Dr Angela Caradice, 2013. 'Five Session CAT' Consultancy: Using CAT to Guide Care Planning with People Diagnosed within Community Mental Health Teams: Brief Summary Report. Reformulation, Winter, p.15,16,17,18,19.
There are a number of clients that CMHTs struggle to help. This group often have a diagnosis of some kind of Personality Disorder. All workers can experience the client’s presentation as challenging and this sometimes results in unhelpful repeated patterns between clients and the services. Difficulties for this client group include abrupt state shifting, difficult/complex relationships with (often numerous) services and emotional dysregulation. Some people with these difficulties can present to services with a number of factors that mean it is hard to work helpfully with them such as, having unstable and chaotic lives, experiencing ongoing risks from others, and often cope by using a variety of harmful strategies such as, self harm and planning suicide. The group of clients who experience these difficulties are often assessed as not able to benefit from individual psychotherapy in the community. ‘Five Session CAT’ consultancy has been developed as a method to work jointly with mental health workers and their clients to develop an SDR to map the understanding of their current difficulties and patterns of coping, which is then used to guide care planning. This paper summarises the steps of ‘Five Session CAT’ consultancy and some of the skills involved. This is a summary of a more detailed paper by Carradice (2012) and permission was kindly given by John Wiley & Sons, Ltd (Copyright © 2012 John Wiley & Sons, Ltd) to reproduce this edited version of the original paper.
‘Five Session CAT’ consultancy was inspired by the Dunn and Parry (1997) paper which describes a service offered from an external Psychotherapy Department to clients of CMHTs in Hull. The approach involves four sessions with the client to develop a CAT reformulation that is then fed back to the client and later their care co-ordinator (Dent-Brown, 1999). The aim is for this understanding to help guide the care plan within the CMHT. The service was well received by teams and clients and has a number of positive advantages including the provision of help for clients who were usually not offered therapy, but who continued to present significant challenges to mental health teams. ‘Five Session CAT’ consultancy was developed in Sheffield CMHTs over the last ten years within the context of integrated team working (rather than a separate service) and has been evolving over time through its use by a number of CAT clinicians (each with their own style of working), across different settings and other geographical areas of the UK e.g. Teesside. This paper summarises the steps of ‘Five Session CAT’ consultancy and some of the skills involved.
‘Five Session CAT’ consultancy is an approach designed to be offered for referrals to help clients who seem unsuitable for individual psychotherapy (Kerr, 1999) or for whom if offered, poor outcomes would be predicted (Ryle & Golynkina, 2000). The service users often have some type of Personality Disorder diagnosis and because of the nature of the difficulties that they experience, mental health teams can understandably find it difficult to provide effective treatment approaches (Kerr, 1999). This can include abrupt state shifting (such as moving rapidly from an ‘overwhelmed child-like’ state to ‘adult rage’), powerful dynamics (e.g. pleas for help, then apparent rejection of help offered, or they elicit counter-attacks or rejection from the workers involved with them), difficult/complex relationships with (often numerous) services, emotional dysregulation and the potential for self abuse.
‘Five Session CAT’ has been developed by adapting therapeutic skills to work in a highly structured and containing way with the difficulties experienced by the client in order that the client has access to a therapeutic approach guided by a CAT formulated care plan. The kinds of difficulties they may experience which can make individual psychotherapy seem unsuitable for them include having few positive coping strategies; their patterns of coping are self destructive and increase risks, experiencing a high frequency of dissociative symptoms that limit the opportunities for revision of problematic procedures and a lack of higher order capacity for self reflection (Level Three in Ryle’s (1997a and b) Multiple Self States Model). The aims of the approach include to begin to support the development of each client’s capacity for self reflection, self control and to initiate working towards the integration of states (Beard et al., 1990). Additional aims include enabling effective ways for teams to work with the client, whilst ensuring that at the very least, the aim is they ‘do no harm’ (Dawson, 1988).
The ‘Five Session CAT’ consultancy approach is intended for use in a setting where the consultant is integrated within the team and it involves working together with the service user and the worker (such as, the care co-ordinator). The process involves developing a ‘here and now’ SDR (as deduced from the medical notes and the experiences in the present), which is sketched out and describes the core RRs (from early experience) and the unhelpful patterns of coping that were developed by the client. The map links the aims of the patterns to outcomes and indicates how problematic (unhelpful) procedures fail to achieve the intended aims (Ryle & Kerr, 2002a). The SDR may be an individual client’s map or a ‘contextual map’ (a map which includes service/team issues) (Kerr, 1999; Ryle & Kerr, 2002b). The aim is that by the end of the five sessions, this map helps inform care planning and case management (see Carradice (2012) for fuller description of this approach).
The approach depends on having an empathic alliance with the care co-ordinator (as well as the client) and working with the client’s risks, developing goals, agreed ways of working, plans for change and a contract with the service, including planned endings. The consultant typically works with the client and care co-ordinator together for five sessions, including time alone with the worker before and after sessions with the client, to enable them to work well using the agreed approaches. This additional time with the worker allows space for them to express their struggles, reactions and difficulties working with the client, to help them understand the process that they are part of and become involved in developing the reformulation. The benefits from experiential learning, teaching, and reflection with the worker include helping them to understand their own reactions to the client, try different ways of responding to the service user, helping them understand how to work with recognition and revision of the client’s unhelpful patterns and how to manage the case in a way that is intended to ‘do no harm’. The aim is for this experience to be empowering, supportive and containing for the care co-ordinator. Following on from these sessions, additional support or supervision is provided if appropriate and at the care co-ordinator’s request.
The approach involves a number of different tasks within the sessions which are highlighted in Table One and summarised in more detail below:
i. The 24 Hour Clock (Session 1 and 2)
The main task in the first session is called ‘the 24 Hour Clock’ exercise. This is a method of imagining the face of a clock to guide the questions to help develop an understanding of the client’s experiences and patterns of coping in the ‘here and now’. The task involves imagining a clock and choosing a time to start, then going around the clock and finding out about the client’s average day. The questions follow around the clock e.g. ‘tell me about night time, do you have a usual time to go to sleep? What happens next?’ The therapist listens to what the client says and looks for patterns, states, blank periods, and exceptions and the therapist responds with compassionate explanations and feedback the jointly developed understanding to the client. Service users describe this process as really ‘being heard’ by the therapist and the information gained is sufficient for the therapist to have a good idea about a draft map by the end of the process.
ii. The Psychotherapy File (Session 2 and 3)
The next stage which begins in session two involves the therapist and client going through the Psychotherapy File (PF) (Ryle, 1997a) together. This process gives opportunities to clarify aims, links and triggers, to build up clarity around the patterns/states. The therapist continues to reflect descriptions of the patterns back to the client to clarify their understanding and feedback compassionate ways to understand them.
iii. Getting Clear about Risks (Session 1-3)
The '24 Hour Clock' exercise and the PF are opportunities for developing understanding about risks. The therapist will gradually develop some hypotheses about different aims, triggers and functions of risk behaviour, but it is important to gather the client’s views of these where possible, so that a clear understanding can be gained together. Most service user’s maps will then include a number of different types of risks, with different aims or functions and varied intensity of risks.
|Session Screening||Explain the model and what it involves
Explain that by the end there aims to be a map to help understand the repeating patterns that the client experiences and have a plan for the care co-ordinator and client to take forward
Possible goals if the clients can identify any
Address expectations ensuring the focus is on realism and being clear about what can be achieved by the end and implications - patterns, map, ideas about what might help
Ending issues, deal with processes that arise
Answer questions and gain informed consent
Set the contract - number of sessions, the dates, what happens if someone is ill, DNA's
|1||Revisit issues above, ensure have informed consent
Looking for pattern/states using 24 hour clock exercise
Give a copy of the Psychotherapy File and explain it
|2||Complete 24 hour clock
Psychotherapy File, presentation in session and examples from daily life - Goals for care plan, thoughts about change and motivation
|3||Complete Psychotherapy File, ensure clear understanding of the risks
Revisit goals (if needed)
|4||Explain the concept of Reciprocal Roles (RR) and suggest their unhelpful ones from the material from the sessions
Draw draft SDR (may be contextual)
|5||Feedback on map
Work together on identifying/clarifying goals, steps of change, exit list and plan
iv. The Draft Diagram (SDR)
At the outset of the approach the therapist would have explained to the client that they will be developing a draft map based on what they have told them. The idea of the map is that it will help guide the development of the care plan and work towards change. The process of sharing the map with the client is different to how it would be done in therapy. In therapy, developing a map is ordinarily a joint mapping process, where a map is collaboratively developed together between the client and therapist. In ‘Five Session CAT’, the draft map is drawn by the therapist, for the client, based on the material from the earlier sessions (which is edited if there are inaccuracies identified by the client). The patterns for the map have been developed collaboratively with the client, but the map is a draft the therapist has constructed (maybe with the worker) outside the sessions. This method has been developed because this client group struggle with collaborative mapping as they can experience extreme anxiety (that they struggle to tolerate), which often leads to symptoms such as ‘state switching’ where they are unable to work collaboratively on the task. Clients describe difficulties during map drawing which include expecting the map to be a judgment of how ‘evil’ they are, or entering the state drawn as if ‘falling into the map’ and not being able to look down on it and discuss it, without becoming overwhelmed by the state or pattern.
This approach involves drawing the map rapidly with the client, whilst explaining the patterns/states compassionately and remaining closely attuned to the client’s experience in the room. This means that the therapist is moving between the task of drawing, to focussing on helping structure the session to help the client tolerate the process e.g. by grounding techniques, taking breaks, distracting the client and covering up sections of the map where necessary, to help the client stay in the ‘here and now’, whilst the process of drawing the map is completed. The RRs are drawn on the map as words deduced from material in the sessions, but the past is not talked about during the sessions.
v.Exits for the Care Plan (Session 5)
During session five the therapist aims to clarify the client’s goals and develop an understanding of exits to guide the ongoing care plan and therapeutic case management. This process is done as collaboratively as possible, whilst setting realistic expectations and where possible, a contract to work towards planned ending with services. The care plan will include a period of revisiting and becoming familiar with the map, working on recognition tasks and then areas for change. The plan will include areas that the service user has already considered or started (if applicable) and then work on areas they may not have considered. The plan may include agreements around managing risks and contact with services. Sometimes the plan will include preparation for psychotherapy, if this is considered a possibility for the service user and something they want to consider. The aim would be for the care co-ordinator to work through the steps with the client over the coming months following the final session.
vi.Working with Goals, Motivation and the Idea of Change
These tasks are threaded throughout the ‘Five Session CAT’ approach and are often difficult areas for the clients. For example, this client group often find it difficult to identify their goals, they often experience their mind ‘going blank’ when these issues are raised. If they do have ideas about goals, they are usually based on the ‘perfect fantasy’ of how they think things can be, whereas it is important to try to come up with something ‘real’ together if possible. The clients often find it difficult to imagine change, how to go about it, or that change can be possible. Understandably, they are usually frightened of change and the consequences of change (real or perceived). These issues are often linked to fears of abandonment, including fear of ending with services. It also raises issues related to the idea of giving up things that they ‘enjoy’, perceive that they experience benefits from, or patterns that have just been with them so long, they can’t imagine wanting to change them. The therapist using the ‘Five Session’ approach will explore these issues with the client, convey hope for their potential for change, and help them consider alternative ways of considering the issues. Motivation can also be low around change, but this can be understood together in relation to the map and how patterns can interfere with successful change. Experience shows that often service users experience an increase in motivation following the reformulation process.
‘Five Session CAT’ consultancy involves the same skills used in individual psychotherapy, but the emphasis is on using specific process skills more frequently and this makes the approach appear different to what generally happens in therapy. For example, in therapy, if the therapist is closely attuned to the client’s ZPD (Vygotsky, 1978; further described in Ryle and Kerr, 2002a) and the client is unable to tolerate intense emotions, then this would guide the extent that the therapist would stay with difficult emotions, so the client can develop their tolerance to work through emotions, in a more graded way. The ‘Five Session’ approach uses these skills frequently through the sessions, but because the client has a low threshold for what they can tolerate, the approach involves a greater level of explicitly structuring the process to avoid overwhelming the client and triggering reactions such as state shifting, than one would expect to use during psychotherapy.
moving between The Task (outlined in Table One) such as going through the PF, and developing and managing an Explicit Structure of the Process which involves responding appropriately to alliance ruptures, enactments, state switching and levels of emotional distress. The clients may have previously experienced contact with services as overwhelming and the aim of this approach is to provide a different experience in which the client experiences more containment, emotional regulation, and control, trying to help them stay relatively stable. The explicit structure includes all conversations relating to the ‘here and now’ and the therapist develops explicit agreements about how to actively structure and manage this with the client. The ways that the therapist supports the client during the process are explained and agreed at the start of the work together and each time the methods (e.g. grounding techniques or switching the subject to help the client feel safe enough to refocus) are used to help the service user develop their own understanding and sense of control. As in any CAT approach the therapist would respond to the client’s enactments and potential threats to the alliance (see Bennett et al., 2006). In ‘Five Session CAT’ these skills are important and actively used as early on as possible. For example, a client may become irritated with the therapist for stopping them and changing the subject. They may be enacting part of a reciprocal role. The therapist would address this straight away using descriptive and empathic responses. The core skills of the ‘Five Session’ CAT Consultancy approach are for the therapist to seamlessly (where possible) move between focussing on the content (the Task) and managing the Process in an explicitly structured way. See Carradice (2012) for a fuller description of the skills used to manage the process of the sessions.
Experience has shown that ‘Five Session CAT’ is well received by staff members within teams and subjective feedback questionnaires have reported care co-ordinators feel they gain understanding of the client’s presentation, clarity about how to help clients and that they feel more contained, have increased confidence, motivation and ability to engage with the client. They also report that they have more focus to their work and are able to apply the experience to other clients.
A single case evaluation by Styring (2010) involved interviews with a care co-ordinator and client in relation to their experience of ‘Five Session CAT’ (the interviews were tape recorded, transcribed and analysed). The study illustrated positive findings from the client and worker’s reported experience of the approach. A number of themes were described including how CAT tools helped the client, the importance of the ‘here and now’ focus, the internalisation of the map as providing alternatives, installation of hope, and raised awareness of exits. The client illustrated the internalisation of a more helpful reciprocal role, for example:
“I feel like a better person…I really do you know, at one time I would put myself down all the time…but now I feel like a better person altogether…”
More extensive evaluation is being carried out in Teesside by Freshwater and colleagues. However, evaluation of ‘Five Session CAT’ is in the early stages and more systematic research is needed. This could then help consider the effectiveness of the approach and potential drawbacks.
ii.Applications and Flexibility
There are a number of advantages for using the approach including that this is a way to use CAT with a group of service users who have traditionally been excluded from therapy or if offered, often experience little benefit (Kerr, 1999; Ryle & Golynkina, 2000). The approach can be applied to different settings where the therapist is integrated into the team (e.g. CMHTs, acute wards and crisis teams), timing is flexible (for example, at the beginning of care; when the worker and client are ‘stuck’ or experiencing crises; and to facilitate moving towards discharge from services) and styles of working within different contexts (e.g. prison service, physical health teams and inpatient forensic teams).
The approach can be applied to different areas of focus for example, to help a client become more motivated to work on reducing their use of alcohol or drugs, in preparation for medical treatments which affect mental health such as, treatment for Hepatitis C, and to help promote a client to work on changes to prepare for later therapy. The approach is particularly useful for service users who say they want to change, but are ambivalent about change, or it isn’t the right time for them and they are unlikely to benefit from therapy at the present time. The method can be varied for the client for example, extended for a diagnosis of Dissociative Identity Disorder, which typically involves 8-10 sessions, rather than five (due to the addition of the States Description Procedure (Bennett et al., 2005; Ryle, 2007)).
The contribution of everyone who has participated in ‘Five Session CAT’ consultancy over the years has been invaluable to the development of the approach. This includes the CAT clinicians (who have used the approach and then made it their own), and the mental health workers and service users who have embraced this way of working. We are grateful to those involved in evaluation studies as these also help the method evolve over time. I appreciate the encouragement and feedback from Dr Anthony Ryle. Thanks also go to Dr Dawn Bennett for her energy and support whilst co-training on the ‘Five Session CAT’ Skills training courses available through www.acat.me.uk
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