Providing a Clear Way Forward: Providing a Clear Way Forward: Using Using CAT to Integrate Forensic CAT to Integrate Forensic

ServicesServices

Mark Ramm, Mark Ramm, Head of Forensic Psychological Services, Head of Forensic Psychological Services, The Orchard Clinic, NHS LothianThe Orchard Clinic, NHS Lothianmark.ramm@nhslothian.scot.nhs.ukmark.ramm@nhslothian.scot.nhs.uk

Into the Future Conference

4th October 2012

OverviewOverview Hard to help offenders/patientsHard to help offenders/patients The treatment taskThe treatment task Using CAT formulation to guide:Using CAT formulation to guide:

Individual therapyIndividual therapy Team workingTeam working Risk AssessmentRisk Assessment Systemic workSystemic work

How we are doing this at the Orchard How we are doing this at the Orchard Clinic Clinic

Case exampleCase example

Hard to help Forensic PatientsHard to help Forensic PatientsSome Types:Some Types:

Uncontrollable affect Uncontrollable affect (lack ability to self regulate)(lack ability to self regulate)

Can’t think, Don’t think Can’t think, Don’t think (Lack insight re: internal (Lack insight re: internal states of self and others) states of self and others)

Confusion Confusion (Things just happen)(Things just happen)

Too split up, Moving target Too split up, Moving target (Flipping)(Flipping)

Too aggressive / rejectingToo aggressive / rejecting

Too needyToo needy

Low Motivational readinessLow Motivational readiness

‘‘Defend’ against problem/othersDefend’ against problem/others

Don’t think there is problemDon’t think there is problem

Don’t change, Revolving door patientsDon’t change, Revolving door patients

Treatment: The methods by Treatment: The methods by

which we deliver therapywhich we deliver therapy

GROUPWORK

INDIVIDUAL

PSYCHOTHERAPYPOSTIVE

PURPOSEFUL

ACTIVITY

SAFE & SECURE

Rehabilitation ServicesPrison

Families

MEDICATION

Community

The Forensic MatrixThe Forensic Matrix‘stepped care’‘stepped care’

HSI

Specialist I

High intensity interventions

Low intensity interventions

Information

Highly specialist Interventions

Formulation Driven

But less specific about how you hold the But less specific about how you hold the whole thing together (Psychology, whole thing together (Psychology, Occupational Therapy, Social Work etc)Occupational Therapy, Social Work etc)

Or about the how to use of the Or about the how to use of the therapeutic relationship outside therapeutic relationship outside particular individual or group therapies particular individual or group therapies

GROUPWORK

INDIVIDUAL

PSYCHOTHERAPYPOSTIVE

PURPOSEFUL

ACTIVITY

SAFE & SECURE

RELATIONAL

INTERACTIONS

Rehabilitation ServicesPrison

Families

MEDICATION

Community

There are successful treatments for There are successful treatments for Borderline Personality DisorderBorderline Personality Disorder

Dialectical Behaviour Therapy – DBT Dialectical Behaviour Therapy – DBT (Linehan et al, 1993)(Linehan et al, 1993)

Transference Focussed Therapy –TFT Transference Focussed Therapy –TFT (Clarkin et al, 2007; Levy et al, 2006; Doering et al (Clarkin et al, 2007; Levy et al, 2006; Doering et al

2010)2010) Cognitive Behavioural Therapy -CBTCognitive Behavioural Therapy -CBT

Davidson et al, 2006)Davidson et al, 2006) Shema Focused Therapy – SFTShema Focused Therapy – SFT

(Glessen-Bioo et al, 2006)(Glessen-Bioo et al, 2006) Mentalizing based therapy-MBTMentalizing based therapy-MBT

(Bateman & Fonargy 1999, 2001)(Bateman & Fonargy 1999, 2001) Systems Training for Predictability & Systems Training for Predictability &

Problem Solving STEPPS Problem Solving STEPPS (Blum et al, 2008)(Blum et al, 2008)

Cognitive Analytic Therapy CBTCognitive Analytic Therapy CBT (Chanen et al, 2008)(Chanen et al, 2008)

Comparisons: Comparisons: Treatment vs TreatmentTreatment vs Treatment

Psychodynamic supportive therapy vs Psychodynamic supportive therapy vs transference-focussed therapy vs DBT transference-focussed therapy vs DBT (Clarkin et al, 2007) (Clarkin et al, 2007) ““Generally equivalent”Generally equivalent”

MBT vs Psychodynamic Supportive Therapy MBT vs Psychodynamic Supportive Therapy (Jorgensen et al, 2012)(Jorgensen et al, 2012)

Comparisons:Comparisons:Specific Treatments vs Good Clinical Specific Treatments vs Good Clinical

CareCare DBT vs good general psychiatric DBT vs good general psychiatric

management (McMain et al. 2009, 2012)management (McMain et al. 2009, 2012) No differences in outcomeNo differences in outcome

MBT vs structured clinical management MBT vs structured clinical management (Bateman & Fonagy 2009)(Bateman & Fonagy 2009) Outcome was similarOutcome was similar

CAT vs manualised good clinical care CAT vs manualised good clinical care (Chanen et al, 2008)(Chanen et al, 2008) No major differences in outcomeNo major differences in outcome

Conclusions?Conclusions? BPD at least can benefit from BPD at least can benefit from

treatmenttreatment These specialised treatments are These specialised treatments are

clearly better than treatment as usualclearly better than treatment as usual Outcome /efficacy does not differ Outcome /efficacy does not differ

substantially between specialised substantially between specialised treatmentstreatments

Specialised therapies have yet to Specialised therapies have yet to demonstrate better outcomes than demonstrate better outcomes than good tailored clinical care good tailored clinical care

Conclusions?Conclusions? It may be that some problem It may be that some problem

domains respond to some therapies domains respond to some therapies better than others better than others

butbut it seems outcome is largely due to it seems outcome is largely due to

change mechanisms common to all change mechanisms common to all the therapies and good tailored the therapies and good tailored clinical care clinical care

PD and disorders that have their PD and disorders that have their

origins in childhood and adolescenceorigins in childhood and adolescence

Common change mechanisms

CAT

Schema F T DBT

Transference FT

MBT

STEPPS

But this does not mean unstructured intervention

Common Change Common Change Mechanisms?Mechanisms?

A generic supportive therapeutic stanceA generic supportive therapeutic stance

StructureStructure Clear conceptual basis – Clear conceptual basis – Therapeutic ModelTherapeutic Model Structure for interventionStructure for intervention Limit settingLimit setting

Building and maintaining a collaborative Building and maintaining a collaborative therapeutic relationshiptherapeutic relationship validation, motivation, self –reflectionvalidation, motivation, self –reflection

ConsistencyConsistency Change methodsChange methods

Creating a Team CultureCreating a Team Culture Models of working which help teams should include:Models of working which help teams should include:

Having a clear common language which is Having a clear common language which is understandable and makes sense to both patients understandable and makes sense to both patients and teamworkers and teamworkers

A stress on the therapeutic relationshipA stress on the therapeutic relationship (Roth & Fonagy, 1999)(Roth & Fonagy, 1999)

This results in: This results in: Improved communication between teammatesImproved communication between teammates Improved team functioning (minimizing Improved team functioning (minimizing

“splitting”, “buck-passing” and “burn out”“splitting”, “buck-passing” and “burn out” Improved job satisfaction and team moraleImproved job satisfaction and team morale Improved results and cost-effectivenessImproved results and cost-effectiveness

MODEL / FORMULATIONMODEL / FORMULATION

Common change mechanisms

CAT

Schema F T DBT

Transference FT

MBT

STEPPS

STEPPED CARE

RISK

MANAGEMENT

CAT CAT FORMULATIONFORMULATION

Common change mechanisms

CAT

Schema F T DBT

Transference FT

MBT

STEPPS

STEPPED CARE

RISK

MANAGEMENT

Because Interpersonal Dysfunction lies

at the core of these patient’s problems

CATCAT FORMULATION FORMULATION

Common change mechanisms

CAT

Schema F T DBT

Transference FT

MBT

STEPPSSocial workers

Care staff

Medical staff

Families

Applied Health Professionals

STEPPED CARE

RISK

MANAGEMENT

Carers

Patient

GROUPWORK

INDIVIDUAL

PSYCHOTHERAPYPOSTIVE

PURPOSEFUL

ACTIVITY

SAFE & SECURE

RELATIONAL

INTERACTIONS

Rehabilitation ServicesPrison

Families

MEDICATION

Community

We need an overarching formulation and We need an overarching formulation and reformulation to plan the type, level, timing, reformulation to plan the type, level, timing, order and length of interventionsorder and length of interventions

CAT as a ‘relational model’ is particularly CAT as a ‘relational model’ is particularly applicable because we need to work throughapplicable because we need to work through therapeutic relationships across the whole therapeutic relationships across the whole processprocess

FormulationFormulation

Core Issues & Entrenched patterns

Skills building & strengthening

Engagement & motivation

Consolidation & integration

Cognitive Analytic TherapyCognitive Analytic Therapy IntegrativeIntegrative

““A theory based on the integration and A theory based on the integration and extension extension of ideas and methods used in conventionally of ideas and methods used in conventionally opposed approaches”opposed approaches” (Anthony Ryle)(Anthony Ryle)

More than just Cognitive & PsychoanalyticMore than just Cognitive & Psychoanalytic

CognitiveCognitiveBehavioural Behavioural Psychoanalytic Psychoanalytic Developmental Developmental SocialSocial

CATCAT Distinctive individual psychotherapyDistinctive individual psychotherapy

CAT accepted as a distinctive and CAT accepted as a distinctive and independent form of psychotherapy - independent form of psychotherapy - Roth & Fonagy (1996)Roth & Fonagy (1996)

An integrated theory of personality and An integrated theory of personality and changechangeSoSo applicability to a wide range of applicability to a wide range of situations, problems and settingssituations, problems and settings

How does CAT approach it ?How does CAT approach it ?

Relational: Relational: Most distress in human beings is Most distress in human beings is relationship basedrelationship based

self and othersself and othersself and selfself and self

Dynamic: Dynamic: Explains how people can act very Explains how people can act very differently at different times and in differently at different times and in different contextsdifferent contexts

DEVELOPMENTDEVELOPMENT

Babies are born attuned to interact with others

Each baby has its own genetic predispositions

The baby interacts with carers who are massively influential - Attachment issues

The infant internalises its experienceForms joint understandings with others

Forms concepts about others

Formation of Relationship templatesFormation of Reciprocal Roles

CATCAT

All mental activity, whether conscious or unconscious, is rooted in and highly determined by our repertoire of Reciprocal Roles

RECIPROCAL ROLESRECIPROCAL ROLES Mother or Main Other

(Critical & demanding)

SELF

(Unworthy & Striving)

SELF

(Critical & demanding)

Other

(Unworthy & Striving)

SELF

(Critical & demanding)

SELF

(Unworthy & Striving)

Other

(Critical & demanding)

SELF

(Unworthy & Striving)

BALANCED PERSONALITY ORGANISATIONBALANCED PERSONALITY ORGANISATION

A Reciprocal Role is a block of procedural knowledge about how to ‘do’ a particular relationship and what to expect from it (Denman 2001)

PROCEDURESPROCEDURES

Abusing

Abused

Unmet needsNegative emotion

Stress

e.g. Avoiding

,

e.g. impress others

Alternative

Reciprocal

Role/self state

““RIGID” PERSONALITY ORGANISATIONRIGID” PERSONALITY ORGANISATION

Particular Reciprocal Roles have a dominance and extreme polarization or there are a limited in number of Reciprocal Roles.

Self State DisordersSelf State Disorders Disruption of integrating proceduresDisruption of integrating procedures Deficient and disrupted self reflectionDeficient and disrupted self reflection Dissociation of self-statesDissociation of self-states

Confused, Can’t think, Unstable

Some dissociation normal

Using CAT formulation to Using CAT formulation to inform and integrate treatment inform and integrate treatment

with forensic patients with forensic patients

All staff trained in CATAll staff trained in CAT

100 trained in last 3 years100 trained in last 3 years

CAT Therapy, Team working, CAT CAT Therapy, Team working, CAT informed workinginformed working

CAT KNOWLEDGE COMMON LANGUAGE

CAT INFORMED TEAMWORK

CAT THERAPYCAT MAPS

Trained/supervised staff

Shared FormulationShared Formulation

- CAT reformulation developed with patient CAT reformulation developed with patient shared with care teamshared with care team

- CAT formulation developed by care team CAT formulation developed by care team to work with patientto work with patient

Team working to develop a CAT Team working to develop a CAT formulation to guide therapyformulation to guide therapy

Angry Aggressive PatientAngry Aggressive Patient

Why is the person like they are?Why is the person like they are?

What is actually happening?What is actually happening?

How will we try to improve things?How will we try to improve things?

Abusing

Abandoning

Rejecting

Abused

Abandoned

Rejected

Perfectly caring

Protecting

Perfectly cared for

Protected

ANGRY NEEDY

Angry

outburst Seeks perfect care

Seeks distraction through excitement

Doesn’t last or rejected

PreventedRefuses to ask for

care but expects itNeeds not met

GROUPWORK

INDIVIDUAL

PSYCHOTHERAPYPOSTIVE

PURPOSEFUL

ACTIVITY

SAFE & SECURE

RELATIONAL

INTERACTIONS

Rehabilitation ServicesPrison

Families

MEDICATION

Community

CAT and Working as TeamsCAT and Working as Teams

Benefit to teamBenefit to team Consistent approach, prevent splitting etcConsistent approach, prevent splitting etc

Benefit to patientBenefit to patient Better treatment, breaking the cycle of Better treatment, breaking the cycle of

damaging responses from othersdamaging responses from others

Application of CAT at many Application of CAT at many levels – Integrated Workinglevels – Integrated Working

Individual therapy – Formulation, client Individual therapy – Formulation, client focusedfocused

Multidisciplinary, team approachMultidisciplinary, team approach Recovery focussed milieuRecovery focussed milieu Flexible application to mode and Flexible application to mode and

modality of intervention, Stepped caremodality of intervention, Stepped care Collaborative, Service user involvementCollaborative, Service user involvement Psychologically informed and literate Psychologically informed and literate

workforceworkforce Improved relational securityImproved relational security Improved risk assessmentImproved risk assessment

CATCAT Ryle A. & Kerr I.B. Introducing Cognitive Ryle A. & Kerr I.B. Introducing Cognitive

Analytic Therapy (2002) John Wiley & Sons Analytic Therapy (2002) John Wiley & Sons

RCT’s for PD RCT’s for PD

Chanen A.M., Jackson H.J., McCutcheon, l.K Chanen A.M., Jackson H.J., McCutcheon, l.K et al. (2009) Early intervention for et al. (2009) Early intervention for adolescents with borderline personality adolescents with borderline personality disorder: quasi-experimental comparison disorder: quasi-experimental comparison with treatment as usual. with treatment as usual. Australian and New Australian and New Zealand Journal of Psychiatry, Zealand Journal of Psychiatry, 43, 397-40843, 397-408

Prof Sue Clarke, RCT of CAT vs TAU for PD As Prof Sue Clarke, RCT of CAT vs TAU for PD As presented at a recent conferences presented at a recent conferences (submitted to B. J. Psych). (submitted to B. J. Psych).