Shannon, K. Butler, S. Ellis, C. McLaine, J. and Riley, J., 2016. Use of Cognitive Analytic Concepts; A relational framework for Organisational service delivery and working with clients with Multiple Complex Needs (MCN) at the Liverpool YMCA. Reformulation, Winter, pp.12-20.
This paper describes the introduction the training and use of concepts from Cognitive Analytic Therapy Skills training as a relational organisational framework for Liverpool YMCA (LYMCA). I describe the context for this client group, the background of service development at LYMCA, CAT research in relation to indirect working and contextual reformulation, and application of this at LYMCA. I am pleased to write this paper in partnership with colleagues at LYMCA who share some of their experiences.
According to Ipsos Mori there are 58,000 people in the UK who have contact with all 3 services; homelessness, substance misuse and criminal justice system services. LYMCA provides services for clients who are multiply excluded, hard to reach and help, with MCN (eg substance abuse, offending behaviour, physical health problems, mental health problems and homelessness).There are 1,200 People in Liverpool with MCN. 63% of service providers reported that support in Liverpool was fragmented, not sufficiently intensive or comprehensive to meet individual’s level of need (Ipsos Mori). Psychosis, dual-diagnosis, and personality disorder are all more prevalent in the homeless population (Rees, 2009) as are histories of trauma, poor attachment and early.
As a result of ‘cost improvements’ in NHS and social services budgets, an increasing number of clients with MCN are being cared for by voluntary sector organisations and charities, such as LYMCA. These services do not have multidisciplinary teams of staff with training in mental health backgrounds as exist in NHS. Yet these services and dedicated support staff are still required to enhance care and reduce costs to public spending in a time of austerity. Public spending for someone with MCN costs £21,180 each year, compared to £4,600 per average adult without these difficulties (Ipsos Mori).
In 2014 LYMCA approached me to discuss their training needs, seeking to enhance their way of working in a psychologically informed way with clients with MCN. I submitted a CAT introductory training proposal within their bid to provide Multiple Complex Needs Services (MCNS) at LYMCA, which aimed to improve stability, confidence and capability of people with MCN to lead better lives as a result of timely, supportive and coordinated services; leading to fewer custodial terms, reduced drug abuse, stable accommodation and enhanced mental health. The aim was to transform service provision for MCN clients who, because of the nature of their difficulties, historically fell across or between service criteria, and whose needs were therefore ‘unseen’ and not provided for.
LYMCA developed an intensively staffed nine-bed unit to accommodate MCN. Additionally, a resettlement team that provided good quality endings once a resident’s placement has ended. They also provide continuity of care within the community and the development of external networks from private landlords to registered managers of care homes.
CAT as a therapy has diversified in its application to a broad range of presenting problems, clinical groups, formats and settings with adaptations for cognitive limitations. However, services such as LYMCA, do not provide therapy yet are required to support clients with MCN.
It is CAT’s strength as a contextual formulation (Ryle and Kerr, 2002), which is of particular value in non-mental health organisations such as LYMCA. Within these services use of a Diagrammatic Reformulation (SDR) provides a description of the relationship between the team, service, and the client as a reflection of the client’s ways of relating to others, internalised from childhood (Kerr et al. 2007). The reformulation, or ‘CAT map’ makes explicit the more complex staff processes involved in perpetuating and exacerbating an individual’s psychopathology (Carradice, 2004). It provides an explanation for staff members’ different dysfunctional reciprocation to different parts of the client resulting in splits and team conflict amongst staff (Ryle and Kerr, 2002). This is also associated with the subsequent enactment or parallel processes for staff burnout, serious incidents, demoralisation, communication problems and staff sickness (Kerr, Dent-Brown & Parry 2007).
Increasingly, staff, mental health teams and entire services are accessing training in CAT to provide it a CAT formulation and understanding of clients for general multidisciplinary teams. Evaluation of a skills level training, which included six months supervision in CAT formulation, provided a Community Mental Health staff team with a structured, unified approach that led to enhanced communication, improved confidence, increased team morale (Thompson et al 2008) and containment of anxiety and hope for change in management of complex clients. Kerr et al 2007 reviewed the introduction of CAT as a model for staff groups, and outcomes indicated that CAT introductory training and CAT informed care were helpful, in routine work, improved team function, communication and morale within the team, and provided an improvement in the experience of clients.
However, despite the benefits of relational understanding of clients and team working, it is usually those with the most contact with clients that have minimum training (Moore 2012) and they are more likely to slip into re-enacting clients’ unhelpful Reciprocal Roles. It is for these reasons that a relational understanding and regular reflective practice for all staff, preferably enhanced by CAT-informed training for staff, is arguably a necessity.
Initially introduction of training in concepts from CAT training was provided only for the MCNS project staff. They also received the ACAT accredited 6-month CAT skills Case Management course to enhance and inform their practice and psychological management of their residents. Members of this team (the operational leadership manager, Sean Butler and 7 support workers) engaged in course requirements: intensive supervision, personal reformulation, course work and they successfully completed the course. LYMCA as an organisation witnessed the positive impact this had on client care and staff practice and subsequently supported CAT as a hostel wide relational framework.
Since 2015 LYMCA has become a CAT informed service impacting on key areas of organisational and team functioning (see diagram overleaf). All 75 staff, who have non-therapy roles in working with 141 clients at YMCA, including CEO/Directors, support workers, domestics, receptionists and horticultural workers, attended a 2-day introductory training in use of Cognitive Analytic Concepts . Also in 2015 the Director of operations Judith McLaine, 2 further operational leadership managers and a 5 further support workers completed another 6 month ACAT skills course to enhance each of their different roles.
In the process of providing supervision to CAT skills training staff in a broad range of roles at YMCA, the valuable application of increasing relational understanding with use of concepts from CAT became clear: to aid Team Reflective Practice & Case Management for all staff; to enhance service strategy: induction and endings for staff and residents, and human resources and management especially for staff subject to disciplinary processes, and on-going supervision for ACAT accredited skills certificated staff. Using CAT in these areas resulted in culture change at LYMCA, enhanced client stability, team Resilience Flexibility/compassion, planned endings, Workforce Development and Savings to Public Spending.
The following sections summarise each of the key areas and illustrate how CAT transformed provision of care and support at LYMCA (see figure 1). In each section there are a number of ‘voices’ and reflections (Bahktin theory (Holquist, 1995). From the Director of operations Judith McLaine, who ensured that the service successfully implemented as a hostel framework, Sean Butler the operational manager of the MCNS team who delivered the CAT informed service, and two support work/case managers Claire Ellis and Julian Riley (MCNS Team), who reflect on the implementation of CAT as a relational case management tool. To share the use of CAT at LYMCA, this paper will be divided into two parts with enhanced client care, public savings and team resilience explored further in Reformulation Summer 2017.
CAT reformulation (‘CAT mapping’)and training focused on personality disturbance and dissociation has enabled LYMCA staff to understand the nature of clients’ difficulties and the reasons they are ‘hard to help’ i.e. their development of a narrow repertoire of distorted, rigid, unrevised reciprocal roles, experienced as dissociated states, which impede clients’ self-reflective ability. It helps the worker to understand the reasons for clients’ abrupt, disproportionate, affective and behavioural changes and how the client experiences the self as fragmented and discontinuous, compounded by substance abuse. Clients with MCN typically have damaging developmental experiences that have resulted in early relationships where boundaries have been violated, inconsistent, or absent. They usually experience difficulty forming and sustaining healthy, stable relationships, including a therapeutic relationship, and reject, or are unable to make use of, the care that they need or even seek (Shannon, 2016).
Reformulation aims to allow compassionate and empathic understanding of the developmental origins of the RR and RRP’s to ensure non-reciprocation of unhealthy enactments for both the worker and client; to build a therapeutic alliance which allows, perhaps for the first time, the client to experience a healthy, caring, supportive, reflective, boundaried and non-collusive relationship with the worker, which, over time has the potential to be internalised by the client as a healthy way of relating to themselves and others.
A key emphasis of the training and supervision is that if clients could change their ways of relating without support, they would have done so already. They would not have multiple problems and require homeless services. Therefore if we aim for clients to make psychosocial changes as reflective workers and staff teams, it is we who need to be attuned and flexible and to offer different ways of relating to the client, despite powerful pulls to re-enact unhelpful patterns. This enables the client to internalise healthier, reciprocal roles to enact with themselves and others (Shannon, 2016). “Complexity [therefore] means harder work for the [worker], not the patient” (Leiman, p. 81, 1994).
Following CAT training MCN Steam and LYMCA have implemented a formal scheduled process of weekly reflective practice sessions where two accredited CAT skills workers facilitate development, with their staff team, of a CAT Reformulation for each client who is presenting as ‘hard to help’, including any anticipated problems with ending with the service (see case example in part two of this paper). These clients, their maps and care are reviewed as a team and via CAT informed clinical supervision where the reformulation is agreed. A relational CAT map action plan is then developed; see case example described in part two. This is then applied and embedded within the practice for the whole staff team.
The aim of the action plan is to recognise the pattern, and to exit with a ‘good enough healthy’ reciprocal role, as opposed to provide direct therapy for the client. It includes Reformulation, Recognition and Non-reciprocation and formation of a healthier RR (self to other, self to self and other to self): the Exit, is the psychological intervention.
All staff, including night staff, adhere to the CAT map action plan and bring observations of the formulation back to team wide reflection meetings to discuss, reformulate and record relational changes.
Claire Ellis and Julian Riley: “Due to the nature of the client group (inverted sleep pattern, substance abuse) it was seen that many valuable hours of interaction took place during the night shift and it was seen as vital that night support officers were a part of the reflective process. Night reflections began and aimed to run parallel to the existing reflections process to gather as much information and knowledge surrounding the resident as possible but also to create a consistent formulated approach across the entire team”
Sean Butler: Weekly Reflection meetings have enabled staff to create a shared language, which helps the team to “think CAT” consistently. It has facilitated a safe place where staff can discuss their feelings of frustration, annoyance, anger and even disdain in relation to residents, which helps in the mapping of reciprocal role and procedures. Previously, it has not been common practice for support workers to openly share their feelings around their supporting relationships with residents. This honesty is promoted and encouraged during reflections meetings, offering staff the chance to off load and manage feelings - leading to a reported increase in staff resilience (see outcome). Some of the example reflections from staff regarding residents include the following:
“I have been aware of a change in approach in myself toward him”
“I’ve seen a dramatic change in his attitude towards staff. He is much lighter and more jovial and I feel more comfortable interacting with him.”
Clients who have had a CAT reformulation and action plan are placed on a list for their care, reformulation and process for ending with the service, to be automatically reviewed by the whole team in 3 months (similar to a NHS CPA approach) and brought to CAT informed supervision, if further assistance is needed. This aims to ensure that it is not only the challenging clients that are the focus of team reflection and care and to ensure we do not enact an overlooking, neglecting to forgotten RR- common for clients in homelessness services.
Traditionally services that assist clients MCN (perhaps unknowingly) expect that only significant observable changes in the client presentation are indicative of psychological and social change; usually according to outcome measures stipulated by commissioners e.g. abstinence from substances, reduced offending. Using CAT, workers are helped to develop appropriate and realistic expectations regarding the nature, process, pace and meaning of change referred to as the ‘drip drip’ effect (Shannon, 2009). This allows recognition of what might appear to be small, insignificant changes as important achievements, not least engagement in a working relationship (Shannon, 2016). For example, a client’s reference to a key worker by their first name as opposed to swearing, thanking a peer for a cup of tea, combing one’s hair for the first time in months, screaming less. These ‘softer ‘outcomes are recorded and understood as newly forming healthy reciprocal roles for the staff team to build upon. These too are communicated to commissioners.
Importantly, the presenting problems of MCN (homelessness, violent behaviour, substance abuse) are recast as a Target problem and Target Problem Procedure that provides an understanding of the underlying relational nature of a client’s difficulty, has been particularly valued at the MCNS and LYMCA. This has allowed staff to connect with and empathise with the client when they elicit strong aversive responses.
Sean Butler: Reformulation and “increased empathy’ [for residents] resulted in staff being able to focus on target problems rather than the symptoms e.g.aggressive behaviours, urinating and sometimes defecating as a self to self act of neglect, thereby humanising the resident in the eyes of the team.
Importantly, the recognition and importance of meanings of endings for staff and residents in the hostel has also been transformed. There is recognition for the MCNS and LYMCA staff that homeless clients have experienced repeated episodes of inconsistent care with life long experience of multiple breakdowns of foster placements or care homes and/or loss of a parent (via death or repeated ‘absences’ e.g. custodial sentences, habitual drug abuse, mental health problems). Services commonly re-enact these unpredictable, difficult endings by failing to recognise the necessity of planning service provision and the need to communicate with clients about planned endings or transitions (e.g. change of keyworkers, hostel), unplanned ‘mini-endings’ (e.g. staff cancellation, holiday) or unplanned endings eg (recall to prison, custodial, death). Services unknowingly re-enact feelings of loss and anxiety in clients. Notably, this reinforces clients’ intolerance of perceived loss and difficulty in forming healthy alliances with current staff and services, either because of non engagement or clinging to services for rescuing care, making future move on difficult.
Within LYMCA changes to care are, wherever possible, planned for and communicated to the client by staff, to allow feelings of uncertainty, loss, and abandonment to be anticipated and worked with. This has included the key worker formally saying goodbye to their client when they leave their shift, and in advance when they are going on holiday with an explicit, phased handover in cases where experiences of rejection are significant in an individual’s life. This process is repeated for all clients when a staff member leaves the service. Unresolved feelings of loss and abandonment (current and past) that are inevitably elicited are given space (as initiated by the client) for delicate discussion in support work sessions. Move on is planned for collaboratively and realistically, to ensure predictability, stability and the security for current and future care (Shannon, 2016).
Within the MCNS programme a pre-accommodation visit is offered, where the resident is given the opportunity to meet the staff who explain the collaborative, CAT emphasis of care and support provided. It is explained that the team work reflectively and collaboratively as one service to ensure the resident receives appropriate support from all staff, not just their individual key worker. This process allows the resident to make an informed decision about whether the setting and care/support offered is suitable for their needs. Endings are discussed and, over time, a formalised plan is collaboratively established regarding where the individual wants to go after their placement with the service has ended.
Additionally, prior to arrival, LYMCA and MCNS staff gather details of a clients past endings with services. These are discussed and formulated. A list of types of endings, understood, as RR and RRP’s, have been developed to help the whole staff team to reformulate initial patterns, likely to be enacted from the outset, which have historically jeopardised stable accommodation. For example in relation to non-payment of rent and eventual eviction, patterns are anticipated in advance, exits are then put into place and seeking rent is now considered and enacted as a positive relational process. Importantly, staff communicate that the aim is for client to accept care and maintain placement, not continue to neglect themselves and repeat the pattern of homelessness; rather they internalise supporting to cared for self-to-self roles. Instead, internalising, caring, supporting to cared for supported, self to self.
Resettlement from the service is planned with and alongside the residents to promote informed choice, residents are supported throughout the move on and are then allocated a resettlement worker to support them in the community. Ending will also be followed up with ‘goodbye’ cards (a meaningful transitional object) and feedback from the staff team regarding resident’s time within the service. In addition to this when an ending is planned farewell meals take place to give the resident and the community the opportunity (if they choose) to discuss any feelings around the ending; anxieties, sadness as well as ambivalence or hope for the future.
In the event of an unplanned exit from the service, a goodbye card is sent to the ex-resident outlining their time within the service and, where appropriate, briefly and compassionately what relationally resulted in the placement breakdown. A community meeting is held with the current residents and opportunity is provided to discuss feelings and the meaning of the departure.
Importantly this process demonstrates to all staff and residents (past and current) that residents are cared for and held in mind, a relational experience unfamiliar for this client group. I recall supervising a LYMCA worker whose client, Sue (a 55 year old woman) was being breached and evicted from the hostel for placing other residents at risk. Sue was leaving in a matter of hours. The worker and I discussed getting her a card and writing an authentic paragraph about the workers’ relationship with Sue, briefly the reason Sue had to leave, and what Sue would need to do differently in order to return, with best wishes. Sue disappeared, the relational card was pushed under the door of her room; the worker had to go home. On return the worker went to Sue’s room, all her belongings chaotically ‘shoved’ into bin bags, which she had left behind. However, there on her bedside table was the card, carefully placed by Sue after she had read it. It was not torn up, burnt or thrown out of the window, as was anticipated. Two months later Sue returned to LYMCA to discuss her future placement. A meeting was held with the keyworker, the content of the card used to reflect on how Sue needed to relate differently with others and self, with support, to secure her accommodation. She agreed to this and she was accepted back as a resident of LYMCA.The challenge of giving good enough care, so that Sue could accept this, continued.
CAT introductory training has helped LYMCA to consider and revise their staff job descriptions, interview and induction processes for staff.
At LYMCA managers have also welcomed CAT reformulation as a valuable means of understanding conflict and relational management issues between their management team, within their staff teams, between staff and clients, between service and other external organisations. CAT has helped transform the culture of the organisation, see outcome section below.
The wider societal patterns of dismissal and rejection for this client group are re-enacted time again; Society to services (cessation of funding, ‘turning a blind eye’ to an ‘unseen’ population), by services to clients, staff to clients and clients to other clients. Within managerial processes this pattern is enacted by managers to staff and staff and clients to themselves.
Here Judith McLaine tells how CAT has transformed their managerial practice and ways of relationally understanding conflict/disciplinary processes with staff.
Judith: The CAT training days were beneficial in learning the theory behind the practice, but the supervision had a huge impact on how we work together as a management team and how we manage our staff consistently and fairly; particularly in line with our HR / Disciplinary processes.
It was enlightening for me to consider reciprocal roles, how transference and counter transference formed our relational make up and how understanding this could give me more understanding of my team’s ways of relating towards each other, toward the management team, and in return how we as a management team related to our staff.
I started to understand the flexibility of CAT and on upon further research and supervision to understand from a management/ organisational perspective how CAT, with its radically social understanding of the formation of the mind, its subsequent enactments’ could contribute useful insights and understandings into the function and dysfunction of groups and organisations, to assist in the understanding of dysfunctional organisational process (Ryle and Kerr, 2002).
It struck me how a CAT informed service contributed to the ‘wellbeing’ of the organisation and how crucial that the management team had undertaken further training in CAT to ensure an organisational approach and development of a “Management Observing Eye”.
I aim to have a truly CAT informed approach right across, up and down all of the services we deliver. I have started to learn through my CAT supervisions with Karen that CAT reformulation informs our strategies, polices, HR recruitment and disciplinary processes.
Due to CAT’S flexibility we can incorporate it into everything we do.
Sean: Clinical supervision groups are held monthly with Karen Shannon. Each group has its own focus depending on the purpose of the specific group. Each group relates to specific areas of the service and the diagram below shows the whole service approach utilising CAT as a psychological framework.
Judith: The newly recruited staff team of the MCNS program, based in LYMCA were highly motivated, skilled and committed.
The program had a heavily resourced training budget that included the newly introduced CAT Skills Case Management training provided by Karen.
In contrast, LYMCA was a 70-bed hostel accommodating increasingly challenging/complex client group with a ratio of 1 staff to 9 residents. It could be suggested that the existing staff lacked self-awareness, showed little empathy/understanding of residents and had low morale. It was a largely unsupportive group, suspicious of each other, managers and the MCNS CAT skills trained team.
Prior to the introduction of CAT, the wider LYMCA team were required to adopt the ‘flexible hostel approach’, a person centred approach (understanding, empathic to understood) where punitive measures and evictions were only to be used as a very last resort. With the aim of residents maintaining their accommodation (negotiating/supporting to negotiated/ supported). LYMCA championed the Flexible Hostel Approach, led by myself and team.
A large proportion of the LYMCA team didn’t accept this, enacting the rejecting to rejected (residents, flexible hotel approach, managers) reciprocal role. Staff felt threatened, as if they had no authority over residents because they were no longer able to routinely evict.
Sean: When the MCNS team completed their CAT training, they experienced RR enactments from the wider LYMCA. MCNS residents required intensive support from all staff and this created increased anxiety. Wider LYMCA staff disregarded and disrespected the MCNS team, who subsequently felt ignored and disrespected. Also initially to further compound anxieties, due to the MCNS teams underdeveloped understanding of CAT principles at that time, when residents were challenging, the whole team were ‘pulled’ to rescue (100% responsibility to rescued). Therefore the working environment with both staff and residents for MCNS staff was challenging.
Claire and Julian: “There was a feeling [that the wider staff] were being undermined by the “new kids on the block” who had been recruited, trained in CAT concepts and tasked with embedding these within “the old firm”. This dominant established culture was using punitive measures, of power and control over residents; a “three strikes and you’re out” warning system that lead to inevitable evictions. As more was learned about CAT, the MCN team began to question these old values. Slowly and surely (drip-drip) the wider team began to take notice of the positive results that began to emerge and gradually “bought in” and recognized the value of CAT approach.
Sean: As the MCNS team ,we developed a reformulation of the enactments between the two teams and then a CAT map action plan (see below) with exits. From this, we developed CAT informed weekly reflective practice group to include both teams which promoted a united, shared care approach to residents of LYMCA and MCNS.
Sean: The CAT reflection process resulted in a change in culture within the entire service. The united staff team (both LYMCA and MCNS) now actively seek helpful exits to avoid repeating relational patterns that have historically been re-enacted between support worker and resident. Punitive measures, such as threats of eviction and the traditional warning system have ceased. Staff instead work alongside the resident rather than imposing control, authority and power. This has resulted in staff and residents building stronger, healthier and more trusting relationships.
Systemically, CAT Supervision has also helped LYMCA and MCNS staff not to be pulled into the unhelpful enactments between external services, but instead to exit with an informed supportive, compassionate response. The aim is to reduce conflict between services, encourage agencies to work in partnership with collaborative, client focused relationships in order to help address wider psychological, health and social needs of this vulnerable client group.
A detailed Case study to illustrate enhanced client care and outcomes will feature in part two of this article.
Sean: The biggest way, in which CAT influenced the team that I manage within the MCNS programme, is how the team is organised, focussed and able to express themselves as workers. Two years on, there is clear evidence that the MCNS team is still motivated to work with MCN residents, with little to no signs of fatigue, burnout, demoralisation or lack of empathy. There are reduced sickness rates, in comparison to other services. Further detail will be provided in part 2, but some brief findings of a recent anonymous staff survey are:
Example statement “Using CAT in my everyday work has made me more understanding of my residents and how I behave in front of them needs to be positive to invite a positive effect”
“It has bonded the team to such an extent that everyone is aware of each other. This support is reciprocated which makes the team very cohesive”
“The most effective part of CAT is the increase in my resilience as a worker”
“Mapping residents helps us understand that some residents’ behaviour is historical and it is not always about us”
Sean: It is these factors that make CAT the ideal workforce development tool in terms of enhancing team satisfaction, cohesion and productivity.
Sean: Due to sustainable, good enough care provided for MCN there have been some extraordinary savings to public services (housing, health, criminal justice, drug/alcohol). These will be discussed further in part two. For one person alone, since starting the program and achievement of stability, cessation of arrest, court proceedings or remand in the CJS savings is £40,220pa.
Use of Cognitive analytic concepts from CAT has shown to be a flexible, user-friendly, valuable and effective relational way of enhancing and transforming working within organisations, teams and with clients with MCN. Importantly it ‘pushes where it moves’ and is needed; with the most vulnerable, hard to engage and help client group; those with MCN and the vast numbers of staff who offer care for them.
Judith: We have recently been awarded the lead of consortia of services delivering supported services within accommodation, and will be contract managing 364 homeless beds across Liverpool for the next 5 years - my vision now – for all homeless services across the city to have a CAT informed approach.
At the time of commencing this project there were no resources available to research the project fully. In future team/service development it would be useful to evaluate all aspects of CAT’s impact on services including team functioning, staff resilience, and impact of CAT informed human resources. With the hope that the value of CAT for indirect, contextual working for staff who do not have a mental health background, can be recognised and applied further.
LYMCA are also beginning to develop processes to work with other services: to in-reach into services when residents move on, to share CAT formulations and positive ways of working with the client, and to provide on-going support for a time; to promote RRs of Supporting to held staff, and vicariously cared for ex-client, until the worker-client relationships are established in the new service. The aim is to share relational thinking about clients with MCN with other services, so that the positive impact on staff and client experience continues.
I take this opportunity to acknowledge and thank colleagues at LYMCA who unwaveringly placed their faith in CAT and guidance from me, so that we could nurture CAT development at LYMCA, enhance service; client and staff care, and learn from each other.
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Use of Cognitive Analytic Concepts; A relational framework for Organisational service delivery and working with clients with Multiple Complex Needs (MCN) at the Liverpool YMCA
Shannon, K. Butler, S. Ellis, C. McLaine, J. and Riley, J., 2016. Use of Cognitive Analytic Concepts; A relational framework for Organisational service delivery and working with clients with Multiple Complex Needs (MCN) at the Liverpool YMCA. Reformulation, Winter, pp.12-20.
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