John, Dr C., Darongkamas, J., 2009. Reflections on Our Experience of Running a Brief 10-Week Cognitive Analytic Therapy Group. Reformulation, Summer, pp.15-19.
This article briefly describes our experience of developing and running a 10 week CAT-informed therapy group for patients in a small but busy NHS psychology secondary care mental health service.
There is very little literature on time limited CAT groups for this population. This article is intended to promote the use of CAT therapy in group settings by helping other clinicians to learn from the experiences and dilemmas that were encountered along the way. As is usual in NHS practice, the desire to provide “perfect care” was balanced against the pragmatics of getting people from the waiting list seen for therapy.
Although it is well-established that both Cognitive Behavioural Therapy (CBT) and Psychodynamic Therapy can be effective within group settings (e.g. McDermut, Miller & Brown, 2001; Burlingame, Fuhriman & Mosier, 2003) there has been little research on the effectiveness of group CAT. Indeed, although the potential for CAT to be carried out within group settings has been specifically advocated within key CAT texts (e.g. Maple & Simpson, 1995), there is relatively little guidance available for clinicians on how the well-established, structured individual CAT approach should be adapted for groups (but see Duignan & Mitzman, 2004; Duignan & Mitzman, 2008). Hence, individual clinicians who are interested in developing CAT as a group therapy have on the whole needed to develop their own idiosyncratic approaches. It is likely that a lack of clear guidance on how to adapt CAT for use in groups, and a lack of evidence that this is something that is worth doing, is discouraging for clinicians.
This article presents reflections on one pragmatic approach to the setting up and running a CAT group within a community adult mental health service, with the aim of illustrating some of the choices and dilemmas made in order that other interested clinicians may learn from our experience and perhaps be encouraged to experiment with their own approaches.
Since qualifying as a CAT practitioner, one of the authors had been thinking about how to develop a CAT group for those people on our therapy waiting list for whom the therapy would be appropriate. Against a background of having run many CBT groups within the service, it was recognised that over the years the nature of the client population has changed such that we no longer tend to see those with milder or focussed difficulties, and often our patients now have more complex issues to do with their personality traits and interpersonal interactions.
In addition, during the last CBT group, discussion had digressed onto drawing a Reformulation diagram for the group (looking at how people reacted differently when faced with someone who takes on a controlling role relative to themselves). Within 5 minutes the group had developed a partial diagram to which most people could relate. We drew the different ways of coping that people used, whether that was self-harming, self-imposed isolation, etc. Most people contributed to the discussion at that point and it seemed to be a really good addition to the cognitive therapy group content. It also helped people to see the relational component of their difficulties more clearly, to realise that there might be a limit to how much the cognitive therapy could help when their difficulties were stemming from unhelpful interactions towards them, and how they could then start to conceive of changing.
The idea of running a CAT group to help people on the waiting list was attractive in terms of reducing the waiting list, as well as being a stepping stone for some people after they have completed some cognitive work initially. We envisaged that suitable clients who attended the cognitive group could have a few individual sessions to consolidate that work and then move into a CAT group. Although this may be common practice in specialist psychotherapy services, for us as a small Psychology sub-team (2.1 w.t.e. psychologists working into 3 CMHTs), this represents the best use we can make of our role and of trainees passing through our service.
People chosen for the CAT group were already on the waiting list for psychological therapy. Some people had been assessed using some ideas and terms from CAT, or indeed had a draft Reformulation diagram, from the initial appointment with the psychology service. Following the initial assessment people were either waiting for CAT specifically or for a cognitive group (or, for one person, whichever came first as both were thought to be useful).
The group was facilitated by a trained CAT practitioner and two trainee clinical psychologists on specialist CAT-informed placements. In addition to the benefit to clients, a major potential benefit of running the CAT group was for the trainee clinical psychologists to learn how to do diagrammatic reformulation with clients on the spot, which would also help them with their concurrent individual CAT cases.
We initially identified 10 suitable people to invite from the waiting list. However there was only a 50% uptake to our invitation so we ended up with just 5 in our group. This was a smaller group than we expected given the length of time people had been on the waiting list (over 14 months at the time) and had implications for the interpersonal functioning of the group. For example, we wondered whether this was too few a number for members to challenge each other comfortably?
People in the group variously had presenting problems of depression, anxiety, excessive worrying and reassurance seeking, obsessive compulsive difficulties, and unresolved issues from previous abuse experiences. Superficial perusal of the above broad diagnoses might suggest that, according to NICE guidelines, CBT would have been the therapy of choice, but individual assessment had determined that people’s issues were largely relationally based, and that for some, CBT had been tried previously and unsuccessfully.
The group was time limited and was mainly constrained by the availability of the trainees on placement. Originally we had hoped to run a 16 week group in order to more closely match the average session structure of individual CAT, but this had to be changed to 10 weeks to fit in with the University timetable. We considered the ethics involved in running a short course of therapy (e.g. whether such a group would be viable and helpful within the available timeframe for those with longstanding difficulties), but decided that the intervention still had the potential to provide benefit and that individual needs would be reassessed at the end of the course.
Unfortunately it was not possible to co-facilitate the group with any other trained CAT practitioner/psychotherapist as there are only a handful of trained CAT workers across the whole of the West Midlands. Working with trainee psychologists new to CAT presented its own challenges. For example, we were conscious of the impact that the trainees’ relative inexperience in the model might have on the group, and the need to strike a balance between providing a learning experience for the trainee practitioners as well as an effective intervention for clients.
Before we ran the group, we considered whether group members would benefit from having some individual sessions prior to the first group session first to draw up their individual reformulation diagrams (see Mitzman and Duignan, 1993). We identified pros and cons of drawing up a diagram either within the group or separately and individually. We thought that once group members realised the very personal nature of the diagram, people might feel uncomfortable “exposing” themselves in the group, to strangers. Similarly by drawing up the diagram within the group setting, people might not realise until after they had already shared their resulting diagram, the personal nature of the information it contained. The issue of client choice was highlighted as we explored the exact nature of informed choice and if this was achievable when people didn’t know what diagram they might end up with until after they had worked on it. Ultimately, we decided that we would not offer individual sessions before the start of the group. We decided this mainly for logistical reasons, but also because we thought that we would be able to sensitively handle the issue of personal exposure and consent within the group setting. We also thought that early sessions should enable group members to become comfortable enough to be able to share personal issues with each other, and that the extent to which the reformulation diagram reflected details that the clients were uncomfortable with sharing could be decided dynamically by the client within the session. However, we did provide group members with a copy of the Psychotherapy File before the first group meeting, and asked them to fill it in as best they could and bring it to the first session.
This was a group that focussed on the Reformulation and Recognition aspects (Ryle, 2002). We emphasised that it was likely that people would be going onto other things after this initial 10-week CAT group ended. We started off using a partly psycho-educational approach, explaining the CAT tools as we went along.
We found that early group discussion about the concept of Snags was very useful, and the group spontaneously gave many personal examples of Snags. It was helpful to have such issues out in the open from the start including, fear of change, of the unknown, of a loss of identity, etc. This helped with the promotion of choice, openness, honesty, ownership of issues and motivation for change.
In the first session, we devoted half the time going through the Psychotherapy File systematically page by page as an introduction to thinking about people’s own personal styles and patterns. However, this became somewhat laborious as a group task, and appeared to stifle spontaneity. Due to the unfamiliarity of terms such as Reciprocal Roles, we wondered whether clients were unsure about saying things in case they got things “wrong”, and initial discussions on this seemed particularly hesitant.
To help members identify Reciprocal Roles, we asked them to interview each other about their lives. This worked moderately well, but we later wondered whether more creative approaches may have led to a more productive discussion. For example, we thought about using the “six-part story” method (see Dent-Brown & Wang, 2004), which is a projective drawing technique used to help clients “show and tell” imagined stories (e.g. fairytale or cartoon-like) including elements of a task, obstacles and aids. Instructions for using this method can be found in Dent-Brown and Wang, 2004 (who also cite the originators, Lahad & Ayalon, 1993). We also considered that a form of “incomplete sentences” exercise could have been used, with clients asked to imagine one or both of the main caregivers from childhood speaking. Sentences could start with something like “women are..., men must..., you are...., you should....”. This technique, believed to be from Gestalt Therapy, helps people to look at messages from childhood and to unearth internalised voices (a summary of such projective techniques is to be found in Babiker, 1993).
This worked moderately well, however, we noted when people recorded their Reciprocal Roles in pairs that what got written down was dependent on the other person writing. Despite feedback from facilitators (e.g., repetition of something that could be a key word for a Reciprocal role), this was often ignored. We were then left with the difficult decision about whether to become more directive and ask participants to “write that down as I feel that is important”. In retrospect, we feel that a group exercise to help people think about the roles that they and others have taken would be useful, but that the actual identification of key Reciprocal Roles should be left to group facilitators to work more directly with participants to help identify such.
By session 3, we were uncertain about how we were going to help clients draw up their Reformulation diagrams. Should we go round in turns and help people draft up a diagram individually to work on? We were mindful that we recently heard of a CAT practitioner who had run a CAT group for 16 weeks who had drafted up diagram for clients after only two group meetings! (Ruppert et al, Jan 2008, ACAT conference workshop) and felt a pressure that it would be helpful to move participants to this stage as soon as possible.
A dialectical tension between how much to guide and direct versus how much we should let people find out things for themselves was ever present. We debated whether it was more important from a therapeutic point of view that the Reformulation be as thorough and accurate as possible, perhaps allowing people to take the majority of the ten-week course before they produced a Reformulation diagram for themselves, or whether it was more efficient to provide more guidance to enable clients to have a rough diagram by session 4 that they could then keep re-drafting for the remainder of the group. We opted for the latter, on the basis that Reformulation diagrams are by nature tentative and amenable to change as new information and new insights are gained, and also to help stimulate group thought and debate.
We encouraged participants to take their Reformulation diagrams home with them to consider and work on in-between sessions. However, one patient did not take their diagram home, and we did not realise why until this she revealed towards the end of the group that she felt she had nowhere private to put it, feeling that she had to share everything with a member of their family. This highlighted the difficulty in balancing materials used within the group and materials for participants to utilise personally, as the diagram had been drawn on large A-0 flipchart paper, and hence would have been more difficult to conceal at home.
We had difficulty deciding how to structure the group participants’ interactions; For example, whether people should work in pairs to increase familiarity with group members on a gradual basis, or whether that would lead to different people having different “secrets” about different people in the group which would ultimately hinder the beneficial aspects of working in a group. The issue was made more difficult in our group due to the small number of members, which limited the potential for smaller group conversations. After the second session we decided that dividing the group up within sessions was not desirable, and the rest of the sessions were conducted as whole-group interactions. In retrospect we feel that this might be the best model for future CAT groups, as participants were noted to become reluctant to talk about personal issues in front of the whole group if they had first discussed them in pairs. Also this whole group interaction would help people recognise each other’s Target Problem Procedures in the here-and-now.
We read out a Reformulation letter to the group as a whole at session 4. We constructed the letter as we went along, noting key points from the first 3 sessions. The structure of the letter comprised a paragraph for each person, as well as observations that were common to several members, and some general observations about the group as a whole (cf. Hepple, 2008). In writing the letter, we had to consider how to decide what portion of time and space would be given to each client, and what messages this might send to individual participants. In the end, one client did end up with a proportionally bigger paragraph, but this was largely because she had taken up a larger portion of the time within the group, as she had chosen to share about her abuse history for the first time to other people and group members acknowledged that this was an important step for her.
Group members all responded very positively to our Reformulation letter. They said that hearing such a letter was a new experience and highlighted the difference between this group and other groups that people had taken in the past. The letter was useful both as a reminder of some of the issues that the group had covered in the first three sessions, and also in helping participants understand how the facilitators and others within the group perceived their problems. We produced a similar letter at the end of the 10 week course, which was also reacted to positively. Group members were invited to present a letter of their own to the group at the last session, which two members did. As one of the members subsequently revoked their permission for the group letters to be published we have not included them here.
Over the 10 weeks, there was limited time to look at relational issues in the group itself. One man with an issue of being overlooked and neglected had his roles repeated in the group clearly and this could be discussed fairly easily and safely. Another client we feel did not draw a “true diagram”, preferring to use safer Reciprocal Roles and avoiding the main ones that were obvious to the facilitators who knew the client’s individual history. Another group member appeared to repeat the pattern of seeking reassurance from the others and this was recognised along with a tendency to strive to please.
Although we did not explore in great depth, here-and-now process issues as much as we thought we would, we wondered would it have been too frightening so early on in the group process, to try and draw out Reciprocal Roles and draft a diagram for what was going on in the group in the here-and--now to help people understand what we were aiming for in drawing the diagrams? With such a small number in the group the participants appeared to find it hard to challenge each other when there were differing views and this had to be actively encouraged and modelled by the 3 facilitators. Initially we were concerned whether 3 facilitators would feel out of balance for the group and whether there would be a “them and us” feel. Although this did happen to some degree, it was workable with and did not appear to be too damaging given the short lived nature of this group. Over the course of the group several personal crises arose, for example relationships ending, moving out of the marital home, etc. Group members were supportive and the common helpful factors of groups (see Yalom, 2005) seemed to be present.
Clinical supervision was obtained through peer supervision with other CAT colleagues. We discussed ethical issues of how much clients should have control of what is drawn up and shared in the group. Would people take to a more psycho-educational approach at the start in learning how to use the CAT tools and be open? Alternatively if people had to go in with their individually formed diagram and had to share then, would this not be expecting too much for people to reveal in front of a bunch of strangers.
Attendance at the CAT group was good, with participants attending 45 out of 50 slots (90%). Everyone who began the course also finished, there were no drop-outs.
After the final session, all participants were offered brief individual review/ follow-up appointments. Two clients went on to continue with individual CATs and two to individual CBT. One client was referred to a self esteem CBT group as he felt that the CAT group had increased his confidence generally and wanted to work more on this aspect. Symptomatically, he reported feeling better. The therapist impression was that for both who went on to individual CAT, the group experience had been very helpful as a starting point. One person was much more open to drawing up a diagram with roles that appeared to “ring true” and another decided to take ownership of the case for change.
Following the final group session, participants were asked to briefly feedback their experiences of the group using a satisfaction questionnaire. Two of the clients also fed back their thoughts and feelings to the rest of the group in the form of an endings letter that they produced. Ideas from clients to improve the group included ensuring that participants had problems that were more similar (i.e. selection on the basis of diagnosis rather than simple suitability for a CAT intervention); increased use of practical skills for coping with life problems; and a group format that encouraged more conversation, as there were times when discussions were quite stilted and uncomfortable.
We had planned to evaluate the group formally, including the use of tape-recorded sessions. However, tape-recording was unfortunately abandoned for logistical reasons. We drew up a consent form for clients to sign asking for permission to formally utilise data (questionnaires and group materials) as part of an analysis. Although all gave their verbal (and later written) consent, one person withdrew their consent subsequently for any of their material to be published. Therefore we have been unable to include all group materials.
We used the Symptom Checklist (SCL-90R), which is a standard outcome measure used within the psychology department, along with the Inventory of Interpersonal Problems (IIP-32). Both measures were administered pre- and post-treatment. Post-treatment data was only available from 3 out of the 5 participants, despite active reminding. Due to the small number of participants, it was not appropriate to conduct group or individual statistical analysis on the outcome measures. However, very modest reductions were noted for every participant for which there was outcome data on both the SCL-90R and IIP-32s.
Perhaps of greater significance as an outcome measure was the fact that of the four participants who went on to continue with individual therapy (CAT or CBT), two were discharged to their satisfaction within 12 weeks, and two group members who continue to receive therapy on a fortnightly basis are reported to be making excellent progress, where all were previously considered to be cases that would require long-term psychotherapy work.
The concept of Reciprocal Roles is a difficult one to grasp quickly. We feel that it would be useful to develop techniques to help people with their recognition and understanding of Reciprocal Roles. For example, we thought that it would be useful to have a general discussion first, with the facilitators noting key words before explaining idea of Reciprocal Roles, before then working with people, in small groups again or as large group, to think about how their words might fit with their particular Reciprocal Roles. Alternatively having some kind of “fill-in-the-blanks” task could be used, or having facilitators directly note key words for participant (e.g., sounds like you experienced your (...eg, one parent) as being quite critical? (draw ‘criticising’) and pole then, ‘what was that like for you?’).
We noted that the process of developing diagrams may occur in phases for some people, and facilitators should be aware of and accommodate this. In the first phase people may tend to choose issues and problems that are less directly relevant, as there is reticence to reveal vulnerabilities to the group. After a few more sessions, participants may respond to the suggestion that they begin a new, less avoidant diagram, and the learning process of reflecting on the development of the diagram may then be useful in itself.
Spotting patterns that group members are enacting within the group, in the moment, is one of the most powerful intervention strategies, and also feels very natural and a supportive thing to do. We believe that this aspect is something that should form the core of CAT-based group therapy, and that facilitators should be mindful to capitalise on opportunities to identify and describe such patterns as they occur.
We considered whether the group would benefit from the development and use of quite structured group materials. For example, we thought of using some pen and paper exercises quite early on, to help people get a grasp of ideas such as Reciprocal Roles and Snags/Traps/Dilemmas in a non-threatening way, e.g. through the use of neutral case studies. The fact that we did not use this approach was due more to the time constraints of the group we ran, and not because we thought they were redundant or irrelevant. In the context of a sixteen-week CAT group or longer, it may be quite appropriate to structure some of the early sessions in this way.
In retrospect, a piece of learning that we should have carried over from the experience of running CBT groups is that we ought to have more explicitly set up the idea of regular homework from the beginning of the group (e.g. the expectation that members would take their diagrams home and work on them in-between sessions). Some people chose to, but more often than not they left their work behind, so it only gets looked at within the session, which is obviously limiting. To facilitate this, it would probably be useful to encourage people to take things away by issuing them with a personal folder at the start, ensuring that they keep hold of all their work and handouts, and ensuring that tasks are set at the end of every session.
We feel that the early sessions of the group would be better handled without splitting off into pairs or small-group work, in order to develop better group cohesion and prevent the forming of “cliques”. It is also likely that a slightly larger group of around 7-10 people might have operated more effectively, and we would suggest that 5 people is probably too few.
On balance, we felt that we did not necessarily agree with the participants’ suggestion that the group should be more consistent in terms of diagnosis, nor focus on the learning of generic techniques for reducing stress or distress. However, we do acknowledge that it is important to be more explicit about the rationale and scope of the CAT group. From a clinician’s perspective, we felt that it would be useful for clients with different problems to interact and hear alternative perspectives on their difficulties, but clients may not have perceived the benefits of this approach.
Although the group achieved some progress within ten sessions, particularly with respect to thinking about individual repeating patterns of behaviour and their historical development, we feel that this is probably too short a time to develop some of these ideas fully, and that sixteen sessions would be a more viable timeframe. The brevity of the ten session approach was accentuated by trappings of CAT therapy such as the Reformulation letter at session 4 and discussions around preparing for ending which occurred around session 7, both of which drew attention to the small number of sessions remaining.
We remain unsure on the best approach to take with individual reformulation. By its nature it is easier and more effective to carry out in a one-to-one setting, yet this misses some of the vicarious learning that might occur from observing others reformulate their own problems. Essentially the problem lies in group members feeling inhibited in revealing too much about their personal problems early on in a group setting, yet ultimately feeling unsatisfied if their individual formulations lack detail (or, as happened, if they chose a “safer”, less relevant problem to formulate). We feel that this could be at least partially addressed by more active efforts to encourage group cohesion at the start, along with a more directive style from group facilitators at the point of initial reformulation. The use of more structured homework tasks in-between sessions might also enable participants to make better use of the group time, and also permit satisfactory separation of public and private issues.
The development and running of this brief 10-week CAT group seemed helpful to the group members themselves as well as being a valuable learning experience for the facilitators. Many lessons have been learnt from the way in which the group was presented, and hopefully these lessons will help inform the thinking of other clinicians who may be considering developing CAT-based groups for the first time. We feel that it is essential that experiences and reflections from the running of innovative new approaches to group therapy are shared amongst professionals in order to more efficiently refine and improve such interventions.
We are very grateful to Jason Hepple for sharing with us his draft paper on his experience of running a longer term CAT group. His experience was invaluable in alerting us to some of the above issues and in helping us feel confident enough to run such a group. Thanks also to Karen Appleby, Adrian Newell and Cal Nield for sharing their views during clinical discussions.
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