Mulhall, J., 2015. A CAT Informed Approach to a Time-Limited (Closed) Group within an Adolescent Inpatient Setting. Reformulation, Winter, pp.20-28.
Like many people who undertake therapeutic work, I enjoy the professional challenge of trying to connect with those who seem lost, adrift, struggling and damaged. The relational world of an adolescent can arguably be as complex as any person, and is often characterised by extreme ambivalence-especially towards things that may be considered helpful or useful to them, by others.
Over the past three years I have practised full time as a CAT therapist within a tier 4 adolescent inpatient NHS CAMHS provision. Whilst I would like to think I have always tried to be realistic about what can be achieved therapeutically, this experience has really demonstrated the absolute need to “Cut your coat according to your (contextual) cloth”. In this setting (for reasons explained within this paper) I have to acknowledge that it is unlikely that I will be able to work with someone either individually or within a group for 16 sessions. I have to accept that circumstances surrounding their difficulties; for example, admission, ward life and discharge are likely to make achieving a consistent therapeutic alliance precarious. There is a distinct need to postpone what you might have in your minds eye (what you might want to do) and get on with what is practically possible, and what might just be helpful enough. This might be viewed as situational or contextually- influenced CAT; how to move forward and feel scaffolded by CAT understandings and approach in the face of many service and patient group constraints, which arguably dictate the clinical territory.
Group CAT and the clinical issues surrounding the dynamics of this have become of real interest to me and I have had the opportunity to explore this more as the topic for my dissertation during the IRRAPT training. In that document I wrote about the journey of setting up the initial cycles of this group. Since doing this, the group has now been through thirteen cycles of this six week intervention; 56 patients, 78 sessions, 117 clinical hours. Much has been learned along the way, but this paper will focus on the following: i) setting the scene for the need for adaptation; ii) discussing interesting contextual limitations and inpatient dynamics that influence this; iii) describing and exploring CAT informed group therapy ideas, and exploring a specific CAT informed structure and approach which can be clinically appreciated in this particular type of setting. It may give other practitioners “food for thought” for adaptations in their particular contexts and settings.
This 6 session intervention does not seek (necessarily) to be a standalone treatment, or indeed rival or replace individual (CAT) therapy. Groups are acknowledged as part of a balanced (inpatient) therapeutic diet (Carrell 2000), and perhaps may reach some places where individual therapies cannot (Ruppert et al. 2008). Within this brief intervention, during momentto- moment interactions (Levitt et al. (2006), the focus of the therapists is to perhaps sow “relational seeds” and enable pennies to be put into the “relational piggybank”, where the benefits might be noticed and drawn upon further down the line (perhaps similar to “sleeper effects” (Reid & Kolvin 1993:49).
I find it interesting, as I prepare myself to compile this paper, that my mind wanders to thoughts along the lines of; “ what will my contemporaries make of this clinical work?” Then perhaps my own roles and procedures come into dialogue and say something like; “I fear some might be unfairly critical if it doesn’t strike a chord with them”.
Perhaps those who practise outside of the more mainstream areas of recognised CAT practice are more likely to carry some of these questions and doubts? I don’t think that I am the only practitioner of CAT to hold these thoughts. Youth CAT debated the question “What constitutes CAT” ( within a CAMHS context), at their study day last year, (Mortlock 2014:37). Practitioners in the field of intellectual disabilities voiced concern that some of their clinical work might be viewed as unlikely to be “real” CAT by some of the wider CAT world (Crowley et al 2014:6). When thinking about CAT and groups, practitioners have debated similar questions; “What constitutes a CAT group experience?” (Anderson 2009). I notice that at this year’s forthcoming ICATA conference in Greece, Steve Potter and Liz McCormick in their video poster will be raising the question; “What is and is not CAT, and who decides?”. It is natural that practitioners will hold differing views on whether CAT is; a treatment model, a way of thinking, an approach, an understanding? Perhaps it is a bit of each and our position on this is influenced more by our working contexts and situations?
In therapeutic conditions where the context and setting can be so influential , in order to practise well, one has to feel held by the understandings of their therapeutic and theoretical foundations. Once your (CAT) eyes and senses have been initially stimulated, nourished and awakened by exposure to all that the CAT model and approach offers, practitioners then continue to move forward and look to widen their CAT eyes and deepen their CAT senses. This then instinctively becomes a main lens and understanding through which one tends to try and make sense of the relational world that happens in and around us.
Once your therapeutic and theoretical mind is attuned to seeing the world reciprocally, relationally, procedurally and integratively, it becomes natural for your CAT eyes and senses to observe and respond to things in a CAT informed way. So whilst this paper discusses a 6-session CAT intervention (which doesn’t use too many unadapted recognised CAT and therapeutic tools, but which responds to all manner of group relational communication and behaviour through a CAT lens and understanding) - then surely this is CAT, and CAT practice?
For example, if during an icebreaking activity we ask participants to think of a superpower that they might wish to have, and they say “to be invisible by merging myself into the wall and disappearing from sight”, we can ask them; “What usually happens to evoke this feeling?”, “ How do you feel when you have become part of the wall, observing the other(s)?”, “ What happens when you are in a situation where you wish you could fade into the background, but can’t?”, and so on........ So an icebreaker isn’t necessarily just an icebreaker, it can start a dialogue into many helpful CAT areas-especially when another group member says “I feel similar to that sometimes, but it’s a bit different”...... And the dialogue continues.
Of course the answer to our noticing, enquiring and tentative naming could be......”it was just the first thing I thought of”......or......”I saw it in a film and thought it would be cool”. But we keep the possibility in mind, as a role or procedure. Again it can be really helpful when later in the group the young person who said this becomes quite absent in the group discussion or activity, and another group participant says: “Have you just disappeared into the wall again?” ......”Did we say something that bothered you?”...... And the helpful dialogue may find a way to be aired and explored further, or not. So, in these short term groups, relational opportunities are waited for, hopefully noticed, and responded to through CAT eyes and a CAT approach.
The group is set on the 15-bed generic ward within a 25-bed NHS inpatient adolescent unit. Patients might originate from some considerable distance from the unit. The age group is 13 to 17. 75% of patients stay for 12 weeks, the average length of stay is 9 weeks. Typical presenting symptoms and issues are; anxiety, low mood, depression, self harm, overdosing behaviour, OCD, PTSD, suicidal behaviour, eating disorder and emerging psychosis - a significant spread of difficulties, ages, cognitive abilities and relational experience. At any one point in time, several young people may be on a Section of the Mental Health Act 1983 prior to, or during, admission. The focus of the unit is to work towards a rapid stabilisation of the patients’ symptoms and situation so that they can be managed in the community and family context. The unit operates multi-modal care pathways. Each patient is everyone’s patient, which has its own strengths and difficulties. The group CAT that is described here is therefore a small part of an overall therapeutic package.
Patient, unit and ward dynamics common to (adolescent) inpatient work
I am sure that every inpatient unit has its own particular dynamics relating to the reciprocal role repertoire of the predominant theoretical influences of that unit, and the experiences and motivations of its staff and ever changing patient group. This can have both helpful and unhelpful influences on the already challenging therapeutic task in hand.
Patients have often been admitted from families that are under great strain at home and often a role of hopeless to helpless shrouds the young person when they are admitted. They fear judgement, a role of judging to judged and condemned. Life in the community can be chaotic, which often elicits a guarded and mistrusting role. Many have roles in line with rejection, abandonment and being dismissed. Connecting with these patients is fraught with difficulty and, as could be expected, they can be quite arbitrary in who they choose to relate to, often as the result of/in reaction to a difficult mental representation/ internalisation of a parental figure. They come in to a setting that is quite controlled (locked doors), with a structure and expected routine. Their response to this control is often defiant refusal and resistance. Young people can often seem anxious and overwhelmed in response to these overwhelming circumstances. Mackenzie (1990:33) discusses general systems theory and suggests that inpatient settings can give rise to a dynamic that is often hard to fathom. By definition, Tier 4 inpatient cases are usually the most complex. Young people are admitted in a crisis, usually after making an attempt on their life. Soon after admission, although patients might find themselves in a setting where they might find some containment, they also enter into a controlling to controlled, and being cared for general dynamic. At this time many young people are not sure how they feel about survival and negotiating the immediate future. The ward dynamic (15 patients plus staff) can often take over and become the focus of their relational efforts. Ryle (1995) suggest that most role enactments are in response to issues of care, control and vulnerability. Inpatient admission understandably seems to push associated states and roles to the fore.
When describing “universality” in groups Yalom (1985:8) reports that the phenomenon finds expression in the cliche, “we are all in the same boat”, or perhaps more cynically “misery loves company”. This is a helpful backdrop to try and make sense of the layer upon layer of enactments and communications inherent within inpatient work. Misery loves company, or better still-unhappy company (and you feel a bit better because you have it). One might say pathology loves companyespecially pathological company. This is an inherent problem that settings like this are up against. Therapy is anti-pathological (insofar as it aims to de-pathologise the patient, and open up the possibilities for more conscious positive choice), but positivity usually gets trumped by the negative and pathological in the ward milieu and group sessions. The push towards health and pull towards pathology is a permanent underlying tension. The more potentially healthy the subgroup might become, the more the big group will tend to pull them back. On the one hand patients are desperate for staff to make them better, on the other hand despair says that “you don’t know and will never understand”. On the surface they will often oppose staff (defiant refusal, rebel, resistance) in response to control but the unconscious dialogue might sound something like;” you are trying to help me,.....I am driven to stop you,.....but I want you to help me,.....but don’t” - self-states which depict the push and pull of hope and despair.
All of these relational dynamics significantly challenge the employment of more conventional approaches towards collaboration and establishing an independently grounded therapeutic alliance (but the subconscious wish for its existence is often undeniably there).
Group work, and therapeutic work with adolescents
“For a variety of reasons, attempts to get adolescents to open up are often met with resistance” (Vernon (2002:6). Carrell (2000:1) warns that adolescents are “fearfully fascinated” with their peers, “peer interaction is what they most desire, yet most fear”. The group work challenge is to conceive activities that will enable adolescents to disclose emotional material that is otherwise difficult to express, to open emotional doors in a safe and non-threatening way.
Reid and Kolvin (1993) also discuss the importance of activity, as young people are more likely to reveal themselves through activity rather than just through discussion. They posit that existing research demonstrates that young people with a wide range of problems can make use of groups. Perhaps most interestingly, Reid & Kolvin (1993:49) discuss “sleeper effects”, the delayed effects of therapy, with some young people making positive improvements 18 months after treatment. This suggests that positive processes had perhaps been set in motion by the therapy but were not evident during the time-span of the active group-work.
Commentators suggest that time-limited groups usually exist for higher functioning individuals, and usually to address a specific problem common to all participants (Yalom 1985, Mackenzie 1990). However if the situation dictates, and the patients are aware and prepared for the limitation, it can still be helpful and worth doing (well).
Group CAT contribution
A number of commentators describe a group CAT structure which broadly corresponds with the one that is routinely offered in individual CAT therapy: Mitzman & Duignan (1993), Maple and Simpson (1995), Stowell- Smith et al (2001), Ruppert et al (2008), Carson and Potter (2010), Hepple (2013), Murphy & Dhaliwal. (2013). (I am aware that many more group CAT examples exist and are practised, but are perhaps yet to be discussed in papers.)
In slight contrast, John & Darongkamas (2009) describe their running of a brief 10-week group CAT. Both reformulation and goodbye letters (group, as opposed to individual) were written and read out to the group in a “section per patient” style. This paper also discussed the (possible) use of CAT informed activities (eg six part story method) to help group cohesion, and the potential power of using enactments in the group as both a CAT education opportunity and a focus for intervention.
At the 2012 ACAT conference I attended two interesting group CAT workshops. Boyd and Pennycook (2012) described their 6 session group CAT with adult patients with eating disorders. Nick Barnes (2012) presented his 12-week programme of CAT informed work with socalled hard-to-reach adolescents incorporating the use of football.
Six part story making (6PSM)**
6PSM is now a recognised tool for CAT practitioners. Dent-Brown (2011) describes 6PSM as a projective technique using structured instructions to help a client create a new, fictional story which can be used in psychotherapy assessment and treatment. The newly created story demonstrates the way the client habitually perceives or reacts to the world, and builds on the way that this kind of communication by metaphor is useful in psychotherapy.
Something within each of these papers enabled me to think that there were ways to conceptualise and deliver a brief CAT-informed group intervention to this patient group within the constraints and dynamics of the setting. Learning from experience, the group has now developed to run in the following fairly consistent format.
Broad current structure into which the group has developed
Patients are selected in terms of them being; mid stay and settled, psychologically ready to cope with the group, unlikely to be discharged mid group, and reasonably compatible. We then meet with the selected young people briefly on the ward together to discuss aims and expectations (we hope that they might be able to identify and focus on one particular problem area within the group), and explain how the group might run. We also give them these details in the form of a letter (including dates and times), which is also copied to their carers. This also includes a list of (helpful) comments from previous attendees, for example,
“It had meaning, I felt understood, I got things out which helped”
Session 1, Explain the group again. Discuss and agree ground rules.
The focus for the entire session is icebreaking – getting to know one another. We encourage participants to ask questions of one another, and we model curiosity. Where needed, we suggest questions of varying intensity, for example, everyone’s favourite chocolate bar, or would be superpower. Everyone is encouraged to ask the group a question, and answer questions from others.
A big box of a plastic animals and similar relational objects are emptied on to the floor. We then encourage participants to handle and “get amongst” the materials. An animal/ object is then chosen to represent ourselves in some way, and discussion about this is encouraged.
Session 2, Re-cap and remember what was learned in the previous session.
Introduce and undertake the 6PSM. Explore the stories together. Be mindful of reciprocal roles and procedures. Tentatively name and suggest possible connections. Assess what they make of this potentially revealing activity.
Session 3, Re-cap and remember what was learned in the previous session.
Assess where the group is at (guide towards thinking more about relational self and discussing a problematic area). Gauge the group ZPD (Vygotsky 1978), and where they might be able to therapeutically go. Either, explore the 6PSM some more, or, utilise another activity as a bridge to identifying and discussing links to a problem area.
Session 4, Re-cap and remember what was learned in the previous session.
Explore commonalities within participants problem areas and how they manage things. Empathise with how the unhelpful pattern came to develop - model mapping the problematic procedure.
Session 5, Re-cap and remember what was learned in the previous session.
Think as a group about how procedures come about and become nestled. Encourage the group to think about possible; alternatives, change, conscious choice, exits and solutions. Explain goodbye letters.
Session 6, Re-cap and remember what was learned in the previous session.
Read, (sometimes compile) goodbye letters. Encourage reflection on progress and links to the group experience. We have developed a couple of “goodbye rituals”. Firstly the therapists remember, purchase and share participants’ favourite chocolate bar (a thoughtful surprise). Secondly, everyone writes a final goodbye message on a cardboard cut-out animal (remembered) from the first session (another transitional object from a positive relational experience).
Roles of Activity based relational activities utilised within the groups
6PSM has come to be the central and consistent first activity after the icebreaker session (session 2). It has rarely failed to bring something helpful and relational to be noticed and named in the group, even when it is a person’s self-doubting object relation and procedure towards the task - for example their belief that they can’t draw or be creative. However, more often, the group notices how the task reveals something interesting, personal and hard to be denied about the subject. As with most activities we suggest in the group, participants are adept at turning our suggestions into something that they may find more useful, as their idea instead (perhaps a characteristic of adolescence?). However, we are more than happy to follow their helpful to helped lead and notice and negotiate the communication and dialogue that starts to flow. Several groups have then suggested a storyboard method to both communicate and express other serious and immobilising relational struggles in their lives, through a sequence of words and pictures. When the situation seems right, the group might then suggest links between past and present difficulties, then discussions about reciprocations and procedures can start to emerge and flow from there. Some groups have been very activity driven (keeping busy to avoid anxiety and demands?), whilst others have put the activity materials down, asked for the tea and chosen verbal dialogue as their way forward (and everything in between). We have found that virtually all materials need adapting to some degree so as to perhaps come “through a side door”. We have regularly tried to use some formal CAT tools such as the psychotherapy or self-harm files. So far most groups have found this too “in your face” (overwhelming to overwhelmed) and this can lead to them rejecting the activity out of hand. We have found ways to utilise ideas and information within CAT tools, usually by turning them into some sort of recognition- based activity. We have made adaptations from existing relational therapeutic materials (eg Margot Sunderland 1993), and devised many simple relational and reciprocal ideas from our own professional experience. For example; represent self (and others) as; a tree, a ball, an animal, a country, any object they wish - then discuss. Also questions such as: “What roles would you be likely to take on in an expedition?”, or perhaps suggestions such as “Visually represent the people who are close, or distant to you!”. All of these activities once explored can then focus on change and exits via shaping exercises (contemplating change, in stages).
Animals, puppets, craft materials, papers and pens are always available to assist this relational exploration and sign mediating group activity. Group ZPD is always a main consideration in order to “push where the group moves” (Anderson 2009). Moment to moment dialogue and interactions, and seizing the moment as it happens is key in this CAT approach.
Patient letters and feedback
From the very first cycle, the group facilitators wrote a CAT style goodbye letter to the group which contains a specific section per person, and an overall group section summarising the experience- like an “enriched” goodbye letter. The facilitators have always encouraged participants to write back. We have had all manner of responses ranging from; nothing at all, to a letter that mirrors a CAT style, to encouraging letters largely addressed to fellow patients. In addition to letters, feedback was sought from patients at the end of each session (Miller and Duncan 2000). Examples from both forms of written feedback are reproduced (with permission) below;
“ Throughout the strange situation that in the “real world” we would never have been put in, we have all bonded and learned something about each other, and most importantly, ourselves”.
“I’m not a massive fan of groups in general, but this one was definitely alright “.
“I felt like I could relate, and that I wasn’t just a depressed freak”.
“I liked getting to know you all a lot better and “fortunately” I felt comfortable enough to open up and share things with you which was very beneficial (so thank you). CAT is good”.
This gave us the confidence to continue with what we had started.
“You are not alone, trust more. The group was difficult when it was really serious, but it came at the right time for me. It helped people to get closer, don’t change anything”.
“It was hard when we did the serious bits. It went from not serious to serious feelings. It was good to see other people get through it too. Just because you’ve been hurt in the past it doesn’t mean that others will hurt you. Trust people. The number felt safe, closed groups feel better. We have similar problems”.
“it helped me reach out and say stuff that i usually wouldn’t to a therapist, and definitely not to my peers. It has shown me the value of opening out to people. I think it’s helped, it has helped”.
“the storyboard allowed me to express myself in drawings instead of talking”.
......When I was first invited I thought it would be shite. But actually I’ve really enjoyed it. It’s the best therapeutic group I’ve done....... I can understand you all and myself a bit better now.....
...... This group seemed like a stupid idea at first...... But after a few sessions I understand why we do smaller closed groups...... It not only helps patients on the ward get to know each other...... It helps us get to know the therapists and more approaches to take in the long run...... You are all Fabbi and although I seem to hate the group, I’m going to miss it!
...... You have been very helpful in closed CAT with all of your therapist analytical speech and ironically funny wording. I wish you all the best of luck trying to get me to talk in therapy. Thank you for inviting me to closed CAT, it was much better than I expected......
3) One patient’s whole observations of other group members;
(Of patient A)...... You have come a long way since our first CAT session. Before you were quiet and unwilling to participate much, but since then you’ve become one of the most talkative and funny people there. You are very gifted in making people feel comfortable in a given situation, and we can always rely on you to make the atmosphere happier...... I will miss you a lot.
(Of patient B) ...... I know that CAT group has been fairly difficult for you and I am impressed with how far you have come. Although you were mostly quiet and shy, I think that you’ve been a very valuable member of our group. You have a lot of intelligence and interesting things to say, and I hope that the group has made you feel more comfortable in expressing yourself...... Good luck, and I will miss you!
(Of patient C)...... I feel that you and me were always on the same wavelength in our sessions. We could relate to each other a lot, and we always had fun looking out of the windows and laughing at people going past. I think that you have become more confident and sure of yourself through the CAT group. You seem much more brave than you were before, and I think that you have more of an understanding of your problems now, and how to overcome them. I hope that you take something positive from here, and get discharged soon! I’ll miss you!
(Of the facilitators)...... I am very grateful for all the things you’ve done for us over the past six weeks. You are organised and help make us feel more comfortable...... I’ve always loved your enthusiasm in every group. You’ve never once lost interest in us or became boring......
4) Excerpts from a whole group;
......I don’t really know what to say about this group, since I’m never really sure about anything. But I guess it’s given me chances to ask questions I’m too scared to ask anyone else...... ......
We have discovered a bit more about what makes you feel the way you do and how we can help you and what you have to do to help yourself..... I know you don’t believe you’re clever, but you are.....
...... I will never forget how kind you were towards me that week when I wrote my cycle of my life. I really appreciate your hug you gave me, it made me feel a lot better. I’ve loved the topics you’ve come up with over the last six weeks and hearing what you think about......
......CAT group would always be something I looked forward to as it was the only place I liked to come and talk about how I felt. I opened up more in CAT group then I do to anyone, I will definitely miss it. Thanks for everything......
..... I am worried about you, as much as you try to put on a brave face, I know things aren’t quite right. Try to let people in to help you. I know it’s difficult to take down the walls in which you protect yourself, but instead you should build a bridge to meet people halfway.......
.....thank you for running this group and putting up with all our behaviour.
Summary and Discussion
1) 4 patients is the optimal number for this group. It allows all participants the therapeutic space and safety which it is felt they need, and avoids too fertile a ground for the formation of an anti-group (Nitsun, 1994).
2) 6 sessions is an optimal amount of meetings to ensure maximum attendance. This allows the therapists to synchronise sessions with school terms and to avoid losing so many participants to discharge related issues.
3) 1 1/2 hours is an optimal amount of session time. Incorporating a drink and snack break is also highly useful.
4) The whole icebreaking session is clinically important, avoid the temptation to shorten it.
5) Complete questionnaires and feedback within sessions, they often do not return and lose their poignancy to the patient once the moment has passed.
6) Group CAT adaptations are likely to be contextually necessary, and things learned along the way should continue to be reported, discussed and shared.
7) Feedback indicates that young people do want and benefit from relational group work (despite their fears). If there is a need for this, why not adopt a CAT approach to inform it, and offer it in formats of varying duration and intensity according to the contextual and situational constraints?
8) Group CAT therapy in the “here and now” is not to be underestimated. I once heard it said that “nothing ever happens”, (or, “something always happens”!), and, that “no good experience is ever wasted”. Faith in this inspires me to believe in sleeper effects, especially with this patient group.
9) Overall, whilst this particular group CAT approach arose out of a necessary contextual adaptation, feedback suggests that it is a potentially helpful and meaningful relational experience for this often hard to engage and connect with patient group.
I would like to thank all of the young people who have attended these groups and been willing to offer their feedback, and consent for their comments to be shared. I would especially like to thank Dr Kate Furnish for co-facilitating the groups and for helping to develop ideas and practise. Without her commitment and enthusiasm it would have been difficult to get this group up and running. Thanks also go to Louise Watson and Lis Bakes for the groups they were involved in co-facilitating. Finally, I would like to thank Hilary Beard, Hilary Brown and Françoise Hentges for their encouragement (and ideas).
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