Collins, J., 2010. The Development of a 12-Session CAT Therapy for Use in a Workplace Setting. Reformulation, Summer, pp.13-16.
Many organisations now provide counselling for their employees. This may be in-house in a Counselling Service or be provided through an Employee Assistance programme. Such counselling has a very wide scope, akin to a general practitioner for mental health, and deals with a full range of emotional and psychological difficulties of staff, as well as issues particular to the context of such a counselling service: stress, bullying, interpersonal difficulties with colleagues, lack of motivation. These are all ‘personal’ difficulties but also profoundly affect someone’s functioning as an employee.
I work in the Staff Counselling Service of a large university, which offers time-limited counselling, available free of charge to all staff, for work or personal difficulties. Most of our clients self-refer, sometimes at the suggestion of the Human Resources department, Occupational Health, their manager or colleague, or their G.P., but rarely through a formal referral route. We see the whole range of staff who work here: academic, researchers, administrative and technical support staff, and manual staff, both men and women, with an age range of 18-65. Sometimes the clients we see are on sick leave, but usually they are still at work, albeit in a distressed and troubled state. We work with a wide range of presenting difficulties and client needs. Sometimes these are directly based in the work context, such as stress, bullying, workload, redundancy, but they can also be personal difficulties which are affecting their ability to work effectively: relationship difficulties and marital breakdown, anxiety and depression, often severe, eating disorders, self-harm, borderline personality disorders, family difficulties including eldercare and child protection issues, anger management, sleep disorders, bereavement. We are a team of one full-time counsellor/manager and three half-time staff, available to 9000 employees. We have a variety of approaches within our team: psychodynamic, person-centered, Cognitive Behavioural Therapy [CBT], and Cognitive Analytic Therapy [CAT].
Any workplace counselling service has to find a way to work in an effective therapeutic way with limited resources, which inevitably means in a time-limited way.
Cognitive Analytic Therapy has evolved as a brief, focal therapy, usually based on a model of 16 sessions. It is an intervention which can be useful to a very broad range of people suffering mental health problems and is informed by both cognitive therapy and psychodynamic psychotherapy. Dr. Anthony Ryle, originally a G.P., was aware of the high proportion of his patients who were suffering some type of emotional problem and of ‘the high prevalence, persistence and personal cost of common neuroses, and of how they were inseparably bound up with the social context and problems of living for my patients, and with their family structure and personal relationships’ . Access to psychotherapy on the NHS was then, as now, limited, with long waiting periods, so was not available to many of the patients he would see in general practice, who, whilst not having acute psychological problems, had lives and health compromised by the emotional difficulties which they experienced. He saw a need for a therapy which was manageable in the NHS, but above all would be effective with the patients seen.
After I had completed my CAT Practitioner training I began to think about how I could offer CAT more widely within the constraints of our resources, as the usual 16 session + follow-up structure, with an assessment session as well, was almost doubling what we can offer if our waiting time was not to become unmanageable. A briefer model of CAT has been thought about. In his first book Ryle refers to a ‘satisfactory 12-16 session therapy’ and in later writing says ‘The time limit is usually of 16 sessions but this can be extended in treating more disturbed and damaged patients or shortened where the threshold to consultation is low and mildly disturbed patients are seen’, which applies to most of our clients who self-refer and are functioning in their lives. A requirement of my training was to offer an 8 session CAT, but there was little guidance or information available about what form it should take or how the standard 16 session model could be adapted for use in 8 sessions - what should be left out? The 8 session model was originally developed for use in an NHS setting where patients often come to therapy with quite a lot of information already known about them from the assessment and referral process, rather than the self referrals in our service, thereby allowing for less information to be gathered during the initial phase of therapy.
I wanted to continue to offer CAT, and thought it an excellent therapy for the setting I work in, but I had to find a way to offer it in fewer sessions. As everywhere else, there is a greater demand on the Service than we have therapist time available, so we usually work within 8-12 sessions, our average session time being 7.5 per client. I started working with an 8 session therapy, as suggested by the course, encouraged by Jackie Baker’s research on using 8 session CAT- informed work in a G.P. surgery, which found an improvement measured by CORE in this time frame. However, I found 8 sessions too rushed and cramped, with not enough time to develop and introduce the various CAT tools – the two letters, the Psychotherapy file, the SDR, the Rating sheets. To me, it felt too mechanistic and as if I was losing the therapeutic essence of CAT. So I settled on 12, being the other end of what was possible in my service.
But time was not the only criteria; there were other reasons why a brief CAT would be helpful for this client group; we see the ‘walking wounded’, exactly the group who Ryle originally developed CAT for. The CAT emphasis on client participation, self-monitoring and self-help is very relevant to this population of clients of university staff. They are usually coming at some point in their working day, [and we offer some appointments after work until 7.30pm], and are mindful of not making a commitment for too long a period, so a time-limited contract suits them, as they are busy people working in a demanding and pressurised environment. They are, on the whole, very motivated to engage in counselling. They have sought out the information about the Service, usually from the website, and have maybe thought about coming for some time before they make the decision. They might have been strongly encouraged to come by a colleague who has had a positive experience of using the service. They have completed a Pre-counselling form to register, and possibly waited on average 6-8 weeks to begin therapy. As a population who work here in the university, they are self-directed people, perhaps more than average. They are often fresh to therapy, with no previous engagement with NHS Mental Health Services or counselling, either in another agency or privately. The provision of this Service by their employer provides an endorsement of coming, and the familiar setting of work reduces the stigma of seeking help, and the environment of the workplace here is broadly a facilitating and containing one.
Clients often come requesting a structure to the work, being more familiar with the format of teaching plans, deadlines and work routine, and expect us to provide this as a way to analyse their difficulty. CAT provides this, but more importantly, also offers a way to begin to think about underlying relational difficulties. When they come, some of our clients need to learn to feel; others to think; for all of them CAT offers a way to understand the relationship between their early experience, their present difficulties, and their understanding of how they relate to other people. As the CAT saying goes, ‘From an eye, an I can grow’. Clients come to see the impact of their beliefs, attitudes and behaviours on their daily lives, relationships and approach to work in a different way. The work starts with the presenting issue which the client has come to get help; from this central focus a CAT approach helps us identify the repeating patterns of the underlying historic Reciprocal Role Procedures, which, of course, are also played out in the enactments and counter transference in the sessions. As therapist, I use my own emotional response as a barometer to what is going on for the client. Hopefully, by the end of the sessions, the client has found a response to the issue they came with, but has also gained an understanding of themselves.
Our clients come to us with no therapeutic history; we rarely have referral letters from doctors or mental health practitioners; there is no medical file, or assessment record from another therapist, so we are starting with a clean slate. At our first meeting we usually have no knowledge about this client from other sources. What we have is a Pre-counselling form which the client has completed and returned to us, to be registered on our waiting list. Part A of this form collects basic contact and statistical information for our database, and the client completes a chart of their availability to attend appointments, and whether they need to be seen in our ground floor accessible room. They also sign an agreement for this sensitive personal information to be collected.
Part B then invites the client to write as much or as little as they want to about their difficulty and why they are seeking help now. Some people write just one word in each section, and others write at some length with additional pages. Question 1 is ‘The problem as you see it’, with prompts asking them to describe the problem, why they are seeking help now, and how it has affected their health, both physical and emotional. Question 2, entitled ‘Background’, asks for any ideas which they might have about the origins of the problem or events in their life which may have contributed to it. The third question asks how they are coping, how the difficulty affects them in their daily lives, what support/social relationships they might have, about use of alcohol/drugs/food, and whether they ever feel like harming themselves. The last question asks what previous help they might have had with this problem, if any, and what they would like counselling to do for them now.
By completing this form, the collaboration of the client in their therapy has already begun before they attend, and most report in our evaluation questionnaire that completing the form has been therapeutic in itself, that it has been difficult but thought provoking, and even cathartic. If, for any reason, someone is unable to complete the form - unwilling to put personal information to paper, difficulty with literacy - or it would be inappropriate for them to do so - too distressed, coming following a sudden crisis - we offer a Pre-counselling session instead, when we assess the client, collect the necessary contact information, and then register them on the waiting list.
In supervision I considered how to structure the 12 sessions I had available to work with. I wanted to extend therapy over as long a period as possible to allow enough time for reflection and change, but also wanted a concentrated period at the start of the therapy to enable a good working therapeutic relationship to be established and for the client to become actively engaged in the task of Reformulation. This led me to consider spacing some sessions at longer than weekly intervals. I considered which CAT tools could be used and how, and especially, how the time-intensive but therapeutically essential letters could be adapted to working with fewer than 16 sessions.
The structure I decided on for 12 sessions is to have 6 weekly sessions, and the remainder at fortnightly intervals, with a 3 month follow-up. This is the plan for the 12 sessions but inevitably it gets varied by holidays, work commitments, illness etc, just like any other therapeutic encounter does. But this is the plan, and for the most part it does actually go along these lines. The 6 weekly sessions are the Reformulation phase, where the usual tasks are done and usual tools used: a history is taken, a Psychotherapy File completed, a diary is kept, Target Problems [TPs] and Target Problem Procedures [TPPs] formulated. A Reformulation letter is written for session 4 or 5, and an SDR which has been developing, is finalised enough to be a working tool by the end of session 6.
The next block of sessions are spaced fortnightly to allow more time for the client to develop an understanding of their difficulties by recognising the TPPs and beginning to revise them. A diary is kept during this period and provides a focus for the work in each session, and a Rating sheet for each TP is completed at each session. Rating sheets are the part of CAT which I have always struggled with, and I don’t think I am alone with this. I have no difficulty with the other CAT tools which I feel very at ease with, but coming from a psychodynamic background, I have always felt uneasy when using the Rating Scales, whilst appreciating their value in recording change, and observing how clients find it useful to see their progress marked. I now use an adaptation, which has columns for sessions 6-12 and Follow-up, rather than the standard one with spaces for sessions 4 -16 and Follow-up, as the unused columns for the ‘missing’ sessions seemed to indicate what was being offered was a lesser version of a ‘real’ therapy. I have also found clients sometimes find the terms ‘Recognising and Revising’ and ‘Stopping’ a bit confusing, so I have renamed them ‘Noticing’ and ‘Changing’, and find this easier to work with.
As part of the process of writing this paper, Anthony Ryle offered to read it, and suggested that in this particular setting it might be useful to develop a Personal Questionnaire to use with clients, rather than working with TPs and TPPs. This could have questions such as ‘One of the main difficulties/symptoms which brought me to counselling is...’ and ‘I would hope to change this in therapy by...’. This could be formulated around session 4, around the time of the letter if there was one, and changes rated thereafter. I find this a very interesting suggestion and will develop it for use. It is more direct and less cumbersome, and could integrate the rating process more smoothly into the structure of the therapy.
My original plan was that the two final sessions would be weekly, with the Goodbye letter in the penultimate session, as is often the way in a 16 session therapy, but I have revised this as I have gone along. It often felt that session 11 came too soon in the therapy to review, and a couple of cases where unplanned events meant the final session was later, showed me that having the Goodbye letter in the final session worked well, and provided more time in the already time pressed therapy for reflection. So now, in session 11, I have a discussion with the client which reviews our work and what the ending means, evaluating change and identifying areas for further work, in a sense verbally covering the tasks of the therapist’s Goodbye letter. I invite the client to write the Goodbye letter, balancing the Reformulation letter I have written earlier, and all clients so far have done this with much willingness and thought if some trepidation, and usually writing a letter which mirrors the one at the beginning of the therapy. I now also call this a Review letter, rather than a Goodbye letter, which always felt a bit contradictory when we would then meet for a final session the next week, and a follow-up session a few months later. I do not write one myself, because of time pressure. With a usual caseload of 18 clients, as well as managing the Service and Team, I would not be able to use CAT if I had to write 2 letters for each client. I also felt 2 letters from me in a brief therapy might feel a bit unbalanced. I aim to provide my input into the review in the discussion we have in the penultimate session.
The follow-up session has been very important in the sequence of sessions, providing a containment once therapy has stopped. I have been encouraged that at follow-up revision of procedures has been maintained, and often has continued to improve, and, in only one case, has it been necessary to offer further work, which was a case of a young woman who in her teens had been successfully treated for severe anorexia, but was now, ten years later, experiencing work stress from her self-critical and perfectionist approach to all she did. A few clients had felt they wanted more sessions during the therapy, itself often an enactment of a procedure, but a frequent response is surprise at what is appreciated as a generous allocation by their employer, compared to the 6 sessions usually available in their G.P. surgery, or having to fund private therapy themselves.
Recent financial constraints in the university and one of the team leaving and not being immediately replaced meant we developed a lengthy, for us, waiting list of two to three months. In some settings, this might be regarded as good, but in ours, expectations from clients and management are that we should and will respond quickly when work is being affected. In response to this I began to work with 4 sessions with a diagram, and two monthly follow-ups. This was helpful to the clients, but really did not feel adequate, as there was not enough time to monitor and revise a client’s difficulties. I’m now trying it with 4 follow-ups at fortnightly intervals, but I do feel something is lost from the therapy without the Reformulation letter. It is interesting that Ryle, writing about CAT in Primary care and the effectiveness of CAT with frequent attender patients, comments that 6 sessions were not sufficient to effect change. ‘This suggests that a full course of CAT may be necessary to achieve clinically significant and lasting results in many patients….raises important questions about the widespread practice…of restricting therapists or counsellors to delivering such a limited number of sessions only’.
The issues in this paper highlight the tension between being both a therapist and the manager of a service with a provider to answer to in a increasingly tight financial climate, which I know all services are grappling with: how to offer a genuinely useful therapeutic experience and encounter to clients, which is ethically sound, within the resources available, and which satisfies the motivation of the employers in providing such a service and funding it. I think a 12 session CAT provides a therapeutically useful and manageable way to help staff with personal difficulties affected by their work or affecting their work.
Jill Collins is a BACP Senior Accredited Counsellor, and an Accredited Cognitive Analytic Practitioner. She has a background in Education, beginning her career as a secondary school teacher, and whilst raising her children gained experience in a variety of ways: teaching adults in community settings; training and then running classes with the National Childbirth Trust as an ante-natal teacher; working as a youth worker with pregnant schoolgirls. After studying for a Masters degree in Human Relations she trained with Relate, and worked with them for a number of years. She began full-time work as a counsellor in 1993, working with students and staff in a large further education college, and also worked in an NHS Psychotherapy Service. In 2000 she moved to the University of Cambridge to develop a counselling service for its 9000 staff, offering individual and couple counselling, where she now manages a small team of 3 counsellors.
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