It’s All About Relationships

Nick Barnes, 2016. It’s All About Relationships. Reformulation, Winter, pp.7-11.


Introduction – working in “relational mental health”

Building on the last 2 articles that I have written for Reformulation I felt that this final article should seek to highlight both the variety and breadth in ways of working through and with CAT, whilst at the same time, explore how CAT tools and theory have effectively become the foundation of my own practice – irrespective of the role expected of me.

In the first article1 I was keen to reflect on how my role within an Outreach Team had provided the opportunity for testing out ways of working within the community that may not have been possible had I been completely tied to a clinic. Utilising concepts such as working with the Zone of Proximal Development2, seeking to offer interventions that were sufficiently meaningful for a young person and their family, within a setting that also felt accessible, drew me more and more to a CAT framework of understanding – almost irrespective of case complexity or diagnostic uncertainty. 

The second article3 hoped to highlight this way of working and thinking with young people by drawing on specific clinical material – case studies that hopefully demonstrated how CAT can be sufficiently adaptive to work with the young person and /or their families or networks in their own time, their own space and at their pace. By conceptualising the idea of working “in the middle”, and building on tools such as the template map4, it has been possible to co-develop an understanding of distress with young people that offers clarity without being dismissive or negating of context.

I therefore saw this article needing to pull together some of these earlier themes, whilst also demonstrating how this work has evolved in practice. Overall, I am hoping that the 3 articles will reflect a personal journey that has been informed by CAT taking me from a place where I may have toyed with a crude understanding of the concept of reciprocal roles through to ensuring that CAT now informs and guides all areas of my clinical practice and project development. This journey has been punctuated by specific incidents or approaches along the way that have driven my conviction to ensure that the needs of those young people that are “harder to engage” are addressed, and I believe that CAT has offered the scaffolding to enable this journey. 

But there has also been a wider shift in my thinking and approach over the last few years that I mostly attribute to a growing understanding of CAT and CAT theory. With an appreciation that change for a young person requires trust, then it is clear that we need to be more explicit about the role of relationships in allowing that trust to emerge and evolve. As service providers we need to be clearer about what we offer (to both service users and commissioners), and hence the belief that we need to be talking more about relational mental health – acknowledging that our work is “all about relationships”.

K.Dot and the evolution of Time 2 Talk

In January 2011 a 14-year-old student was killed outside a chicken shop following an altercation with a man carrying a knife5. The incident occurred straight after school with many of the student’s peers around him. The loss of this student was profound – affecting the whole of his school as well as his family and community – and it was clear that both staff and students would need considerable support to process their grief. Yet, as time progressed, and routines began returning to normal, it became increasingly clear that a core group of close friends who had known this student remained stuck and unable to move forwards. They were profoundly traumatised and were placing themselves at significant risk of harm. Multiple services and interventions were offered to these young people, and to their families, but none were of any use – or often, even accepted. These young people became increasingly shut off, isolated and detached; lost in their grief and experience of trauma.

K.Dot was a film based project (developed in partnership with the school mentoring programme, the Kiyan Prince Foundation6 and film makers Individio Media ltd7), that offered this group an alternative; a more creative way of approaching and considering engaging with support. With grant funding the group were offered the opportunity to make a tribute film for their friend so that they might feel his life could be appreciated, valued and remembered. The film that was eventually produced offered a dialogue and narrative about trauma, grief and loss that was profoundly moving and powerful – bringing a packed school auditorium to tears. But perhaps more importantly the film, and the impact of its public showing, enabled these young people to start to believe they had “permission” to move forwards and begin to get their lives back on track. 

Hopefully the reciprocal roles stand out for themselves, as the young people involved move from a position of disconnecting to disconnected, disengaging to disengaged, to a place where they are appreciating and feel appreciated, valuing and valued, remembering and acknowledged. The mapping was able to occur within the supervision of the delivery team rather than with the young people themselves – allowing for an application of contextual reformulation to underpin the project’s understanding of the young people’s needs.

But this project enabled a wider development within the same school – building on the relationships established through the K.Dot project. Having seen the impact of this film project the local Public health department agreed to commission a wider project – Time 2 Talk8 – a whole school approach to challenging mental health stigma and raise awareness about emotional wellbeing and mental health. Broadening the partnership to involve deep:black9 a creative media group, we looked to generate a dialogue about mental health and emotional wellbeing that could then be owned and progressed by young people within the school to inform opportunities for peer support, mental health awareness and understanding, as well as support systemic change in practice within the whole school community.

The focus of the work throughout this project was about enabling a dialogue about mental health, but ensuring that the students involved felt able to take some sense of ownership and agency of the project, enabling them to facilitate change within the school. From narratives taken from young people presenting with significant mental health need workshops were developed within the school that enabled the students to create a piece of drama – as forum theatre – for performing to the whole school. This drama was then converted to film so that it could inform the template of a module of learning (3 lessons) within the PHSE curriculum about mental health, developed by the students. Beyond these lessons students were then invited to become peer mentors and were offered training in being able to support students both one to one and in group settings – training that has now been embedded within the school as a sustainable intervention. Finally, students were then invited to assist in training, guidance and policy development for teachers, parents and governors so that the whole school community felt involved and informed about young people’s mental health.

Again the role of CAT and the development of a relational understanding of mental health underpinned most of the project progression – with regular mapping and reflection on reciprocal roles being used to inform supervision and team discussions. But in this setting, it felt as though it was an understanding of the relationships within the delivery partnership which was the most important in ensuring the success and impact of the wider project. Seeking to offer a project that works across a whole school community can feel daunting for some schools, and there needs to be sufficient trust to enable this to occur. For there to be trust, we needed relationships – relationships that have developed from the K.Dot work. Time 2 Talk therefore allowed not only a whole school approach to raising awareness about mental health and emotional wellbeing, but from its inception through to the model of practice delivered within the school, allowed for the focus to be entirely on relational mental health.

A Wider Reach - Peer Support and contextual reformulation

Projects such as Time 2 Talk have highlighted the need to promote dialogue about relational mental health – and especially if we are to consider more preventative practice and earlier help. The transformation of CAMH services nationally has endorsed a more preventative approach to support10, but also recognises the need for improved access to support – appreciating the barriers preventing children and young people from being able to engage with services. Being mindful of these wider transformational drivers, but being cautious to ensure that this is not just financially directed, I have been keen to explore the wider role of peer support and peer mentoring in a variety of settings.

Time 2 Talk highlights one approach for peer support and peer mentoring, within a specific school setting, and I feel its strength lies in being able to be very clear about the focus on relational mental health. Other similar projects have included the More than Mentors11 programme, developed by a partnership lead by UCL Partners, which likewise seeks to develop a peer mentoring framework with an established focus on offering a preventative intervention around mental health – moving away from other peer mentoring programmes in schools which predominantly focus on promoting academic attainment or school attendance.

Peer support and peer mentoring within mental health services is becoming increasingly recognized as having an important contribution to the overall recovery and support of mental health service users12. Whilst, again, I remain concerned there could be cost saving priorities behind some of these initiatives, I do embrace the appreciation of the need for clients to have workers “being alongside” them in their recovery. This role clearly spells out the relational dimensions of mental health support and speaks to a language familiar to all CAT practitioners. Where I feel we need to be embedding the role of CAT is in the supervision and support of these workers and mentors – so that they have a clear understanding of the impact of their relationships, and that an “arm’s length” CAT-informed approach underpins the practice of peer support, in whichever setting.
Taking this work a step further I am also aware that there are many young people who will refuse to meet with mental health practitioners, no matter how approachable. Working within an area such as Tottenham, where many young people find themselves drawn to groups and gangs (themselves a place of peer support – no matter how uncomfortable this feels), the prospect of offering an intervention that seeks to address mental health need is highly remote. And yet opportunities arise.

Working with gangs’ workers or detached youth workers from both statutory and voluntary youth sectors it has been possible to offer a supervisory framework based on contextual reformulation that informs practice and approach. Much of this work is located within particularly difficult areas for services to access and offer support, and so it is by working through the skill set of the gangs’ worker that one is able to enable real opportunities for change. After all, a lot of gangs based work is focused on exploring “exits” and hence mapping and developing a clear SDR, has repeatedly helped the gangs’ workers to decide on how and when to implement a plan around gang exit – thinking about the risks for the young person, but also about their family. But it is also evident that violence tends to paralyse people and services from being able to think how best to support. This is not a statement of criticism, but is a reality of nature of violence, and hence it can be hugely helpful to have tools available, such as mapping that help give clarity and the space for thinking when our more evolutionary instincts may drive us to “run away”. The map developed above highlights the repeated potential for violence and aggression for one young person, driven by the need to avoid the risk of humiliation. Hence the exit from a gang must also be balanced with ensuring that this doesn’t reinforce a “loss of face” or “shaming”, as this could easily re-ignite the original patterns and procedures.

Tailoring delivery to work within the ZPD – A Game of 2 Halves

Where it might be possible to engage young people in therapeutically informed work, whilst appreciating that they might not want to engage with a specific service, or perspective of need, then the focus is more on the where, when and how of delivery and thinking about the work within the Zone of Proximal Development. Although this has been a principle in all projects I have been lucky enough to be involved with, it is perhaps most evident in the project A Game of 2 Halves13 – which has been evolving over the last 6 years.

A Game of 2 Halves is a programme aimed at preventing young people from being excluded from school – being very aware that the cost of exclusion has repercussions across a whole host of social environments further down the line14. Taking a group of up to 12 young people, aged 13 – 14 years, and offering a group based intervention, informed by CAT, but delivered entirely through a dialogue about, and engagement with, football had a significant impact on how the young people felt about and viewed themselves and each other. But most importantly, the programme was able to show that there was a significant shift in the perspective of the young person by the school and the teaching staff – with a marked improvement in pro-social behaviours. The table below outlines the scores shown on Strengths and Difficulties questionnaires (SDQs15), with highlight areas on stress, behavioural, conduct difficulties, kind and helpful behaviour and impact of behaviour in the classroom all being reported by the teachers.

A Game of 2 Halves perhaps best demonstrates the core features of the relational developmental model of CAT – that the dialogue is self to self, self to other and other to self, the teachers’ perspectives of the young people showing a clear awareness of “other to self”.

Working Alongside Parents

When I have been lucky enough to be involved in teaching or training sessions about CAT I have often asked participants how much work they do with parents. Invariably the answer is “very little” – but then I beg to differ. I suspect that the majority of us work with parents - especially those that work in adult services – but we don’t necessarily think of our clients primarily as parents – seeking to address their own needs on a more individual basis. However, I was struck, when completing my own CAT training how often adults come to therapy driven by the desire for there not to be a replication of their experiences of difficult relationships with their parents with their own children. They were often driven by a desire for something to be different between themselves and their children – allowing for a dialogue about the relational development of the child (both about themselves and their offspring).

CAMH services however do allow a window for working with parents that can have a huge impact on the family as whole, but also be an opportunity for work, even when the young person is not interested in engaging with services. For the non-engaging teenager, the prospect of their parent thinking about them differently can be enormously valuable – and this work can easily translate to group settings. Running groups for parents, facilitated around “mapping in moment” offers a way of fostering greater peer support and guidance for all the parents.

The model of intervention, and the use of CAT specifically for working with parents has been far better outlined in articles by Alison Jenaway in past issues of Reformulation16 than I could offer. The use of templates for mapping and being sufficiently creative in working with the wider CAT tools has had significant impact for parents and certainly merits an exploration of a trial in comparison to other parenting interventions17. The strength of the CAT parenting model possibly lies in addressing the needs of the more complex parents, perhaps parents who may have significant personality difficulties, and for whom the earlier, more preventative programmes (such as Webster Stratton18 and Triple P19) are insufficient. However, I am particularly interested in the work of Marie-Anne Bernardy-Arbuz in Paris who has been looking to find ways of embedding individual CAT for parents within a Webster Stratton (24 week Incredible years) programme as a way of ensuring there is greater relational understanding informing these opportunities for change.

From “being in the middle” to working at “arm’s length”

Hopefully the examples of application and practice of CAT outlined above show some of the potential of our field. The work outlined here is much more about supervision or contextual reformulation, working with parents, or applying theory, rather than specifically about direct clinical contact. However, I hope that they demonstrate what CAT can offer.

Through CAT I feel that I have been able to find a way of working with some young people – either directly or indirectly – and therefore overcome a few of the barriers that might prevent young people from accessing support. Working with young people and being able to focus on being “in the middle” has been a way of allowing clarity, whilst also ensuring that we can “keep it simple, stupid”. But by being “in the middle”, we are also enabling young people to learn to develop and explore their “negotiating voice20”.

But the scope for working at arm’s length, for working indirectly or for informing the wider development of services to be more based upon a relational approach to mental health is also where CAT can work to its strengths. Being highly aware that so many services are under threat at present, it might feel rather glib to be talking about how practitioners may be able to “reach out” and offer alternative ways of working. I too have found that I have ended up needing to do most of my “project work” outside the working hours of my regular job, which also results in its problems and tensions. I am not for a minute pretending that any of this is easy.
However, overall, I hope that these 3 articles together have shown that the world of CAT is a rich one, and one that has much to offer and to be explored. My hope is that this account of my own journey within the field of CAT will make others curious to test out their own ideas, and push the boundaries of their own services, and what they offer. There are many opportunities developing that will be all the better if informed by CAT thinking. The move towards wider integration of services makes a good example, as do specific interventions such as Open Dialogue21 which make a natural fit with an equally Bakhtinian informed theory such as CAT. But mostly importantly, CAT allows services and practitioners to focus on the relational. It allows us to develop the discipline of relational mental health – and fundamentally asserts that “It’s All About Relationships”.

References

1. Barnes, N (2015) Reaching Out -  A Journey Within and Alongside CAT, Reformulation, .45, pp 30 - 32

2.  Ryle A, Kerr, I. (2002). Introducing Cognitive Analytic Therapy: Principles and Practice. Wiley. p41

3.  Barnes, N (2016) Learning With Young People About Being “In The Middle”, Reformulation, 46, pp 11 - 18 

4.   Jenaway, A (2013). Change your Parenting for the Better - exploring CAT as a parenting intervention. Reformulation, Winter, p.32 - 36

5.   Baker, H (2012) Friends of murdered Tottenham teenager Kasey Gordon get lottery grant for knife crime film project. 12th May 2012, Haringey Independent (Online). 
Available at; http://www.haringeyindependent.co.uk/news/9701368.Friends_of_murdered_teenager_Kasey_Gordon_get_lottery_grant_for_knife_crime_film/

6.  Kiyan Prince Foundation - http://www.kiyan.org/

7.  Individio Media Ltd - http://individio.com/

8.  Time 2 Talk – Winner of the HSJ award 2015 – Innovation in Mental Health. 
https://www.hsj.co.uk/more/awards/hsj-awards/hsj-awards-2015-innovation-in-mental-health/7000296.article

9.  deep:black - http://www.deepblack.org.uk/

10.  Department of Health (2015) Future in mind. Promoting, protecting and improving our children and young people’s mental health and wellbeing. NHS England.

11.  Brown, J (2015). Peer Mentoring Plan Set to Boost Mental Health in Schools. Children & Young People Now, 10-23 November 2015. Further information about More than Mentors available at; http://www.uclpartners.com/news/pilot-project-awarded-newham/

12.  Peer support workers: Theory and Practice “(2013) Implementing Recovery through Organisational Change (ImROC) programme – a joint initiative from the NHS Confederation’s Mental Health Network and the Centre for Mental Health

13.  A Game of 2 Halves – Royal College of Psychiatry website – “The ‘Beautiful Game’ helps support young people at risk of exclusion from school” - http://www.rcpsych.ac.uk/mediacentre/pressreleases2014/

14.  Cost of Exclusion - Counting the cost of youth disadvantage in the UK. The Prince’s Trust, November 2010.

15.  Strengths and Difficulties Questionnaires - http://www.sdqinfo.org/

16.  Jenaway, A (2007) Using Cognitive Analytic Therapy with parents: some theory and a case report. Reformulation, 29, pp 12 - 15.

17.  Call for Evidence – Working Alongside Parents with CAT https://www.surveymonkey.co.uk/r/58CY3JG

18.  Webster Stratton Parenting Programme - http://incredibleyears.com/

19.  Triple P – Positive Parenting Programme - http://www.triplep.net/glo-en/home/

20.  Potter, S (2016) Negotiator’s Mind. Reformulation, 46, pp 29 – 32.

21.  Open Dialogue - http://open-dialogue.net/

 

Full Reference

Nick Barnes, 2016. It’s All About Relationships. Reformulation, Winter, pp.7-11.

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