ian kerr

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Cognitive Analytic Therapy forBorderline Personality Disorder

SPD Network Meeting Aberdeen

4th June 2009

Ian B. Kerr

NHS Lanarkshire, Department of Psychotherapy,Coathill Hospital, Coatbridge,

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Cognitive Analytic Therapy

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www.acat.me.uk

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Cognitive Analytic Therapy:Active Participation in Change

Anthony Ryle 1990

J. Wiley & Sons

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Cognitive Analytic Therapy: Developmentsin Theory and Practice. (1995) Ryle, A. (Ed).(Wiley & Sons)

Cognitive Analytic Therapy and Borderline

Personality Disorder: The Model andthe Method.(1997) Ryle, A. (Wiley & Sons).

Introducing Cognitive Analytic Therapy:Principles and Practice. (2002)

Ryle, A. & Kerr, I.B. (Wiley & Sons).

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In the beginning is the relation.

- Martin Buber, I and Thou (1958).

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Object-relations informed approach tocognitive therapy (including personal

construct theory) transformed by Vygotskian

activity theory and Bakhtinian concepts of the

dialogic self.

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Based on a radically social model of selfwhich 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.

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Influence in recent years of findings in

developmental research (e.g Trevarthen)stressing the infants 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.

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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.

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From this perspective it can be argued

that there can be no such thing asindividual psychopathology - but only

socio-psychopathology.

(NB Winnicott- there is no such thing as a

baby)

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Infant Observation Research (Stern, Trevarthen et al)

Verbal self from c.18 months: meaning (the relation ofthoughts 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.

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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)

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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.

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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 tounderpin all mental activity whether

conscious or unconscious.

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Reciprocal role procedure- stable patternof 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.

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Vygotsky & Activity Theory

Concepts of internalisation; psychological

tools ; zone of proximal development (ZPD).

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Vygotsky & Activity Theory

Any function in a childs development appears twice - or ontwo planes. First it appears on the social plane and then onthe psychological plane. First it appears between people as

an interpsychological category and then within the child as anintrapsychological category. This is equally true with regard tovoluntary attention, logical memory, the formation of conceptsand the development of volition. We may consider thisposition as a law n the full sense of the word, but it goes

without saying that internalisation transforms the processitself and changes its structure and functions. Socialrelations or relations among people genetically underlie allhigher functions and their relationships.

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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

individuals social structure. Their

composition, genetic structure and means ofaction, in a word, their whole nature is

social.

(from The Genesis of Higher Mental Functions`)

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Lev Vygotsky

Psychological toolssign-mediating cultural

artefacts which can influence the mental activity of

others or of oneself internally. Their mastery may

require prolonged use and practice.

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Lev Vygotsky

Zone of proximal development the gap between

what an infant can achieve on its own unaided andwhat can be achieved with the active assistance of

an enabling other - or a peer group.

B khti d N ti f th

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Bakhtin and Notions of the

Dialogic Self

I am conscious of myself and become myself only

while revealing myself for another. The mostimportant acts constituting self-consciousness aredetermined by a relationship toward anotherconsciousness ( toward a thou) not that whichtakes place within, but that which takes place on the

boundary between ones own and someone elsesconsciousness , on the threshold a person has nointernal sovereign territory; he is wholly and alwayson the boundary; looking into himself, he looks intothe eyes of another or with the eyes of another.

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Cognitive analytic therapy

Now a mature model of development and

psychopathology.

Increasing amount of workusingthe model (as

opposed to simply doingit as therapy) - (Potter).

E.g. work on re-conceptualisation of self in old ageand dementia, in psychosis, in consultancy work and

CAT-informed clinical practice.

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Basic CAT

Behaviour and experience organised by

procedures.

These link perception, appraisal, actionplanning, prediction with action and the

consequences of the action, which are

evaluated leading to confirmation or revision.

Reciprocal role procedures - to play or enacta role is to anticipate or elicit the reciprocal.

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Basic CAT

Reciprocal role procedures are early in origin,

are general and resist revision.

They embody parental and cultural meaningsand values transmitted by pre-verbal signs

and, later, language.

An individuals repertoire of role procedures

determines both interpersonal relationshipsand the internal dialogue of thought and self-

management.

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(CAT)

Essentially time-limited (usually 16-24 sessions).

Pro-active, collaborative (doing with), highly

structured. Aims through extended assessment phase overfirst few sessions at joint description of keyproblem (reciprocal) role procedures by means

of written (narrative) and diagrammaticreformulations. These should also effectivelyoffer a sensitive, (micro-) cultural descriptivedimension.

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(CAT)

Subsequent work focuses on the enactments, of

these both outside and during sessions.

Use of transference and counter-transferenceunderstood as enactments of repertoires of

reciprocal roles.

Final summary (goodbye) letters by therapist

and patient.

Labour intensive!

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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 uncommunicativeand 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 hopelessand 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 himcompounded 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.

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(Dominic - possible SDR)

criticised

conditionally lovedmy fault, am worthless

*criticising

conditionally loving

apologeticstrive to perform and

please

results in emotional isolation, exhaustion,

cant manage confirms worst assumptions

depressed

ODs

or, defiant, rebellious,*criticising

briefly self assertive

but, feel guilty and

*criticised

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CAT recent developments

Although initially devised as a time-limited

therapy for neurotic type out-patientpopulations, the model has been further

developing to deal with more severe &

complex (e.g. personality, psychotic)disorders in a range of modalities/settings.

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CAT models of severe and

complex disorders.

Seen to involve deeper levels of damage to the

self and its processes beyond existence of arepertoire of maladaptive RRs/RRPs. This will

include failure of integration of RRs,

impairment of self-reflective capacity and of

executive function. Usually understood as dueto developmental deprivation/trauma in context

of biological /neuro-cognitive vulnerability.

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complex disorders.

Psychopathology is always seen asrooted in and highly determined by

repertoire of RRs and therefore, critically,

to include an (internalised and frequentlyre-enacted) relational component.

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CAT and borderline

personality disorder

Deficit model of psychopathology.

Trauma-induced dissociation rather thanrepression/conflict seen as primary

mechanism.

In addition to maladaptive reciprocalrole procedures, describes and

addresses multiple self states.

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CAT and borderline personality

disorder

Postulates different levels of damage to selfdue to developmental deprivation/trauma(possibly in conjunction with e.g. poor

impulse control, poor self-reflective capacityand 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.

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complex disorders.

From a CAT perspective, severe andcomplex disorders could be seen in part

as self-state and relational disorders.

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neglected

abandoned

neglecting,

abandoning

cut off,numb,

do drugs

OK for a while, but..

feel even worse,

nothing changes

poor self care,

deserve nothing,

do nothing

seek perfect

care - expect

too much

abused

abusing

always let

down

desperate,

unmanageable

feelings

self harm

some relief, but

nothing changes

deserve

punishment

self harm

if feelabused

may explode

into justifiedrage

upsets people,rejected, put down,

alone, feel whole

world against me

give people

a bad time,

(e.g. partner)

staffcaring,

trying to help

fearful, fed-up,

burnt-out, rejecting

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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 patients self-state and role

enactments and their effects on others.

Helps establish therapeutic alliance andcommunicates that patient has been listened

to and understood.

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Contextual reformulation

Educates patient into effects of behaviour and staffinto patients 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 professionallyallowed (e.g. anger) by locating these in anon-judgmental system of causality.

Permits discussion of these difficulties by wholeteam.

Stimulates thought about the patients inner worldbeyond getting stuck in negative responses

(viciouscircles) to difficult behaviour.

A Fi ti li d C E l

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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 friends 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.

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Anna - Background

Currently living alone in small flat paid for by

parents in a small town in a very socio-

economically 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 verycompetitive) but dropped out in first year because

of mental health problems.

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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 wouldnt attend due to sickness.

Couldnt tell anyone about this. Younger sister Mary was less

pressured and somehow more thick-skinned but has alsohad problems with anxiety. Tells Anna she should now be able

to pull herself together and get on with life.

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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) isapparently only about 14. She refuses to see local eating

disorder service who she says dont listen to her or take

her seriously. However agrees to see CPN intermittently

and attend a (different) psychiatrist for occasional review.

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Anna - Therapy

In the absence of any more specialist intensive treatment

service locally she is offered, and agrees to, an initially time-

limited (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 anyfuture. Attends regularly apart from two periods when she is re-

admitted 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.

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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. Isable 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.

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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 thiswill 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.

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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 ofnothaving other peoples

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 firstthings 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..

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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 viciouscycle fashion seems to reinforce your original experiences and keep them going.

These cycles do seem to have acquired quite a life or their own.

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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 cancontinue 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

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Self States Sequential Diagram - Anna

conditionally loving

treating as not good enough#

conditionally loved(real me not loveable)

never good enough(?mentally retarded, something wrong,

never knew how to be good enough)

emotionally neglecting,

disbelieving*,

not taking seriously*

looked after materially but

emotionally neglected (eg by dad),

not listened to or taken seriously,

disbelieved

want to be dead

unbearable feelings,

withdraw, cant tolerate

seeing anybody

become ultra

competitive

(?cultural too)

restrict eating,

cope with laxative abusesometimes (more recently)

cut or OD sometimesneed to feel punished #

sometimes get reliefshort lived

(becomes harder to cut

deeply)

feel disgusting (anyway)

makes a mess,

constantly running,

avoids deep thoughts

nothing changes,

reinforces original

experiences

exhausted

isolated

dont take self seriously,

treat self as not good enoughjust carry on as below,dont care for self,

whats the point?

(eg blood tests)

When I look into the mirror Im not

sure who I see or who is seeing*

sometimes kickfurniture, bang head

restrict eating

- can be a

weapon

pisses people

off

ill, numb

no change,

no result,

lose power

A K I

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Anna Key Issues

(Target Problem Procedures)

(1) Because of your experience of being frequentlycriticised, pressurised and only ever conditionally loved,you have finished up assuming that there is somethingwrong with you (eg missing some chromosome!) and havefinished up frequently enacting these criticising rolestowards yourself. This leads you to never feeling goodabout 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 self-pressurising voice and identify it as we have been doingand to try to consider whether you really accept its validity.

A K I

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Anna Key Issues

(2) Because of your experiences of never feeling properlylistened to or respected, you finish up feeling abandoned andalone and often full of desperate feelings which you havecoped with in various ways including self-harm and dietaryrestriction - as well as sometimes perhaps behaviour which

may have been experienced as apparently difficult towardsother people. This all tends to lead you to be again rejectedand misunderstood and leaves you still unappreciated andwith your emotional needs unmet, so reinforcing your originalexperiences.

Aim: To try to bear in mind when you are feelingdesperate how it is that these feelings have come about andthe consequences of your traditional ways of coping and tryto consider alternatives such as communicating calmly totrusted people (as we have begun perhaps to do in therapy)how you are feeling and what your needs are.

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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 patternsof 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.

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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 sociallyisolated 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

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Issues

Problems due to mix of temperamentalvulnerability (obsessional perfectionism, ?dissociation), dysfunctional, intense (nuclear)family dynamics (criticising, conditional love, notlistening to or taking seriously), cultural factors(competitive school environment, pre-occupationwith dieting and appearance).

?Exacerbated and perpetuated contextually bydoing to, authoritarian approach of many mentalhealth services - colluding with her historic RRs.Lack of any meaningful attempt at socialtherapy/rehabilitation.


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Therapeutic Issues

Attempt to establish a therapeutic alliance onbasis of authentic encounter (new RR) - aidedby collaborative work of joint reformulation(offering both insight and empathic narrativevalidation).

Aim to generate understandings of the origins ofrelational positions (RRs), of unbearablefeelings and habitual maladaptive copingpatterns (RRPs) including dialogicalunderpinnings of these where relevant soenabling work on challenging and changing

these.


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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 herfather.

Anna Overview of Therapeutic

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Anna Overview of Therapeutic

Challenges

RRPs around anorexia very long standing andresistant even when obstacles to addressingthem have been worked on. Will require active

behavioural approaches. Beliefs around diet and appearance and theimportance of individual success reinforced bycultural norms.

Absence of real (joint) community involvement insocial therapy/rehabilitation. Perpetuates lack ofany sense of common identity or purpose.

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CAT: Further Applications

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around PD

Brief interventions using standardised CAT

diagrams in A&E.

(Sheard, T., Evans, J., Cash, D. et al. (2000). A CATderived one to three session intervention for repeated

deliberate self harm: a description of the model andinitial experience of trainee psychiatrists in using it.British Journal of Medical Psychology, 73, 179-196.).


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around PD

A CAT framework for understanding and

managing problematic frequentattendance in primary care. Pickvance, D., Parry, G.D., & Howe A. Primary Care

Mental Health, 2, 165-174.


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around PD

Residual PD in the elderly.

Sutton, L. et al. (2003) When late life brings adiagnosis 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. Brunner-Routledge.


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around PD

Early intervention studies in adolescentsat high risk of developing BPD.

(Chanen, A.M., Jackson, H.J., McCutcheon, L.K., etal. (2008). Early intervention for adolescents withborderline personality disorder using cognitive

analytic therapy: randomised controlled trial. BritishJournal of Psychiatry,193, 1-8.)


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around PD

Skills level training for generic mental

health workers: brief CAT-based trainingin working with difficult/PD patients.

(Thompson, A.R., et al. (2008). Multidisciplinary

community mental health team staffs experience of askills level training in cognitive analytic therapy.International Journal of Mental Health Nursing, 17, 131-137.)

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CAT-based skills training for a

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g

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.


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g


mental health problems:Background

Community mental health teams (CMHTs) areincreasingly central in many services to theroutine delivery of care for a range of oftencomplex and difficult mental healthproblems, including personality disorders.

But...


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gCMHT in working with complex


Widespread uncertainty about nature ofclinical models used and their effectiveness.

Poor history of effective implementation oftraining programmes (eg family therapy, PSI).

Frequent demoralisation, poor job satisfaction

and burn out amongst team members.

CAT based skills training for a

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CMHT : Background

Increasing expectation from consumers forpsychological treatments for mental healthproblems acknowledged and encouraged inthe UK by recent DoH guidelines (NIMHE2003; DoH 2002)

Increasing expectation that generic mentalhealth workers should offer psychologically-informed management and/or treatment topatients with complex and PD type problemsin wake of emerging treatment models (APA2001; NIMHE 2003; 2004;NICE 2009).


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CAT based skills training for a



Current paucity of appropriate or effectivetraining packages well recognised (NIMHE2004) as is urgent need for theirdevelopment.


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g


mental health problems: Aims

To provide CMHT members with a training in

a common, coherent model to inform routinemanagement of complex and difficultpatients, notably those with PD.

To improve overall team function.

To improve clinical outcomes for patients.

CAT-based skills training in

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g

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 theoreticallectures, conceptualisation of clinical materialand experiential sessions (reflective groupsand personal reformulations).


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CAT based skills training in


health problems.

Followed up by experience of treating

two cases under extended supervisionover 6-9 months.

Further training/supervision (possiblypractitioner level course) for those

wishing to extend experience/expertise.


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CAT based skills training in


health problems.

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.

Personal reformulation experience:

C

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CAT-based team training:

qualitative evaluation.

Questionairre and confidential in-depth

interviews conducted and evaluated byindependent researchers (EP and JD).

Quantitative evaluation of responses to

formal questions. Further evaluation of themes emerging

from interviews.

T i i l i

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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 lotsof different therapies over the years, who have been stuck or

dependent on the servicepeople who have been labelled as difficult

or challengingit's nice to see a framework to let them open up

and look atwhy they were entrenched in maladaptive functioning

My understanding was that it would equip us with the skills of

CATso that we could develop a language to discuss what was

going on with some of our complex and difficult clients

T t i i l ti

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(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 timeit has helped the team bonding,

it's created a lot of banter and debate, jokes and support.a verysatisfying extra. It's comforting to have that baseline language

I dont think that teams will often have that shared knowledge or

shared understanding of the language

"The main thing is empowering clientsthe breakdown of the

practitioner-client boundariesit 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.

T t i i l ti

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(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,

Im more comfortable taking on a heartsink personality disorder case

knowing that I have some understanding of CAT

"It helps my assessmentsprovides a clear structure for my work and my

endings with clients

It brings together issues I think are important within social workalongside psychological modelsit includes issues of discrimination,

power, it allows for some understanding of political structure

T t i i l ti

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(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 inthe ways that they doBeing 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.

theres 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.

T t i i l ti

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(iv) Impact on level of support and supervision

Very positive, it was tremendous - lots of knowledge,experience and wisdomdifferent perspectives from people

bringing in different cases.

There has been a shift of focuswe used to work very

differently and think differently: rather than do it, do it now

it's am I on the right track?

T t i i l ti

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(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 elsein 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 wehave something to offer people who are often dismissed as

having untreatable personality disorders

CAT-based skills training for aCMHT i ki ith l

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mental health problems:Conclusions Training is feasible, welcome and helpful to team

members.

Sustained improvements in perceived skills levelsgeneralising 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 aCMHT i ki ith l

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mental health problems: Whatnext?

Disseminate manualised training programmeincorporating improvements to other CMHTs inservice.

Controlled evaluation of impact on clinical outcomesand patient satisfaction.

Assist several team members to further specialistCAT psychotherapy level training!

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G i i t d h ll

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Growing points and challenges

CAT now a mature and robust general theory ofdevelopment 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 andsocial origins and determinants of human

psychopathology as well as its current social

context.

G i i t d h ll

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However, CAT needs to continue to integrateand 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?) bothalone and in multimodal treatment approaches.

G i i t d h ll

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Although CAT emphasises the social andcultural formation of self, does the modeladequately address the need for social therapyand the issues of treating psychological damage

and distress in different cultures and contexts?

Could contribute a socio-psychodevelopmentaldimension to current, often polarised, highly

individualistic either disease model or socialinclusion type approaches to public mentalhealth initiatives?

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Thank you!

ian kerr

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