Calvert, P., 2014. Applying CAT in an Acquired Brain Injury Neuropsychology service: Challenges and Reflections. Reformulation, Summer, pp.16-21.
The possibility and efficacy of psychological therapy with people after an acquired brain injury (ABI) has long been debated (Weatherhead, et al. 2013). There is currently a lack of what is considered Level I evidence (NICE, 2004), that is randomised controlled trials, meta-analyses and systematic reviews, that demonstrate this population can benefit from psychological approaches. However, there is a growing body of evidence to support the effectiveness of psychological approaches based on case studies and qualitative research (Weatherhead, et al. 2013). This, along with an ever growing literature of practice-based evidence, has continued to provide support for the need to consider the provision of psychological therapy as part of the neurorehabilitation approach. National guidelines, such as the National Clinical Guidelines on Rehabilitation Following Brain Injury (British Society of Rehabilitation and Royal College of Physicians 2003) and Psychological Care after a Stroke (NHS Improvement 2011) have recommended that psychological care is key to improving outcomes. Such documents highlight how psychological approaches can contribute to increasing an individual’s understanding of, and adjustment to, the permanent physical and cognitive impairments and emotional reactions that can accompany an ABI. However, a key feature of working with people after an ABI is the wide reaching effects it has, not only on the individual, but their family, the health and social work professionals involved in their care, work colleagues and communities, suggesting that the role of psychological approaches should not just be focused on individual psychological therapy, but on supporting families, rehabilitation teams and the individual’s wider support systems.
A variety of psychological therapy models are utilised in ABI/neuropsychology services (Weatherhead et al. 2013) and are adapted to the individual’s needs. To date, little has been published about the possible application of the Cognitive Analytic Therapy (CAT) model, yet the versatility of the model lends itself well to this type of setting, whether it is individual psychological therapy, formulation or consultation. It is widely accepted that an ABI can exacerbate certain difficulties or personality traits that existed pre-injury (Prigatano 1999). These difficulties could be formulated in CAT as Problem Procedures aimed at managing emotions and getting the person’s needs met. Individuals who sustained damage to the frontal lobe, and/or to connections between the frontal lobe and the rest of the brain, commonly experience breakdown in relationships (Wood, et al. 2005), rejection and isolation (Elsass and Kinsella 1987).
Prigatano (1999) highlights that all aspects of neurorehabilitation involve relationships, whether between the individual and their family, the individual and the rehabilitation team or the family and the team. This places an emphasis on understanding and working with interpersonal interactions, if neurorehabilitation is to be effective. The CAT concept of Reciprocal Roles (RR) may help teams work more effectively with an individual and their family, as well as understanding what is often referred to as ‘functional overlay’ in cases where people struggle to adjust to their difficulties after an ABI. The following is an exploration of the current available literature and reflections on my experience of using the CAT model with individuals and teams in an ABI/ neuropsychology service.
Psychotherapy and Acquired Brain Injury: the case for a using a CAT approach
Studies investigating the effectiveness of neurorehabilitation have demonstrated the importance of emotional adjustment following an ABI. For example, West et al. (2010) found that individuals experiencing low mood and depression after a stroke had poorer rehabilitation outcomes. This, combined with how the individual had previously learnt to cope with diffi culties and emotions, can present unique challenges in the successful adjustment to the lifelong impairments associated with ABI.
Neuropsychologists have long advocated the need for a psychotherapeutic approach in helping individuals and families in the understanding and long-term adjustment (Tyerman & Humphrey 1988) to the challenges an ABI presents. As in psychotherapy, the therapeutic alliance has been identifi ed as one of the most influential factors in neurorehabilitation (Schönberger, et al. 2006). Prigatano (1999) outlines the role of psychotherapy with an emphasis on relationships, collaboration and understanding how the individual is attempting to cope. Prigatano has been a staunch advocate of applying psychoanalytical ideas and how such an understanding is essential in an individual’s adjustment post injury.
In setting out the process of individual therapy, Prigatano (1999) emphasises several elements of the neuropsychotherapeutic approach that are consistent with the CAT model: (1) individuals with an ABI can struggle to understand the repeated failures in relationships, which further contribute to emotional difficulties and social isolation. This could be likened to repeating RR Procedures; (2) emphasis is placed on the therapeutic relationship and how the therapist attempts to make sense of the difficulties with the client, using their language. This approach is consistent with the emphasis in CAT of collaboration and developing a shared understanding as well as the importance of the therapeutic relationship as a vehicle of change; (3) an initial, joint understanding that incorporates the whole person is essential before the consequences of the ABI can be focused on. I compare this to the process of reformulation and the need to develop an understanding of how and why the individual has learnt to cope with difficult emotions and get their needs met. This is particularly important in ABI as it can aid the understanding of why the person is attempting to cope in certain ways; (4) once a joint understanding has been reached, the therapist helps the client to observe and recognise aspects of their behaviour that they may not have been fully aware of previously. This process is similar to the recognition phase, and the CAT tools could aid the individual to manage any cognitive difficulties that may otherwise create a barrier to this work; (5) Prigatano likens the process of learning about the impact of the ABI to the analogy of slowly turning up the lights in a room full of bear traps. If done too quickly, the individual will struggle to adjust, and is likely to fall victim to the traps. This struck me as similar to the concept of the Zone of Proximal Development (ZPD) in CAT and the need to work within the client’s ZPD. The consequences of not doing so could result in engagement difficulties and an inability to develop the necessary skills to navigate the problematic procedures.
Given the systemic impact of an ABI, it is important not to solely focus on individual psychological therapy in neurorehabilitation. A particular difficulty is the apparent ‘resistance’ or ‘sabotage’ of compensatory strategies from both the client and their families, which can result in a breakdown of the relationship with the rehabilitation team. Psychotherapeutic approaches should therefore attempt to help identify and explicitly work with these relational dynamics and the resulting distress that the team and the families can experience (Prigatano 1999). Potter (1999) discusses the difference between ‘doing’ and ‘using’ CAT, arguing that using the model to aid a team’s understanding and ability to work with interpersonal challenges should not be viewed as a lesser use of the CAT approach (Jellema 2001). This stance supports the use of the CAT model in helping teams understand and explore how they interact with clients and their families, or what responses they may inadvertently be invited into that could interfere with the attempts at rehabilitation.
Cognitive Analytic Therapy and Acquired Brain Injury: Current Literature
Yeates et al. (2008) considered the possibility of CAT providing a framework to explore a compensatory approach to dysexecutive difficulties after an ABI. Previous research has identified that individuals who sustained frontal lobe damage can present with behaviours similar to those in people diagnosed with borderline personality disorder, particularly when their pre-injury relational style was suggestive of such difficulties (Gagnon, et al. 2006). This emphasises the need to consider an individual’s pre-injury history, which is consistent with the CAT model. Yeates et al. (2006) proposed that a ‘neuro-CAT’ approach could help bring together neuropsychological factors with emotional and motivational issues in problems with goal-directed behaviour after an ABI.
The two case studies focused on key RR Procedures and the integration of technology to aid the recognition and revision stages. The Reformulation was reported to help increase the individuals’ understanding of their difficulties to make changes. However, their cognitive impairments limited their ability to implement exits without the assistance of technology. Interestingly, the report suggested a RR enactment appeared to occur between one gentleman and the technology he was trialling, depending on which Self State he was in. This prompted me to explore the possibility of such an enactment occurring for the individual in relation to the ABI when formulating a hypothetical client’s difficulties from a CAT perspective (Weatherhead et al. 2013).
Building on this work, Rice-Varian (2011) discussed themes that emerged from working with three individuals using a 16 session CAT format. All had mild to moderate ABIs and were presenting as psychologically distressed but with clear rehabilitation goals and evidence of engagement with the rehabilitation team. Rice- Varian highlights the sense of loss for people after an ABI and explored whether a CAT approach could help with the adjustment process. Common themes amongst the clients were of a striving pattern that interfered with the effective management of fatigue that many people experience after an ABI. This, along with a critical to criticised RR, was a prominent feature of their pre-injury relational style and contributed to low mood and a sense of failing at their rehabilitation. Post-therapy, all clients reported to understand the unhelpfulness of these procedures and engaged better with compensation strategies. Rice-Varian also highlighted an interpersonal RR of Controlling to Controlled in relation to the rehabilitation staff, resulting in confl icts in their medical and rehabilitation management. Post therapy clients, families and staff reported improved interactions, increased empathy and tolerance, particularly when parts of the reformulation were shared with key staff members.
The available evidence of applying a CAT model in neurorehabilitation in conjunction with existing literature and other psychotherapy approaches suggest that CAT has a place in enhancing the understanding of people’s difficulties after an ABI. While the published literature does not extensively explore the use of CAT as a consultation model with staff teams, I suggest this may be a further useful development in applying CAT in ABI services.
Applying CAT in an ABI, Neuropsychology Service
The community ABI neuropsychology led service I am part of is a relatively new team consisting of clinical neuropsychologists, assistant psychologists, vocational occupational therapists and a case manager. The service is an interdisciplinary team offering neuropsychological assessments and interventions in conjunction with vocational rehabilitation following an ABI. The service offers input to adults, and those traditionally described as older adults, who have experienced an ABI either as a result of a stroke or a traumatic brain injury sustained for example as a result of a road traffic accident. The clinical neuropsychologists also offer an in-reach service to the medically led neurological rehabilitation inpatient unit where people receive postacute rehabilitation from neurological physiotherapists, occupational therapists and speech and language therapists.
Referrals for neuropsychological therapeutic input tend to be for psychological therapy for depression, anxiety or adjustment difficulties after an ABI, or due to an individual struggling to engage with the rehabilitation programme. A common term used within medical settings is ‘functional overlay’, suggesting that an individual’s psychological difficulties exacerbate the difficulties caused by the organic injury. Due to a high referral rate and service demand there is a need for brief interventions and team working. Neuropsychological assessments are a core part of the service aimed at identifying and describing cognitive impairments the individual may have developed as a consequence of the ABI, the interaction between these and the individual’s coping style and the likely impact of these difficulties on the day to day activities and engagement in rehabilitation. There is currently little familiarity with the CAT model and the high referral rate limits the scope for ‘doing’ CAT in terms of 16 or 24 session therapies with individuals as the team does not carry a waiting list. This has been a particular challenge in starting to apply the CAT model within the service and has led to more of a focus on ‘using’ CAT to enhance my work within the various teams I provide input to.
The following are examples of how I have started to apply my developing knowledge of the CAT model within this service. The client’s initials have been changed as have certain details to maintain confidentiality.
Contribution to neuropsychology assessments: DM is a 30 year old woman who suffered an ABI in her late teens following a hanging attempt. DM had attempted suicide due to struggling with overwhelming feelings about sexual abuse she experienced as a child. DM currently lives in a group home and the staff have reported frequent verbal and physical aggression, which they struggle to manage.
Given DM’s history I was mindful of potential RRs about abusing to abused and controlling to controlled and how these could potentially be enacted between DM and I during the assessment. Some clients can fi nd cognitive tests understandably challenging and can experience the assessor as controlling, as we can appear to withhold information about how well they are performing. I therefore decided to ensure I spent time building a rapport with DM, trying to notice any key RRs being enacted or elicited during the assessment. While this is part of the standard approach in testing, the CAT model gave me a framework in which to talk to DM about the assessment process and helped contribute to a more open discussion about how she tends to feel criticised and dismissed, which she desperately tries to avoid. She also tends to criticise and abuse herself, having internalised some of the messages she has received both from the abuser and legal process. Using the CAT understanding of RRs and procedures contributed to the observations and overall understanding of DM and her difficulties, which in turn led to jointly devised recommendations regarding managing her interpersonal difficulties and behaviour.
Direct client work: NF is a male in his mid-20s who was in a car accident at the age of 12, which resulted in cognitive impairments that affect his ability to think flexibly, self-monitor and regulate his emotions, particularly when he is anxious. NF has recently become a father for the first time. His girlfriend has a mild learning disability and currently lives in supported accommodation. NF was referred to the service by his GP due to concerns that he was struggling to manage his relationship with his girlfriend’s father, resulting in frequent arguments and concerns being raised over his ability to be a parent. NF was described as having ‘grandiose delusions’, often appearing to think that he knew better. His mother described struggling to know how to support NF.
During the assessment NF and his mother described NF’s biological father as violent and abusive, suggesting a RR of abusing to abused. With this in mind I attended to the descriptions NF gave of his girlfriend’s father and together we identified NF would often experience this man as attacking and controlling, leaving him feeling anxious. This helped identify a RR of attacking/controlling to attacked/anxious and an associated procedure where NF would attempt to manage his feelings of anxiety by defending himself and rigidly “sticking to his guns”, which resulted in him occupying a controlling and attacking position, with grandiose beliefs.
Focusing on this key RR helped NF and I to link how he related to his girlfriend’s father in a similar way to his own father. A map of this pattern was developed and NF was encouraged to look at it between sessions to aid his recognition and was shared with his mother who reported this helped her understand her son’s reactions. Further sessions were used to help NF recognise when this enactment occurred and to take a step back to consider whether his girlfriend’s father was intending to ‘attack’ or whether there may be another explanation. This work has helped NF to reduce his defensiveness and consider alternative coping strategies, as well as encourage his mother to support him in talking to his girlfriend’s family about the arguments, potentially introducing a new RR of understanding to understood.
Team formulation/consultation: RM is a 74 year old lady who experienced a stroke six weeks prior to being referred to the neuropsychology service. The physiotherapist referred RM due to difficulties with engagement in the physiotherapy sessions. She was reported to be constantly criticising the staff, dismissing their efforts to support her. RM declined to meet with me and I therefore offered the physiotherapist and occupational therapist the opportunity to think together about what may be happening and how to work with RM.
The physiotherapist reported spending large parts of the sessions trying to persuade RM that the physiotherapy was helpful. She reported feeling dismissed by RM, which led to further attempts to convince RM of the necessity to have physiotherapy. Similarly the occupational therapist would often feel dismissed and belittled by RM and was left feeling irritated and wanting to discharge her. We explored what we knew about RM’s history and identified that she had been very independent throughout her life and considered whether she had previously needed to be in control, but was now experiencing the staff as controlling. I wondered with the team whether feeling dismissed by RM they had been drawn into being critical and dismissive of her. Using the concept of RRs we mapped out how, when RM possibly experienced others as controlling, she felt controlled and became critical and dismissive, leading the staff to becoming controlling and critical of RM. This repeated itself to the point where the team were drawn into dismissing her, potentially leaving RM feeling dismissed, angry and upset.
We considered how the team could try to view her in a more compassionate way, aiming for a respecting to respected RR. The discussion helped the physiotherapist in particular to consider how she could talk to RM about the sessions and what RM’s goals and concerns were. This experience also contributed to more collaborative working between myself and other parts of the service.
Service formulation: One particular challenge has been developing effective working relationships with the existing services which my team work alongside. The medical and physical services for ABI had long been established prior to the commissioning of the team I work for approximately 18 months ago. It has been challenging to work in a service where the ‘medical model’ is the prevalent approach and is applied to psychological difficulties such as depression. ‘We’ are therefore separate and appear to have a distinctly different approach from our medically trained colleagues, potentially creating an ‘Us’/ ‘Them’ split, not dissimilar to how people with mental health difficulties have been viewed by services in the past and continue to be so in some contexts.
This difference of approach and opinion has created high levels of tension and stress within the team and across the ABI service. Within the neuropsychology-led service we have considered different models to try and understand these dynamics, such as Tuckman’s (1965) team development process of forming, storming, norming and performing. Revisiting this theory, I wondered how the CAT model could help enhance my understanding and manage the highly emotive service meetings. Others in the team experienced these dynamics as draining, deflating and not good enough, while others felt angry and vigorously defended our service. I wondered whether this might indicate possible RRs of criticising/attacking to either deflated/not good enough or angry/resentful.
Potential procedures may involve: feeling not good enough, we try hard to please, attempting to avoid criticism, which leads us to strive in relation to a demanding other. Such a procedure is unsustainable and exhausting, reinforcing the sense of not being good enough and potentially inviting further criticism. Alternatively, feeling angry and resentful, we attempt to defend ourselves by highlighting the shortcomings of the other parts of the service, meaning we become critical and attacking. Each pattern results in increasing tension and misunderstanding. Exits from these patterns may involve exploring alternative ways to express concerns and manage expectations, such as more regular meetings between senior managers, increased joint working and developing a shared understanding of each other’s roles and approaches.
Throughout the CAT teaching I have often found myself thinking about the clients from my neuropsychology role and mapping out potential RRs and procedures that might help me understand our interactions and the client’s difficulties. This has helped me take a step back when I have felt overwhelmed both by the demands of the service and by the demands I place on myself. Applying the CAT model more directly has been challenging, particularly as the opportunity to contract a standard 16 session therapy has not yet been possible, meaning if I was going to apply CAT it would be with an emphasis on using it in consultation and to inform other aspects of my work. In part this has helped me extend my own ZPD.
Given that the main CAT tools of the reformulation letter, diagram and goodbye letter are considered central to CAT, these limitations have challenged my idea of what it looks like to apply the CAT model. The work described above has led me to focus on how to use the model of understanding and adapting the therapy tools to fi t the needs of clients and the service, rather than attempting to fi t the client and service into a more traditional way of working, perhaps working within the ZPD of the service. I see this as another key element of the CAT model, as each understanding is jointly developed and truly idiosyncratic. The concept of ZPD has helped me work with other rehabilitation professionals to consider the pace of input and consider where the client is at (Burnham 1986; Prigatano 1999). Although the concept of transference and countertransference has long been considered important in neurorehabilitation (Prigatano 1999), it can feel alien, frightening and impenetrable to people unfamiliar with psychodynamic theory, yet understanding relationships is pivotal in an approach that relies heavily on interpersonal interactions. The language of CAT and experimenting with mapping out interactions with staff have helped facilitate a growing understanding between myself and the other rehabilitation staff, perhaps helping to find an exit from the problematic procedures between our teams.
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About the author
Dr Phillippa Calvert is a Clinical Psychologist and works part time in Cheshire and Wirral Partnerships Foundation NHS Trust in an adult ABI Service. She also works part time for Lancashire Care NHS Foundation Trust in a Complex Care and Treatment Team providing psychological therapy to adults with severe and enduring mental health problems. She is currently training in CAT on the Catalyse/ACAT North Practitioner Course 2011-2013.
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