Jellema, A., Crowley, V., Griffiths, T., Twist, G. and Gray, S., 2003. Developing and Promoting CAT in the NHS - Problems and Possibilities. Reformulation, Spring, pp.13-15.
Anna Jellema, Val Crowley, Tina Griffiths, Graham Twist and Sally Gray
We are CAT Practitioners/Psychotherapists, Supervisors and trainers working largely in the NHS. Our professions are clinical psychology, psychiatry and psychiatric nursing (adult mental health and learning disabilities). Over the last nine years or so we have shared our hard-won and often painful experiences of trying to develop CAT in NHS settings. We have put together some notes on strategies and tactics which we have found to be effective, and which could be helpful in other NHS settings – we would also be very interested to hear from other ACAT members about your experiences.
Be Patient and Get Support
You can’t do much alone – network, exchange ideas and get as much support as you can from other “CATs”, to avoid burnout. The “hero-innovator”(Georgiades and Phillimore, 1975) who is isolated in his or her attempts to produce radical change - like a knight in shining armour - is unlikely to get very far.
We have found that it takes a lot of time to develop a “critical mass” of “CATs” from scratch, to provide a proper service or offer training. CAT developments often seem to follow an exponential growth pattern, so the start is likely to be slow. A CAT Practitioner/Supervisor is the minimum “fertile unit” (i.e. able to produce another one, with help!) and it may take four or more years before someone is trained to this level, given the number of cases required before beginning Supervisor training. It helps CAT’s good name if you try to get the most able and committed people you can involved at the start of any CAT initiative. Reputations travel far.
If you are working in an area where other therapies are strongly represented, having the added experience of CAT Psychotherapy training should enable you to develop a profitable dialogue with them.
Limit and Tailor What You Offer
It helps to target scarce CAT resources carefully, as we are still thin on the ground in many parts of Britain. It’s better not to raise others’ expectations too high of what you can do and then disappoint. You could offer something that is sustainable on a long-term basis, even if it’s small, such as an ongoing supervision group.
Increasingly NHS monies follow specific, well-evaluated initiatives, e.g. a six-month in-patient project based on CAT management strategies.
It may not be helpful to offer CAT therapy as a tertiary service; it can be publicised instead as a specialism within a secondary or primary care service. When other forms of therapy, such as psychoanalytic psychotherapy, are offered as a tertiary service (e.g. serving a Region) it can result in many patients being rejected as unsuitable following assessment (though this is less likely to be the case with CAT). Offering consultation routinely before accepting referrals could overcome difficulties here. To build and maintain a successful service it’s better to be over-cautious and selective about taking on patients.
Show Other Clinicians How Much CAT Can Offer Them
CAT’s understanding of how disturbed patients can elicit unhelpful and disturbing roles from staff can help work against the “blame culture” in the NHS when things go wrong. (This is also something which managers now have to address as an aspect of clinical governance - see “An Organisation with a Memory”, 2000). Mistakes become meaningful and informative.
Helping staff groups (e.g. on in-patient wards) understand more about RR enactments such as “rescuing” can bring long-term dividends; getting them to work with their counter-transference feelings helps staff feel cared for and taken seriously. They can also get to see the patient’s unhealthy early strategies at work in the here and now, which validates the reformulation, and the CAT model. A variety of primary and secondary mental health teams can also benefit from CAT-based consultation. Many staff need help in formulation and are very grateful for what our model can offer.
Junior doctors in psychotherapy posts need experience in different therapeutic models, such as CAT (see e.g. Rees, 2000). SHO’s are now coming through in large numbers and some could be offered CAT placements. If it goes well they may favour CAT developments once they become Consultants and have more clout; as potential referrers, medics are usually the first customers of a service. Good networking with other NHS staff is likely to pay off long-term.
CAT still has the ability to provide a “common language for the psychotherapies” (Ryle, 1978) and has something helpful to say to most other therapies, provided one is tactful; but being triumphalist or over-zealous helps nobody. CAT isn’t for everyone – for some the language is too alien, and other therapists usually have enormous emotional investment in their models. Although CAT can deal with a wide variety of presentations, there will increasingly be pressure to define referral protocols and assessment criteria for CAT in the context of newly-forming Psychological Therapies Services, which offer a variety of interventions.
Develop a Variety of Trainings and Supervision Packages
We cannot hope to increase the number of CAT-knowledgeable staff via Practitioner courses alone. Practitioner training is really for the most committed, suitably experienced and able NHS staff, and might not be what staff and managers want – at least, not at first. Mental health workers such as staff nurses may not see themselves as therapists, and managers may not support them in undertaking such roles. However we can do much to promote CAT thinking, theory and tools among the NHS workforce by differently targeted training events and courses (accredited where possible), as for example with Ian Kerr’s skills level training offered in Sheffield.
Many people find that CAT isn’t easy to learn without sustained practice. We have often found that those who are highly-trained in other models can feel very de-skilled when learning CAT; when beginning supervision they may need a lot of containment, and explicit valuing of the skills they already have. Introductory workshops usually seem to work best if they’re followed by ongoing supervision groups, so people don’t get demoralised. If you don’t have much time available it may be more fruitful to offer ongoing supervision rather than training days. Placements in CAT for third-year clinical psychology trainees have been popular. CAT-informed supervision for experienced B grade psychologists has also proved very successful in stimulating interest in formal CAT training.
As well as the regular introductory workshops, we think that ACAT could offer one-day introductions to CAT the day before CPD/updating events, and publicise both days to non-ACAT members, which would spread the word more widely. Tim Leighton and Kirby Gregory’s very interesting CPD workshop last summer on CAT and addiction was attended by some people who had little previous knowledge of CAT, yet were able to take something from the material and find it very useful.
Become a Manager
We have found that we needed to get better at selling CAT in a variety of ways. Having a vision for what you could do with CAT locally provides impetus. It’s important to try to get in positions where you can take decisions and influence others about the usefulness of CAT. Find out who are the local key players and try to get on the major Trust committees, HImP groups, etc. General managers can often provide plenty of guidance in writing business cases, with clear service development objectives and potential results.
Work towards money being reallocated to CAT from unfillable posts in other specialties. If you have a likely applicant for a CAT post, the money is more likely to follow the candidate now than it did in the past. Offering external staff CAT training and supervision will generate income, which can then be used to build more of a service.
There are more opportunities now to develop management or leadership skills. (The national White Hart Management and Professional Development Training for Clinical Psychologists (Harrogate) is excellent).
Work Closely with Managers to Address National Targets and Strategies
Although CAT was developed to address local circumstances, national targets are major drivers now; CAT may help general managers achieve their “must do’s”. It really helps to get to know key new NHS documents (NHS Plan, NSF, etc.) available on the NHS and Department of Health websites (www.nhs.uk; www.doh.gov.uk) and work out how a CAT initiative might fit in locally or could be tailored to address these needs. The new Personality Disorder strategy (2003) gives CAT a good press, and could be used to make CAT an essential part of a new local P.D. service.
As Primary Care Trusts now control much of the NHS’s resource allocation, there may be more requests for brief therapies in primary care settings. CAT is well placed to meet the challenge set by the NSF Standard 2 in meeting the requirement for providing assessment and psychological treatments for people experiencing common mental health problems in primary care. It will be recalled that some of Ryle’s early ideas emerged as he was practising as a busy GP himself.
In Leicester, brief CAT, typically 8 to 12 half hour sessions, has been one therapeutic approach used over the past year in GP surgeries, as part of the new Common Mental Health Problems Service. An SDR is usually jointly constructed within 2 to 4 sessions with the help of Kelly’s self-characterisation sketch - it can get to RR’s quickly and is used to complement the Psychotherapy File. The volume of patients coming through the door militates against standard reformulation letters in these early sessions. However, a more comprehensive ‘goodbye’ letter emphasises some points that would ordinarily be incorporated in the Reformulation letter.
Early statistical analysis in Leicester (from last year, when this service began), indicate that wider availability and access to psychological assessment and treatment (including CAT) situated within GP surgeries, has impacted positively on both primary and secondary care. Referrals from GP’s to local CMHT’s have been almost halved. Furthermore, patients have benefited from engaging in a safe first-line CAT who might otherwise never have been offered such an experience of therapy, or who might have sat on a secondary care psychotherapy waiting list for several years. This is very good news for managers of mental health services striving to meet numerical targets. CAT formulations have also helped other members of the primary care team better understand some problematical procedural enactments of patients in Primary Care.
Help Develop CAT’s Evidence Base
Our evidence base is still weak when compared with CBT – and CBT features strongly in government documents, eg. the Treatment Choice document (Treatment Choice in Psychological Therapies and Counselling: Evidence-based Clinical Guidelines: Department of Health. 2001).You need to marshal your arguments for CAT when preparing to negotiate with managers and purchasers, especially with those who have no clinical background, and thus may make naïve decisions.
The development of a Practice Research Network (Audin et al, 2001) within ACAT should help in providing “practice-based evidence”. CORE is already used widely but it would be good to have a large amount of data from many sites (non-CAT plus CAT measures) to boost our case nationally, and attract more funding.
Locally, we can all keep psychometric outcome data now (many therapists and departments still don’t bother). We can do a lot with less than perfect data; “quick and dirty” research (Paxton, 1987) can be very useful. It is also increasingly what managers seem to want; they are more interested in the effectiveness of treatments, rather than their efficacy. Good local audit data are very helpful to make a case for the development of services. (The current year two CAT Shropshire Practitioner trainees are collecting outcome data on their four final patients, with a view to write-up).
Use CAT’s Understanding of Organisational Roles and Procedures
All organisations will enact unhelpful roles and procedures; you could try mapping those in your own organisation, and likely exits, as e.g. in Sue Walsh’s 1996 paper. (Is CATNET still active?) Organisational cultures can be extraordinarily persistent and CAT may never thrive in some.
Managers may ask for a CAT perspective to help with the rapid organisational change that is now required in the NHS - they appreciate CAT’s organisational perspective once they know about it. It’s also helpful to get to know other organisational models, particularly models of change (see e.g. Iles and Sutherland, 2001). Soft Systems Methodology (SSM – Checkland and Scholes, 1990; Checkland, 1999) can add a broader cultural perspective to a CAT understanding; it is particularly applicable to exceptionally complex systems like the NHS (with over 1,100,000 staff, how could it not be?) which lack a unitary power structure. SSM offers a useful mnemonic - coincidentally called CATWOE! – to aid thinking about the purpose of whatever you’re trying to do, and the helping/hindering aspects of the system.
The classic paper by Georgiades and Phillimore (1975) also recommends following the “path of least organisational resistance” and working with the healthier parts of the system which have the will and the resources to change – and with those who have sufficient authority to implement the kind of developments you want.
Encourage User Involvement
User involvement is increasingly promoted, although not often realised. Patient satisfaction matters; it should be high with CAT, if we are collaborative and dialogical enough, and satisfaction questionnaires can give good evidence of this. We can also use their opinions to improve the CAT service we offer. (Service users with BPD have had a major impact on the Government’s P.D. strategy). Local advocacy services (e.g. PALS) usually offer a wealth of knowledge.
As a last thought, we already have a Private Practice Interest group – so perhaps we could also think about an NHS interest group? It could run via email.
An Organisation with a Memory (2000) Department of Health.
Audin, K. at al (2001) Practice research networks for effective psychological therapies. Journal of Mental Health, v.10, pp.241-251.
Checkland, P. (1999) Soft Systems Methodology: a 30-year Retrospective. Chichester: Wiley.
Checkland, P. and Scholes, J. (1990) Soft Systems Methodology in Action. Chichester: Wiley.
Georgiades, N.J. and Phillimore, L. (1975) The myth of the hero-innovator and alternative strategies for organisational change. In: C.C.Kiernan and F.D.Woodford, (eds.), Behaviour Modification with the Severely Retarded. London: Association of Scientific Publishers.
Iles, V. and Sutherland, K. (2001) Organisational Change: a Review for Health Care Managers, Professionals and Researchers. NCCSDO.
National Service Framework for Mental Health (1999) Department of Health.
Paxton, R. (1987) Why are we here? Some quick and dirty reasons. Clinical Psychology Forum, June, no.9.
Personality Disorder: No Longer a Diagnosis of Exclusion (2003) Department of Health, Leeds: NIMHE.
Rees, H. (2000) Cognitive-analytical therapy – a most suitable training for psychiatrists? Psychiatric Bulletin, v.24, pp.124-126.
Ryle, A. (1978) A common language for the psychotherapies. British Journal of Psychiatry, v.132, pp.585- 594.
Treatment Choice in Psychological Therapies and Counselling: Evidence-based Clinical Guidelines (2001) Department of Health.
Walsh, S. (1996) Adapting cognitive analytic therapy to make sense of psychologically harmful work environments. British Journal of Medical Psychology, v.69, pp.3-20.
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