The 4P’s model: A Cognitive Analytic Therapy (CAT) derived tool to assist individuals and staff groups in their everyday clinical practice with people with complex presentations

Phyllis Annesley and Lindsay Jones, 2016. The 4P’s model: A Cognitive Analytic Therapy (CAT) derived tool to assist individuals and staff groups in their everyday clinical practice with people with complex presentations. Reformulation, Summer, pp.40-43.


It is well recognised that working with people with complex needs, particularly those with personality disorders can challenge staff teams (Murphy and McVey, 2010). Sometimes staff can respond to service users and their behaviours in ways that are unhelpful and that re-enact patterns from service users’ pasts. This can contribute to service users’ difficulties being maintained rather than changed and their therapeutic needs remaining unmet (Annesley and Jones, 2013). 

The 4Ps model was developed based on Cognitive Analytic Therapy (CAT). CAT is not just a model for direct one-to one therapy; it offers a framework for reflecting upon and understanding peoples’ interactions and responses within therapeutic environments (Freshwater and Kerr, 2006). Further, it offers individuals a way of reflecting on themselves and their own contributions to interactions and therapeutic relationships. We acknowledge that in common with other therapies the language of CAT can be hard to understand and in developing the 4Ps model we deliberately chose language that was accessible to a wide range of people. The 4Ps model provides a reflective tool for enabling staff from all professional backgrounds, including those with little or no psychotherapy training, to reflect on their interactions with service users. In this way, it facilitates staff in understanding their interactions, maintaining empathy for service users, and behaving in ways that are therapeutic and maintain boundaries rather than reacting at times in unhelpful ways that may re-enact aspects of a service user’s history. 

In this article we describe the evolution of the 4P’s model and the development and implementation of a one day training workshop to introduce staff to the model and give them practical experience of using it. We include initial feedback on the training and outline how we anticipate developing the 4P’s model in the future. 

Background to the development of the 4P’s model 

We both work in secure mental health services for women. The lives of the service users we work with are characterised by comorbid difficulties including histories of trauma and offending and corresponding high levels of distress and interpersonal difficulties (Annesley and Jones, 2013). Five key factors shaped the development of the model:

1. In our joint experiences of working as psychologists in diverse settings including secure forensic settings we have first-hand experience of working with service users who at times present in unpredictable, challenging and threatening ways. In managing our interactions with service users in such situations as well as more ‘everyday’ situations we both highly value our learning and insights from CAT. The CAT model in our experience has enabled us to work more effectively with service users by giving us a much better understanding of people with complex difficulties; by helping us to recognise and work with the repetition of patterns from peoples’ pasts in current relationships; and by assisting us to recognise our own contributions to interactions. 

2. The research literature on the possible impacts of working with people with challenging presentations and our joint experiences of supervising and teaching staff from different settings has given us insight into the clinical challenges that staff experience. Challenges can be experienced at an individual and team level. This can result in team splits where team members are divided in their opinions and consequently may respond differently to the same service user. For example, some staff members may feel “pulled” to rescue or provide special care, whereas other staff may respond in punitive ways to the same client. Such team splits can feel very confusing and unsafe for both patients and staff and can result in lowered staff morale and poor care (Minne, 2008). There has therefore been an ongoing recognition of the need for all staff to be trained and supervised in working with people with complex and challenging presentations particularly those people with personality disorders (Moore, 2012). This includes healthcare assistants who often spend lots of time interacting with patients on a daily basis but who have received less training than their qualified mental health colleagues. 

3. We were keen to develop a simple and accessible model that all staff could use to reflect on both their own position in interactions with services users as well as the position of the service user. We wanted to develop a model that would encourage staff to “pause and reflect” but would also to provide a framework for noticing ‘pulls’ from service users and ‘pulls’ within themselves to respond in certain ways. Further we wanted to incorporate within our model encouragement to consider possible links between current issues and past experiences and an emphasis on the crucial importance of responding within any interaction in a professional manner. In emphasising these we hoped to encourage staff to consider their own contribution to interactions with service users, develop their understanding of themselves and the service user, and above all remain compassionate and caring when responding to service users. 

4. We were keen to develop a model that could be easily recalled in different situations including situations where staff members are under pressure and feel stressed, as well as in more relaxed situations such as reflective practice sessions. For this reason we chose one letter, P, as the first letter for each word in the model. The model provides a framework which is containing for staff, but is sufficiently flexible to be used in varied situations. In this way staff members are encouraged to understand and stay present emotionally rather than fall back on un-reflected upon responses when anxiety is high. We also felt that this could assist staff in building their sense of competence and engagement with the work which may mitigate against feelings of anxiety and demotivation. 

5. Lastly, the 4 P’s model was grounded within our strong commitment to implementing compassionate, sensitive, boundaried and high quality care in line with key strategic healthcare drivers including the 6C’s, a nursing led vision and strategy to promote compassionate organisational cultures (DH, 2012). The 4Ps advocates the importance of reflection and the selection and use of boundaried, sensitive, emotionally-present and compassionate responses to service users. By encouraging a focus on these ways of responding, as well as providing a framework to reflect on our own responses, the 4Ps model can greatly assist staff in remaining compassionate when caring for others. 

Description of the 4Ps model

The 4Ps model consists of a cycle which guides staff members through four stages of reflection (See Figure 1 below).

STEP 1: PAUSE

This is a prompt to stop and if possible take a few moments to reflect. The aim of this is to encourage staff to take a step back in order to allow them to assess the overall situation rather than be caught up in the moment. This is particularly useful at times where staff experience a strong feeling such as a desire to punish or reject. 

STEP 2: PULL(S)

Staff members are encouraged to reflect on what “pulls” they are feeling from the service user / patient, and what “pulls” they are feeling from within themselves (personal). Examples might include the urge to be flippant, to step in and rescue, to avoid, reject, abuse or punish. Please note that the term “patient” is commonly used within secure services where people are detained in hospital, hence our inclusion of this term within this article. This step provides an accessible way of encouraging staff to identify the dynamics of the relationship (reciprocal role enactments) that they might be caught up in. In addition, negative or strong emotions towards service users are often seen as taboo with the result that they remain unacknowledged and the emotional needs of both the staff member and the service user are ignored (Kay, 2009). By normalising and validating staff members’ own emotional reactions, the 4Ps model enables the consideration of the wide range of feelings that staff members may experience in working day to day in clinical environments.

STEP 3: PATTERNS

In this step staff members are encouraged to reflect on whether there are any patterns around what is happening in the moment and possible links to service users’ past histories. This helps them to consider what the service user might be bringing to the interaction and what they might be bringing to the interaction. This also allows staff to think about the possible re-enactments of past histories of trauma and abuse in current relationships (Aitken and McDonnell, 2006). In order to be able to reflect on this step, we emphasise the importance of all staff knowing about service users’ histories. If it is not possible to give this step much consideration when an interaction is occurring we encourage staff to think further in supervision about this step. New insights can then be applied in future interactions. 

STEP 4: PROFESSIONAL RESPONSE/S

In this final stage staff members are asked to consider ways of responding that are respectful, sensitive, maintain boundaries, and “good enough”. Staff members are encouraged to choose an appropriate professional response which avoids collusion or re-enacting damaging experiences from peoples’ pasts. This supports the aims of creating safe and effective services and therapeutic relationships encapsulated in the concept of relational security (DH, 2010). 

Outline of the 4Ps workshop

In order to support multidisciplinary staff teams in understanding and applying the 4Ps model, we developed a one day training course consisting of:

Introductions 
Here we cover introductions and expectations of participants in order to foster from the outset a safe and containing learning environment. 

Group discussion
We set the scene for the day by encouraging discussion on components of therapeutic relationships using a series of statements designed to encourage debate and reflection on the importance of the therapeutic relationship. 

Presentations of key concepts:
We present the CAT concept of reciprocal roles using a combination of experiential learning techniques and didactic methods. Following this we introduce participants to the 4P’s model. 

4P’s experiential learning
Half of the day is spent role playing difficult and challenging situations. The clinical material for this is generated by staff based on their own experiences. Table 1 contains frequently cited examples of such situations with all personal details removed to maintain confidentiality. When staff are not engaged in role plays they act as observers and participate by giving feedback. Participants in role plays can stop at any time and ask observers for advice and supervision. In this way all participants are involved in ongoing learning throughout this session. 

Table 1: Examples of common experiences role played during workshops

  • Feeling anxious or angry in response to verbally hostile, abusive or assaultative behaviour.
  • Feeling anxious in response to a service user saying that the staff member is useless or doesn’t know what they are doing
  • Feeling uncertain of how to respond when a service user gives contradictory accounts of the same situation.
  • Feeling “useless” or hopeless when service users do not follow advice, deteriorate or continue to self-injure.
  • Not knowing how to respond when service users push boundaries such as feeling pressed to disclose personal information
  • Feeling overly responsible for a service user and feeling pulled to want to rescue.

Reflections on experiences of the training

The training has now been delivered on eight occasions within high secure and step down services for women and has been well received by the staff taking part. Evaluation questionnaires have indicated that all participants were able to understand the CAT concept of reciprocal roles and use the 4Ps model to reflect on their interactions with service users. They also reported that they felt that the training would have a positive impact on their practice. The training was kept to one day to facilitate staff in accessing the course. We have therefore demonstrated that this short, cost effective investment in training can have a positive impact and assist staff in thinking relationally in the workplace. The evaluation questionnaires will be analysed in further detail and will be submitted for publication in due course. More research will be needed to determine the impact of the training and we are currently developing a methodology to assess this. 

We consider that the 4Ps training will be most effective if it can be embedded and form part of a whole systems approach which includes supervision (individual and group) and reflective practice sessions in the context of a culture that values the importance of learning and reflection. As more people are trained, the ideas filter into the team as a whole, creating a shared language and way of thinking which can contribute to the development of a compassionate culture (Dutton et al, 2014). In addition, recovery plans can be developed which draw on relational understandings, thus enhancing relational security. We also feel that the approach may have wider applicability in other settings and we have been working with our colleague, Stephanie Petty, Clinical Psychologist, to adapt the model for use with older adults. We also have future plans to involve service users in the delivery of the training as well as developing training in the model for service users in line with proactive service user involvement (Repper and Breeze, 2007).

Summary

The 4 P’s model was developed as a way to support staff, individually and in teams, to reflect on their interactions with service users and respond in professional ways, rather than responding in ways which may recreate aspects of the service user’s history of poor relationships. The central aim was to assist staff members to reflect rather than react, and maintain respectful and collaborative working relationships with service users and with other staff. The 4P’s model also provides staff members with a way of thinking about boundary and power issues in relationships with service users. The importance of taking opportunities to reflect and using supervision is emphasised. Initial feedback is very positive and we are greatly looking forward to involving staff and service users in developing the model further and further assessing its applicability and impact on outcomes for both staff and service users.

Phyllis Annesley is a Consultant Clinical Psychologist, CAT Psychotherapist and CAT Supervisor working at the National Women’s Service and The National High Secure Learning Disability Service, Rampton Hospital. Lindsay Jones is a Consultant Clinical Psychologist, CAT Therapist and CAT Supervisor working in a low secure service within Leeds and York Partnership Foundation Trust. 

Acknowledgements

We would like to express our gratitude to all of the staff members who have participated in the training, and given their feedback. We would also like to thank service managers who have supported the training and enabled it to be used within our organisations. 

References

Aitken, G. and McDonnell, K. (2006), “The use of Cognitive Analytic Therapy with women in secure settings”, in Pollock, P.H., Stowell-Smith, M. and Gopfert, M. (Eds.), Cognitive Analytic Therapy for Offenders, Routledge, London.

Annesley, P. and Jones, L. (2013), “Care and control: Delivering forensic psychological therapies in the high secure hospital setting”, in Compton Dickinson, S., Odell-Miller, H. and Adlam, J. (Eds.), Forensic Music Therapy: A Treatment for Men and Women in Secure Hospital Settings, Jessica Kingsley Publishers, London.

Department of Health (2010), “Your Guide to Relational Security: See Think Act”, DH, London.

Department of Health (2012), “Compassion in Practice: Nursing, Midwifery and Care Staff: Our Vision and Strategy”, DH, London.

Dutton, J.E., Workman, K.M. and Hardin, A.E. (2014), “Compassion at work”, Annual Review of Organizational Psychology and Organizational Behaviour, Vol 1, pp 277-304.

Freshwater, K. and Kerr, I. (2006), “CAT skills training in mental health settings”, Reformulation, Summer, pp 17-18.

Kay, M. (2009), “Managing hate: The nurse’s counter-transference”. In Aiyegbusi, A. and Clarke-Moore, J. (Eds.), Therapeutic Relationships with Offenders, Jessica Kingsley Publishers, London.

Minne, C. (2008), “The dreaded and dreading patient and therapist”, in Gordon, J. and Kirtchuk, G. (Eds.), Psychic Assaults and Frightened Clinicians: Countertransference in Forensic Settings, Karnac, London.

Moore, E. (2012), “Personality disorder: its impact on staff and the role of supervision”, Advances in Psychiatric Treatment, Vol. 18, pp 44-55.

Murphy, N and McVey, D, (2010), “The difficulties that staff experience in treating individuals with personality disorder”, in Murphy, N. and McVey, D. (Eds.), Treating Personality Disorder: Creating Robust Services for People with Complex Mental Health Needs, Routledge, London.

Repper, J. and Breeze, J. (2007), “User and carer involvement in the training and education of health professionals: A review of the literature”, International Journal of Nursing Studies, Vol. 44, No. 3, pp. 511-519.

Full Reference

Phyllis Annesley and Lindsay Jones, 2016. The 4P’s model: A Cognitive Analytic Therapy (CAT) derived tool to assist individuals and staff groups in their everyday clinical practice with people with complex presentations. Reformulation, Summer, pp.40-43.

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