphy, M. D., Moore, M., Shaw, D. L., & O'Neil, P. M. (2008) · American Psychologist · doi:10.1037/0003-066x.63.2.77 · Cited by 408 · see citing works
Why clinical trial outcomes fail to translate into benefits for patients
Heneghan, C., Goldacre, B., & Mahtani, K. R. (2017) · Trials · doi:10.1186/s13063-017-1870-2 · Cited by 404 · see citing works
Krasny‐Pacini, A., & Evans, J. J. (2017) · Annals of Physical and Rehabilitation Medicine · doi:10.1016/j.rehab.2017.12.002 · Cited by 387 · see citing works
Design and Analysis of Cross-Over Trials
Jones, B. C., & Kenward, M. G. (2014) · Chapman & Hall/CRC eBooks · doi:10.1201/b17537 · Cited by 369 · see citing works
Chanen, A. M., Jackson, H. J., McCutcheon, L., Jovev, M., Dudgeon, P., Yuen, H. P., Germano, D., Nistico, H., McDougall, E., Weinstein, C., et al. (2008) · The British Journal of Psychiatry · doi:10.1192/bjp.bp.107.048934 · Cited by 367 · see citing works
Characteristics of single-case designs used to assess intervention effects in 2008
Shadish, W. R., & Sullivan, K. J. (2011) · Behavior Research Methods · doi:10.3758/s13428-011-0111-y · Cited by 338 · see citing works
Negative outcome in psychotherapy: A critical review.
Mohr, D. C. (1995) · Clinical Psychology: Science and Practice · doi:10.1111/j.1468-2850.1995.tb00022.x · Cited by 330 · see citing works
Downey, G., Mougios, V., Ayduk, O., London, B. E., & Shoda, Y. (2004) · Psychological Science · doi:10.1111/j.0956-7976.2004.00738.x · Cited by 264 · see citing works
The dose-response effect in routinely delivered psychological therapies: a systematic review
Robinson, L., Delgadillo, J., & Kellett, S. (2020) · Psychotherapy Research · doi:10.1080/10503307.2019.1566676 · Cited by 264 · see citing works
Self-citationInterpreting Kendall’s Tau and Tau- <i>U</i> for single-case experimental designs
Brossart, D. F., Laird, V. C., & Armstrong, T. W. (2018) · Cogent Psychology · doi:10.1080/23311908.2018.1518687 · Cited by 210 · see citing works
Christ, T. J. (2007) · Psychology in the Schools · doi:10.1002/pits.20237 · Cited by 167 · see citing works
Elliott, R., & Wexler, M. M. (1994) · Journal of Counseling Psychology · doi:10.1037/0022-0167.41.2.166 · Cited by 162 · see citing works
Methodological and interpretive problems of single-case experimental designs.
Kazdin, A. E. (1978) · Journal of Consulting and Clinical Psychology · doi:10.1037//0022-006x.46.4.629 · Cited by 153 · see citing works
I. Women at the Margins: A Critique of the Diagnosis of Borderline Personality Disorder
Shaw, C., & Proctor, G. (2005) · Feminism & Psychology · doi:10.1177/0959-353505057620 · Cited by 124 · see citing works
Schema therapy for patients with borderline personality disorder: a single case series
Nordahl, H. M., & Nysæter, T. E. (2005) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2005.05.007 · Cited by 124 · see citing works
Ryle, A., & Golynkina, K. (2000) · British Journal of Medical Psychology · doi:10.1348/000711200160426 · Cited by 117 · see citing works
Methodological and interpretive problems of single-case experimental designs.
Kazdin, A. E. (1978) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.46.4.629 · Cited by 114 · see citing works
Attitudes Toward Borderline Personality Disorder: A Survey of 706 Mental Health Clinicians
Black, D. W., PFOHL, B. M., Blum, N. S., McCormick, B. A., Allen, J., North, C. S., Phillips, K. A., Robins, C. J., Siever, L. J., Silk, K. R., et al. (2011) · CNS Spectrums · doi:10.1017/s109285291200020x · Cited by 108 · see citing works
Borderline Personality Disorder and Bipolar Disorder
Paris, J., & Black, D. W. (2015) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000000225 · Cited by 95 · see citing works
Pollock, P. H., Broadbent, M. T. M., Clarke, S., Dorrian, A., & Ryle, A. (2001) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.250 · Cited by 95 · see citing works
Rizvi, S. L., & Linehan, M. M. (2005) · Cognitive and Behavioral Practice · doi:10.1016/s1077-7229(05)80071-9 · Cited by 93 · see citing works
The structure and development of borderline personality disorder: A proposed model
Ryle, A. (1997) · The British Journal of Psychiatry · doi:10.1192/bjp.170.1.82 · Cited by 90 · see citing works
Nicklas, L. B., Dunbar, M., & Wild, M. (2010) · Psychology & Health · doi:10.1080/08870440902783610 · Cited by 78 · see citing works
A measure of psychotherapeutic competence derived from cognitive analytic therapy
Bennett, D., & Parry, G. (2004) · Psychotherapy Research · doi:10.1093/ptr/kph016 · Cited by 77 · see citing works
Ryle, A., & Kerr, I. B. (2003) · British Journal of Psychiatry · doi:10.1192/bjp.183.1.79 · Cited by 73 · see citing works
Cognitive analytic therapy: A review of the outcome evidence base for treatment
Calvert, R., & Kellett, S. (2014) · Psychology and Psychotherapy: Theory, Research and Practice · doi:10.1111/papt.12020 · Cited by 68 · see citing works
Self-citationThe Single-Case Reporting Guideline In BEhavioural Interventions (SCRIBE) 2016 statement.
Tate, R. L., Perdices, M., Rosenkoetter, U., Shadish, W., Vohra, S., Barlow, D. H., Horner, R., Kazdin, A., Kratochwill, T., McDonald, S., et al. (2016) · Archives of Scientific Psychology · doi:10.1037/arc0000026 · Cited by 66 · see citing works
Cognitive therapy for antisocial and borderline personality disorders: Single case study series
Davidson, K. M., & Tyrer, P. J. (1996) · British Journal of Clinical Psychology · doi:10.1111/j.2044-8260.1996.tb01195.x · Cited by 65 · see citing works
Jerschke, S., Meixner, K., Richter, H., & Bohus, M. (1998) · Fortschritte der Neurologie · Psychiatrie · doi:10.1055/s-2007-995297 · Cited by 61 · see citing works
Recovering: a process of empowerment.
Nehls, N. (2000) · ANS. Advances in nursing science · doi:10.1097/00012272-200006000-00006 · Cited by 55 · see citing works
Cognitive analytic therapy at 30
Ryle, A., Kellett, S., Hepple, J., & Calvert, R. (2014) · Advances in Psychiatric Treatment · doi:10.1192/apt.bp.113.011817 · Cited by 52 · see citing works
Self-citationScoping the inventory of interpersonal problems, its derivatives and short forms: 1988-2004
Hughes, J., & Barkham, M. (2005) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.466 · Cited by 46 · see citing works
Rizvi, S. L., & Nock, M. K. (2008) · Suicide and Life-Threatening Behavior · doi:10.1521/suli.2008.38.5.498 · Cited by 46 · see citing works
Rubel, J. A., Lutz, W., & Schulte, D. (2013) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.1868 · Cited by 43 · see citing works
Kellett, S., & Hardy, G. E. (2013) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.1845 · Cited by 39 · see citing works
Self-citationKerr, I. B. (1999) · British Journal of Psychotherapy · doi:10.1111/j.1752-0118.1999.tb00473.x · Cited by 37 · see citing works
Kellett, S., Bennett, D., Ryle, T., & Thake, A. (2011) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.796 · Cited by 36 · see citing works
Self-citationSingle-Case Experimental Designs
Hersen, M. (1990) · Springer eBooks · doi:10.1007/978-1-4613-0523-1_9 · Cited by 35 · see citing works
Kellett, S. (2006) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1348/147608306x161421 · Cited by 34 · see citing works
Self-citationWildgoose, A., Clarke, S., & Waller, G. (2001) · British Journal of Medical Psychology · doi:10.1348/000711201160795 · Cited by 33 · see citing works
Working around a contested diagnosis: Borderline personality disorder in adolescence
Koehne, K., Hamilton, B. E., Sands, N., & Humphreys, C. (2012) · Health An Interdisciplinary Journal for the Social Study of Health Illness and Medicine · doi:10.1177/1363459312447253 · Cited by 30 · see citing works
Kellett, S., & Totterdell, P. (2011) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/j.2044-8341.2011.02045.x · Cited by 27 · see citing works
Self-citationAssessment ofDSM–5Personality Disorder
Widiger, T. A. (2015) · Journal of Personality Assessment · doi:10.1080/00223891.2015.1041142 · Cited by 26 · see citing works
Reviewing the clinical significance of ‘fear of abandonment’ in borderline personality disorder
Palihawadana, V., Broadbear, J., & Rao, S. (2018) · Australasian Psychiatry · doi:10.1177/1039856218810154 · Cited by 26 · see citing works
(2005) · UWA Profiles and Research Repository (UWA) · Cited by 25 · see citing works
Publication trends in individual DSM personality disorders: 1971–2015
Boschen, M. J., & Warner, J. C. (2009) · Australian Psychologist · doi:10.1080/00050060802680598 · Cited by 23 · see citing works
Ryle, A. (2007) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.543 · Cited by 20 · see citing works
Kellett, S., & Beail, N. (1997) · British Journal of Medical Psychology · doi:10.1111/j.2044-8341.1997.tb01884.x · Cited by 18 · see citing works
Self-citationSingle Case Quantitative Methods for Practice‐Based Evidence
McMillan, D., & Morley, S. (2010) · Developing and Delivering Practice‐Based Evidence · doi:10.1002/9780470687994.ch5 · Cited by 18 · see citing works
Attributes of the drinker prototype among Thai adolescents
Jaigarun, P., Corte, C. M., McCreary, L. L., Finnegan, L., Hughes, T. L., & Thorkildsen, T. A. (2018) · Cogent Psychology · doi:10.1080/23311908.2018.1502501 · Cited by 15 · see citing works
Kellett, S., Simmonds‐Buckley, M., & Totterdell, P. (2016) · Journal of Sex & Marital Therapy · doi:10.1080/0092623x.2016.1208129 · Cited by 14 · see citing works
Self-citationDoes therapists' competence matter in delivering psychological therapy?
Davidson, K. M., & Scott, J. L. (2009) · Psychiatric Bulletin · doi:10.1192/pb.bp.108.020214 · Cited by 13 · see citing works
Bloxham, G., Long, C. G., Alderman, N., & Hollin, C. R. (1993) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/0005-7916(93)90030-z · Cited by 7 · see citing works
Spence, C., Kellett, S., Totterdell, P., & Parry, G. D. (2019) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2390 · Cited by 6 · see citing works
Self-citationKellett, S., & Lees, S. (2019) · Journal of Psychotherapy Integration · doi:10.1037/int0000170 · Cited by 5 · see citing works
Self-citationSingle-Case Designs: Methodology
Berghoff, C. R., & Forsyth, J. P. (2015) · Elsevier eBooks · doi:10.1016/b978-0-08-097086-8.44054-7 · Cited by 1 · see citing works
Flagged first, then by citations
4 of the 78 references couldn’t be matched to a known paper.
Research works printed but not linked: 3
- Derogatis, L. R. (1993). Brief Symptom Inventory: Administration, scoring and procedure manual (4th ed.). Minneapolis, MN: National Computer Systems.
- Ryle, A., Beard, H., & Marlowe, M. J. (1995). Cognitive analytic therapy of borderline personality disorder: Theory, practice and the clinical and research uses of the self-states sequential diagram. International Journal of Short-Term Psychotherapy, 10,21-34.
- Wirth-Cauchon, J. (2001). Women and borderline personality disorder. New Brunswick, NJ: Rutgers University Press.
Cited by
Sorted by citations
Psychedelic-assisted psychotherapy: Where is the psychotherapy research
Aday, J. S., Horton, D., Fernandes-Osterhold, G., O’Donovan, A., Bradley, E. R., Rosen, R. C., & Woolley, J. D. (2024) · Psychopharmacology · doi:10.1007/s00213-024-06620-x · Cited by 54 · see citing works
Probing commitment in individuals with borderline personality disorder
Michael, J., Chennells, M., Nolte, T., Ooi, J., Griem, J., Christensen, W. D., Feigenbaum, J., King‐Casas, B., Fonagy, P., & Montague, P. R. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.02.062 · Cited by 12 · see citing works
Kellett, S., Alhadeff, L., Gaskell, C., & Simmonds‐Buckley, M. (2022) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12390 · Cited by 8 · see citing works
Self-citationTaylor, P. J., & Hartley, S. (2021) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12292 · Cited by 4 · see citing works
Power, N., Kellett, S., & Gaskell, C. (2022) · Journal of Psychotherapy Integration · doi:10.1037/int0000281 · Cited by 2 · see citing works
Self-citationTaylor, P. J., Gianfrancesco, O., & Hartley, S. (2022) · Oxford University Press eBooks · doi:10.1093/oxfordhb/9780198866572.013.13 · Cited by 2 · see citing works
Horan, A., Kellett, S., Gaskell, C., & Morris, C. (2025) · Reports — Medical Cases Images and Videos · doi:10.3390/reports8020093 · Cited by 1 · see citing works
Self-citationChekan, M. H., Kazemi, R., Taklavi, S., & Narimani, M. (2021) · Studies in Medical Sciences · doi:10.52547/umj.32.7.500
- Authors
- Kellett, S., Gausden, J., & Gaskell, C.
- Affiliations
- Sheffield Health and Social Care NHS Foundation Trust (GB)
- University of Sheffield (GB)
- Corresponding author
- Kellett, Stephen
- ORCID
- Kellett, Stephen
- Venue
- Psychology and Psychotherapy: Theory, Research and Practice
- Publisher
- Wiley
- Published
- 2020-05-12
- Volume
- 94
- Issue
- S1
- Pages
- 96-119
- ISSN
- 1476-0835 (ISSN-L)
- 2044-8341
- OpenAlex
- W3026011603
- Cited by
- 8
- References
- 78
- Citations by year
- 2025: 1 · 2024: 1 · 2022: 3 · 2021: 3
- FWCI
- 0.60
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Psychology and Psychotherapy Theory Research and Practice (publishedVersion, cc-by)
- PubMed (publishedVersion)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- cognitive analytic therapy, borderline personality disorder, single-case experimental design, internal validity, self-hatred, selfhood, relapse, treatment discontinuation
- MeSH terms
- Borderline Personality Disorder, Cognition, Female, Humans, Psychotherapy, Research Design, Cognitive Behavioral Therapy, Cross-Over Studies
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