Exploring whether the 6 Part Story Method is a valuable tool to identify victims of bullying in people with Down’s Syndrome

Pettit, A., 2012. Exploring whether the 6 Part Story Method is a valuable tool to identify victims of bullying in people with Down’s Syndrome. Reformulation, Winter, pp.28-34.


Introduction

The Six Part story is a co-created enterprise between therapist and client which generates some specific products: the pictures drawn by the client to illustrate the story and the words of the story itself, which ideally are audio recorded and transcribed. These features are reminiscent of the prose reformulation letter and the sequential diagrammatic reformulation (SDR) in CAT which are similar joint enterprises resulting in a permanent record. The 6PSM has characters or elements which are in relationship to one another (for example the relationship between the main character and the obstacles s/he encounters.) These relationships in the story are paralleled in a reformulation letter or SDR by the reciprocal roles. Furthermore, the dynamic nature of the story arc means that the character’s task leads them to action to which the environment responds. This sequence is paralleled in the reformulation letter and SDR by elements such as the Target Problem Procedure (TPP) (Dent-Brown, 2011).

Bullying has been found to cause severe psychological trauma to its victims, and it ultimately can be a main source of why people seek therapy. This highlights the importance of CAT therapists having the ability to identify and address this common problem, particularly in people with learning disabilities due to their susceptibility to bullying. Research by Psaila and Crowley (2005) has acknowledged the Reciprocal Roles that often play a part in the lives of people with learning disabilities. This has shown the negative influential impact of abuse on the lives of its victims. Examples of these Reciprocal Roles that may be present in the lives of people who are victims of bullying - Abusing in relation to Abused; Rejecting to Rejected; Rescuing/Caring to Rescued/Cared for; Damaging to Damaged; Abandoning to Abandoned; Unloving to Unloved. These Reciprocal Roles can be incredibly damaging and can end up making the individual feel very unhappy.

Dozens of tools are available to measure victimisation. However, the majority of them require the recipient to understand the concept of bullying, as well as have the ability to read and write. In people with learning disabilities, where there is a high prevalence of bullying, these skills are likely to be impaired. Therefore, a questionnaire would not be a suitable method to identify cases of bullying in this particular group of people.

The main aim of this study was to find an alternative method which could help to indicate victims of bullying in people with learning disabilities. The projective test, the 6 Part Story Method (6PSM) (Dent-Brown, 1999), was adapted for this purpose to explore whether it could identify victims of bullying. Participants, four females and two males aged 25-46, drew a bullying story and a happy story based on the 6PSM instructions. The stories were scored by the researcher and an inter-rater using the Draw-A-Person Test: Quantitative Scoring System (Goodenough, 1926) to ensure reliability. Post-experiment, a questionnaire was sent to the care home to investigate whether the participant had been a victim of bullying or had bullied others to standardise the finding from the 6PSM.

The results found no significant findings, but trends highlighted that the participants who had been a victim of bullying scored lower (performed worse) on the bullying story compared to the happy story. Furthermore, findings showed that those who had bullied others scored higher (performed better) on the bullying story compared to the happy story. These findings suggest that, with further research, the 6PSM may have the potential to be an effective tool in indicating victims of bullying within the learning disabled population. The conclusions of this paper could, ultimately, be treated as part of a screening system to discover victims of bullying.

Bullying can occur in any context in which human beings interact. It transcends all racial and ethnic groups and socioeconomic classes (Orpinas & Horne, 2006). However, there are specific groups of people who are more vulnerable to victimisation. One such group is people with learning disabilities. Statistics show that eight out of ten children with a learning disability are bullied (Lipsett, 2007).  The World Health Organisation (2001, p.5) defines a learning disability as a “condition of arrested or incomplete development of the mind characterized by impairment of skills and overall intelligence in areas such as cognition, language, and motor and social abilities”.

Victimisation can occur throughout an individual's life span, and can take the form of various types of abuse, from name calling to physical violence (Monks & Smith, 2006). Furthermore, bullying can be carried out by people in authoritative, trusted positions. This was highlighted in a recent BBC Panorama programme that revealed members of staff abusing service users who had learning disabilities (Swindon, 2011). In the present day, media publication of such events provokes shock, controversy and cries of injustice. Nevertheless, incidents such as these are a regular occurrence for disabled individuals and are not always acknowledged;  most cases of victimisation are not reported (Glew, Rivara & Feudtner, 2000). This gives prominence to having effective strategies to assess victimisation in groups of people who are prone to being bullied.
Research indicates that there are dozens of scales that measure victimisation and rates of bullying. Various bullying scales are used in several contexts, from government surveys to school interventions. Commonalities between these scales include the style of writing, the use of language and the fact that the majority are formatted in a self-scaled questionnaire. With reference to the learning disabled population, several problems arise with these types of scales. As communication is impaired in people with learning disabilities (Taylor, 2008), it is unlikely that someone with such a disability would understand a questionnaire that is targeted at the general population. Even questionnaires aimed at children would be unsuitable in some cases, as an adult with learning disabilities would have had different life experiences compared with a child.

At present, there is not a tool that is specifically targeted at the learning disabled population to identify cases of bullying and victimisation. To fit this population's needs, a tool would be required to eliminate extraneous variables that may act as a barrier, such as verbal communication. It is important to ensure that the individual actively participates in relaying information of their bullying experiences to a professional person. Therein lies the value of a tool to help identify victims of bullying in the learning disabled population.

Method

The researcher completed a course on Cognitive Analytic Therapy in learning disabilities and training on how to use the 6 Part Story Method with Kim Dent-Brown.  However, the 6 Part Story instructions were slightly adapted for the bullying story to include directions to draw a bully-type theme and characters – and the instructions were kept the same for the non-bullying story. Furthermore, as vulnerable persons were being used, NRES Committee South East – Surrey approved this study to ensure ethical standards were being met (reference number: 911/LO/0931). 

An information sheet with images and simple language to explain the study was shown to the participants by their care manager to ensure they understood the experiment. A consent form was signed a week before the experiment and, again, on the day of the experiment, to confirm each person wanted to take part. The consent form was based on the Arscott, Dagnan & Kroese 1998 protocol to assess consent for people with learning disabilities to participate in research.  This protocol asks what participants have understood is required of them, the advantages and disadvantages of participating and the knowledge they may opt out at any point. Only if participants obtained a full score did the retrieval of data continue.

Data was collected from a sample of six participants who spanned an age range of 25-46 years all of whom had a severe learning disability. Half of the participants completed the bullying story first and the other half completed the non-bullying story first. This was alternated by the researcher to counter-balance conditions. The instructions of the adapted 6PSM were read by the researcher whilst the participant drew.

To avoid bias, the researcher was not informed of the participant's history of bullying. Therefore, one week after the experiment, a questionnaire was sent to the care home for the care manager to complete and identify the participants who had been a victim of bullying, a bully towards others, or neither. This questionnaire would ensure standardisation for the 6PSM as a tool to identify victims of bullying. 

The Draw-A-Person Test: Quantitative Scoring System by Goodenough (1926) was used to get a total score for each story by the researcher - the higher the score, the  more developmentally mature the drawing and the lower the score, the more developmentally immature the drawing. An inter-rater also scored the drawings to ensure reliability and form an average score. As the data was interval, descriptive statistics and a related t-test were conducted using SPSS to see if the projective tool could distinguish among the participants who had been bullied and who had not. Qualitative analysis of the drawings was also employed.  

Results

Although quantitative data was collected, the sample was very small and so the researcher felt that analysing the results using statistical analysis only, might not reflect the meaningfulness of the findings. Therefore, qualitative exploration of the drawings was also employed to explore the value of the 6PSM. The questionnaire completed by the care manager post-experiment classified the six participants into three categories. It was found that three people had been victims of bullying; two had been bullies; and one person was neutral. Thus, there were three victims of bullying and three non-victims.

The mean scores for victims of bullying and the non-victims of bullying, showed as expected, the victims scored lower on the bullied story (performed worse) compared to the happy story in relation to the non-victims. This lends support to the hypothesis, suggesting that the 6PSM may be valuable for differentiating between the victims of bullying and non-victims.

Furthermore, an unexpected finding was that the participants who were described as a bully toward others performed, on average, higher on the bullied story (performed better) compared to the happy story. This suggests that the 6PSM may have the potential to distinguish individuals who have bullying tendencies.

Inferential Statistics

A related t-test was used to establish whether the 6PSM significantly indicated a difference in scores between victims of bullying and non-victims of bullying. Results showed that there was not a significant difference between the scores of victims and non-victims of bullying:    t (5) = -1.21, p > .141 (one-tailed). Therefore the hypothesis was rejected. However, as there were only six participants, qualitative analysis of the drawings was used to explore the value of the 6PSM and the statistical significance considered, but not emphasised.

Qualitative Analysis

Qualitative analysis was employed and the most interesting trends have been chosen, which accounts for participants 2 and 6 not being mentioned.

Participant 1: history of being bullied

In Participant 1's bullying story, the size of their characters fluctuated from small to large. In particular, the picture of running away from the bully – see Figure (i) – showed the main character as shrunk to half the size and was less complete in comparison to the picture introducing the main character – see Figure (ii). Interestingly, the characters in their non-bullying story stayed the same size throughout.

Figure i

Figure ii

In Participant 3's bullying story, there was a stark difference in drawing ability compared to their non-bullying story. In the bullying story, when the bully is introduced to the story – see Figure (iii) – the character only had an outline of their head and abdomen, with no legs, arms or facial features. In contrast, in the non-bullying story, their characters had a more complete image – see Figure (iv). Interestingly, in the last picture which featured the main character being happy because the bully left; the participant’s drawing becomes more complete. This strikes a resemblance to the drawings in the non-bullying story.

Figure iii

Figure iv

Participant 4: history of bullying others

On the other hand, the pictures of Participant 4, who had a history of bullying others, were the opposite of those drawn by Participant 3. The drawings were more complete in the bullying story in comparison to the non-bullying story. For example, the main character picture – see Figure (vi) – on the non-bullying story did not have hands, feet or teeth, whereas on the same picture in the bullying story, they did – see Figure (v).

Figure v

Figure vi

Participant 5: history of bullying others

The themes in both the bullying – see Figure (vii) – and non-bullying stories – see Figure (viii) – for Participant 5 were very similar in that they both contained aggressive and dominating tendencies. The main character in both stories was 'Malfoy', a character in Harry Potter films who is known for his manipulative and bullying nature. The participant kept referring to Malfoy as 'fighting' others. In the non-bullying story in particular, the word 'power' was repeated and related to Malfoy's effect on others. Another dimension to Participant 5's bullying story is that the main character was called 'greedy' but was later known as the 'good Malfoy'. Ultimately, there was a 'good' and 'bad' version of Malfoy.

Figure vii

Figue viii

Discussion

Previous research highlighted that there was no existing tool for identifying victims of bullying in the learning disabled population. Therefore, the aim of this study was to investigate whether the 6PSM was a valuable tool for indicating these victims. Although the findings were not significant and the hypothesis was rejected, mean scores showed that victims of bullying performed worse on their bullying story compared with their non-bullying story, as expected. Another finding detailed that the participants who were described as bullies performed better on their bullying story than their non-bullying story. Exploration of the drawings highlighted interesting trends, including that victims of bullying tended to draw less complete pictures on their bullying story. Moreover, in the stories drawn by the participants described as bullies by the care manager, they drew themes that reflected this bullying behaviour in both stories.

Existing literature has not investigated the usefulness of the 6PSM in the learning disabled; additionally, there was no recorded tool found that had been designed to explore bullying in this population. Therefore, this study cannot compare directly with previous research. However, literature and informal clinician findings suggested that the tool would show differences in the drawings by victims and non-victims of bullying. The findings from this study support this view and, in turn, demonstrate how beneficial art therapy can be for the learning disabled. Councill (2003) stated that art therapy can re-build many aspects of one's sense of self, especially in a safe place where feelings can be expressed. All participants from this study confided in the researcher – a complete stranger – about their difficult life experiences.

Moreover, this study supports the findings of Freilich et al. (2010) - that art therapy can be a medium for emotional exploration and an awareness-insight development with the learning disabled. The drawings from the 6PSM were able to highlight particularly important themes for each individual – for example, Participant 2 based him/herself on a character who was a victim of bullying in his/her story and used real experiences with bullying to make the story. Participant 5 was another example, whose carer described them as someone who frequently uses physical force to gain access to the fridge. Interestingly this participant repeated words such as 'power', 'greed' and 'fight' during their story-making. This could be seen as a reflection of the individual’s underlying cognitions.

The victims of bullying scored lower on their bullying story compared to the non-bullying, suggesting that trauma is ever-present within that individual. Moreover, it suggests that art therapy can be a medium in which this trauma surfaces. Research by Mansor et al. (2011) showed that projective tools can be a medium to demonstrate an individual's emotional adjustment. Again, this study supported this notion as the 6PSM was able to highlight the individuals who had past experiences of trauma, which became evident through the performance and themes that became part of their stories. The conclusion is, therefore, that it may have triggered emotional responses.

Thyme et al. (2008) showed that art and verbal psychotherapies have similar benefits, but for people who can communicate well. Whereas Knight (2009) claimed that art therapy is particularly useful in exploring the fears of children who have little means of communication. As demonstrated by Participant 2, language was sometimes used to communicate particular attitudes and thoughts, even if it was impaired. This participant began the interview by saying "I've been bullied before". In the context of therapy, verbal communication would be seen as a necessity. However, in the case of the 6PSM, it is merely an added advantage for the therapist if the patient can communicate verbally. This method showed that the 6PSM can be easily adapted for a wide range of people and, in this case, emphasis on speech was not needed. Thus, during the data collection, there was very little verbal communication that took place, although these participants’ stories were just as insightful and provided the researcher with a rich understanding of that individual’s past.

This study was not without its limitations. The main limitation was the sample size - only six participants were collected as the study was investigating whether the 6PSM had the potential to become a tool which indicates victims of bullying. Therefore, using quantitative analysis on such a small sample to find significance was problematic to identify statistically whether this tool could indicate victims of bullying. However, descriptive statistics and a qualitative exploration of the drawings were employed, which proved to be very useful in highlighting significant trends. Furthermore, in terms of the sample, the participants were only collected from one home, in the county of Surrey. This was not a representative sample of learning disabled people, as life experiences could vary across geographical locations in the United Kingdom, such as education and rates of bullying.

A potential problem that could have occurred throughout the experiment was the influence of the researcher's expectations on the findings. To ensure that this did not occur, the researcher was unaware as to whether the participant was a victim or not. However, in one case, a participant began the experiment by stating that they had been bullied before, which may have influenced the researcher’s expectations. During the story-making, the researcher avoided any leading statements which may have influenced the participants’ drawings. After the results were collected, the researcher and an inter-rater analysed the results to ensure reliability.

The 6PSM has already been applied to therapeutic settings, particularly to diagnose personality disorders in the NHS (Dent-Brown, 1999). However, this study investigated whether the emphasis of language could be deployed for participants with little verbal communication to determine whether they were still able to understand and follow instructions. When participants had particularly impaired communication skills, this was more challenging for the researcher; however, the instructions were adapted to meet the participant's needs. This suggests that this tool has the potential to be used as part of a screening system in settings such as care homes or in therapeutic settings involved with people with learning disabilities to identify victims of bullying.

One of the most appealing factors of CAT as a therapy is that it does not rely on cognitive or linguistic ability as its mechanism for therapeutic change, but on the felt experience of more adaptive Reciprocal Roles experienced in the therapeutic relationship.  In necessary circumstances, these new more helpful reciprocal role procedures can be offered to staff teams, which in turn would allow more learning opportunities for the client to make a recovery.  Therefore there is a fundamental link between the non-verbal and felt experience of relational CAT and an assessment tool such as the 6PSM.

Future research could replicate this study, but with a larger sample. Participants would need to be collected from various parts of the United Kingdom to make a representative sample, and a larger group of participants would be employed. Statistical analysis could be conducted to investigate whether the 6PSM was a strong enough tool to distinguish victims of bullying from non-victims. Another adaptation of this study could include asking a care manager, as well as a family member, to complete the post-questionnaire which distinguishes whether that person has been bullied or not, to ensure reliability.

Additionally, the drawings showed an unexpected finding that the participants who had a tendency to bully others drew better on their bullying story then their non-bullying story. Further investigations into this phenomenon could replicate this study using the 6PSM, but specifically focus on identifying bullies in the learning disabled, rather than the victims, which could prevent the source of the bullying.

Lastly, this tool has shown to be useful for those with limited language abilities, and who have had traumatic experiences. Therefore, research could investigate whether the 6PSM is capable of indicating children who are victims of sexual abuse in the non-disabled population.

Conclusion

This study explored whether the 6PSM is a valuable tool at indicating victims of bullying from non-victims. The findings overall were that victims of bullying performed worse on their bullying story in comparison with their non-bullying story, whereas victims described as bullies were the opposite, and performed better on their bullying story in comparison with their non-bullying story. Although the results were not significant and the hypothesis was rejected - qualitative analysis was valuable at exploring an individual's experiences and offering an insight into some of their cognitions.

The fact that the victims of bullying were worse at drawing bullying scenes compared to the non-victims, suggests that trauma is ever-present within that individual – and that this trauma impacted their ability to draw pictorially. Furthermore, those certain reciprocal roles that would be suspected in abuse cases, became apparent in the drawings, for example one victim drew a scene of being left alone without any support from staff members – rejecting to rejected. On the other hand, the participants who were seen as bullies drew better on their bullied stories. I wonder if this is because when they were drawing the bullied stories, they were more familiar with these reciprocal roles linked to bullying due to their direct relationship to these roles in real life, without the trauma that the victims would experience.

This tool has the potential to be used in care homes and in therapeutic settings as a screening tool. Future research with a larger, more representative sample would be useful to re-test the significance of the 6PSM in identifying victims. Further investigations could solely focus on whether the 6PSM is a valuable tool for indicating bullies in the learning disabled population and, potentially, child abuse victims in the non-disabled population.

Reflection post-study

Overall, I have really enjoyed carrying out this research. As it was my first time carrying out research with participants, it was exciting and unpredictable at the same time. However, initially I was nervous about how I would perform at carrying out the experiment in terms of not influencing the findings, as well as ensuring that the participants felt comfortable during the experiment, whilst being able to explain the instructions appropriately to each individual. Reflecting back on my experience, I would make changes for next time. This would include using a larger sample and also recording the sessions with the participants so that I could have included more description from each individual regarding their stories.

Acknowledgements

I would like to say thank you for all of the help I have been given during the completion of my project. Thank you to Julie Lloyd for giving me the inspiration to carry out this project. Thank you Becky House for your advice (and patience!) along the way. A big thank you to Jacque Harris, for reading through my project and applying your super editing skills. Also, a big thank you to all the participants who took part in this study.

Aiofe Pettit completed this piece of research as part of her B.Sc Hons in psychology whilst undertaking a placement year in a  NHS community learning disability team.

References

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Freilich, R., & Shechtman, Z. (2010). The contribution of art therapy to the social, emotional, and academic adjustment of children with learning disabilities. The Arts In Psychotherapy,  37(2), 97-105. Retrieved from http://www.sciencedirect.com/science/article/pii/S0197455610000201
Glew, G., Rivara, F., & Feudtner, C. (2000). Bullying: children hurting children. Pediatrics In Review / American Academy Of Pediatrics, 21(6), 183-189. Retrieved from http://pedsinreview.aappublications.org/content/21/6/183.full
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Lipsett, A. (2007, June 18). Eight of out 10 disabled children bullied, report finds. The Guardian. Retrieved from http://www.guardian.co.uk/education/2007/jun/18/schools.children
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Monks, C. P., & Smith, P. K. (2006). Definitions of Bullying: Age Differences in Understanding of the Term, and the Role of Experience. British Journal Of Developmental Psychology,  24(4), 801-821. Retrieved from http://ehis.ebscohost.com/eds/ail?vid=2&hid=101&sid=db848404-d9fa-4049-9da7632a69f0f5aa%40sessionmgr104&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#db=eric&AN=EJ941091
Orpinas, P., & Horne, A. (2006). Bullying prevention: creating a positive school climate and developing social competence. American Psychological Association: University of Michigan.
Psaila, C. & Crowley, V. (2005). Cognitive Analytic Therapy in People with Learning Disabilities: An Investigation into the common Reciprocal Roles found within this client group.  Mental Health and Learning Disabilities Research and Practice  2 pp 96-98.
Swindon, S. (2011, June 1). BBC Panorama care home investigation: four arrested. The Telegraph. Retrieved from http://www.telegraph.co.uk/health/8549228/BBC-Panorama-care-home-investigation-four-arrested.html
Taylor, C. (2008). Assessment of communication in people with learning disabilities. Advances In Mental Health And Intellectual Disabilities, 2(4), 15-20. Retrieved from: http://www.emeraldinsight.com/journals.htm?articleid=1927944&show=pd
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Full Reference

Pettit, A., 2012. Exploring whether the 6 Part Story Method is a valuable tool to identify victims of bullying in people with Down’s Syndrome. Reformulation, Winter, pp.28-34.

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