Transcript Cognitive Analytic Therapy (CAT) – Background and Overview

Cognitive Analytic Therapy for
Borderline Personality Disorder
SPD Network Meeting Aberdeen
4th June 2009
Ian B. Kerr
NHS Lanarkshire, Department of Psychotherapy,
Coathill Hospital, Coatbridge,
Cognitive Analytic Therapy
www.acat.me.uk
“Cognitive Analytic Therapy:
Active Participation in Change”
Anthony Ryle
1990
J. Wiley & Sons
“Cognitive Analytic Therapy: Developments
in Theory and Practice. (1995) Ryle, A. (Ed).
(Wiley & Sons)
“Cognitive Analytic Therapy and Borderline
Personality Disorder: The Model and
the Method.” (1997) Ryle, A. (Wiley & Sons).
“Introducing Cognitive Analytic Therapy:
Principles and Practice.” (2002)
Ryle, A. & Kerr, I.B. (Wiley & Sons).
‘In the beginning is the relation’.
- Martin Buber, ‘I and Thou’ (1958).
Cognitive Analytic Therapy
• Object-relations informed approach to
cognitive therapy (including personal
construct theory) transformed by Vygotskian
activity theory and Bakhtinian concepts of the
dialogic self.
Cognitive Analytic Therapy
• Based on a radically social model of self
which is seen as fundamentally constituted by
internalised, socially-meaningful,
interpersonal experience and is described in
terms of a repertoire of ‘reciprocal roles’ and
their procedural enactments.
Cognitive Analytic Therapy
• Influence in recent years of findings in
developmental research (e.g Trevarthen)
stressing the infant’s capacity for and active
pre-disposition to ‘inter-subjectivity’.
• Implies the socially and culturally determined
formation of the self through collaborative,
meaningful, sign-mediated activity.
• ‘Human beings are biologically predisposed to
be socially formed’. A. Ryle.
• Bruner, J. (2005). Homo sapiens, a localised
sub-species. Behavioral and Brain Sciences,
28, 694-695.
Cognitive Analytic Therapy
• From this perspective it can be argued
that there can be no such thing as
individual psychopathology - but only
socio-psychopathology.
• (NB Winnicott- ‘there is no such thing as a
baby…’)
Infant Observation Research (Stern, Trevarthen et al)
Verbal self from c.18 months: meaning (the relation of
thoughts to words), results from interpersonal
negotiations. (Stern)
Ultimately awareness and understanding of states of
mind and intentions of others by c.3-4 years.
(“Theory of Mind”)
Stress on joint, sign-mediated intersubjectivity ab initio.
Infant characterised predominantly by joyfulness,
curiosity and activity in “companionship”. (Trevarthen)
Importance of real experience on development (eg effect of
depressed care-giver – Murray). Infant liable to depression,
frustration, shame.
Infant Observation Research (Stern, Trevarthen et al)
Early “emergent self” – carers act as physiological
regulators but infant capable of, and predisposed to,
active intersubjectivity and gradually increasing
collaborative playfulness.
(“innate motive formation” – IMF – Trevarthen)
Core self by c.6 months – agency, coherence, affectivity,
Procedural memory of interactions with others linked
to sense of core self. (representations of interactions
that have been generalised = RIGs – Stern)
Subjective self and gradual awareness of the worlds of
others by one year; “shared framework of meaning and
means of communication” (Stern)
Infant Observation Research (Stern, Trevarthen et al)
No evidence for early states of fusion.
No evidence for early complex operations such as
“splitting” or “projective identification”.
No evidence for dominant, inherent predisposition to
anxiety and destructiveness.
‘Reciprocal role’ - complex of implicit
relational memory, perception (including
beliefs, values and meanings) and affect
– often associated with a dialogic voice .
Repertoire of reciprocal roles seen to
underpin all mental ‘activity’ whether
conscious or unconscious.
‘Reciprocal role procedure’ - stable pattern
of interaction originating in early internalised
relationships which determine current patterns
of relations with others and of self-management.
Enactment of a role always implies another,
whose reciprocation is sought or expected.
Vygotsky & ‘Activity Theory’
• Concepts of ‘internalisation’; ‘psychological
tools’ ; ‘zone of proximal development’ (‘ZPD’).
Vygotsky & ‘Activity Theory’
• ‘Any function in a child’s development appears twice - or on
two planes. First it appears on the social plane and then on
the psychological plane. First it appears between people as
an interpsychological category and then within the child as an
intrapsychological category. This is equally true with regard to
voluntary attention, logical memory, the formation of concepts
and the development of volition. We may consider this
position as a law n the full sense of the word, but it goes
without saying that internalisation transforms the process
itself and changes its structure and functions. Social
relations or relations among people genetically underlie all
higher functions and their relationships.’
Lev Vygotsky
• ‘The very mechanism underlying higher
mental functions is a copy from social
interaction; all higher mental functions are
internalised social relationships. These higher
mental functions are the basis of the
individual’s social structure. Their
composition, genetic structure and means of
action, in a word, their whole nature is
social.’
• (from ‘The Genesis of Higher Mental Functions`)
Lev Vygotsky
• Psychological tools – ‘sign-mediating’ cultural
artefacts which can influence the mental activity of
others or of oneself internally. Their mastery may
require prolonged use and practice.
Lev Vygotsky
• Zone of proximal development – the gap between
what an infant can achieve on its own unaided and
what can be achieved with the active assistance of
an enabling other - or a peer group.
Bakhtin and Notions of the
Dialogic Self
• ‘I am conscious of myself and become myself only
while revealing myself for another. The most
important acts constituting self-consciousness are
determined by a relationship toward another
consciousness ( toward a thou)… not that which
takes place within, but that which takes place on the
boundary between one’s own and someone else’s
consciousness , on the threshold… a person has no
internal sovereign territory; he is wholly and always
on the boundary; looking into himself, he looks into
the eyes of another or with the eyes of another’.
Cognitive analytic therapy
• Now a mature model of development and
psychopathology.
• Increasing amount of work ‘using’ the model (as
opposed to simply ‘doing’ it as therapy) - (Potter).
• E.g. work on re-conceptualisation of self in old age
and dementia, in psychosis, in consultancy work and
CAT-informed clinical practice.
Basic CAT
• Behaviour and experience organised by
‘procedures’.
• These link perception, appraisal, action
planning, prediction with action and the
consequences of the action, which are
evaluated leading to confirmation or revision.
• Reciprocal role procedures - to play or enact
a role is to anticipate or elicit the reciprocal.
Basic CAT
• Reciprocal role procedures are early in origin,
are general and resist revision.
• They embody parental and cultural meanings
and values transmitted by pre-verbal signs
and, later, language.
• An individual’s repertoire of role procedures
determines both interpersonal relationships
and the internal dialogue of thought and selfmanagement.
Cognitive analytic therapy (CAT)
• Essentially time-limited (usually 16-24 sessions).
• Pro-active, collaborative (‘doing with’), highly
structured.
• Aims through extended assessment phase over
first few sessions at joint description of key
problem (reciprocal) role procedures by means
of written (narrative) and diagrammatic
reformulations. These should also effectively
offer a sensitive, (micro-) cultural descriptive
dimension.
Cognitive analytic therapy (CAT)
• Subsequent work focuses on the enactments, of
these both outside and during sessions.
• Use of transference and counter-transference
understood as enactments of repertoires of
reciprocal roles.
• Final summary (‘goodbye’) letters by therapist
and patient.
• Labour intensive!
Dominic was a young psychology student brought up and studying in the UK,
but of Chinese ethnic background who had been referred from a student health
service for a psychotherapy assessment because of difficulties in studying, depression
and a recent self-harm attempt. He appeared initially withdrawn and uncommunicative
and sat looking at the floor for several minutes. In response to a general enquiry about
how things were he became angry about “having to go through all this yet again” and
anyway “what was the point of it all”. He immediately followed this by looking up and
apologising profusely for his outburst saying that he was wasting my time because he
had to get on with things anyway and there were plenty of people out there who needed
my help more that he did. Eventually he confided that he felt pretty fed up and hopeless
and could not see his way forward doing a course that he was not sure that he wanted
to do but had to carry on with in order not to let his parents down. Again there was a
brief moment of anger at the attitudes of Westerners towards their parents and older
people in general when discussing the implications of always having to please his
parents. It appeared that he tended to keep his worries pretty much to himself feeling
“you ought to be able to manage”. His worry about not managing seemed to him
compounded by his being gay which in his original culture, he said, was seen as a
sign of weakness and certainly not something he could discuss with his family.
He did feel however that a small part of him did want to sort things out for himself
– although it was hard to know how – and maybe finish his course and possibly even
become a therapist himself one day. He agreed that perhaps it was this small part
which had in the end brought him along to our meeting.
(Dominic - possible SDR)
*criticising
conditionally loving
criticised
conditionally loved
‘my fault’, ‘am worthless’
‘depressed’
ODs
apologetic
strive to perform and
please
or,
results in emotional isolation, exhaustion,
can’t manage – confirms worst assumptions
briefly self assertive
but, feel guilty and
*criticised
defiant, rebellious,
*criticising
CAT – recent developments
Although initially devised as a time-limited
therapy for ‘neurotic’ type out-patient
populations, the model has been further
developing to deal with more ‘severe &
complex’ (e.g. personality, psychotic)
disorders in a range of modalities/settings.
CAT models of ‘severe and
complex’ disorders.
Seen to involve deeper levels of damage to the
self and its processes beyond existence of a
repertoire of maladaptive RRs/RRPs. This will
include failure of integration of RRs,
impairment of self-reflective capacity and of
executive function. Usually understood as due
to developmental deprivation/trauma in context
of biological /neuro-cognitive vulnerability.
CAT models of ‘severe and
complex’ disorders.
Psychopathology is always seen as
rooted in and highly determined by
repertoire of RRs and therefore, critically,
to include an (internalised and frequently
re-enacted) relational component.
CAT and borderline
personality disorder
• ‘Deficit’ model of psychopathology.
• Trauma-induced dissociation rather than
repression/conflict seen as primary
mechanism.
• In addition to maladaptive reciprocal
role procedures, describes and
addresses multiple ‘self states’.
CAT and borderline personality
disorder
• Postulates different levels of damage to self
due to developmental deprivation/trauma
(possibly in conjunction with e.g. poor
impulse control, poor self-reflective capacity
and tendency to dissociate):
– Level 1: Restriction and distortion of the
procedural repertoire.
– Level 2: Disruption of integrating procedures.
– Level 3: Deficient and disrupted self-reflection.
CAT models of ‘severe and
complex’ disorders.
From a CAT perspective, ‘severe and
complex’ disorders could be seen in part
as ‘self-state and relational disorders’.
deserve
punishment
poor self care,
‘deserve nothing,
do nothing’
give people
a ‘bad time’,
(e.g. partner)
self harm
neglecting,
abandoning
feel even worse,
nothing changes
‘OK’ for a while, but..
‘cut off’,
‘numb’,
do drugs
neglected
abandoned
seek perfect
care - expect
too much
staff
caring,
trying to help
abusing
some relief, but
nothing changes
abused
upsets people,
rejected, put down,
alone, feel ‘whole
world against me’
self harm
always let
down
if feel
desperate, abused
unmanageable
feelings
fearful, fed-up,
burnt-out, rejecting
may explode
into ‘justified’
rage
Contextual reformulation
• Systems based approach using techniques
of cognitive analytic therapy (CAT) as well as
some features of family and group therapy.
• Permits non-confrontational, collaborative
mapping of patient’s self-state and role
enactments and their effects on others.
• Helps establish therapeutic alliance and
communicates that patient has been listened
to and understood.
Contextual reformulation
• Educates patient into effects of behaviour and staff
into patient’s subjective ‘self-state’.
• Mapping may also be containing and educative for
staff (especially about splits in team)
– Permits owning of ‘negative’ emotions and
responses which may not feel professionally
allowed (e.g. anger) by locating these in a
non-judgmental system of causality.
– Permits discussion of these difficulties by whole
team.
– Stimulates thought about the patient’s inner world
beyond getting stuck in negative responses
(‘vicious circles’) to difficult behaviour.
A Fictionalised Case Example:
Anna - Background
Young woman in mid 20s with a long history of
anorexia and ‘borderline’ personality difficulties.
Multiple hospital admissions for emergency treatment
of anorexia and for serious self-harm episodes
(overdoses and cutting). Spent several months in a
residential therapeutic community but discharged to
local hospital after self harming in the wake of her
best friend’s suicide and her own involvement with a
member of nursing staff. Referred for further
assessment for psychotherapy by despairing local
psychiatrist and community mental health team.
Anna - Background
Currently living alone in small flat paid for by
parents in a small town in a very socioeconomically deprived area. Feels very isolated
and rarely goes out - spends lots of time on the
internet where she also obtains illicit medication
(e.g analgesics, thyroxine). Had previously started
university after doing well at school (was very
competitive) but dropped out in first year because
of mental health problems.
Anna - Background
Family background characterised by atmosphere of tension
between parents. Father (an aggressive alcoholic
accountant) very preoccupied with material wealth and
‘succeeding’ in life. Mother tried to keep the peace and not
offend or upset her husband - described as the ‘queen of
denial’. Anna forced to attend a distant private school which
she hated and sometimes wouldn’t attend due to ‘sickness’.
‘Couldn’t tell anyone about this. Younger sister Mary was less
pressured and somehow more ‘thick-skinned’ but has also
had problems with anxiety. Tells Anna she should now be able
to ‘pull herself’ together and get on with life.
Anna - Presentation
At presentation states that sees no point in living nor any
future and that perhaps only a small part of her wishes to
think about any further attempts at treatment. Part of her
would rather join her dead friend Susan whom she envies.
Appears very wary and rather hostile towards therapist.
(Requests that a painting in the consulting room which is
slightly squint be straightened up). Relates that she is still
abusing laxatives and medication (e.g. thyroxine) and
eats only liquid baby food. Her body mass index (BMI) is
apparently only about 14. She refuses to see local eating
disorder service who she says don’t listen to her or take
her seriously. However agrees to see CPN intermittently
and attend a (different) psychiatrist for occasional review.
Anna - Therapy
In the absence of any more specialist intensive treatment
service locally she is offered, and agrees to, an initially timelimited (24 sessions with subsequent review) course of CAT.
Remains worryingly underweight (looks like ‘skin and bone’)
although continues to feel overweight and to believe that this
would be disgusting to everybody including her therapist.
Serious concern about her (cognitive) ability (concentration and
memory) to make use of therapy. During initial months remains
mostly very gloomy and hopeless about change or about any
future. Attends regularly apart from two periods when she is readmitted to hospital following self harm episodes. One of these
occurs during a period of therapist absence and when CPN is off
ill with no replacement.
Anna - Therapy
Supported by regular contact with her mother from whom she
receives some (mostly practical) support. Has worries about
contact with father whom she rarely sees and about whom she
clearly has strong feelings but about she is reluctant to talk. Is
‘able’ to engage with the work of reformulation which she finds
‘illuminating’ and acceptable. This appears to firm up the
therapeutic alliance considerably and to provide an agreed
joint understanding which can be reasonably referred to.
Repeated calls over this period from other colleagues (eg
psychiatrist) about ‘dealing’ with her and whether therapy is
‘working’.
Anna – Reformulation Letter
Dear Anna,
This is a letter attempting to summarise some of the key issues which seem
to have emerged in the course of our initial work together and to try to think
about how they are impacting on your life at present as well as to think about
what might historically lie behind them, as we have been doing. I hope that this
will ultimately help you to move on to a more rewarding future. We have already
attempted to sketch some of this in a diagrammatic form which I think by your
account seemed quite useful although I think it seemed also quite disturbing
and upsetting in some ways as well. This will only be my version of what we
have been talking about and is very much open to your feedback or modification….
Anna – Reformulation Letter
…in looking back over some of the things I have jotted down over the past
few months I am very struck by the importance for you of not having other people’s
versions of events or their expectations imposed upon you which does seem to
have been your experience very frequently throughout your life, both in childhood
and more recently. In fact looking back at our very first meeting one of the first
things you said to me was that you felt that you had not really ever been listened to.
In looking back over some of my notes I am also struck by just how painfully
difficult life must seem to you day-to-day and this was also reinforced by
looking through your psychotherapy file again where you highlighted some very
extreme and difficult states…..
Anna – Reformulation Letter
… As well as the unbearable feelings, I have been very struck by how difficult life
must be day to day with little to do or few real social contacts, your difficulties
with sleep and the terrible dreams which you sometimes describe and just generally
the panicky feelings which seem to accompany you for most of the time. We have
talked about various ways you have coped over the years with these unbearable
feelings by doing controlled overdoses, laxative abuse and other forms of self-harm
such as cutting although this seems to have become more difficult for you recently
It did seem very striking both from our chats and the diagram we did that the
consequences of these ways of coping unfortunately on the whole still leave you,
even if numbed out for a while, ultimately on your own, unappreciated and often
pressurised and rejected by people again. All of which of course in a vicious
cycle fashion seems to reinforce your original experiences and keep them going.
These cycles do seem to have acquired quite a life or their own….
Anna – Reformulation Letter
…I would like to emphasise however how impressed I have been at you
sticking with the work we have been able to do even if it has been interrupted
by your trips to the ward occasionally or our other difficulties in getting together
(sometimes mine) and that if the small part of you which is holding on can
continue to keep thinking together about these issues, reflecting on them and
considering jointly ways of addressing and challenging them, then it is perfectly
possible that you will be able to move on to a more fulfilling and meaningful life
- although the path I am sure will not be easy or straightforward…
Self States Sequential Diagram - Anna
just carry on as below,
don’t care for self,
‘what’s the point’?
(eg blood tests)
‘When I look into the mirror I’m not
sure who I see or who is seeing*’
don’t take self seriously,
treat self as not good enough
conditionally loving
treating as ‘not good enough’#
want to be dead
nothing changes,
reinforces original
experiences
conditionally loved
(‘real me not loveable’)
exhausted
isolated
never good enough
(?mentally retarded, something wrong,
never knew how to be good enough’)
feel disgusting (anyway)
makes a mess,
constantly running,
avoids deep thoughts
become ultra
competitive
(?cultural too)
restrict eating,
cope with laxative abuse
(becomes harder to cut
deeply)
short lived sometimes get relief
emotionally neglecting,
disbelieving*,
not taking seriously*
looked after ‘materially’ but
emotionally neglected (eg by dad),
not listened to or taken seriously,
disbelieved
unbearable feelings,
withdraw, can’t tolerate
seeing anybody
sometimes kick
furniture, bang head
restrict eating
- can be a
‘weapon’
sometimes (more recently)
cut or OD – sometimes
need to feel punished #
no change,
no result,
lose power
ill, numb
pisses people
off
Anna – ‘Key Issues’
(Target Problem Procedures)
• (1) Because of your experience of being frequently
criticised, pressurised and only ever conditionally loved,
you have finished up assuming that there is something
wrong with you (eg missing some chromosome!) and have
finished up frequently enacting these criticising roles
towards yourself. This leads you to never feeling good
about yourself or never trying to do good things for yourself
– which reinforces your original experiences.
• Aim: To try to watch out for that self-criticising and selfpressurising “voice” and identify it as we have been doing
and to try to consider whether you really accept its validity.
Anna – ‘Key Issues’
•
•
(2) Because of your experiences of never feeling properly
listened to or respected, you finish up feeling abandoned and
alone and often full of desperate feelings which you have
coped with in various ways including self-harm and dietary
restriction - as well as sometimes perhaps behaviour which
may have been experienced as apparently “difficult” towards
other people. This all tends to lead you to be again rejected
and misunderstood and leaves you still unappreciated and
with your emotional needs unmet, so reinforcing your original
experiences.
Aim:
To try to bear in mind when you are feeling
desperate how it is that these feelings have come about and
the consequences of your traditional ways of coping and try
to consider alternatives such as communicating calmly to
trusted people (as we have begun perhaps to do in therapy)
how you are feeling and what your needs are.
Anna - Progress
Continues to attend therapy with apparently increasing
commitment and less wariness and hostility. Continued
collaborative use of diagram appears to assist containing
‘unbearable feelings’ and to reflect on her habitual patterns
of feeling, thinking, and coping. More willing and able to
discuss feelings in relation to therapist. Towards end of
initial contact finally agrees to discuss feelings about her
father and to address him using an empty chair approach
through which she expresses some powerful, unresolved,
and angry feelings about the effects of his behaviour on her
and her wish that he would still be able to appreciate this.
This appears to be an important moment which seems to
considerably ‘loosen up’ her thoughts and feelings overall.
Anna - Progress
Despite this progress, patterns (RRPs) of eating restriction
and laxative and medication abuse remain a major problem
with little change apparent. Is always tired, finds
concentration difficult and experiences frequent palpitations.
However states is now keen to remain in therapy and further
24 session course agreed. Reluctantly agrees to consider
seeing a dietician to address nutritional concerns. Agrees
reduction of various medications is a long term aim but
reluctant to countenance this at present. Remains socially
isolated and lonely and feels stigmatised by family and
others. Recurrently talks of wishing rather to be ‘out of it all’
and appears still a considerable risk of serious self harm...
Anna – Overview of Background
Issues
• Problems due to mix of temperamental
vulnerability (obsessional ‘perfectionism’, ?
dissociation), dysfunctional, intense (nuclear)
family dynamics (criticising, conditional love, not
listening to or taking seriously), cultural factors
(competitive school environment, pre-occupation
with dieting and appearance).
• ?Exacerbated and perpetuated ‘contextually’ by
‘doing to’, authoritarian approach of many mental
health services - colluding with her historic RRs.
Lack of any meaningful attempt at social
therapy/rehabilitation.
Anna – Overview of Background
Therapeutic Issues
• Attempt to establish a therapeutic alliance on
basis of authentic ‘encounter’ (new RR) - aided
by collaborative work of joint reformulation
(offering both insight and empathic narrative
validation).
• Aim to generate understandings of the origins of
relational positions (RRs), of ‘unbearable
feelings’ and habitual maladaptive coping
patterns (RRPs) – including dialogical
underpinnings of these where relevant – so
enabling work on challenging and changing
these.
Anna – Overview of Background
Therapeutic Issues
• Self-reflective capacity and containment of
‘unbearable feelings’ aided by understanding of
existence of multiple dissociated self-states
• Importance of jointly acknowledging and
processing powerful emotions in relation to her
father.
Anna – Overview of Therapeutic
Challenges
• RRPs around anorexia very long standing and
resistant even when obstacles to addressing
them have been worked on. Will require active
‘behavioural’ approaches.
• Beliefs around diet and appearance and the
importance of individual ‘success’ reinforced by
cultural ‘norms’.
• Absence of real (joint) community involvement in
social therapy/rehabilitation. Perpetuates lack of
any sense of common identity or purpose.
CAT: Further Applications
around ‘PD’
• Brief interventions using standardised CAT
diagrams in A&E.
– (Sheard, T., Evans, J., Cash, D. et al. (2000). A CAT
derived one to three session intervention for repeated
deliberate self harm: a description of the model and
initial experience of trainee psychiatrists in using it.
British Journal of Medical Psychology, 73, 179-196.).
CAT: Further Applications
around ‘PD’
• A CAT framework for understanding and
managing problematic frequent
attendance in primary care.
– Pickvance, D., Parry, G.D., & Howe A. Primary Care
Mental Health, 2, 165-174.
CAT: Further Applications
around ‘PD’
• Residual PD in the elderly.
– Sutton, L. et al. (2003) When late life brings a
diagnosis of dementia and early life brought trauma. A
cognitive analytic understanding of ‘loss of mind’.
Clinical Psychology and Psychotherapy, 10, 156-164.
– Also, in Cognitive Analytic Therapy and Later Life.
(2004). Eds Hepple, J. & Sutton, L. BrunnerRoutledge.
CAT: Further Applications
around ‘PD’
• Early intervention studies in adolescents
at high risk of developing BPD.
• (Chanen, A.M., Jackson, H.J., McCutcheon, L.K., et
al. (2008). Early intervention for adolescents with
borderline personality disorder using cognitive
analytic therapy: randomised controlled trial. British
Journal of Psychiatry,193, 1-8.)
CAT: Further Applications
around ‘PD’
• Skills level training for generic mental
health workers: brief CAT-based training
in working with ‘difficult’/PD patients.
• (Thompson, A.R., et al. (2008). Multidisciplinary
community mental health team staff’s experience of a
‘skills level’ training in cognitive analytic therapy.
International Journal of Mental Health Nursing, 17, 131137.)
CAT-based skills training for a
CMHT in working with complex
mental health problems.
•
•
•
•
•
Emma Warnock Parkes
Jenny Donnison
James Turner
Glenys Parry
Ian Kerr
• Sheffield Care Trust/Sheffield University, UK.
CAT-based skills training for a
CMHT in working with complex
mental health problems:
Background
• Community mental health teams (CMHTs) are
increasingly central in many services to the
routine delivery of care for a range of often
complex and ‘difficult’ mental health
problems, including personality disorders.
• But...
CAT-based skills training for a
CMHT in working with complex
mental health problems:
Background
• Widespread uncertainty about nature of
clinical models used and their effectiveness.
• Poor history of effective implementation of
training programmes (eg family therapy, PSI).
• Frequent demoralisation, poor job satisfaction
and burn out amongst team members.
CAT-based skills training for a
CMHT : Background
• Increasing expectation from consumers for
psychological treatments for mental health
problems – acknowledged and encouraged in
the UK by recent DoH guidelines (NIMHE
2003; DoH 2002)
• Increasing expectation that generic mental
health workers should offer psychologicallyinformed management and/or treatment to
patients with complex and PD type problems
in wake of emerging treatment models (APA
2001; NIMHE 2003; 2004;NICE 2009).
CAT-based skills training for a
CMHT in working with complex
mental health problems:
Background
• Current paucity of appropriate or effective
training packages well recognised (NIMHE
2004) as is urgent need for their
development.
CAT-based skills training for a
CMHT in working with complex
mental health problems: Aims
• To provide CMHT members with a training in
a common, coherent model to inform routine
management of complex and ‘difficult’
patients, notably those with PD.
• To improve overall team function.
• To improve clinical outcomes for patients.
CAT-based skills training in
working with complex mental
health problems.
• Intensive one week training on complex and
‘difficult’ mental health problems (especially
PD) for generic workers/teams.
• Aim to inform routine practice rather than
produce specialist therapists.
• Based around CAT model of development
and psychopathology; comprising theoretical
lectures, conceptualisation of clinical material
and experiential sessions (reflective groups
and personal reformulations).
CAT-based skills training in
working with complex mental
health problems.
• Followed up by experience of treating
two cases under extended supervision
over 6-9 months.
• Further training/supervision (possibly
practitioner level course) for those
wishing to extend experience/expertise.
CAT-based skills training in
working with complex mental
health problems.
Personal reformulation experience:
• Invitation to explore personal roles (and their background if
desired) at work in relation to the CAT model over a few hours in
a confidential session with a CAT practitioner from out of area.
• Gives experience of creating and receiving brief rudimentary
narrative and diagrammatic reformulations. Follow up offered if
requested.
• NOT aimed at being therapy.
CAT-based team training:
qualitative evaluation.
• Questionairre and confidential in-depth
interviews conducted and evaluated by
independent researchers (EP and JD).
• Quantitative evaluation of responses to
formal questions.
• Further evaluation of themes emerging
from interviews.
Team training evaluation
(i) Experience of training
“I was hoping it would extend my skills range and that I could use
it in a focused and structured way in people that have had lots
of different therapies over the years, who have been stuck or
dependent on the service…people who have been labelled as difficult
or challenging…it's nice to see a framework to let them open up
and look at…why they were entrenched in maladaptive functioning”
“My understanding was that it would equip us with the skills of
CAT…so that we could develop a language to discuss what was
going on with some of our complex and difficult clients”
Team training evaluation
(i) Experience of training
“It's created a great momentum for debate and exploration and
a culture of a single modelled approach that we are all using
and learning at the same time…it has helped the team bonding,
it's created a lot of banter and debate, jokes and support….a very
satisfying extra. It's comforting to have that baseline language…
I don’t think that teams will often have that shared knowledge or
shared understanding of the language”
"The main thing is empowering clients – the breakdown of the
practitioner-client boundaries…it involves clients, changing the
culture, people know what's happening, it reduces client
dissatisfaction and complaints”. “I actually enjoyed the impact
that the CAT has on the client, its been a bit of an eye opener in
terms of their response to it”.
Team training evaluation
(ii) Impact on team members approach to work
“It's improved my confidence as these were highly anxiety provoking
clients - it goes back to the idea that you have something else to look at,
I’m more comfortable taking on a heartsink personality disorder case
knowing that I have some understanding of CAT”
"It helps my assessments…provides a clear structure for my work and my
endings with clients”
“It brings together issues I think are important within social work
alongside psychological models…it includes issues of discrimination,
power, it allows for some understanding of political structure…”
Team training evaluation
(iii) Impact on team function
“The CAT model is a common tool that is often used in team
meetings to analyse difficult cases that people are struggling
with. I think this helps with the way decisions are made and
with understanding why people respond to difficult clients in
the ways that they do…Being able to discuss it more using a
particular model leads to consensus on how to engage with someone.”
“nobody is personalising problems, the team is now a source
of strength rather than being defensive.”
“…there’s a collective practice, a collective view of
where we are going, people know the aims. We now have a model
to talk about difficult clients and find out why we are struggling
with people the way that we are.”
Team training evaluation
(iv) Impact on level of support and supervision
“Very positive, it was tremendous - lots of knowledge,
experience and wisdom…different perspectives from people
bringing in different cases.”
“There has been a shift of focus…we used to work very
differently and think differently: rather than ‘do it, do it now’
it's ‘am I on the right track?”
Team training evaluation
(v) Impact on morale and well being of members
“The stress is still around but actually being
more confident and having a joint position with everybody else
in the team helps you deal with it.”
“The training has lowered my anxiety levels with regard to
working with complex needs clients, also knowing that we
have something to offer people who are often dismissed as
having untreatable personality disorders”
CAT-based skills training for a
CMHT in working with complex
mental health problems:
Conclusions
• Training is feasible, welcome and helpful to team
members.
• Sustained improvements in perceived skills levels
generalising to routine generic work.
• Improvement in communication and morale in team.
• Perceived improvement in team function.
• Apparent improvement in experience of patients.
CAT-based skills training for a
CMHT in working with complex
mental health problems: What
next?
• Disseminate ‘manualised’ training programme
incorporating improvements to other CMHTs in
service.
• Controlled evaluation of impact on clinical outcomes
and patient satisfaction.
• Assist several team members to further specialist
CAT psychotherapy level training!
Growing points and challenges
• CAT now a mature and robust general theory of
development and psychopathology. Increasing
range of applications for different conditions and
in different settings.
• Contributing to re-conceptualisation of mental
disorders or aspects of them. Consistent theme
in such work has been the interpersonal and
social origins and determinants of human
psychopathology as well as its current social
context.
Growing points and challenges
• However, CAT needs to continue to integrate
and take account of advances in allied
disciplines e.g. cognitive and developmental
psychology, neurobiology, sociology etc.
• Needs further process and outcome research to
establish its comparative validity and
effectiveness (‘what works for whom’?) both
alone and in multimodal treatment approaches.
Growing points and challenges
• Although CAT emphasises the social and
cultural formation of self, does the model
adequately address the need for ‘social therapy’
and the issues of treating psychological damage
and distress in different cultures and contexts?
• Could contribute a ‘socio-psychodevelopmental’
dimension to current, often polarised, highly
individualistic either ‘disease model’ or ‘social
inclusion’ type approaches to public mental
health initiatives?
Thank you!