Lorna Gray, 2013. Disappointingly Different? Perhaps not.... Reformulation, Winter, p.21,22,23,24,25.
In this article I want to share my reflections of my experience working in an Adult Community Mental Health Team in the NHS. Specifically I would like to share my thoughts about how the struggle to experience and tolerate ‘disappointments’ seemed to be being enacted in the behaviours and responses of staff in the CMHT, resulting in what could be termed a pathological relational system.
I use the term disappointment as an overarching descriptor for experiences such as loss, pain, change, distress and illness to name but a few. Underpinning disappointment is, I believe, a more broadly running theme of ‘difference’ and the challenge of being able to tolerate the disappointment of the experience of being or feeling different.
Firstly, I will describe the system I was working in and what I did to try to make sense of it and my experiences within it through the process of reformulation. I will then describe some theoretical literature on individual and organisational ‘patterns of relating’, which helped me think about how such patterns are shaped and impacted upon by a range of individual, organisational and societal factors.
I will end by reflecting on how doing this impacted upon me as I attempted to negotiate and survive in as healthy a way as possible in my relationship with this system.
I was working as a clinical psychologist and CAT practitioner in an integrated CMHT for adults. The CMHT had been going through various restructures over a number of years, with staff being re-deployed into various ‘re-formed’ teams. Caseloads were in turn being repeatedly re-allocated based on these new structures, bringing abrupt endings to alliances and relationships with patients.
Local psychology resources had also been ‘re-deployed’ into these teams in line with New Ways of Working, raising issues for the CMHT about “what to do” with patients now they had “no psychology department to refer on to”. Challenges ensued in relation to how to manage demand and provision for psychological therapy with fewer resources per team.
At the organisational level, ongoing ‘change’ processes were being implemented around introducing ‘lean’ philosophies (NHS Institute for Innovation and Improvement, 2007), and nationally driven targets were frequently being communicated with teams being told to focus on “meeting the quality targets” for patient contacts, discharges from the service and so on. Significant changes were also happening with commissioning and referral criteria, assessment and allocation processes, all of which were proving to be a source of continual disagreement and confusion.
These changes evoked a wide range of responses. On a basic team level, there was a constant “confusion” about the structure, function and remit of the new team as a whole entity, as well as of the roles and responsibilities of the individual professions within it. From some there were expressions of “outrage” or overwhelming anxiety, from others there was a resigned acceptance with them stating “it’s just what happens”.
Staff could be observed being critically attacking of immediate management as well as “them up there” in more removed positions. They also directed criticisms within the team at individual colleagues or professional groups. Reflective practice and supervision were referred to as a “luxury” rather than a necessity for good practice and by most CMHT staff as something “I am just too busy to make time for”. Such messages also seemed to be implicitly communicated through the organisational systems with there being no way to record activities that were not direct patient contacts.
From a managerial perspective, there appeared to be the grouping of staff into those who were either; incompetent, under-performing/lazy, complaining/moaning and uncooperative, or helpful, hard-working, and dependable.
From my own position, I was aware of feeling on the receiving end of criticism, and of also becoming critically attacking myself of the system and colleagues. I could also experience feeling overwhelmed by a pressure to “do more”, or provide the answers and to be the one who would make it better somehow. However I felt that no matter what I did offer (more training, more supervision, more formulations), it was never enough! Or it was as if what I offered was forgotten, ignored or dismissed. I found myself mechanistically busily striving and unthinkingly getting on with things, reverting to a more avoidant covert rebellion, or exhaustedly giving up. I could also feel enviously attacked for the different position I held as a therapist in a team of care coordinators.
It thus became important (if not vital to my sanity!), to make sense of these experiences. CAT, with its “radically social understanding of the formation of mind”, provided me with a way to try and do this, and others, such as Walsh (1996), had already demonstrated the usefulness of CAT in making sense of a “dysfunctional and disharmonious” staff groups.
So i sat down and wrote my team (and myself)a Draft Reformulation Letter:
There have always been changes and challenges in working in a community team like this one. But recently, it seems to feel as though it is becoming all so much harder to cope with. There have been many changes of late, in lots of different areas; changes to teams, roles, responsibilities, even changes to what desk you sit at or what room you are in. With these changes it has felt that there are increasingly unrealistic expectations being placed upon you; demands for ‘better’ and a pressure to meet more targets, which seem to you to be solely financially driven. You have even said you feel increasingly expected to do therapeutic tasks you don’t feel you are trained for and that are ‘not in my job description’. And all of this with no sense of thanks, recognition or appreciation for your efforts and your struggle, or the things you do well. You describe more of a feeling of hopeless helplessness than even before. You also described feeling less and less supported by those around you and that there is an increasing culture of conflict, blaming and shaming. You have also been aware of feeling more resentful and critical yourself of various people in the team and management, finding it harder to see the value in those around you.
Perhaps we could sum this up as a target problem where there is a struggle to recognise and cope with the difficult feelings that are emerging in relation to changes and new ways of working.
A number of underlying procedures seem to relate to this problem. In order to cope and survive, you seem to have developed the tendency to go into and switch between a number of different places (which in CAT we might call self-states). These self-states seem to include: i) an Indispensible Omnipotent Place, ii) a Crap Useless Place, iii) an Uncaring ‘Automaton’ Place and iv) a Hell-pless Place.
Linked to these self states are a number of more specific procedures, including: i) ‘being seduced into thinking “I am the only one who can”; ii) having to try harder, do more, be even better’; iii) fobbing things off OR digging my heels in; iv) giving up Or keeping going, but mechanistically - as if with no emotions; or v) becoming aggrieved and attacking.
Sadly, no matter which of these procedures are used, it seems to always end up that nothing is ever enough and new demands arise. And you are left feeling unheard, inadequate, undervalued and overwhelmed.
I know these things can be hard to think about, particularly if you feel that to do so could result in others seeing you as ‘not on board’, ‘not a team player’, or a ‘moaner’. You might also feel that it could result in criticism and that it’s just better to keep doing things the way you always have. But I wonder, rather than keep cycling round these places which lead to stress and distress, that perhaps this is an opportunity to start thinking about what is really going on here, and whether there are things that can be done to move towards more compassionate and healthy patterns for the future.
It has been argued that the work setting provides “an arena for the playing out of sibling rivalry, oedipal conflict, dominance-submission issues, separation/individuation issues, need-to-control and being-controlled issues, sadomasochistic wishes, and for the attaining of narcissistic gratification and the sufferance of narcissistic injury”. (Levin, 1993)
Isabel Menzies-Lyth (1970) highlighted the presence of social, and one might add relational, systems that operate as defences against anxiety (or other difficult emotional responses). She described defensive practices including; splitting, depersonalisation, categorization and denial of the individual (person), and detachment and denial of feelings as just some of the systemic procedures that were frequently enacted within a nursing service.
Within the psyche of the workforce it is as if there has had to be the separation of personal emotional experiences from professional emotional experiences; with the personal having to be disavowed with only what is professional and sanitised allowed. It is clear that in the team described here, such processes were indeed being enacted. CAT, of course, would not term these defences as in classical psychoanalysis, but instead as “one aspect of limited role procedures, derived from the internalisation of...relationship patterns and self-organisation marked by disorganisation and discontinuities” (Ryle & Kerr, 2002, p. 96).
But what is it that leads to such limited role procedures and the resulting emotional restriction in the workplace? One explanation offered by Burke is that this results from the fear that the emotional characteristics of our social and familial relationships would contaminate and unduly influence the ‘rational work of work’ (Burke, 1986). Gerhardt takes this further and describes how industrialisation and the move towards a society more concerned with capitalism and individualism has developed the tendency (a necessary procedural response perhaps?) to ignore emotional needs, seen as a “hindrance to the practical drive to produce more and more” (Gerhardt, 2004, p. 6) (Gerhardt, 2010). In the book Why Love Matters she describes how such social and cultural influences, and their effect in turn on things such as parenting, can impact on the ability to manage emotional life through their effects on the development of the basic biological systems that manage emotions, such as neurotransmitters and neural pathways (Gerhardt, 2004).
In relating these ideas to CAT, Jellema has described how such early attachment experiences impact on the development of ‘core states’ and thus the origins of the “overtly expressed” reciprocal roles and procedural patterns (Jellema, 1999, 2000). Insecure dismissing attachment patterns consist of the subjective cutting off from or devaluing of attachment and relationships experiences, resulting in a think rather than feel relational style. In contrast, insecure preoccupied attachment patterns are characterised by the expression of intense emotions linked to difficult relationship experiences, resulting in a feel rather than think relational style. These attachment patterns were clearly evident in systems described here.
The experience of these relational styles can also be thought of as being partially dissociated. In terms of Ryle’s Multiple Self States Model (Ryle, 1997), and the procedural ‘levels’ we can see that there are disruptions and discontinuities at each of the three levels. At level 1 there are a limited and distorted number of organising relationships available to have with others and the self within what the system will allow. At level 2, the continual changes and reorganisation, along with uncertainty about ‘what might happen next’ within an environment experienced as attacking and unpredictable contributes to a care-giving system that is disrupted and inconsistent. Finally at level 3, there is the lack of value for and use of mechanisms for conscious self-reflection, along with a preoccupation with performance, appearance and external things (e.g. performance targets) rather than with subjective internal experiences.
Related to the impact of disruptions at these procedural levels, Skovholt and Rønnestad describe a model proposing how the absence of continuous reflective experiences and the perpetual fending off of the experience of anxiety arising from confrontation and challenges can lead to ‘pseudo development’ (Skovholt & Rønnestad, 1995). There may appear to be apparent development (of the self/team/service), but in actual fact there is a premature closure to development as behaviour becomes defensively motivated and predominately repetitive (Skovholt & Rønnestad, 1995). As I write about this, I find myself wondering that this could be used to make sense of the kind of ‘incompetent’, ‘uncompassionate’ and even abusive behaviours we are seeing happening in various healthcare settings and organisations?
So, did thinking about all this help me? I believe it did. This process helped me to start joining up with myself more and with the reality of this experience and how it felt. Through supervision, reading and writing this reflective piece, I slowed down enough to start connecting with my feelings about the situation. I could start to feel my grief and fear and sadness, rather than being aggrieved, mechanistically disconnected, or overwhelmed by emotions. And in feeling this I shifted into a more accepting and compassionate place both towards myself for my struggle and towards all other parties too. This in turn seemed to free me up to have a bit more space to respond thoughtfully and also in ways that felt more comfortable: I shifted from being caught up enacting the unhelpful patterns described above and became more able to just be there, to be still, and to think and feel – and then make a choice about what to do. I also found myself feeling more able to keep hold of what I could and was offering that was valuable.
I have come to wonder that, for me, this journey was about finding a middle position between either being: ‘totally different/specially different and admired’ (but where my only value is in my specialness) OR ‘totally the same, not distinctive, not admired (and not feeling of any value). The middle ground, for me, being: ‘healthily different, respectful and valuing, where boundaries, limits and difference are thoughtfully worked with – not unthinkingly attacked, ignored/denied or overridden.
Now, rather than feeling always so pulled out-of-shape by the demands of the Service and others, I am more able to preserve what I have since come to call my ‘healthy difference’ – my ‘me’ – where I can hold my CAT and clinical psychology focus, my boundaries, my capabilities and my limits. What you might also call my personal and professional integrity. In holding this position, I can feel more connected to my sense of ‘aliveness’ and purpose rather than feeling overwhelmingly engulfed by emotions or zombie-like and deadened. My value is, in fact, in my ‘healthy difference’.
Underpinning the issues I have described here is, I believe, the challenge of facing disappointment and difference – at an individual, organisational and societal level. And the challenge, at each of these levels. of the willingness and courage to turn towards these.
For instance, what would it mean to mental health services to be in touch with a disappointing reality that it cannot always fix distress or take away difference, pain and ‘mental illness’? How could a Service do this and find a way to ‘sell’ itself in the economic climate of commissioning of services and payment by results? In what has become termed the ‘helping professions’, allowing these feelings to exist and be felt would mean a move towards accepting (and helping others accept) the disappointing reality that illness, loss, pain, suffering – difference – cannot always be medicated or ‘therapised’ completely away. Are we really capable of doing this in the current climate we find ourselves within?
But then in not doing this, and continuing to perhaps behave in ways like the relational patterns described here, which ultimately lead to the denial of the ordinary normality of difference and disappointment and the constructive aspects of these, we repeatedly collude with the (unrealistic) message that there are parts of emotional experiences, life and living that are abnormal and avoidable when they are in fact not, but are important for growth and healthy emotional development. This is summed up eloquently in a quote from the book The Importance of Disappointment, by Ian Craib where he states;
“I might deny it first because I cannot stand the suffering of others, most probably because if I accept the suffering of others, then I would have to accept my own suffering; and secondly because I cannot tolerate the thought of my own ‘failure’, my inability to achieve what I set out to do, which is to alleviate suffering. If I cannot accept any of this, then I engage in the business of cutting out gingerbread men, trying to form people into a shape which would make me, the family, the GP and the rest of society happy."
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