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My Experience of Cognitive Analytic Therapy (CAT) within a Secure Forensic Setting

Moon, L., 2015. My Experience of Cognitive Analytic Therapy (CAT) within a Secure Forensic Setting. Reformulation, Winter, pp.12-15.

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As a Clinical Psychologist working within a forensic mental health secure hospital, the role comprises of many complex levels. A significant part of the work involves consultation primarily focused upon public protection and minimising risk. Other levels, which can sometimes come into conflict with this, is being patient centred and positive risk taking. In terms of working with a forensic population, Tuck (2009) highlighted the significant emotional impact when working with forensic patients on both the service and the professionals providing that care, due to the complex, challenging, and often traumatised patients residing in them. Forensic inpatients have often committed acts that most people, including those whom work with them, find horrifying and shocking not just towards others, but against themselves. As a consequence, psychologists are often seen to be the people to not only make sense of these acts, but also provide therapies to change these harmful behaviours into more healthy and prosocial ways of relating.

Within the forensic service, CAT was proposed as an overarching relational model to enhance clinical practice by providing the staff team with a common language to understand their interactions with the patients (Marshall, Freshwater and Potter, 2014). CAT was also to compliment the other interventions that were offered, not replace. In implementing this, I was able to gain funding for my CAT training. I felt it to be a helpful way to understand the challenges faced within forensic services, mapping out some of the healthy and unhealthy procedures. It also gave me a tool in order to work with patients who so far had refused formal psychological therapies. Through consultation and formulation I could make sense of not just where the patient was, but also as a staff team and where we might be on their map. What I particularly liked about CAT was the emphasis on ‘exits’, thus encouraging me to just focus on difficulties, but also to proactively make changes.

When thinking about how I as an individual was going to contribute to the forensic service, it was important to reflect upon how to make sense of the organisation, the patients, the care staff and the wider environment, and how my work would fit into all these potentially competing elements. The wider care team’s role was that of providing security, often managing violent and aggressive behaviour, in parallel to developing therapeutic relationships. This is a significant part of my role: supporting staff, trying to formulate and understand the sometimes confusing and occasionally violent behaviour that someone has inflicted upon them, and to keep up morale in doing so. In terms of the organisational demands, due to limited resources, this must all be done within a time cost effective manner, providing the highest quality of service; a balancing act in its self. I was attracted to Cognitive Analytic Therapy (CAT) as a model to support, innovate, and provide emotional containment to the work I was doing; one which would specifically give me the time and space to reflect upon transference and relational issues. Also the very ethos of CAT appealed to me, in terms of collaboration, in that it aims to work alongside people to develop a relational reformulation. In this paper, I reflect upon my experience of using CAT within a secure forensic setting, within which I have been given the opportunity to consider how my practice has been shaped.

Secure Services: Some of the Challenges

The Environment

The environment and the nature of hospital itself was a significant challenge within my CAT work. As a secure hospital, there are a number of security requirements which can re-enact unhelpful and potentially damaging reciprocal roles such as controlling/controlled and punishing/ punished. For example, high perimeter walls maintain a barrier to the rest of society, with bedrooms and lounges facing a blank white wall. The wards are locked, with staff holding keys on their belts, controlling not only bedroom access, but also when patients may need to use the toilets or gain refreshments. On all wards there are CCTV cameras, recording patient and staff movement continuously. Trying to develop a collaborative therapeutic relationship in such an environment is a challenge in itself.

Time Limits and Complexity

CAT is a time limited therapy, offering between 8, 16 and 24 sessions. “The reciprocal role repertoire of the forensic patient is frequently grossly restricted, damaged and damaging” (Mitzman, 2010). When working with such complex, challenging and at times dangerous individuals, how can all of this be addressed in so few sessions? Especially as these are often life-long patterns of relating which have enabled individuals to survive some of the most terrifying situations; thus difficult to leave behind. The expectations of the clinical team can be another potential difficulty, believing that once therapy is completed the patient’s risk and maladaptive reciprocal roles have been eradicated. However, the reality of episodic change in therapy was highlighted by one patient I worked with who included in their goodbye letter that “therapy has been a journey, one that we started together and now I must go alone,” reflecting the nature of therapy, in that change doesn’t just occur in the one-to-one sessions, but generalises in interactions outside these. Through the CAT model and the transparent nature of the therapy, the patient often becomes insightful into the difficulties ahead, and if change has been possible, that maintaining this is going to take significant personal resources. However, this is sometimes not recognised by the wider clinical team and service as a whole, who view therapy as completed and not an evolving process of self-reflection.

As CAT is a relational therapy, the patient may try out new strategies in their relationships with staff. The staff that are open to this development in relationships may encourage and support the patient in doing so, commenting on these differences and empowering them to continue. However, if the work is not understood, and the goals for therapy are not shared, this can result in a crushing or dismissive response, perhaps replicating earlier unhelpful reciprocal role patterns. For example, one female patient I worked with had a strong drive to ‘people please’ and put everyone else’s needs before her own as a way of trying to achieve perfect care from others as she feared being abandoned. Relating to others in this way often left her feeling ignored or neglected, or bottling up feelings of rage. We had discussed the importance of self-compassion and care, and the ways that she could demonstrate this. One example was she was often asked by other patients for head/ hand massages or manicures when they were feeling stressed and she would stop whatever she was doing and to do this. We spoke about how when feeling distressed, it was important to look after herself and how she could say no to such requests in a sensitive manner. In between sessions the patient tried this, which resulted in the staff making comments of her being ‘selfish’ especially as ‘you’re just lying in your room.’ When talking about this together the patient spoke of feeling devastated that in trying to show herself some care and compassion she had met with criticism and attack. This had then reinforced the desire to people please for fear of abandonment. It also resulted in her becoming verbally aggressive towards staff due to her increased anxiety of being ignored. This clinical experience where therapy had been misunderstood by the clinical team highlighted to me the importance of using CAT as a consultation model within forensic services and integrating this within the team, promoting psychological thinking and understanding to their role and patient care.

CAT as a Consultation Model

When gaining service support for my enrolment for CAT practitioner training, there was a proviso that I would provide weekly CAT formulation groups for staff (for a description of the adapted CAT model used refer to Marshall et al, 2014). This involved facilitating “contextual reformulation … highlighting the factors associated with offending, making sense of difficult ward dynamics and splits within the team and between ward professionals” (Mitzman, 2010). However, this was not about ‘doing’ CAT as a therapy, but ‘using’ CAT as Steve Potter has proposed, to aide understanding and to reflect upon how we as a staff team may become collusive in our reactions to a patient, for example describing them as ‘attention seeking’, ‘behavioural’, ‘bad not ill.’ The benefits of CAT reformulation with the team are that the problems can be located within the system (Ryle and Kerr, 2002b). As a consequence, staff can feel that sharing their own feelings and reflections on their work is validated, listened to and contained, and that empathy for patients increases (Marshall, in press). To achieve this it is important that the contextual Sequential Diagrammatic Reformulation’s (SDR’s) are collaboratively ‘mapped together’. Steve Potter emphasised that this “early sketching together is giving birth to something other than a CAT diagram. It is cultivating a therapeutic attitude” (2010).

For example, a staff team, which included nursing, social work, psychiatry and occupational therapy, requested a formulation meeting on a patient in a Low Secure setting. The patient had been within the service for a number of years, and although his mental health and risk behaviour had improved leading to his move from Medium Security, they were feeling stuck as to how to help him to progress to live in the community. The staff found that whenever they tried to talk to the patient about his behaviour (this may be about minor ward infractions) he responded by either ‘disengaging or shutting down’ or becoming ‘verbally hostile, as if he thinks we’re against him’. When trying to think about how the patient may be experiencing them as staff, they worried that he may feel ‘criticised’, mirroring earlier experiences from his mother. The team acknowledged that they shied away from challenging the patient as they wanted to keep him involved in discussions about his care and not experience them as ‘critical’. They did this because they wanted to empower the patient, providing him with only positive feedback. However through the SDR, they recognised that this also kept the patient in the stuck position as he was never made aware of what he had to change in order for him to take the next step into the community. This led to the team to think about creative ‘exits’ from these unhelpful patterns: how to talk to the patient about the behavioural difficulties, but in a way that didn’t leave him feeling criticised. The team were able to think of examples when problems had been addressed without the patient responding with unhelpful procedures and to think about how they could build upon this. In developing the SDR, the team spoke of their changing view of the patient, in that they initially felt frustrated with him, but increasingly felt empathic. They also recognised the reciprocal relationship of how the patient must feel when receiving only positive praise but nothing changing for him. This was due to the lack of dialogue around what needed to change so that the patient could progress through the hospital system into the community.

Integral to this way of working was the support from senior managers. They agreed that a significant proportion of my time would be taken by introducing CAT to different staff, particularly the nursing team, as well as agreeing to fortnightly formulation meetings for staff to attend. It was emphasised to managers the importance of ‘scaffolding’, enabling them to understand that without the support of another, the potential for the staff team could not be achieved, in terms of their interpersonal relationships with the patients. Also, the importance of giving staff the time and space to think about the emotional challenges of working with forensic patients. Thirdly, the investment within the staff team’s wellbeing and clinical practice, which in turn reinforces that the work they do is meaningful. Another positive element of the training process was promoting consistent understanding and shared practice of the treatment needs of the patient, thus minimising the chances of splitting within the team.

In terms of my personal experiences of facilitating the CAT formulation meetings, I was initially overwhelmed at the sheer size of the task. When first in these meetings, I was perplexed as to how I would made sense of some of the more chaotic group discussions which involved conflicting views and experiences, and to keep staff on board with what we were trying to achieve through these. I was aware of my own reciprocal roles, needing to stay strong and ‘in control’, bottling up my own anxieties and not allowing myself to appear weak and exposed, which anecdotally mirror those of the hospital setting. However, when reflecting upon my CAT practitioner training and the importance of being ‘good enough’ and staying with difficult moments, I thought back to my supervision, in which I had developed multiple SDRs with patients prior to producing ‘the one page map’. This led me to think about the formulation meetings as a journey, where there are multiple discussions and can be adapted to incorporate changes. As we get to know our patients, the map can change, and as we alter or adapt our clinical practice so might their map transform. That in itself gave confidence to the process, and encouraged me to ‘go with the flow’. This meant that the SDR didn’t have to be perfect, and what made it helpful were the revisions and adaption’s, modelling to staff the fluidity and relational nature of the work.

Reflections

In terms of my experiences of CAT within a secure forensic setting, I have found it an invaluable model for working with not only this patient group, but also when working with staff teams. Within forensic inpatient services, you are never a lone worker and even when meeting with a patient on an individual basis, there is always a team of people in the background supporting you. As such, CAT has not only influenced my practice, but also contributed to the changing culture of the service in terms of keeping in mind a relational therapeutic stance. It is important to highlight that this is not always a smooth transition.

Within the NHS, there are increasing restrictions around resources, and it is important to reflect upon how CAT can respond to this without losing the essence of what it is. The use of CAT as a consultation tool is a good example of how we can impact upon clinical practice and care through multiple layers, without having to directly work with a patient. Research has also started to show that the introduction of CAT skills to a wider staff team encourages compassionate care (Marshall et al, 2014 in press). In such a controlling environment as a secure hospital, this compassionate stance is imperative in understanding our patient’s difficulties, and how to promote change. Also within forensics due to the length of stay of some patients, some of which can stretch to decades, the time limited nature of the therapy can provide containment. That this is not unwieldy and never ending. Also the CAT tools encourage a more interpersonal position, rather than one of reports written about them, they receive letters written to them, hopefully readdressing some of the power imbalance within a forensic environment.

As illustrated by the above examples, there can be difficulties from the patients, staff teams and the service itself, when working therapeutically in such an environment. However, the CAT model lends itself to reflect upon such experiences, encouraging me to think about where I fit into this and what is ‘good enough’. It is difficult to describe my emotional journey of beginning to incorporate CAT to my internal world, but as was reflected in a goodbye letter by one patient, this is a journey that I have begun. As it continues, there may be instances where I may need to “go it alone,” or feel overwhelmed and uncertain, experiencing a mixture of apprehension, anxiety, vulnerability and exposed; but most of all enthused and excited by my experiences so far.

Acknowledgements

I would like to thank Dr Jenny Marshall, Dr Kate Freshwater and Steve Potter for their support in delivering this adapted model of CAT. Also thanks go to Ruby Bell for her support, advice and care.

Dr Lauren Moon is a CAT practitioner in Training and Clinical Psychologist working in Forensic Mental Health Services in Tees Esk and Wear Valley NHS Trust.

Contact for further discussion: Lauren.moon@nhs.net

References

Marshall, J., Freshwater, K. & Potter, S. (2014). Using Cognitive Analytic Therapy within a forensic setting: An overarching relational model. Forensic Update 2014 Annual Compendium, 132-137.

Mitzman. S.F. (2010). Cognitive Analytic Therapy and the role of brief assessment and contextual reformulation: the Jigsaw puzzle of offending. Reformulation, Summer. Retrieved 17th February 2014.

http://www.acat.me.uk/reformulation. php?issues_id=18&article_id=155  Ryle, A. & Kerr, I. B. (2002). The ‘difficult’ patient and contextual reformulation. In: A. Ryle & I.B. Kerr (Eds) Introducing Cognitive Analytic Therapy. Principles and Practice. Wiley: Chichester.

Potter, S. (2010). Words with arrows: the benefits of mapping whilst talking. Reformulation Summer p.37-45

Tuck, G. (2009) Forensic systems and organisational dynamics. In: Aiyegbusi & Clarke-Moore (Eds). Therapeutic relationships with offenders: an introduction to the psychodynamics of forensic mental health nursing. Jessica Kingsley Publishers: London

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