Jenny Marshall, Kate Freshwater and Steve Potter, 2013. Adaptions of a CAT skills course. Reformulation, Winter, p.6,7,8.
Courses in cognitive analytic therapy have been running for many years, including introductory levels, accredited skills courses and practitioner training. A skills certificate accredited by ACAT has become fairly well established (Freshwater and Kerr, 2006) involving teaching days offering a working introduction to the model, models of development and psychopathology and applications to different client groups, skill development in understanding and applying concepts such as reciprocal roles and reformulation. Alongside such teaching content, individuals undertaking the course also undertake a personal reformulation experience and supervised practice involving two formal CAT cases over a period of 6 months.
The introduction of a skills certificate within the forensic mental health service in Tees, Esk & Wear Valley NHS Trust was first identified as part of the development of an overarching relational approach based on CAT, following a tiered model. The tiered model aimed to provide staff with different levels of training ranging from a two day introduction, an accredited skills certificate, practitioner training and supervisor training (Marshall, Freshwater and Potter, in press). The model was specifically designed to allow the opportunity for professional and organisational development through the tiers of training. The aims of the two day introductory training were to provide all staff with a basic knowledge and understanding of the cognitive analytic approach which could be used to enhance relational awareness and be applied to developing greater insight and understanding to ward based interactions, day-to-day dynamics and critical incidents. A key concept within this model was based on Potter’s (2010) use of ‘mapping the moment’ which he describes as “an engaging and accessible way of teaching the relational imagination at the heart of CAT”. This drafting and sketching which takes places between staff has been considered to be about more than developing traditional CAT diagrams and having wider implications by way of “cultivating a therapeutic attitude”. Mapping the moment is simultaneously a way of developing listening skills, collaborative working and the process of perspective taking and reflective practice as well as reformulation. Despite the initial success of the two day training (participants felt they had found a common language and more insight into team dynamics with patients), there were some concerns about how to maintain the learning from this in a way which allowed staff to consolidate and continue to develop their skills following the training. One response to this was partly anticipated with the inclusion of reflective practice sessions as a follow up to the training. These were reflective meetings around a white board and involved building a more joined up map of the relationship between the moments with patients on the ward, their life history and current treatment dynamics. Whilst these reflective practice sessions recruited supporters for the model it was felt that more needed to be done to sustain a team of ward based champions and pioneers for this approach. It was decided to have the addition of a skills training for several staff from each of the three wards so far trained at introductory level. A specific aim of the accredited skills training was identified as an aid to embedding the relational model within the ward environment for use as reflective practice for frontline staff.
From the outset of planning, the delivery of an accredited skills course, posed numerous challenges. Given the aim of embedding the relational model and language within the nursing team and as part of the culture of treatment and care, recruitment of appropriate staff was crucial. The skills certificate in its traditional form requires individuals to already possess sufficient therapeutic knowledge and skills alongside a core professional qualification. However, a large proportion of the nursing team did not possess a professional qualification and those who did, may not have had the relevant therapeutic background to equip them for the supervised practice aspect of the skills certificate involved contracting with the patient as client and in the role of weekly psychotherapist. There was a philosophical debate relating to what constitutes therapy, and it can be argued that all nursing and care interventions could be considered therapeutic in the broadest sense, however for the purpose of the accredited skills certificate, it had to be acknowledged that there would be limited staff with sufficient therapeutic experience to be able to offer formal cognitive analytic therapy as an individual psychotherapy. In addition, although they would benefit from the relational competencies of CAT as traditionally conceived, the application of these skills in a contractual client therapist relationship rather than a nursing patient relationship did not appear the best or most appropriate application of such skills to this population of patients. Another significant consideration related to the role of staff without a professional qualification. These staff are often those spending the majority of time on the frontline with the most patient contact and therefore could be argued to be most in need and to benefit most from the development of additional helping, caring and therapeutic skills using a relational model such as CAT.
These challenges led to consideration of how to adapt the traditional skills certificate in order to make a psychological model, and more specifically, a relational model which was accessible to core, frontline staff.
A revised proposal for ACAT approval and accreditation was drawn up and submitted with some key changes from the traditional skills certificate. The overall focus of the course was to be the development of skills based upon the cognitive analytic model but with care and treatment by staff as the main focus and vehicle for change as opposed to direct therapy. Therefore although the CAT curriculum, the teaching methods, personal mini reformulation and completion of academic work remained the same as for a traditional skills course. Changes were made to the proposed nature of the work with the two supervised cases. In recognition of the aims of the skills certificate within the context of ward-based relational training and the overarching model being introduced, the focus of the two cases was designed to use and demonstrate CAT concepts such as reciprocal roles, procedural sequences and the development of sequential diagrammatic reformulation through indirect working instead of through formal cognitive analytic therapy cases. This drew a clear distinction between “using” CAT and “doing” CAT, with the focus being on “using CAT”. As such an adapted model was developed as outlined below. The model has five overlapping stages with a focus on the treatment and care of a particular patient during his or her stay on the ward.
Stage 1: With the aim of embedding reflective practice within the staff team, those on the training course would draw out multiple ‘maps of the moment’ with a colleague on shift based on a brief incident or interaction which had occurred. The focus here would be on careful accurate description of patterns of interaction, and on using staff feelings and countertransference responses as a key part of the information gathering process.
Stage 2: Once multiple maps of the moment had been developed, staff would then draw these together into an overarching map reflecting key themes, reciprocal roles and procedures. Particular attention would be placed on identifying times when staff identified or took on a particular reciprocal role procedure and highlighting the potential problems or consequences of this.
Stage 3: Attention would be given to the patient’s life history (from various sources) and treatment history and understanding developed of the origins of reciprocal roles and development of problematic procedures. This may also involve reflection on the history of the ward/team and incorporation of this into the diagram.
Stage 4: A reformulation (both prose and diagrammatic) would be drafted from the information gathered above. Key areas for staff recognition and revision would be developed from the understanding of problematic procedures and in particular staff care and management, which may be identified as inadvertently making the problems worse or progress more difficult.
Stage 5: The above stages would be summarised in both written and diagrammatic form and shared with the wider staff team and MDT. Revisions would be made and areas for intervention developed into relationally informed care plans.
Stage 6: Progress through direct and indirect interactions with the patient would be monitored in line with the reformulation.
Stage 6: Progress through direct and indirect interactions with the patient would be monitored in line with the reformulation.
There will be some to and fro between the stages of this model as there would be in individual therapy done along traditional CAT lines. Whilst the patient is not directly recruited to the role of client and explicit therapeutic work done, the patient is being engaged in more informed and more relationally aware treatment and care. The same Vygotskian concept which stands at the core of CAT’s approach holds true in this indirect work in that what the patient can do with enhanced care and treatment today they may more easily do for themselves tomorrow. stands at the core of CAT’s approach holds true in this indirect work in that what the patient can do with enhanced care and treatment today they may more easily do for themselves tomorrow.
Case 1: The Ward Level
Adaptations of the model were used to consider dynamics of the ward; current problematic procedures were identified whereby staff tended to take up polarised ways of managing the complex patients on the ward; a “controlling/security guard” role or a “pacifier role” with some middle ground of staff being able to take up a “negotiating” role. These roles were similar to those identified by Hamilton (2010) as being represented by staff with a high secure service. Consideration of the ward’s history led to an appreciation of the dreaded place which often reflected some variation on a dangerous or chaotic environment and an acknowledgement of past trauma experienced by the ward in relation to patient violence and suicide. The staff team coped with their fear of the dreaded place by often trying to achieve ultimate control, which could lead to further problems with rebellion or passive acceptance. Starting to recognise these roles along with their origins allowed the team to consider how they might start to change them and how the team would like to develop more collaborative ways of working and engaging with often difficult to reach patients (McCauley, in press).
Case 2: The Patient Level
One example of using this model with a specific patient involved a woman who had a long history of service involvement and problems with engagement, particularly transition and moving on. There was a sense of staff having given up hope of any change. Careful and accurate description of the interactions with staff identified that, although staff felt that they were being consistent in their approach with this individual, subtle differences could be identified. The patient was described as particularly needy and dependent on staff and staff were able to, with support, identify that some would respond to this by being very over-involved, “doing for her”, whilst others would respond by withdrawing and expecting her to manage by herself “do it yourself”. A third position was identified “doing with her” and the staff member sensitively developed guidance for care plans encouraging staff to take this approach. Exploration of the patient’s history indicated common themes relating to the origins of these difficulties; an over-involved mother coupled with difficult and traumatic experiences when without the support of others. The development of cognitive analytic care plans allowed for progress to be made both in relation to community leave but also the successful transition to a less intensively supported ward (Gilchrist, in press).
This skills course has proposed an alternative model for training using Cognitive Analytic principles for purposes other than psychotherapy in order to develop relational awareness and understanding to inform care and treatment in a ward setting. The particular value of this model has been in adapting the treatment model for those individuals whose presentation may be too complex to be able to access a more formal psychotherapy. It offers therapeutically and relationally enhanced treatment and care. The skills of working with CAT in this way are just as complex and personally involving as doing therapy. It brings job enrichment and appropriately therapeutic ways of working to the everyday life of working on the ward. It is important to acknowledge that formal therapy may only form one part of an individual’s treatment journey as an inpatient and that therapy in the broadest sense is ongoing 24 hours a day, but often being provided by frontline staff who may have little understanding or training in psychological or relational ways of understanding. The adaptations of this model were aimed at providing a training which brought relational thinking to a staff team in an accessible way in particular acknowledging the idea of shared responsibility, the complexities of the helping relationship whereby it is easy to become entangled in particular ways of helping, and encouraging staff to be able to stand back and identify the impact of their role, the patient and the system around them (Potter, in press)
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