Cognitive Analytic Therapy in an Open Dialogic Group - Adaptations and Advantages

Hepple, J., Bowdrey, S., 2015. Cognitive Analytic Therapy in an Open Dialogic Group - Adaptations and Advantages. Reformulation, Winter, pp.16-19.


Introduction

This paper for Reformulation is an update on the model of Group CAT that we have been developing in Somerset over the last ten years. The basis of the approach is described in detail in Hepple (2012) and this paper hopes to tell you about adaptations we have made to the model since the group became an open group a year ago. The introduction of new clients, when spaces become available, has many advantages that will be discussed, but the obvious challenge is that the usual temporal sequence of CAT tools needs to be adapted because clients will always be at different stages in their experience of Group CAT. We will give a brief summary of the dialogic Group CAT approach before discussing the reasons for starting an open group and then the way that we have adapted the CAT tools and the challenges that an open group presents.

Dialogic Group CAT

We are calling our approach ‘dialogic’ to distinguish it from the more widely practiced briefer, more structured forms of Group CAT that have more of a psychoeducational feel, particularly when there is pressure to enable clients to experience the CAT tools in just eight or sixteen group sessions – this briefer approach is typically delivered in a closed cohort format, often with clients with similar presenting problems, for example, eating disorders or abuse survivors. Sometimes clients see the therapists individually for a ‘mini reformulation’ prior to joining the group or are expected to bring with them their CAT tools from their previous individual CAT.

The dialogic approach described in Hepple (2012) is a more principled rather than structured approach (and thus lends itself more to an open group format). The group allows clients to stay for up to a year thus giving more space to go with the material of the day, allow disclosure of abuse and trauma at different rates (depending on the ZPD of the client) and does not have an expectation that any previous CAT or therapy experience will need to be exposed in the group. This dialogic approach, like CAT itself, is a work in progress, but at the time of writing the headline principles could be described as:

What is known in the group

Only material shared in the group by the clients is discussed in the group and used to construct the CAT tools. The therapists are clearly obliged to assess the clients and consider material from the client records but this knowledge, or ‘surplus of seeing’ is not used to ‘ambush’ the clients in the group. ‘The most important aspect of this surplus is love… This surplus is never used as an ambush, as a chance to sneak up and attack from behind. This is an open and honest surplus, dialogically revealed to the other person…’ Bakhtin 1984

The issues of the day

Clients with histories of abuse and neglect will bring current relational problems like arguments, split ups, angry conflict and even episodes of violence to the group. The longer time frame allows current issues like this to be mapped and the whole group is able to offer support and advice from their own experience. The other clients are often able to say things that would seem critical and blaming coming from the therapists. This function has been very good for group cohesion in our experience.

Mapping, mapping, mapping

Maps are constructed almost every week based on recent events, enactments within the group or material disclosed from clients’ pasts. The same basic reciprocal role procedures are mapped again and again using new starting points. In the men’s group the recurring themes include rage, dissociation, social avoidance and isolation and fantasies of revenge. Clients at any stage in their group journey are able to contribute to and share a simple map if they can find a common experience in their own story.

No pressure (but when you’re ready)

We explicitly say that there is no pressure to disclose or discuss material related to childhood abuse and neglect, although we actively encourage this in the group when clients feel ready. CAT makes a clear connection between past trauma and current problem procedures and we also emphasise the therapeutic effects of group as a witness and the transforming power of responsive understanding (Hepple, 2006). We extend an open invitation for clients to bring no-send or therapy letters. We also acknowledge when clients have been actively listening even if they have not contributed their own material on that occasion.

Past, present and future (exits)

There is a constant movement from current events or enactments to past causation and possible future alternatives. This is mediated mainly by mapping but we have learned to be opportunistic about adding exits and actively thinking about a different sort of future when a client is open to it. In an open group it seems a good opportunity for newer clients to see how others have found ways forward and maybe, to use a ‘snakes and ladders’ analogy, they can find a ladder with another client’s guidance.

An Open Cat Group

It seems easiest to list what we see as the advantages of moving to an open group format followed by some of the challenges and opportunities for adaptation of the CAT tools.

Advantages:

• Service/client friendly – Referrals do not need to wait for the next group cycle. Clients can be assessed or introduced when there is space.

• Security – The group is less vulnerable to clients dropping out and other clients feeling abandoned and unsafe and then managers questioning the value for money aspects of the group, as new clients can be added.

• Group like life – In life people are at different stages of the life cycle; there are generations and we learn from the experiences of others ahead of us.

• Group history – After a while an open group develops its own history and becomes something bigger than any particular group of clients and therapists. The voices of clients who have left the group can be remembered and in this way that current clients may also begin to feel part of the history of the group.

Challenges:

• How to adapt the CAT tools to an open format?

• Introducing new clients to a bonded group.

• Helping clients to leave after the agreed time even though the group continues.

Adapting the CAT Tools

Reformulation

We have moved to a staggered mini-reformulation approach which seems practical and does not lose the narrative re-telling opportunity that particularly suits some clients. We tell clients that we will write, and read out to them in the group (with their consent) a reformulation letter based on what we have learned about their past and present difficulties from what we have heard, and experienced, in the group. We explicitly ask clients for clarification of their material in the group when we are working on their reformulation. The end result takes the form of a ‘meaty procedure’ which combines an element of empathic re-telling with a problem procedure that has surfaced in enactment within the group. A fictional example will probably demonstrate what we mean:

Dear Andrew

This is the Reformulation letter we have been talking about in the group. We hope that it summarises some of the issues that you have brought to the group and makes links with what has happened to you in the past. Please feel free to make any changes as this is only a draft and starting point.

You came to the group because you had been feeling ‘burnt out’, depressed and suicidal. It was brave of you to tell us about the time you took an overdose and were found accidentally by a friend. It was moving to hear how sad and alone you felt, with nowhere to turn. Despite all this you have managed to keep working in your job as a plumber but the stress of being self-employed means that you are constantly ‘spinning plates’ and running around in circles to please your clients and avoid criticism; but this ends up with you feeling exhausted and resentful that, at the end of the day, there is no one there for you.

Thank you for telling us about your childhood experiences. Your mother seems to have suffered from depression and was often in a world of her own, leaving you, as an only child ‘staring at the wall.’ Your father left the family when you were seven and told you that he would not be seeing you again as he had a new family now; even though this was in the same town. It was very sad to imagine this little boy trying to please and be accepted but being faced with such rejection and neglect.

From this experience we have seen that you have learned to expect no emotional support or love but have never stopped trying to please in order to be accepted and show that you are something and someone and not ‘non-existent’ as you often feel. This struggling alone has led to depression and resentment and ultimately to the overdose. In the group you have been keen to please the therapists by delivering your outcome measures even if you cannot attend the group or have to leave early due to a client’s demands. But, because of all these other demands on you, you have missed a lot of the group and sometimes you have seemed on the edge of the group; a face who wants to fit in but does not feel welcome. Maybe like the way you felt with your father and his ‘new family’?

We hope that the group can continue to make you feel welcome and that by giving support to other group members you will feel both valuable and valued.

All our best wishes.

Therapists

Maps

As discussed above, mapping is the mainstay of the way CAT signs are generated in the group. Reciprocal roles are introduced each time a map is drawn. Copies of the maps are offered to the client’s to take home and often clients photograph a map that is meaningful to them on their phone. 

Recently we have spent time ensuring that clients have an individual map that they are happy with (that includes exits) before they leave the group. On a few occasions we have successfully split the group into pairs to give time for clients to work on their individual maps. The therapists hover and intervene as necessary. This small group work has felt very creative and engaged but can only be done at a time when there are not pressing issues of the day. Sometimes we have explicitly asked to work an individual’s map in the whole group if it seems that they have not had enough focus given to them. It is an aim for each client to present their map during their last session.

Goodbye letters

An open group allows more focus as the individual client who is leaving that week. The therapists will write a short goodbye letter to the client and read this out between them. Other clients are invited to say their own words of goodbye, but clients will rarely prepare this in advance, so we are intending to invent a stock of ‘art postcards’ so that, as an in-group exercise, clients can choose a card and write a short message to those leaving. ‘What would you like to say to X as the train leaves the platform’ is a possible prompt. The client or clients leaving may like to write a card to the group in the same way or could be asked to do this in advance in a more traditional letter form. The form of the goodbye letter probably depends on the style and ZPD of the client. Some clients will just want to say some words.

Other adaptations

Introducing new clients

It can seem quite daunting introducing new clients to an established group. Thought needs to be given to timing and trying to maintain numbers around seven with a range of say five to ten. So far we have introduced new clients in pairs and given advance notice to the existing group members. Generally the existing members have been very welcoming and remember that they were once in the same boat. There is a difficult issue around the starting cohort of a new group as they are all technically due to finish at the same time, but it is fairly inevitable that some people will leave for both positive and negative reasons during the first year, allowing the next generation to be gradually added. At the end of the first year of the open men’s group we will have four leaving on the first anniversary with four remaining and two due to start.

Helping clients to leave

It probably is important not to extend the year for anyone in the group as it would likely become increasingly difficult to keep the boundary. Leaving dates are referred to in a list kept in the mapping book so that there is no doubt. Talking about the ending, as usual, is important as is helping the clients think about the next step, what arrangements they may need to make, some discussion between the therapists and care co-ordinators and the future direction of their life in the light of the map and the exits. Hopefully for many, the future will not involve mental health services. Followup attendance probably wouldn’t work as they may be coming to report back to a group of strangers, as the make-up of the group may have moved on a lot in three or six months.

Conclusion

We hope that this paper will help you to think about the way you might run an open CAT group. There is a feeling of security knowing that the group is an on-going project without an end-date (and it is good not to have to constantly have it recommissioned), and it is very popular amongst referrers and clients as clients can have access to the group when they are ready and without a lengthy wait. The idea and therapeutic intentions of the group become part of the culture of a service after a while as it rolls forward as a central feature of the services for people with more complex needs. It creates an atmosphere of hopeful, patient and in-depth therapeutic work that is often needed in public sector services.

References

Bakhtin, M., M. (1984) Problems of Dostoevsky’s Poetics. (trans. and ed. C. Emerson). Minneapolis, Minnesota: University of Minnesota Press.

Hepple, J. (2006) The Witness and the Judge, Cognitive Analytic Therapy in Later Life: the case of Maureen. The British Journal of Psychotherapy Integration. 2(2): 21-27

Hepple, J. (2012) Cognitive Analytic Therapy in a Group. Reflections on a dialogic approach. British Journal of Psychotherapy 28(4): 474-495.

Full Reference

Hepple, J., Bowdrey, S., 2015. Cognitive Analytic Therapy in an Open Dialogic Group - Adaptations and Advantages. Reformulation, Winter, pp.16-19.

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