In Praise of Practitioner Training

Potter, S., 2002. In Praise of Practitioner Training. Reformulation, Spring, pp.3-4.


ACAT is ten years old and it is time for review. We have plenty to celebrate and much to debate. What, for example, should we say about the robustness and continuing evolution of the model or our range of clinical applications and our research record? What do we think of our impact on a society that under-funds the care of those affected by mental ill health? How are we doing in reaching socially marginalised or minority groups? How stands our ability to create a well-regulated, stable environment for establishing, maintaining and monitoring competence in the practice of CAT? Let’s debate. What we may easily overlook is our most immediate and distinctive achievement in developing the practitioner training courses now established in ten places around the UK.

What a gem of an idea the practitioner training is! It offers a post qualifying training for people working within a variety of contexts and from a variety of mental health professions. The key word is practitioner. We are training practitioners all of whom have a core mental health profession behind them, some of whom are already psychotherapists, others are psychiatrists, nurses, clinical psychologists, counsellors or social workers. Some will greatly value using the practitioner training as a stepping stone to completion of the psychotherapy level training in CAT by doing a further two years of training and supervised practice.

Like the therapy it espouses, the practitioner training is pragmatic, focused and works to promote an early educational alliance with the trainee. It seeks to give the trainee practitioner the tools and the scaffolding to develop and enrich his or her practice within a more integrative and relational understanding. CAT is partly a therapist's therapy, attracting experienced professionals who find their own model not strong enough to help with the range of work to which they are exposed. Many describe having hit a wall in the model in which they first trained. Perhaps CAT's attraction is its offer of a framework which reconciles the, often opposing, tasks of therapy of sustaining a problem solving focus of activity on the one hand whilst maintaining and using a self reflexive and engaging relationship on the other hand.

For some cognitive therapists CAT is felt to counter the tendency of other cognitive approaches to be distancing and reductive of the client-therapist relationship. For the psychoanalytic or person centred therapists, with their abiding interest in the therapeutic relationship, CAT offers a more versatile, manageable and communicable way of making therapeutic use of the relationship with the client. For all therapists CAT’s tools and concepts for mapping the role of social and power dynamics in the formation of self in early experience offers something new and very relevant to working with the damaged and disaffected client or patient. The practitioner training brings these contrasting needs together in a cost-effective framework relevant to people working in the public sector. Ten years ago I was one such psychotherapist looking for a wider and more pragmatic integration of the methods and ideas of psychological therapies which could be used in ways that sustained a practice of respect for, and active collaboration with, the client.

The tools of procedural and dialogical reflection on the working of the self can be applied, as much to educational and professional development, as they can to the dysfunctional patterns and target problems of the psychotherapy client. Try it now for yourself by spending an hour identifying a target problem of yours in your current therapeutic practice and write out the reciprocal role procedure behind it. Work at recognition. Look for exits. CAT is a framework for normal learning and development as well as for therapy.

There is something about the practitioner training which induces us to practice educationally what we preach therapeutically. It is a tightly but carefully packed programme, with its twenty training days, eight supervised cases, weekly small group supervision, local seminar groups and a personal CAT training therapy. Like the basic sixteen session CAT treatment, it is a good first intervention for a journey of further exploration of the world of integrative, dialogical and relational therapy. From the clear vantage point CAT therapy, I now find myself interested in Safran's relational approach (Safran and Muran 2000), the work of Horowitz (1998) on the dynamic construction of meaningful selves and Young’s methods for eliciting typical schemas (1999) all close neighbours of CAT. It is like finding parts of the CAT integrative framework being worked upon and refined elsewhere. Though CAT seems unique in offering a socially interactive approach to the formation of damage and disturbance in the organisation of self. If qualified CAT practitioners do subsequently go off in more versatile directions, they may be helped by use of CAT’s meta-scaffolding to guide, hold and focus them.

Of course ACAT, like other psychotherapy organisations, gives importance to training people for psychotherapist accreditation within UKCP and the practitioner training is, in one very important part, a stepping stone for this. The consolidation of psychotherapy as a pluralistic, democratic and well-regulated field is a clear concern of ACAT’s and organisational membership of UKCP expresses this.

At the other end of the continuum of applied psychology in mental health work we encourage people from a wide variety of backgrounds to get an initial view of CAT through the two-day introductory and foundation courses. Such foundation courses will probably develop more in future years and several are now being developed. For some mental health professionals a CAT informed foundation course in thinking relationally and reflexively about their work will be all they want. But the practitioner training is probably, for most people, the minimum necessary to truly get a grasp of both using and doing CAT. As the practitioner training develops we may want to develop group, therapeutic community, family and contextual ways of practising CAT and count those alongside the individual casework in our training and assessment.

CAT practitioners and researchers are right to be challenged to endeavour to take CAT through the full randomised controlled trial neck of the hourglass of research into outcome evidence according to the Salkovskis model. Whether a model that arose out of process and outcome research and has accumulated an impressive array of small scale research studies to help further conceptualise the emerging model is ready to go through the neck of the hour glass just yet is debatable. Frank Margison clearly details this challenge in the British Journal of Medical Psychology (2000) in his case study of CAT as a treatment development. We may reply that it is not for want of ideas or motivation among researchers and practitioners in CAT to set up the gold standard RCT but funding is a mighty challenge. Two CAT (RCT) projects are under way one in Australia and one in the UK. Other projects seek funding. ACAT is very keen to promote such research. Frank Margison suggests a pause to obtain RCT grade outcome evidence before ‘moving further into dissemination into yet more diverse fields’. I doubt this is an ‘either-or’ choice which CAT practitioners can or want to make. Whilst RCTs which test CAT's effectiveness for particular treatment needs will ultimately be invaluable we should also keep in mind CAT’s use as a general training vehicle for improving the overall competence and self-reflexivity of the practitioner regardless of treatment choice, setting or need.

Experienced mental health practitioners must respond increasingly, not just to the evidence base and the pragmatic need to be versatile in treatment approach. They also need to respond to, and have a theory which mobilises, those common factors (the therapeutic relationship, the client's resources, rekindling hope, utilising favourable life events) which contribute to the client's change through healing and learning seemingly regardless of treatment choice or theory and method (Hubble et al 1999). These, now fashionable, common factors have always been a main concern of CAT theory and an early quote from Tony Ryle speaks nicely to this point.

"Since factors unrelated to the therapist’s theory play a very large role in the therapeutic success it could be argued that theory does not matter very much, and that practitioners might be left to draw upon their different traditions and to work in terms of their own preferences, personalities and pragmatically acquired skills. Such a dismissal of theory would, however, be a pity. There is a need for a theory that does not, subtly or obviously, deny aspects of the humanity of those we set out to help."(Ryle, 1978)

No doubt each model of psychotherapy gets the kind of organisation of training it deserves. CAT is not a 'Sunday worship' model of therapy seeking devotees, more a pragmatic 'what to do on Monday morning with five clients waiting' model. CAT grew out of self reflexive practitioner research and its tools encourage joint reflection with the client on outcome and effectiveness. There is something inherently empirical about CAT’s method of formulating and evaluating with the client. And CAT's reciprocal role method of reflecting upon the working relationship is as good a research tool as any being developed in the field of qualitative research in social science. General service audit tools such as the CORE (clinical outcomes routine evaluation) fit nicely into the CAT approach offering an additional evaluative tool which can be used dialogically with the client whilst also aiding both individual and service audit. The current work of Dawn Bennett and colleagues (Bennett, Parry and Ryle in press) will enrich the practitioner’s means of self evaluation and supervision with its emphasis on both CAT specific and general therapist competencies.

In this context and with the practitioner training in mind, I wonder if CAT is something more than another formal psychotherapy model offering a treatment choice with an evidence base slowly being cultivated and harvested? Is not our drive to develop diverse clinical applications of CAT, and our enthusiasm for training practitioners from a wide range of mental health backgrounds, also a small beacon pointing to a re-alignment of the terms by which practical psychology is traded in the alleviation of mental illness and distress? Is ACAT, in promoting the practitioner training, offering not just a training for psychotherapists but a contribution to a general theory and practice of the reflexive, relational and integrative aspects of psychological therapy and help? Does it not seek to offer a scaffolding for an integrative and pluralistic conversation among a number of approaches which speak to the psychologically minded and engaged mental health practitioner in many roles and situations? I suspect the answer my lie in researching the effectiveness of the practitioner training’s ability to sustain the self reflexive practitioner, not just in the psychotherapist’s consulting room (important as that is), but in a myriad of settings, from the playground to the hospital ward; from the nursing home to the therapeutic community and the classroom.

Steve Potter


References

Bennett D, Parry G and Ryle A (in press) C-CAT; 10 domain measure of competence in CAT – rates skilful application of CAT and generic psychotherapeutic competencies.

Mardi J. Horowitz (1998) Cognitive Psychodynamics.Wiley

Mark A Hubble, Barry L Duncan, Scott D Miller. (1999) The Heart and Soul of Change. American Psychology Association

Frank Margison (2000) Editorial: Cognitive Analytic Therapy: a case study in treatment development. British Journal of Medical Psychology Vol 73 Part 2 June.

Anthony Ryle (1978)

A Common Language For The Psychotherapies

British Journal of Psychiatry, 132. 585-594

Jeremy D Safran and J Christopher Muran (2000) Negotiating the Therapeutic Alliance (A Relational Treatment Guide) Guilford

Jeffrey E Young (1999)Cognitive Therapy for Personality Disorders (3rd Edition) Professional Resource Press.

Full Reference

Potter, S., 2002. In Praise of Practitioner Training. Reformulation, Spring, pp.3-4.

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