Cognitive Analytic Therapy (CAT) and (Open) Groups with Adolescents within an Inpatient Psychiatric Setting: Initial Thoughts and Experiences

John Mulhall, 2013. Cognitive Analytic Therapy (CAT) and (Open) Groups with Adolescents within an Inpatient Psychiatric Setting: Initial Thoughts and Experiences. Reformulation, Winter, p.37,38,39.


Context

I took up an opportunity to work as a CAT Therapist in a brand new 25 bedded NHS child and adolescent mental health service (CAMHS) unit.

Patients and Service structure.

Patients are typically 12-17 years of age. Some are planned admissions, others are young people who have been involved with the CAMHS crisis team. The usual gateway to this team is the accident and emergency department. Some typical presenting issues are; low mood, self-harm, suicidal ideation, overdosing, anxiety, and eating disorders. At any one point in time approximately 50 % of these young people may have been sectioned under the Mental Health Act 1983. The average length of stay is usually between 6 and 12 weeks, but there are an increasing number who stay between 6 and 12 months. The focus of the unit is rapid stabilisation of the patients' symptoms and situation.

Groups

Group work is usually a significant therapeutic component of inpatient psychiatric settings. Carrell (2000) acknowledges groups to be part of a "balanced therapeutic diet". I have long held a view that CAT could be a good framework for group work and have attended several informative and inspiring group workshops at ACAT conferences (e.g. Boyd and Pennycook, 2012; Carson and Potter, 2010) . With this in mind I set up an Open CAT informed group as part of the unit's therapeutic programme.

Approach to setting up the group

I started by reading a classic group work text (Yalom, 1985) and papers that exist in CAT literature on groups (Anderson, 2009; Duignan and Mitzman, 1994; Hepple, 2012; John and Darongkamas, 2009; Maple and Simpson, 1995; Mitzman and Duignan, 1993; Ruppert et al. 2008; Stowell-Smith, 2001). Nothing existed on open CAT groups, or CAT groups with adolescents. This reading gave me helpful ideas. I was also coming to learn that many of the young people were harder to engage than I had imagined. They had huge fears and ambivalence about being in the unit, being in groups, and indeed thinking about their difficult situations and struggles.

Initial observations and challenges

Group membership was continually changing for many reasons; admissions, discharges, refusals, and patients' attendance to other activities. In addition, there were so many potential reciprocal roles (RRs) that individual patients could get hooked into (negative or damaging role enactments) over which the facilitator had little control. Promoting safety within the group would be a major consideration. This was highlighted in some of the early patient feedback. For example, if a patient started to talk quite personally within a group and we followed where this was going, I learnt that they risked being called a "suck up" by fellow patients outside of the group, (which I began to see as a reciprocal role aligned to defiant resistance in response to the dynamics of control).

The need to protect patients from over-exposure (disclosure) whilst encouraging them to be involved became apparent. I started by mapping the situation out as I experienced it and encouraged attendees to offer views, so as to co-create a group SDR, see figure 1. The empty boxes are for collaboratively developed exits. Some attendees seemed to understand the SDR and for others it appeared to make less sense. However, it influenced my thoughts as to how a consistent structure for the group might become established.

Perhaps the most significant variables that I became aware of were patient situation dynamics and their relationship to the unit. Understandably there is a controlling component to the unit's functioning. This can then evoke a controlled role in the patient, and quite often a defiant or rebellious response to the control. On some level I was surprised to see how difficult collaboration could be to achieve, and how guarded and mistrustful many of the young people were. Although on one hand they were aware that the unit was trying to help them, they also knew that the relationships that they establish would be short lived. Prominent RRs are variations on rejecting to rejected, dismissing to dismissed, abandoning to abandoned, uncertain to unsure.

For many of the patients, there can be a deep sense of hopelessness about the prospect of things improving. Thinking about change and the future can be extremely difficult and motivation for change can fluctuate significantly.

Findings and observations

The group is now into its second year with over 40 sessions having taken place. 68 patients have attended and have had exposure to CAT ideas. The largest group contained 16 patients and the lowest number was 2. Patient feedback has been central to developing an encouraging and collaborative structure for the ongoing group, attempting to address; safety, fun, psycho-education, mental health and relational awareness, positivity and change.

A wide range of activities and modes of interaction are utilised. Group safety is continually held in mind by doing some of the more challenging relational explorations in the third person perspective. Patients are given the opportunity to put forward points and experiences via 'post its' which are read out to the whole group anonymously and explored without as much personal exposure. Sessions usually run in the following format;

The membership of the group is constantly changing. Therefore each group is approached as a standalone session. In a residential setting the choice of room and how patients get to it can be very important. I try not to use the room where their CPA Reviews are held as it can hold difficult memories. Preferably it needs I.T. facilities and to be set out in an inviting and encouraging way (avoiding corners and hiding places) (though they usually find them anyway). Things seem to work better when the ward staff take responsibility for preparing people to attend the group and deal with ambivalence and protestations because occupying this dual role can lead to additional difficulties within the session (It can set up a controlling to defiant RR which cuts across the collaborative aim of the group).

Perhaps the most challenging aspects of the whole group experience is the patient dynamic. Many young people are not sure how they feel about survival and negotiating the immediate future. They are often "stuck" with ( themselves, others or familial factors. They may also have had previous negative experiences of therapy. On top of this, the ward dynamic can often take over and become the focus of their relational efforts. In these conditions it can be hard to achieve collaboration in the usual CAT sense. Within an inpatient setting the group session is happening in "their" home, and they are required to attend. Thus, it is not the more usual position of patients making a personal journey and effort to see their therapist, or directly contracting for what is being offered.

Success of the group can feel quite arbitrary. The same session has been rated both 0 and 10 out of 10 by different attendees. The ZPD (Vygotsky, 1978) of the group changes from week to week and within sessions. The mood and states of individuals, and the group, are continually affected by happenings on the unit. What may have been successful one week can fail the next. Even those patients who work well with CAT on an individual basis can be disruptive in the group. They might fear being viewed negatively by their peers if they contribute well. Also, a person's seeming disinterest can be misleading. On many occasions those who look as though they have been disinterested surprise me with demonstrations of what they actually took in, at a later time.

I have wondered whether this dynamic could be viewed as perhaps a competition dilemma? "do I trust the adults here and risk being let down or ridiculed by my "mates", or, " do I go with the solidarity/resistances/rebellion of my "mates", in defiance of these controlling-useless-arbitrary parent figures, but risk their retaliation, or, even the sliver of hope I have that they can/can't hold for me?

I make a conscious effort to ask everyone their opinion, even if they appear detached or distracted. I am often surprised by what is said and it also gives patients the message that their views are equally valued.

Conslusions and thoughts for the future

I feel that the group has made a positive contribution towards giving the young people the message that we are interested in their relational and procedural struggles, and that there are theories and tools to help this be explored.

It has been difficult to design a rolling format of repeating main activities and relational topics because I try to tailor what we do to the mid ZPD of the group, which is subject to continual change. I would like to try and align the group trajectory to follow the recognised stages of the CAT model more closely. It may be more possible now that my confidence, experience and CAT group facilitation ZPD is growing and extending.

At various times, limiting the places in the group has felt like an attractive proposition, as on the whole the smaller groups seem to run better. However, I always come back to the thought that all of the young people who come through the service are contemplating change on some level (Prochaska and DiClemente, 1992). Keeping the group open gives more opportunity for more patients to have more exposure to the possibility of things being different.

There does seem to be a place for both an open and closed (fixed membership and duration) CAT informed groups within an adolescent inpatient setting. A closed group is now in existence and most patients will have the opportunity to attend.

"CAT group" has been spoken about affectionately and was mentioned positively by patients at a recent QNIC (Quality network for inpatient CAMHS) inspection.

The group gives a platform to float potentially helpful CAT ideas to a fairly large number of patients and staff. It also gives them an opportunity to experience a potentially positive, context responsive, relational experience with a number of their peers, with some safety measures.

Patient Feedback

Specific feedback sessions with the young people suggests that they want a better understanding of their; thoughts, patterns, relationships, behaviour, coping strategies- all balanced with a bit of fun. Their fears seem understandable, i.e. judgements, confidentiality, disruptive behaviour of others, others not participating, feelings of awkwardness, potentially opening a can of worms.

Each session, attendees are asked to rate the group out of ten, and to say; 1) why?, 2) what was helpful?, 3) what they might take away?

Examples of these routinely collected data are;

1) "I could relate to the topic, which was both difficult and interesting."

"I found it depressing, but in the long run it could be helpful."

"It hurt my head, sad subject matter."

"It was ok, but a bit boring and pointless (sorry I'm learning to tell the truth)."

2) [Risk SDR session] "The plan of why people may be acting the way they are in groups-I thought it was interesting to see why people don't take risks in groups and take the routes they take."

"How to help people feel safe and how to feel safe around others."

"Talking about cycles and ways of breaking them."

"I could, but no!

3) "I don't know, not sure, probably not."

"No, because I'm stubborn."

"Change is scary."

"To think about what is important in life to me."

Conclusion

CAT can be a helpful model to inform group work to both encourage and help young people recognise that perhaps their relational ways, thinking and fears can get in the way of making headway with immediate and long standing struggles.

Acknowledgements

There are many people who have contributed richly to the development of these CAT group ideas. Thanks to all the young people who have been willing to consider the ideas and offer their feedback. Thanks also go to Françoise Hentges and Cat Fagan for their willingness and capacity to help turn relational ideas into CAT informed group session material.

Full Reference

John Mulhall, 2013. Cognitive Analytic Therapy (CAT) and (Open) Groups with Adolescents within an Inpatient Psychiatric Setting: Initial Thoughts and Experiences. Reformulation, Winter, p.37,38,39.

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