Barnes, N., 2015. Reaching Out – A Journey Within and Alongside CAT. Reformulation, Winter, pp.30-32.
Reaching Out – A Journey Within and Alongside CAT
Having attended the “CAT at 30” conference in Autumn 20141, I have to confess leaving with almost a sense of relief, and if not relief, then certainly with a greater degree of clarity about where others in the field felt CAT was heading. The conference had been called to reflect on the history and development of CAT over the last 30 years, but also to explore current evidence base for CAT and the future use and applications of the CAT approach in individual, group, family and contextual or team-based settings. Discussions highlighted the need to find ways of using CAT so that the thinking and theory come to forefront in CAT’s contribution to the fields of mental health, psychological support and wider societal challenges. But there was also room for the focus to be not entirely driven by the need to prove, through the holy grail of a randomised control trial, the therapeutic efficacy and validity of CAT in comparison to the growing range of brief therapeutic interventions. Rather, this conference seemed to allow attention to also be directed more on the essence of our practice and thinking: that we have a coherent integrative model that allows for an understanding and realisation of “relational mental health”.
For me, the relief came from feeling that this conference allowed me permitted me to feel that I could continue to explore using CAT within a wide range of settings – seeking to push the boundaries of where, when and how we might be able to offer opportunities for change, but held together by a core understanding of CAT theory and its capacity to offer this fundamental relational perspective of mental health and emotional distress.
When thinking about my own practice and development within my service, an Adolescent Outreach team (part of Child and Adolescent Mental Health Services - CAMHS) CAT has clearly provided a framework (scaffold) and underpinning (foundation) to so much of my work. From individual work with young people, to working with parents, from offering consultations to services and networks to working within groups; all have probably been informed by my own understanding of the practice and theory of CAT. CAT is an approach that has resonated well with many of the young people and families with whom I have been lucky enough to work. But it has been the adaptive nature of the model – and in particular the collaborative nature of the practice – that has allowed me the chance to use CAT, or CAT informed practice, to “reach out” and work with young people in settings beyond the four walls of the clinic.
Over a series of three short articles, in this and future editions of Reformulation, I shall be seeking to discuss some of the features of this exploration, and subsequent service development, over the last few years,in the hope that it creates the space for a wider dialogue about creativity and innovation within and alongside CAT. It is perhaps through this dialogue that others might also feel free to explore how they might be able to adapt the tools we have available to us into something that works within their setting and practice – for their clients and communities.
Working within a Child and Adolescent Mental Health Service
Often working within a CAMH service (although this is by no means exclusive to CAMHS) there is a need to where “multiple hats” – often being impossible to work within asingle modality. At one moment you might be a therapist, working 1:1, at another moment you might be a psychiatrist (and prescriber of medication) and on other occasions you may be offering to work with the whole family. The practice is often eclectic and requires clinicians to think creatively to try to address need – a need which is becoming increasingly appreciated across the country2.
Over recent years there has been a heightened awareness of a “national crisis” regarding care and support for children and young people’s mental health and emotional well-being 3. There has been a realisation of growing levels of need which has been sitting alongside a recognition that past expenditure on and provision of services has been woefully insufficient. Perhaps being able to generate a cross party political consensus on the need for increased funding for young people’s mental health during the 2015 general election, despite campaigning within the economic paradigm of the case for “austerity”, goes some way to illustrate the magnitude of this crisis.
However, this appreciation of need has also allowed for closer inspection of what is being offered and provided through current services and asking whether the present model of Childand Adolescent Mental health services is “fit for purpose”4. The previous Minister for Health and Social Care, Norman Lamb, talked about the need for a total overhaul of children and young people’s mental health services, highlighting the sense of chaos and “dysfunction” that can exist when there can be four separate agencies involved in commissioning these services (Local CCGs and wider NHS bodies, Local Authorities,Education and Employment) . Many of the services provided are felt to be “working in the dark ages”,whilst others are simply unable to cope with and address the demand.
The prospect of further change in service provision will always be received with caution, but if we are to offer something for children, young people and families that is accessible and meaningful to their situations and circumstance, then we need to be fully involved with young people in re-developing and re-designing these services, and CAT has much to offer in this process.
For some families, the idea of engaging with mental health services is frightening and raises a number of difficult and complex issues. Not only might there be issues regarding mental health stigma, but also concerns about the prospect of diagnosis being seen as unhelpful “labelling” of children, as well as questions about whether a westernised perspective of family and distress is sufficient to understand and address emotional need within their own familial, cultural or religious contexts.
CAMH Services therefore need to become places for creativity and innovation, as they undergo much needed change. But if we are to bring about change for the better, then we need to ensure that the process is informed, understood and collaborative– and hence a role for CAT.
Stepping outside the clinic
Having initially started working as a Child and Adolescent Psychiatrist within a small, and chronically under resourced CAMHS team I have been repeatedly aware of trying to balance demand with offering something that appears meaningful and useful to young people and their families. My role has been predominantly within an Adolescent Outreach team, set up as a multi-disciplinary team, as well as having multi-agency involvement,which therefore had the potential to offer a perspective for integrated practice for young people (12 – 18yrs) with serious and significant mental health concerns. From psychosis to suicide prevention, from being stuck at home with OCD to severe depression, this team offers an intervention that can be adaptive and responsive to young people’s mental health.
But working within this team also gave me an understanding of what can be achieved within the community; allowing work to take place where the young person felt most safe - be this at home, school, youth centre or McDonalds. The concept of working Zone of Proximal development (ZDP)- “the gap between what a child is able to do alone and what he/she could learn to do with the provision of appropriate help from a more competent other, be they parent, teacher or mentor 5”– supported this outreach perspective, and the application of CAT theory, informed by the Social Learning theory of Vygotsky, suggested a natural progression in my own professional development. CAT seemed to be a model and approach that offered the necessary tools that could enable a safely scaffolded practice to evolve outside of the clinic and become more embedded within the community.
Building my own foundations
Given the type of work that we were offering in the outreach team, it is not surprising that I found myself being repeatedly drawn back to CAT as a therapeutic treatment for some of the young people referred to this service. The studies by Chanen etal 6 in Australia are suggesting how useful CAT could be – especially for those young people who were on a trajectory towards a diagnosis of Borderline Personality disorder. This particular cohort of young people cause considerable worry and concern to services and their families,with crisis management and risk assessment being the most frequent interventions offered. The work of Chanen and his team suggests a therapeutic approach that might offer interventions that could prevent this trajectory from becoming a reality – or at least provide a young person with the tools to manage their distress in more healthy ways without resorting to self-injury or other risky behaviours. CAT is not the only approach, but it offers a theory and framework that felt accessible to young people, whether that be through its clear relational and developmental approach, or from the collaborative experience of co-creating dynamic maps, whilst also being sufficiently versatile to be transferrable to different settings.
Subsequently, when finally getting round to doing a formal training in CAT, I was clearly excited about the opportunities that this training could provide. It would be invaluable in taking me back to the basics ensuring I was able to apply the theory and model within a more established therapeutic setting, whilst providing a solid foundation for much of my other CAMHS-based practice. But from these foundations I could see the potential for a wider reach of practice: taking the principle of working in the zone of proximal development and really stretching its meaning and application. Vygotsky focused on the relational, socially historical and iterative nature of how we learn, and that this way of learning is central to all aspects of our lives. It is what we do in therapy. The ZPD can be thought about within any domain of development; for example cognitive, social, physical, and emotional, but it can also be thought about environmentally and geographically. I have always felt that the ZPD is very much about working where someone “is at” – and it has been this understanding that has allowed me to step out of the clinic and apply practice in all settings.
What has evolved over the last few years is a series of approaches, interventions, projects, programmes and trainings that have all built upon this journey and understanding. Outreach work provided the opportunity to experience and witness what is possible in the community 7 but CAT has given me the understanding and the tools to open up the potential for what can be delivered in and alongside communities.
Over the following two articles I shall outline some of my work on this journey, looking at some of the successes as well as some of the professional and organisational challenges. It is a progression from working alongside young people in a more formal therapeutic setting to working with parents. It has involved working with young people in programmes based entirely around football - A Game of 2 Halves 8 – which has been used in schools, in pupil referral units and in cages on estates. There has been group work with parents – facilitating a peer support approach and seeking to empower parents and share their expertise. Likewise, it has been tested out in peer mentoring programmes, with mapping being proposed as a tool to facilitate engagement. And more recently it has been used in training, building on the model of contextual reformulation9, and developing maps with teams, which seems to offer some clarity for professionals who can be struggling with complex cases, where individuals, services or networks can often feel quite paralysed and stuck.
This journey has been about testing things out and seeing what works for both client and therapist. But this practice must also be seen within the context of change and redevelopment of services – especially CAMH services. CAT has much to offer – for individuals, families, teams, services and networks – and needs to contribute to this far reaching redesigning of services. CAT, both in theory and in practice, allows us the space to be creative and innovative, as well as being sufficiently versatile to make opportunities for change accessible and meaningful for local communities. I therefore hope these three articles will go some way to enable us all to feel able to test the boundaries of what we offer, no matter where we practice.
CAT at 30 - University of Exeter – October 2014 - http://www.acat. me.uk/event_document_download. php?event_id=797&document_id=1031 2 Growing need of young people’s mental health – The rates of depression in 15 – 16yrs olds has nearly doubled between 1980s and 2000s - Nuffield Foundation (2013) Social trends and mental health: introducing the main findings. London: Nuffield Foundation 3 The Independent 20th August 2014 - Exclusive: Children’s mental healthcare in crisis, Care Minister Norman Lamb admits 4 http://www.theguardian.com/ society/2014/aug/20/child-mentalhealth- dark-ages-norman-lamb 5 Zone of Proximal Development – Ryle and Kerr, Introducing Cognitive Analytic Therapy. Principles and Practice. Wiley - 2002 6 Chanen et al. Early intervention for adolescents with borderline personality disorder: quasi-experimental comparison with treatment as usual, Aust N Z J Psychiatry. 2009 May; 43(5):397-408. 7 Outreach – reaching out in different contexts – Context 12- - April 2012 8 A Game of 2 halves – Engaging young people through football, Special Children Issue 2013, June 2013 The ‘Beautiful Game’ helps support young people at risk of exclusion from school – June 2014. http://www.rcpsych.ac.uk/mediacentre/ pressreleases2014/the%E2%80%98bea utifulgame%E2%80%99helpssup.aspx 9 Kerr, I. Contextual reformulation integrates an understanding of the patient’s difficulties with problematic professional responses, reframing what it means to hold an adaptive professional position when trying to help such patients - Ryle and Kerr, Introducing Cognitive Analytic Therapy. Principles and Practice. Wiley – 2002.
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Learning With Young People About Being “In The Middle”
Nick Barnes, 2016. Learning With Young People About Being “In The Middle”. Reformulation, Summer, pp.11-18.
Prevention and Early Intervention for Borderline Personality Disorder in Young People
Chanen, A., 2000. Prevention and Early Intervention for Borderline Personality Disorder in Young People. Reformulation, ACAT News Autumn, p.x.
Beyond individual therapy - Trainee practitioner reflections on the use of CAT within an Adult Community Learning Disabilities Team
Field, B., 2014. Beyond individual therapy - Trainee practitioner reflections on the use of CAT within an Adult Community Learning Disabilities Team. Reformulation, Summer, pp.33-37.
Update on The Melbourne Project - Prevention and Early Intervention for Borderline Personality Disorder
Chanen, A., 2002. Update on The Melbourne Project - Prevention and Early Intervention for Borderline Personality Disorder. Reformulation, Autumn, pp.6-7.
**Reformulation Explores A Brief Explanation of Six-Part Story Making
Editors, 2015. **Reformulation Explores A Brief Explanation of Six-Part Story Making. Reformulation, Winter, p.29.
A CAT Informed Approach to a Time-Limited (Closed) Group within an Adolescent Inpatient Setting
Mulhall, J., 2015. A CAT Informed Approach to a Time-Limited (Closed) Group within an Adolescent Inpatient Setting. Reformulation, Winter, pp.20-28.
Audit of Factors Predicting Drop Out from Cognitive Analytic Therapy Kerrie Channer and Alison
Channer, K., Jenaway, A., 2015. Audit of Factors Predicting Drop Out from Cognitive Analytic Therapy Kerrie Channer and Alison. Reformulation, Winter, pp.33-35.
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.
My Experience of Cognitive Analytic Therapy (CAT) within a Secure Forensic Setting
Moon, L., 2015. My Experience of Cognitive Analytic Therapy (CAT) within a Secure Forensic Setting. Reformulation, Winter, pp.12-15.
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