Beyond individual therapy - Trainee practitioner reflections on the use of CAT within an Adult Community Learning Disabilities Team

Field, B., 2014. Beyond individual therapy - Trainee practitioner reflections on the use of CAT within an Adult Community Learning Disabilities Team. Reformulation, Summer, pp.33-37.


In this article I wish to share how I have experienced providing CAT to people with learning disabilities as a trainee practitioner within a Community Learning Disabilities Team (CLDT). I aim to focus on the components of CAT that drew me to its use for supporting people with learning disabilities and their systems in the hope that this inspires others to develop their confidences in this area.

Accepting difference – reframing disability

We are, by now, all aware that people with learning disabilities have historically been marginalised within services and society at large. The historical grouping of people in to homogenous labels, such as ‘mental retardation,’ intellectual disability,’ and more recently ‘learning disability,’ has contributed to notions of depersonalisation which has perpetuated stigma and inequalities faced by this ‘group’ of people. For me the joy of CAT, in its appreciation of constructivist epistemologies such as Vygostsky’s, is that it situates us all as ‘meaning-making humans’ within a social world. This gives practitioners working with people who have learning disabilities an important opportunity to begin to re-frame notions of disability. The practitioner can work with the client to help them discover who they are and what their experiences in the world are all about – outside of the limitations that the label of ‘disability’ imposes. Such an explicit attentiveness to power relationships and notions of interdependence has enabled me as a clinician to work alongside individuals who have a label of ‘learning disabilities’ to reveal an alternative, more able, view of the self and to support them to share this view with those close to them. This of course is translatable to clients who present with any kind of disability/ difference/difficulty within services.

The theoretical ideas of Bakhtin and Vygotsky are central to consideration of how labels such as ‘learning disability’ are constructed and held in dialogue between self and others. Vygotsky was one of the fi rst theorists to consider the interactive, reciprocal nature of learning. His learning theories were outlined in his 1929 paper ‘The Fundamentals of Defectology,’ Vygotsky (1993). At the time, notions that the development of the self and intelligence were socially mediated was a revolutionary construct. Prevailing thoughts were centred on physicalist notions of the mind as a fixed physical construct with intelligence and self, emerging through self-generation and self-maintenance (Ryle & Kerr, 2002). Vygotsky diverged from this reductionist path and described how development of the self was constructed within, and mediated via, social interactions which create meaningful signs that, when internalised provide the person with an ability to repeat what they have internalised from these interactions in a novel environment, hence extending the capabilities of self and other. This social learning approach has since influenced development of practice and understanding in education, social and cognitive psychology and artificial intelligence, and is central to aspects of CAT theory (social formation of the mind; sign mediation; internalisation; the zone of proximal development, Ryle & Kerr, 2002 pg.40-41).

Rodina (2006) described how Vygotsky’s theory applies, ‘a dynamic approach to disability, emphasizing the importance of the social situation of development.’ This notion that ‘intelligence’ is a socially mediated ability encourages me to work with disability in a relational frame, with people who have less accessibility to their thinking skills. The concept of reciprocal roles used within CAT can be brought to the picture that clients with learning disabilities present with, allowing a non-discriminatory open dialogue to occur. This acts to open up new possibilities of self-perception for the client, outside of the limitations that ‘disability’ imposes. I have similarly applied this constructivist way of thinking to work with clients without a learning disability, working relationally to construct a new narrative about themselves and their difficulties outside of the stigma that diagnostic labels can impose.

In my practice with people who have learning disabilities, I have found that on clients’ maps the ‘special/perfect’ to ‘learning disabled’ reciprocal role (Psaila and Crowley, 2005) is often hidden within harsh power roles such as ‘controlling’ to ‘controlled’ or ‘not hearing’ to ‘unheard,’ reflecting their disempowering experience of the world. The naming, owning and tracking of such roles with clients has seemed to provide a space for dialogue which has enabled a difference sense of self to emerge for the client.

Case example

‘Robin’, a 43 year old man with a learning disability presented with depression and frequent unexplained health complaints. He contracted to complete a 16 week CAT. The final paragraph of my reformulation letter to him encapsulated the core reciprocal roles that were present for him;

‘You feel you need to show people you are ‘good enough.’ You do this by doing what the Boss says, trying to please. Doing what the Boss says makes you feel ‘not good enough.’ You use depressed thoughts to punish yourself for ‘not being good enough.’ Depression makes you feel that people need to do things for you, but then you feel frustrated that you are not ‘good enough.’ You fear saying what you want in case you are punished by the Boss.

Although a ‘special/perfect’ to ‘learning disabled’ role was not overtly present on ‘Robin’s’ map it was represented in the core pain of ‘unwanted, black sheep.’ Frequent discussions were had in regards to how others’ perceptions of his (dis) abilities (depression, pain, reduced access to thinking skills) were limiting how he was living his life (others control me). A dialogue regarding these experiences was had and his map was used to track these relational experiences. From this he was able to identify exits that he could use to circumnavigate others’ negative perceptions of his (dis)abilities. This seemed to provide ‘Robin’ with hope and he signed up to an evening course with a new found ambition to help others who he perceived as being in a similarly disempowered situation to himself.

Drawing on Bakhtinian infl uences, at follow up ‘Robin’ described how he had been able to use his map during a conversation with his wife where he was trying to negotiate a new role for himself in their relationship. He described his attempts to ‘subvert and de-crown his wife’s taken-forgranted assumptions’ about him (Sullivan, 2010), demonstrating a perception he now held of himself as a ‘work in progress’, open to reorganisation and renewal. He was unclear as to how successful this had been but had demonstrated that taking an open dialogic position with his wife had been a positive step in a position where polarisation of views regarding his (dis)abilities had been a problem. This seemed to lead to the development and experience of a new more constructive reciprocal role for Robin in which he experienced himself as ‘Accepted as different and Heard’ to his wife who was ‘Accepting difference and Listening’ (ACAT, 2012).

As a trainee CAT practitioner working with people with learning disabilities I have been struck in how I have experienced similar dilemmas to those detailed above for Robin. In particular I have grappled with my concerns about ACAT’s training requirements whereby trainee practitioners working within learning disability services are required to complete CAT training cases in both learning disability and mental health services, whilst reciprocation and support for such flexible skill development is sadly not mandatory for my mental health colleagues; with all of their CAT training cases generally being completed with clients who do not have a learning disability diagnosis. This sadness is further piqued when discussions with other CAT trainees identify experiences where aside from service boundaries and restrictions, they feel they would not have the fabled special skills required to work with a person who has a learning disability. For me this regrettably parallels ‘not hearing’ to ‘unheard’ reciprocal roles which further marginalises and stigmatises presentations of (dis) ability; yet in my view, CAT as an inherently collaborative and relational model has the ability to circumnavigate such (dis)ability differences with ease. The aim of this article was to emphasise the meaning making, person centeredness of CAT in the hope that others, not fortunate enough to work in learning disability services, seek out experiences to broaden their sense of confidence and competence in working relationally with (dis)ability and difference. I would hope that this would enhance equality in service provision whilst increasing acceptance and fostering a culture of active listening, hearing and empowerment for both client and therapist across all presentations of disability/difference/ difficulty.

Indeed such competence is fast becoming a necessity for clinicians where the current forces at play within the NHS are furthering the inclusion in mainstream agenda for people with learning disabilities (see for example National development team for inclusion, 2012). I fear a position of further perpetuation of inequality and exclusion from services for people with learning disabilities if current and future CAT trainees are left feeling unskilled and unsupported to develop their skills in working with people who have learning disabilities. I would urge trainees to take this as food for thought and dive into using CAT in its raw relational form to help advance CAT’s evidence base as a truly inclusive model in which all are respected.

Dr Bryony Field, Clinical Psychologist, Cornwall Foundation NHS Trust, Community Learning Disability Team, West Resource Centre, Penryn Street, Redruth, Cornwall, TR15 2SP Bryony.field@cft.cornwall.nhs.uk

References

National development team for inclusion (2012) Improving the Health and Wellbeing of People with Learning Disabilities: An Evidence-Based Commissioning Guide for Clinical Commissioning Groups., Public Health England.

Psaila C.L. & Crowley V. (2005) Cognitive Analytic Therapy in People with Learning Disabilities: an Investigation into the Common Reciprocal Roles Found Within this Client Group

Mental Health and Learning Disabilities: Research and Practice 2(2), 96-108.

Rodina K. (2006) Vygotsky's Social Constructionist View on Disability: A Methodology for Inclusive Education. Enabling Lifelong Learning in Education, Training and Development: European Learning Styles Information Network (ELSIN), University of Oslo: Oslo, CD/ISDN, 82-8075.

Ryle, A. and Kyle, I.B. (2002) Introducing Cognitive Analytic Therapy; Principles and Practice. John Wiley and Sons Ltd.

Sullivan P. (2010) Vygotskian Dialectics and Bakhtinian Dialogics: Consciousness between the Authoritative and the Carnivalesque. Theory and Psychology 20(June), 362-378.

The Association for Cognitive Analytic Therapy (2012) What is CAT understanding? http://www. acat.me.uk/factsheets/Whatis- CAT-Understanding.pdf.

Vygotsky L. (1993) The collected works of L.S.Vygotsky: The fundamentals of defectology. New York, Plenum Press.

The day was organised by Dr. Alison Jenaway (Consultant Psychiatrist in Psychotherapy) and Anna Bettles (Specialist Practitioner in Selfharm) from the Cambridgeshire and Peterborough Foundation NHS Trust. We met at Ortan Hall in Peterborough which provided a relaxed setting for the event. The day afforded an opportunity to share some of the successes and barriers to using CAT within CAMHS settings. The programme for the day included talks, time for networking and our first specialist interest group (SIG) meeting. Feedback for the day was very positive, with the day receiving a score of 8.7/10 (mean average) in terms of how informative it had been for participants, and the quality of speakers was rated at 8.9/10 (mean average). Participants also presented many ideas for future events. Another success was the setting up of the SIG aptly named Youth CAT which can be joined through the ACAT website.

The speakers were all practicing CAMHS clinicians who have been using CAT in their work with children, young people and parents. The day kicked off with a talk from Dr. Alison Jenaway about the developmental diagram that she and the Cambridge group uses as a template for SDRs (sequential diagrammatic reformulations) with young people. Alison used a case example of work she had completed with a parent. The case example Alison discussed explored the experiences of a child who was becoming increasingly aggressive to various members of his family. Alison’s work illustrated the potential CAT has for helping parents recognise the relationship between their own difficulties and the challenging behaviour of their children. The family in question had accessed other CAMH therapies that had not been able to make the positive changes that CAT did for the family.

We then moved onto a thought provoking presentation from Dr. Vicki Richer (Clinical Psychologist) from The Phoenix Adolescent Eating Disorders Unit. Vicki talked about the use of letters in CAMHS generally and more specifically in CAT with young people. We considered the dilemmas that CAMHS clinicians face when writing letters, to young people, which parents may also read. Vicki encouraged us to think about how letters can fit into the CPA process and how we could make the CPA process more relevant to the young person it aims to support. As a group we also reflected on the importance of paper letters for young people who are growing up in the digital age.

Following a well-deserved coffee break, we finished the morning with a presentation from Dr. Debbra Mortlock, (Clinical Psychologist) about her work at The Croft Child and Family Unit in Cambridge, in which parents are admitted to support their children during a Tier 4 CAMHS admission. Debbra talked about using the CAT model with young people and parents as well as using a contextual reformulation approach to support the wider team to develop more positive ways to work with parents. In particular Debbra’s talk illustrated the ways that CAT can inform a range of time limited interventions with parents including parent training work and development of parents refl ective functioning. This presentation led on to a complex discussion about the importance and relevance of parents having therapy in their own right within CAMHS services.

Following a very pleasant lunch, we had two presentations that focussed on working with young people living chaotic lives, who consequently present as difficult to engage. Dr Nick Barnes (Child and Adolescent Psychiatrist) working in a Haringay (London) CAMHS adolescent outreach team, spoke about two projects that use football as a medium for engaging young people in therapeutic work. Nick explained how the programme uses the language, processes and procedures associated with the beautiful game, to help young people reflect on their own lives and relationships. The young people who take part are often affected by gang culture and on the edge of school exclusion. Nick’s presentation once again demonstrated how CAT as a therapy is relevant to young people on the margins. Nick continued to enthuse and inspire us with his description of a new programme “Reaching Your Goals” which attempts to engage young people, already excluded from education, in thinking about how they may be able to shape a better future for themselves.

To complete the day Anna Bettles brought us back to familiar territory in her clinical case presentation about a young person who was self-harming and vulnerable to being caught up in risky relationships. Anna reflected on how risk could be understood and managed within a CAT intervention. Anna described many of the dilemmas that practitioners working with young people at risk of self-harm struggle with. She drew our attention to the particular dilemmas that CAT poses for therapists working with teenagers.

For example, in relation to being able to work within their proximal zone of development regarding their level of independence; the extent to which the outcomes of therapy should remain private (e.g. therapeutic letters) and working in the context of the wider professional networks that support young people. Anna’s talk prompted the audience to think about the reality of delivering CAT to young people who are often caught up in complex family problems and do not have social networks that can support them as they complete their therapy. We also explored “what constitutes CAT” within a CAMHS context.

The audience was made up of people at different levels of CAT training; from pre-trainees and practitioners to supervisor level. As one would expect from a CAT event, the discussion was lively and creative. In line with current practice we discussed issues relating to the evidence base available to support the use of CAT within CAMHS. What became clear is that, despite some progress in this area, we need to develop more of an evidence base to support the work we are doing. The fact that so many practitioners are turning to CAT within their CAMHS work and reports from conference delegates of good outcomes from individual CAT case work, suggests that practice based evidence supports the use of CAT in CAMHS. It is hoped that the formation of the Youth CAT SIG will give us an opportunity to support the great work that is going on and develop a strategy for outcome research in the area. We also plan to have a similar national event next year, set up processes for supporting each other in this work and develop our expertise as a group using the “to do list” we developed at the study day.

Finally I would like to thank all those who came along to the day for making it so inspiring and successful, in particular the organisers Alison and Anna.

Debbra Mortlock

Full Reference

Field, B., 2014. Beyond individual therapy - Trainee practitioner reflections on the use of CAT within an Adult Community Learning Disabilities Team. Reformulation, Summer, pp.33-37.

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