Collaborating with Management in the NHS in difficult times

Carson, R. Bristow, J., 2015. Collaborating with Management in the NHS in difficult times. Reformulation, Summer, pp.30-36.

Psychological Therapies in the NHS today

Everyone concerned is experiencing heavy cuts in the NHS. Within mental health, these have been very severe and will continue to be, with cuts expected to be higher than physical health services in 2015, despite recent changes for children. There might be temporary savings but insuffi cient access to psychiatrists or psychological therapists often leads to more costs later both in
health care and in state benefits. In one of the sessions in the annual meeting of trainers and supervisors, in March 2014, we
shared our experiences of this. For many, there was a feeling of a 'powerful other to a powerless, unheard self'. As a result of this
two of us decided to write a paper building on what was discussed. This gives four examples drawn from case studies (with a senior professional, two staff members, a team and leadership coaching).

Organisations in distress

How organisations behave under stress is an indicator of their health and capability just as it is for societies and individuals. Dilemmas, tough choices and confl icts can be mishandled and escalate. The dynamics of internal relationships and politics between levels, groups and individuals can become defensive in ways that destroy trust and collaboration. With cuts mismanaged, standards of professional services and patient care can be impossible to maintain within acceptable boundaries. This undermines both the public service ethos and professional identity. All of this has been well documented in a 2014 article in the BMJ by the Medical Director of the Practitioner Health Programme for doctors and nurses in the NHS1. Managers can have unhealthy narcissistic characteristics as described by deVries. See also Wikipaedia on Narcissitic Leadership, and the High Conflict Institute on Managing your Narcissistic boss.

A successful Chief Executive in the NHS, in a meeting with one of the authors, described the NHS as a group of organisations, each with their own professional cultures, loyalties and values. He saw that the success of the hospital depended, to a great extent, on building a partnership with each organisation and encouraging medical, nursing and business directors to do this at all key levels. This is all the more important in times of stress, change and severe resource limits. Even without the pressure of cuts health care is particularly stressful as Menzies Lyth showed in her work in the 1950’s when she developed the concept of
“emotional labour” to describe the emotional demands of nursing.

How might a CAT informed approach help?

Some Reflections and Experiences arising during and after the Annual ACAT meeting of Supervisors and Trainers March 2014

Using CAT to help

This can be helping an individual, colleagues, leaders and teams.

(1) Working with an Individual in an organization
One example would be using CAT to help people address bullying

In working with an individual feeling bullied the first stage would be to help the individual to explore and reformulate what is going on in the organization within an historical and societal context as well as their own individual situation and personal and professional history: to see how the systemic patterns of self and organization interact, distinguish what is more specific to the organization at the time and how they are played out in and between people in different positions. This is similar to how CAT has been used to those affected by inter-cultural relations within a society. Clients have said how focusing on both the personal and the organizational helps them to stand back, reappraise and think differently about themselves within the system. They can then be freed up enough to make changes in the way they are responding and feel more in control, less of a powerless victim.

Examples of Reciprocal Role Behavior:

Management                                                                   Staff (all grades)
The Bully Manager:

Increases workloads while reducing resources.       - Overstretched & stressed.                                                           
Shows no understanding of what is needed.             -Unable to maintain
                                                                                           -standards: Experience, conflict, anxiety, loss of respect.                                                
Not listening. Dogmatic.                                               - Unheard, no voice. Unable to influence.             
Avoids personal contact.                                               - Cut off             
Treats without respect or with contempt.                   -Angry or hostile compliance or fight back                                          
Forcing, or using implicit threats.                                -Angry: Silent or Stand up for Rights 


Staff alienated and not trusting or respecting management. Management destroy their reputation as an employer. Staff either
separate and leave, often feeling victimised or stay pressured, anxious, (leading sometimes to depression and sickness absence).
Others remain but can feel guilty as their colleagues suffered. There can be peer competition and betrayal in the earlier stages too.

The Constructive Manager

-Describing the situation accurately.
-Respecting, & respected though confronting realities, but offering support.
-Uncertain, Anxious.
-Showing understanding of needs.
-Open when trusting.
-Inviting and encouraging joint problem solving and collaborate with peer group.
-Open to participate with managers.
-Support people through loss of job and finding new job or way of life.
-Retain dignity, Feel more in control.
-Think well of management/organisation.

2. Working with two people in a team having problems working together

Within a department it became clear to the senior manager that an unhelpful dynamic was occurring between several members of the team. The result of this dynamic of splitting and competing was observed.

One of the team’s admin (Susan) was clearly fi nding diffi culties working with a young qualified member of the team (Ann): Susan frequently made complaints to the manager about Ann, expressing her annoyance.

Ann said nothing but other team members began making comments, with people moving into positions of ‘the favorite’ or
‘the effi cient’ one. Ann could be seen trying to engage more with Susan but then feeling rejected. Susan began withholding
information and failing to carry out requests that Ann made. Ann was left in a position of feeling powerless and disempowered.

In supervision the manager worked with Ann and together they identified that Ann was feeling overlooked, powerless
and devalued. It could then be seen that as a way of managing this initially Ann had tried to please Susan (a pattern that she
recognized) but this had resulted in further rejection and dismissal.

As a result, Ann did her own admin to avoid Susan, whilst at the same time reducing Susan’s work load.

In supervision Susan, described a sense of being rejected and undervalued, with her own maturity being dismissed and disrespected by someone she viewed as being young with no experience. Susan used examples of how Ann had compiled letters and sent them out without informing her, stating that this clearly impacted on her own job.
She was worried that this would be seen in a negative way, and that if something went wrong, she would have no control over this.

The manager identified that the staff had initially gone head to head with each other and had then moved to a position of controlling other to controlled dismissed self, each moving between the two positions. She thought it would be helpful to map this out with the two members of staff. So she asked them if they would be happy to meet together to try and resolve this. Understandably, they were a little anxious about this, both worrying that there was going to be an apportioning of blame. The manager made it clear to each member of staff that both members of the team were valued and the meeting was aiming
to help working relationships.

Within the meeting both staff were encouraged to disclose how they felt about the situation they had found themselves in. The manager positioned herself in the ‘curious other’ position, reflecting back and summarising what she was hearing.
After that, the manager mapped out the positions being described and potential procedural patterns for the two members of staff to see. This was in the spirit of enquiry and both staff engaged with it well.

Both Susan and Ann were able to see how they both held powerfully controlling positions, but then also how they could hold this position without pushing the other into an ignored, dismissed or powerless reciprocal position. The manager was able to set clear boundaries for both members of staff and was also able to support both of them to take a ‘risk’ and try something different. Indeed the result was different, with both Ann and Susan working well together, both respecting each other’s positions and being able to value each other. 

3. Working with teams on their internal and external relationships

CAT tools and skills provide a way of describing co-created problematic patterns and procedures and their consequences while recognizing the legitimacy of the needs and intentions behind them. Team members? can then discuss and negotiate how they can best fulfill their roles within the team and with others outside it or other teams.

Some conditions and processes to note in this are familiar to us in our work with patients and clients:

(1) Trust and Safety, Team Resources and Context 
The history, resources, skills and quality of relationships of the team need assessing at the start, and then boundaries set and the approach discussed so that it matches their zone of proximal development. Trust is improved as they begin to understand each other’s needs and values and have them in mind alongside their own, in trying to address issues.

(2) Credibililty and Skills of the CAT Informed Facilitator or Coach 

The qualified CAT practitioner can be a lead member of a service that the Board sees as effective, who has a varied background
both in clinical service and in managment, and can act in such a role. Or s/he can be an outside trainer and therapist who
has worked with the organization, and therefore has credibility with the team. Or both together working as a team.

(3) Familiarity with the CAT Model and Language

As can be seen in these examples, CAT language and forms of description can be used with people without training in it, as with
individual clients, after an appropriate on the spot introduction. It can also be used with teams who have been trained in CAT and use it for managing their relationships with patients and clients (see 6,7,8). They can then extend it to use in their other relationships – both with each other in the team and with others outside it such as staff (see 9) and commissioners.

(4) One-to-One Sessions with Team Members and the Nesting of Relationships

One-to-one sessions are advised fi rst as team members can see more clearly their own perceptions and reactions and have more
opportunity to notice and revise their own behavior in relationships in ways that change the relationship for both self and other. The team can then discuss together their relationships with each other and with those they work with outside the team or organisation

(5) Generative Dialogue

Enhancing the quality of dialogue, familiar to us in CAT, is key. Modelling this and encouraging others to participate in similar ways is essential. This then can lead on to reflective thinking together – each exploring and owning their own beliefs and assumptions, enabling them to be more open in their minds, hearts and goals.

(6) Differentiation and Integration

Where there are confl icts in meetings between people representing different groups, such as managers and professionals, which can involve negotiation alongside problem solving, the interchange and language can often go through a phase of differentiation (apart, “you” and “I”) before fi nding some integration through common ground and tolerable solutions (together, each a part, “we”). Differentiation would then return. This has some parallels with the together – apart dilemma in CAT when it is in an either/or form.

(7) Differing without Ruptures

This is similar to the distinction between assertion in seeking to be understood, and aggression in verbally attacking the other, and balancing seeking to understand with seeking to be understood, and requires moderating and making sense of feelings first.

(8) Role behaviours and relationships with people in different positions 

These can be drawn from the 1-to-1 sessions and summarized for each relationship, without naming who said what.

(a) Managing upwards: your manager and relations with Commissioners.

Problematic roles experienced by a service delivery (S ) team in relation to a commissioning ( C ) team have for example been described as:

Powerful, out of touch ( C ) – angry, controlled then indifferent (S)

Dominant, Invasive (Anxious) ( C ) – not considered, unseen, powerless withdrawn (S). The literature on tips on how to manage your boss or infl uence up or across the organization is relevant here and can be referred to when discussing other behavior10.

(b) Leading and Managing Staff and Direct Reports

The team can discuss the approach they want to adopt to staff, and to particular diffi culties with some staff. The team leader
can respond to feedback from their team and suggest and ask for alternative ways of dealing with situations, depending on
the readiness of all involved.

(c) Relations between team members and with other colleagues

In the same way the team can agree certain ground rules on how they want to work together or handle specifi c issues. The
technique of role negotiation can be helpful here for giving feedback and negotiating behavior between team members or colleagues, with each discussing and agreeing what to stop, start or continue doing after each individual has prepared to discuss each of these questions beforehand (See Roger Harrison11).

(d) Relations with clients, service users or patients

This can be an elaboration of the work done with teams delivering multidisciplinary care in the NHS to mental health patients
to see if team members might in their reactions and behavior be colluding with, and reinforcing, the maladaptive relational patterns of patients - and how, by not colluding, they could provide a more therapeutic environment for patients through their experiences of others relating to them differently. (See CAT literature on the contextual reformulation 6,7,8 ).

Team workshops can be helpful in encouraging staff not to withdraw and isolate themselves in times of stress, or just keep their head down and ignore the wider organization, making themselves feel “done to” by it. Teams can deepen their understanding
and regain their confidence and a sense of control as in a CAT therapy, and feel empowered to address organizational or personal issues through collaborative relationships.

4. Working with leaders

The CAT model can help in the process of leadership coaching generally, and also in supervising leadership coaches. Team
coaching is often combined with using questionnaire feedback from direct reports – and others in other positions such as colleagues or boss, and with reference to best practice12. Here too a CAT practitioner can train leadership coaches to use the CAT model in their work for both self-other and self-self relations. This can also help leaders take on the role of coach or enabler at different levels of scale and complexity:

(a) Manager as Catalyst, Facilitator, and Creator/Holder of a Safe Space

An enabler does not try to make changes happen, but rather creates the conditions in which co-created, self-sustaining
change can take place in ways of thinking, being and acting. The example above of the manager helping Susan and Ann in
their working relationship can be extended and scaled up.

(b) System Leaders for problems involving the wider system

This takes the role of leaders as enablers and catalysts further in transforming relationships between people in different positions within and between organisations in a sector or parts of a society so as to be able to understand and transform the system they are all in. The case for system leadership has been put very clearly in a recent article by Peter Senge and colleagues13. The Kings Fund have also published a paper on system leadership for integrated care in the NHS14 The underlying principles in this have parallels with good one-to-one therapy, and CAT in particular, scaled up to a higher level of complexity and longer timescale. We can work with those assisting leaders in these processes.

Concepts used in CAT can help

The CAT model describes the world, and ourselves in relation to it, as interacting systems. The same systems approach is needed for understanding human organisations and the relationships in and between them, and CAT can make a contribution to this. Mary Parker Follett, one of the earliest women management thinkers in the 1930’s wrote: “I (and my perception of you) am responding to you (and your perception of me)”. Gordon Allport, the founder of what became social psychology, said that every communication is not just about the explicit content but also the implicit message about how the speaker sees themselves and the other, and the kind of relationship they want. The CAT model helps people to look at their own and others’ role behaviour
in relationships in a way that can lead to greater understanding: seeing relationships in terms of role behaviours that seek to elicit or provoke responses in others can help us handle ourselves in relationships better.

Clare Gerada (2014) Something is profoundly wrong with the NHS today British Medical Journal Careers June. Kets de Vries, M.F.R. & Miller, D. Narcissism and leadership: An Object Relations Perspective - Human Relations (1985) 38(6) Pages 583-601. See also: leadership which refers to this and also: http://www.highconfl
articles/most-popular-articles/78- hci-articles/published-articles/89- managing-your-narcissistic-boss . Menzies Lyth (1960) Social Systems as a defence against Anxiety Human Relations 13 pp 95-121 and shortened in http://www. ericsess/sessvol1/Lythp439.opd.pdf Ryle, A. and Kerr, I.B. (2002) Introducing
Cognitive Analytic Therapy: Principles and Practice. Wiley pp 205-213 Kerr, I.B. (1999) Cognitive analytic therapy for borderline personality disorder in the context of a community mental health team: individual and organizational psychodynamic mplications British Journal of Psychotherapy 15 425-438 Dunn, M. and Parry, G.D. (1997) A formulated care plan approach to caring for borderline personality disorder in a community mental health setting Clinical Psychology Forum 104 19-22
Walsh, S. (1996) Adapting cognitive analytic therapy to make sense of psychologically harmful work environments. British Journal of Medical Psychology 73 151-168 See hbr-guide-to-managing-up-andacross/ an/11218-PBK-ENG
On the Role Negotiation exercise see Harrison, R. (1995) The Collected Papers of Roger Harrison McGraw-Hill John P. Kotter (1990) A Force for Change: How Leadership differs from Management. Simon and Schuster Peter Senge, Hal Hamilton and John Kania (2015) The Dawn of System Leadership. Stanford Social Innovation Review  inter
the_dawn_of_system_leadership fi les/kf/fi eld/fi eld_publication_fi le/ system-leadership-october-2014.pdf

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Full Reference

Carson, R. Bristow, J., 2015. Collaborating with Management in the NHS in difficult times. Reformulation, Summer, pp.30-36.

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