‘Seeing the unseen’. Supporting organisational and team working at YMCA Liverpool with multiple complex clients. The use of Cognitive Analytic concepts to enhance service delivery

Karen Shannon, Sean Butler, Claire Ellis, Judith McLaine, and Julian Riley, 2017. ‘Seeing the unseen’. Supporting organisational and team working at YMCA Liverpool with multiple complex clients. The use of Cognitive Analytic concepts to enhance service delivery. Reformulation, Summer, pp.5-15.

“The energy and commitment of those now using and developing … relational approaches … may serve to address pessimism and to offer some clinical and political hope for the future”.

Tony Ryle

Introduction by Karen Shannon
In the last edition of Reformulation (Winter 2016), Liverpool YMCA colleagues and I shared use of CAT as an organisational framework for working with people with multiple complex needs (MCN).

To recap, since 2014 the entire staff group at LYMCA (staffing a 69-bedded hostel, with three smaller hostels totalling 141 residents) have received 2-day introductory training for case management (adapted and provided by Karen Shannon and Marisol Cavieres) and two sixth-month CAT skills case management courses (adapted by Karen Shannon and delivered by Karen and Marisol; course work marked by Dawn Bennett and externally moderated by Jackie Withers). The 6-month courses aimed to enhance the roles of support workers, managers and the Director of Operations at LYMCA. The initial article illustrated the versatile use of CAT concepts to inform LYMCA organisational and service strategy, human resources policy and procedures, and to aid reflective practice, case management and endings processes for staff and residents. This resulted in the necessary and positive changes to the LYMCA wider culture: enhanced team resilience and flexibility, positive workforce development and, importantly, enhanced client care and transitions/move on.

In this article, organisational research will be interwoven with Sean and Judith’s descriptions. Manager Sean Butler shares an anonymised and generalised example of CAT-informed resident care and move on, which gives a brief flavour of the challenges to working with clients who have multiple, chronic, entrenched problems and the value of CAT to achieve sustainable change.

Director of Operations, Judith Mclaine, will share examples of CAT-informed adaptation of managers’ procedural and relational responses to critical and serious incidents, adaptations made at LYMCA to CAT-informed recruitment, induction processes and probationary periods. These ensure staff are suitable and effective for working within a CAT-informed culture and are able and willing to work as part of a team.

Liverpool YMCA provides services for clients who are multiply excluded, hard to reach and help, with multiple and complex needs (substance abuse, offending behaviour, physical health problems, mental health problems and homelessness). There are 1,200 people in Liverpool with multiple needs. Usually little is known about clients’ developmental experiences and triggers for their lives spiralling out of control to the point of incapacitation and enhanced risk to self and others. There is repeated, unrevised oscillation between health services, living on the streets, being picked up by the police and persistent desperation to beg on the streets to fund their addictions and facilitate escape from intolerable pain.

Use of CAT concepts and reformulation allows staff and teams to focus on the ‘here and now’ enactments of developmentally derived Reciprocal Roles and Reciprocal Role Procedures only (as opposed to developmental derived experiences), which is appropriately boundaried for non-therapist intervention.

Case Study: Introducing Kenny
By Sean Butler, Julian Riley and Karen Shannon.

This is an example of what is possible when we have a CAT-informed relational staff team with CAT-informed organisational support.

Kenny is a homeless man in his early fifties with an extensive history of complex physical health and mental health needs in relation to chronic alcohol misuse, and intravenous heroin use and crack use which negatively affects his ability to care for himself and accept care from others.

Little was known about his early history except that he had been living in hostels and on the streets for over a decade because his life had ‘fallen apart’. This reportedly coincided with the death of Kenny’s mother, closely followed by the breakdown of his long-term relationship. Previously he self-reported he had a ‘normal life’.

Kenny was referred to the Multiple Complex Needs Service (MCNS) based at Liverpool YMCA. In 2014. This project was a new initiative designed to try to break the cycle of entrenched homelessness in order to help clients exit the ‘revolving door’ that typically manifested in clients repeating patterns between other services or street homelessness.

Before being accommodated within the MCNS Kenny was a ‘high profile’ client with health and criminal justice services in the city of Liverpool. He would often be found confused and vulnerable in public places, usually incontinent and at times partially undressed, which led to numerous arrests for indecency or hospital admissions due to the general public being worried about his physical safety. He was on the ‘frequent attenders’ list at A&E and was arrested by police almost on a weekly basis, although rarely charged. The human toll of social deprivation, trauma, loss and suffering for Kenny (and others) was understandably enormous.

From a commissioning perspective Table 1.1 shows the economic impact on public funding prior to being accommodated at LYMCA of £83,054 over a two-year period. We can see that aside from his appropriate accommodation costs, the next highest costs resulted from his frequent arrests and significant resources required from the criminal justice system, in comparison to the preferred, yet minimally accessed, resources from the CMHT.

Like so many clients like Kenny with complex needs, he fell prey to the lack of attunement, inaccessibility and inflexibility of services whose criteria reject the multiplicity of complex needs and those who have them; or the nature of the service provision is ineffective in the mid to longer term.

Through CAT reformulation with Kenny at LYMCA we aimed to establish staff compassion and develop authentic meaningful relationships with him to promote his safety, enhance his dignity and wellbeing, and for staff to begin to recognise Kenny’s repeating unrevised relational patterns. These relational patterns were as follows (see Figure 1 CAT map below): he would spend several days conversing with staff, being engaging, charming and complimentary about the service he received. This was usually followed by a very distinctive state shift; a shorter but intense period of him being loud, judgemental, rejecting and extremely critical of staff, the service and everything around him. He would also announce that he could ‘run things better’ if he were in charge ‘like he used to be’ (his reported role in his earlier life). Typically, these enactments lead to a flashpoint - usually an altercation with a fellow resident or verbal aggression toward staff, followed by Kenny leaving the premises and returning in a state of intoxication (heroin, alcohol use) to the point of incapacitation. Kenny’s intoxication led to a prolonged period of self-neglect and isolation where Kenny would binge-drink and self-inject heroin for days with no engagement with staff or fellow residents. We named this state ‘oblivion’ due to the level of detachment (psychological and physical absence) that staff experienced when Kenny was in this state; it was as if he ‘disappeared’.

Thus there were only fleeting opportunities for working with Kenny when he was psychologically and physically available for meaningful contact where staff would strive to engage Kenny. However, Kenny would always find a way to ‘escape’ and ‘disappear’ into substance abuse - a term used by his key worker who felt frustrated and stuck.

This reformulation helped staff to acknowledge their feelings of anxiety, frustration, anger, resentment and stress where they felt de-skilled and inept in finding ways to work successfully with Kenny. At times staff also felt shocked and disgusted in relation to the severity of Kenny’s self-neglect. For example, he would lose control of all bodily functions including bowel function, speech and movement and was also known to sit in his own faeces and urine for periods of time; or he would hit an artery when injecting himself, resulting in blood spurts. Needles were casually discarded.

Shared recognition of the reformulation and feelings identified in staff helped us to identify their unknowing contribution to Kenny’s Reciprocal Roles (RRs) and procedure (see Figure 1.1 CAT map). This empowered staff to make choices to step out of unhelpful patterns and to move toward enacting more helpful reciprocal roles and procedures (exits). This was the process of Revision. This process of learning and application of ‘CAT’s Three Rs’ (Reformulation, Recognition, Revision) helped staff to work together and enhance resilience and team working. We learned through our growing knowledge of CAT how our ways of relating can be recognised, understood and altered to elicit positive change as we invite clients to step into caring, supportive RRs. The staff team began feeling hopeful and talked of ‘seeing light at the end of the tunnel’ in relation to working with their challenging and complex individuals.

(See Figure 1.1 on previous page)

Consistent reflection via reformulation allowed the staff team to stay CAT-informed and to continue to recognise the pulls and invitations from Kenny (and from ourselves, Self–Self RRs). When staff felt criticised or impotent in helping Kenny, they felt that they had an exit plan to not only cope themselves with the situation, but also help Kenny in the long term by not re-enacting unhealthy, critical or rejecting reciprocal roles. For instance, at times when Kenny publically criticized a key worker, they understood the pull to retaliate - to regain power by being critical of Kenny or to neglect and reject Kenny. This would re-enact relationships with services over many years. As an exit, they chose instead to converse with Kenny at this time and try to understand his frustration, negotiate with him or distract him as a means of reducing the intensity of the situation and reflect his behaviours to him. When staff felt powerless and overwhelmed by Kenny’s ‘oblivion’ state and they felt unable to help Kenny, they reminded themselves of his patterns and tried to empathically hold Kenny in mind in relation to his absence. Crucially, Kenny was monitored, observed and kept physically safe. On one occasion this required staff to defibrillate him after cardiac arrest and call an ambulance, whereupon Kenny was taken to A&E followed by a quick return to LYMCA.

Over time, by side-stepping the enactments, staff relationships with Kenny appeared to thrive and Kenny’s risky and self-destructive behaviour lessened. Such was the sustained improvement that we (staff at LYMCA) worked with him to end his time at the hostel and move into independent accommodation.

The anticipation of ‘move on’ naturally was anxiety-provoking and traumatic for Kenny given that he had been dependent on access to ‘ideal’ 24-hour care services for over 10 years. His assumption of needing to dependently access ‘perfect’ (24/7) care to meet his needs was so entrenched that his reluctance to move on is still reflected upon in the service to this day.

He expressed this resistance by displaying his high ‘need’ and attempting to elicit the perfect care, which he didn’t feel he would get residing in the community. Informed by our knowledge of Kenny’s responses to previous endings, we therefore anticipated Kenny might sabotage any planned move into the community so that he could remain within the MCNS at LYMCA.

The process of ending was discussed with Kenny over a three-month period and he was involved to influence the process as much as possible. Through our CAT understanding of the importance of endings with clients in services we know that residents will experience a range of emotions in anticipation of losing the relationship with their key worker/team/service which is likely to trigger past memories of abrupt, unplanned and painful endings. We helped Kenny to tolerate any feelings of loss and isolation (here and now, and past) and explored good-enough exits to his perceived need for 24/7 care and support.

So when on the day of the collaboratively-planned move or ‘ending’ from the hostel came, Kenny predictably ‘escaped’; he went into his state of ‘oblivion’ and he became incoherent and was even drinking in public in the community (a pattern he had not engaged in for almost a year). Staff encouraged and supported Kenny and took him indoors and cared for and monitored him. When he became more aware and ‘available’, we were able to remind him of the work around endings that had led to this point and his involvement in this process (informing/encouraging/supported/guided) and eventually, with his agreement, we moved him into supported accommodation within the community.

Earlier on we had introduced our move onto workers who were informed by Kenny’s CAT map and they were able to side-step the pull to enact unhelpful procedures and continue to encourage him to make supported, positive choices when he moved to the community. This included pre-agreed plans to visit Kenny in his flat - initially three times per day - and providing him with a phone to contact the service if he needed to talk. This was gradually jointly agreed to reduce over time, enhancing Kenny’s independence.

A description of the savings to public spending when placed at LYMCA, a CAT informed service, is shown below, and which is of relevance to funders. However, the personal and interpersonal meaning of the changes in the way Kenny now relates to the world and to himself are immeasurable in terms of his availability to engage with himself and with others in his community (his enhanced independence, his building self-esteem and self-care). For example, he now attends the gym (self-care) which is something he always stated he wanted to do when in 24/7 care services, and his periods of ‘oblivion’ have become less frequent and they are also more manageable. He is keeping himself safer. He is now aware that ‘oblivion’ is a state that he will come out of, whereas in the past he feared he might die at this time and in this state and that he would simply permanently disappear. He now tolerates and appropriately manages his anxiety as his awareness and Zone of Proximal Development (ZPD) increases. He has also developed some self-care for anticipating his periods of oblivion, including buying rehydrating substances such as ice pops to negate some of the physical punishment his body endures during these times. Again this is a sign of his awareness, insight and advanced planning not previously seen from Kenny, and his internalisation of the care from others to develop wider repertoires of self-care.

Kenny has now been in a stable tenancy with no evictions or arrests, just two A&E presentations, no input from rehab/detox services, and just one appointment with CMHT services over a 12-month period.
The positive CAT-informed process used in Kenny’s ending with the service has now been formalised within service MCN beds in LYMCA and is starting to be integrated into wider LYMCA. Endings are now discussed with residents from their very first days of arrival in the service. The ‘move on’ team alongside Karen Shannon have created a ‘transitional object’ document that the move on workers utilise with residents that gently explores past endings with services (only), fears, and expectations and also looks at predicting possible snags that may prevent the individual from wanting to entertain the concept of ending their time with the service and snags for independent living.

This level of attention to CAT-informed care and the focus on creating appropriate endings for complex clients has helped influence and shape service change, not only within LYMCA but also across Merseyside. The value placed in CAT and its positive outcomes were acknowledged and reciprocated in September 2016 when the city of Liverpool commissioned ten additional complex needs beds in LYMCA in response to the increased need for CAT-informed compassionate, flexible care and services with homeless complex people.

CAT-Informed Organisation and Team Working
This work also emphasises the necessity of effective and positive team working for working with complex clients. In organisational psychology literature we are reminded that fundamentally teams outperform the aggregate of individuals working alone and are essential for the performance of many tasks in organisations. Moreover, in MCN work lone-working would not be possible; it would quickly lead to burnout and compound clients’ patterns though multiple enactments.

However, there is the challenge of how to enable people to combine their efforts and imaginations to work in ways that enhance quality of care through the achievement of team shared goals. As West (2012) described: Working on the task of care and support requires effective teamwork. The team must have an overall purpose that adds value and which is translated into clear, challenging team objectives. Effectiveness includes the wellbeing and development of team members as well as the level of innovation in the team. This requires an attuned and compassionate service with effective leadership.

As stated in the winter edition of Reformulation, we described how use of CAT reformulation and exits such as enhanced managerial leadership (see also Judith’s examples below) helped transform the LYMCA culture and team working. West (2012) describes how ‘transformational leadership’ reinforces an inspiring and motivating team purpose that is focused on the needs of the team’s stakeholders (clients, commissioners, other services), and which encourages all team members to value the diversity of its membership. Where members have opportunities to grow and learn in their roles there is a strong sense of continuous growth and development as a team.

Well-functioning teams have a ‘high level of positivity, optimism and a healthy balance of positive and negative interactions’. Members are ‘open, appreciative, kind and genuine in their interactions with each other and eager to learn from each other’. Team members believe in the team’s ability to be successful and effective in their work (team potency). West stated further that staff are secure in their team memberhip and attached to the team because of the level of trust and support they encounter and the fact that members appropriately ‘back each other up’ in crises- a crucial requirement for effective working at LYMCA.

The team actively builds effective inter-team relationships and members identify enthusiastically, not just with their team, but with the wider organisation of which they are a part. Teams enable effective communication and fruitful collaborations in which new ideas are shared and integrated, workload is shared, and mutual support is provided. At LYMCA this has been achieved through team containment and shared belief in the scaffolding function and value of CAT.

CAT focus meetings for managers and support staff occur at planned points throughout the year to ensure ‘managerial and support worker observing eye’ on service provision is continual for flexibly working with clients with the changing and complex needs of clients and stake-holders. CAT focus meetings also allow the service to review performance and to adapt with task reflexivity, tolerance of uncertainty, and social reflexivity.
Research evidence (see Fredrickson, 2009) highlights how important positive emotions such as pleasure, happiness, humour, joy, pride and involvement are a source of human strength. When we feel positive emotions such as hope we think in a more flexible, open-minded way, and consider a much wider range of possibilities than if we feel anxious, depressed or angry. This enables us to accomplish tasks and make the most of the situations we find ourselves in. We are also more likely to see challenges as opportunities rather than threats. When we feel positive we exercise greater self-control, cope more effectively and are less likely to react defensively in workplace situations. The benefits spill over into ‘pro-social behaviour’ – cooperation and altruism and a sense of social responsibility, which encourages organisational citizenship (West, 2012). For the homeless population, this approach is the antidote for a discarding, ‘unseeing’ public/politics to unseen, ‘disappeared’, suffering, complex client group.

How CAT informed management affects the performance of teams and develops resilience
Sean Butler demonstrates signs of effective team working in his team at LYMCA

Jobs in healthcare are known to be more physically, emotionally and psychologically demanding than other jobs. In the 2014 NHS staff survey, 39% of respondents reported being unwell in the last year from work-related stress. Also, the average rate of sickness within the NHS currently stands at 4.8% (or 1.5 days a month per person). Across several studies it appears that between 21% and 67% of healthcare workers experience high levels of burnout. In a study of 151 community mental health workers, Webster and Hackett (1999) found that 54% suffered from high emotional exhaustion.

Since the introduction of CAT in 2014 within the MCNS team (a 9-bedded unit within LYMCA) there has not been a single recorded instance of work-related stress. The team sickness rate currently stands at 2.3% (or 0.3 days a month per person). It is less than half that of statutory healthcare services.

We believe within MCNS at LYMCA that we have enhanced staff resilience and effective team-working with the use of CAT concepts. We have more empathy and a sense of shared responsibility and goals with the use of CAT as a psychological framework and case management tool to inform staff cohesion, mutual support, collective practice and reflection. To me, this has been the defining factor in sustaining an effective workforce that retains its motivation and commitment to work with multiple MCN clients. There is organisational citizenship with social responsibility.

This positive team-working is also enacted in improved outcomes for the client group with resettlement from our service. In general, in supported accommodation for the homeless population of Liverpool where services do not use psychological approaches for care and resettlement, the ‘positive move on’ (i.e. move to accommodation which is preferential and more suitable to the needs of the resident) rate stands at 65%. Within the psychologically-informed MCNS, at LYMCA this figure currently stands at 90.3%. This means over 90% of endings within the service are planned and meet the needs of the residents engaged in the service. This is in keeping with the principles of endings within CAT - that they are collaborative, predictable, planned with each resident and more likely to be maintained.

In general, effective team-working requires the team’s relationship with the wider organisation to be engaged and supportive. In essence, teams enact organisational strategy and enable organisations to learn more effectively and retain this in the resulting service culture. Judith explains more about the application of this below.

Pre-CAT management team procedure CAT management and CAT inspired HR processes
By Judith McLaine, Director of Operational Services

There was a period of time when LYMCA had expanded quite rapidly. The number of staff had tripled and we had acquired several new services across Liverpool city. This naturally increased the amount of pressure and accountability in my role as director of operations at Liverpool YMCA. Additionally, during this time, there was a large amount of external and political pressure with the introduction of a new flagship complex needs accommodation project.

As the service has grown and our understanding of CAT has increased, so has the need for the development of more appropriate HR procedures, policy changes and approaches to serious incidents. I introduce a specific example of this in our work at LYMCA:

A mixture of pressures from commissioners, local media, and social media about council and service responses to homeless and multiple complex needs people in general, and in Liverpool, and my personal characteristics of striving to achieve uncompromising attention to detail and a strong focus on delivering exceptionally high standards of service, has led to compounded high pressure, which resulted in unhelpful enactments.
The example presented here is one before the service and I understood the importance of CAT-informed decision-making as workers, managers and directors of services. I have named this CAT map the generic ‘serious incident’ map: it describes the relational difficulties that go with directing a team of managers, being responsible for the quality of services delivered and for securing funding. Although we have used the word ‘serious incident’ within the map, this could relate to a number of types and severity of incident involving threat to the organisation and its staff and residents. For example, there may easily be a report for commissioners that has not been submitted on time or missing data for the document that may be required for reporting. Serious incidents could, however also extend to assault and death of a resident. People that require this information include commissioners and funders who have the ability to fund our programs of support, or not, depending on the quality of work presented to them and our reputation. This creates a pressuring to pressured and solely responsible reciprocal role for me as a director.

In one particular incident there was a report about to be submitted to seek funding for a new project. Some of the required data was missing. My instinctive reaction to this was to find out who had missed the data, putting pressure on one of the managers to give me information there and then; my only aim was to solve the problem and find the data as this linked to quality, and this quality is linked to maintaining the services and reputation with our commissioners. At that point in time (pre-CAT), such was my anxiety, feeling of being under pressure, fear of failure and exposure, and focus on the task, that the individual manager’s response or feeling about my style of interaction with them did not seem relevant. To me the situation demanded urgency and needed correcting, regardless of who was involved.

In our large open-plan office this was played out publically in front of the rest of the management team and all members of their respective support teams. So with reflection there was an enactment of publically exposing and humiliating those involved in the missing data, unknowingly evoking feelings of unworthiness and embarrassment for the manager involved.

Another manager who had observed this public interaction, then began to feel instantly anxious and pressured and started to worry that ‘she would be looking at me next’, and that she could also be publically, critically exposed. This had been my repeating pattern and individuals had experienced these feelings before and anticipated the same enactment happening again many times.

When I started to understand and apply CAT concepts in managerial practice, I picked up on the manager’s distress in a conversation. The manager was clearly upset and this was then raised in CAT clinical supervision. In that safe and supportive environment, the two managers and I were supported to develop a CAT map to ‘map and track’ the different reciprocal roles and positions the management team and I enacted. During the supervision my own procedures became clearer, as did the managers’ responses to my style of enquiry.

The map opposite was developed, Figure 1.2. The procedure was that either managers internalised this pressure and re-enacted this with their teams (self to self, self to other) or they withdrew, isolating themselves from the pressure to escape and (in their own words) ‘lick their wounds’.

Historically, the temporary resolution would then come in the form of an apology for not meeting the demands placed on them. This was the only exit that the team knew or understood at the time and this scenario was played out too many times to mention. Subsequently, we developed the exit of calmly and confidently, collaboratively reassuring and trusting (director to trusted, calm, empowered, contained and valued (managers).

Post CAT-informed management team procedures and responses

After months of CAT reflective practice, clinical supervision and developing our management ‘observing eye’, we then had another particularly serious incident involving accidental overdose and the death of a resident at the service.

I received a call out of hours and, using the reformulation and recognition we had gained via CAT supervision, I decided that this incident would be handled differently. The reformulation came to mind and I recognised the pull to enact my usual ‘serious incident pattern’ as described above. However, this recognition enabled me to revise my response. I calmed myself (calming to calmed, self to self) and collected my thoughts. En route to the hostel, instead of my usual feeling under pressure and instantly demanding all of the facts and also trying to find what was ‘missing’ (what hadn’t been done), I was calm, confident and contained and reassured the team that I would be there as soon as I could.

On the journey to the hostel I planned my responses to staff. I was still anxious due to needing to respond and report on the serious incident, but I was equally aware about how I would interact with those involved. I wanted to avoid re-enactments of pressuring, demanding and controlling.

I arrived at the service at 3am and ensured that everyone involved in the incident (all of whom will have been traumatising to traumatised) was acknowledged and contained. I then went to find the management team and we then collaboratively reviewed the audit of information and processes involved rather than me isolating myself and checking this on my own. This created a new reciprocal role of valuing, trusting/supporting to trusted/supported, appreciated, between the managers and I, and this was then re-enacted by managers with the frontline support staff.

Support staff on shift were calmly informed that the management team was conducting the necessary audits while the emergency services looked after the incident.

This again informed, reassured, contained and supported both the management team and the support team (director) Other-Self (managers), Self-Self (managers), Self-Others (managers to support staff) who were kept up to date and informed throughout the process.

In addition, as soon as possible after the incident, managers also met with the entire staff team to de-brief them. We also advised them of the necessary audit processes that are involved in a serious incident and the importance of recording information and data. Staff were informed that managers would aim to respond in a calm, trusting, informing and supportive manner to any future serious incidents to enable staff to feel calm, contained, aware and trusted.

The impact of this was that over the coming weeks we noticed that the open-plan office was calmer. Staff were able to contain and support themselves and each other and free up managers to investigate and report on the incident to external services and commissioners.

This has resulted in a more open and transparent understanding between the management team and a confidence in each other’s responses to crisis. For the managers involved in the pre-CAT incident (who experienced anxiety around ‘being next’) they commented that via supervision they are reassured that this won’t happen again because of the learning and also because they have adjusted their own responses to conflict.

CAT-inspired HR processes

To dovetail with this organisational relational learning, the service has also developed many processes which influence and fundamentally support CAT within the recruitment and HR structure.

For recruitment, on assessment days applicants now complete case studies and exercises that focus on values and CAT patterns that we would seek from potential staff to match our established CAT-informed culture. We aim to identify reflective practitioners who can reflect upon and alter their patterns of relating as a result of learning and CAT reformulation.

When a staff member is appointed for a role, their induction process is CAT-inspired. Again, moving away from the traditional ‘tick list’ culture that organisations can apply to induction (for example reading through policies, mandatory training, terms and conditions of employment). This process not only includes these aspects but is complemented with a robust explanation of service expectations, cultural awareness and clear guidelines around the process of how we utilise CAT to shape service delivery and also individual and team responsibility and development. New staff are subject to a probationary review which includes a review of expectations at three months and six months.

The responsibilities from a management perspective in developing new staff in CAT terms throughout the first three months of employment are described in the following reciprocal roles:

However, at times some staff have not responded to these positive reciprocal roles and, for various reasons, enact a dependent, demanding, non-responsible, stuck position in relation to managers. Historically managers have either strived harder to support staff, requiring never-ending resources, which elicited further dependency and/or rejection or eventual dismissal of the staff member after significant periods of time and stress on resources at LYMCA. To function effectively the team needs ‘the right’ people with the required skills in the right roles. ‘They must be ‘enablers not derailers’: people who support effective team working through their behaviours, not people who sabotage, undermine or obstruct team functioning’ (West, 2012).

With this in mind, the CAT-inspired recruitment and induction process aims to employ enabling appropriate staff. To support this we also use CAT reformulations (such as those below) in the service as relational templates to alert managers to possible ‘derailing’ staff and to allow more focused, explicit discussions at the three month probation meeting to identify support needs and shared responsibility, with the view to encouraging appropriately responsible, trusted and capable support staff going forward.

3-Month Review
This describes how the management team would approach an unhelpful pattern they found themselves in with a new staff member at three months. At this point expectations would be re-affirmed along with identifying appropriate support that individual might need.

This has helped to establish clear roles, expectations and responsibilities and transparent, trusting, enduring, relationships with new staff. (See diagrams at foot of page.)

Moving forward: further CAT service development
By Karen Shannon

The value of using CAT as an organisational framework for case management and managerial organisational processes has been invested in further at LYMCA. In September 2017 LYMCA is funding their CEO and the remaining service managers of their satellite hostels, along with additional support workers to undertake the 6-month CAT skills case management program.

Moreover, systemically, separate but connected services of staff (around 30) working with multiple complex needs in Liverpool - such as the Outreach Intensive Support Service (ISS) and peer mentors - have all received adapted two-day CAT skills training and reflective practice sessions (provided by Mandy Wildman and Karen Shannon) using a ‘test and learn’ approach to see whether funders wish to replicate CAT organisational/team working for all services working with MCN. To assist with this we are grateful to Professor Glenys Parry and Dr Kerry Manson who are evaluating pre- and post-CAT training; the impact of CAT training and reflective practice on staff experience at work, the nature of team working, and the levels of burnout and stress experienced by staff.

It is not the disadvantaged, but all of us who have a role in helping to mediate and assist with the societal, political and personal patterns that have resulted in poverty, trauma, homelessness and needless human suffering. CAT’s application can help us work to achieve greater change together, more than we can do on our own.

‘We are now working WITH our clients with the help of CAT. I have found that this leads to goals and outcomes that belong to the client, rather than have them pushed on them by staff. Clients have found their own way, with support’. Support worker, LYMCA

Fredrickson, B. (2009) Positivity, Random House, New York.
Mental Health Confederation (2012). Mental health and homelessness: Planning and delivering mental health services for homeless people.(Briefing April 2012, Issue 235).
Onyettt, S., Pillinger, T.,Mujen, M. (1997). Job satisfaction and burnout among members of community mental health teams. Journal of Mental Health, 6, 55-66.
Webster, L. & Hackett, R.K.Burnout and leadership in community mental health systems. Adm Policy Ment Health (1999). 26:387–399
St Mungo’s 2010 client survey: www.mungos.org/homelessness/facts/homelessness_statistics
Homeless Link (2011) Homelessness, mental health and wellbeing guide.
West, M.(2012).Effective teamwork: Practical lessons from organizational research. 3rd edn, Blackwell Publishing, Oxford.


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Full Reference

Karen Shannon, Sean Butler, Claire Ellis, Judith McLaine, and Julian Riley, 2017. ‘Seeing the unseen’. Supporting organisational and team working at YMCA Liverpool with multiple complex clients. The use of Cognitive Analytic concepts to enhance service delivery. Reformulation, Summer, pp.5-15.

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de Normanville, J. and Kerr, I., 2003. Initial experience of a CAT skills certificate level training for a community mental health team working with complex and ‘difficult’ mental health problems (including personality disorders).. Reformulation, Spring, pp.25-27.

Other Articles in the Same Issue

CAT and the “Incredible Years” programme: Towards a CAT parenting guidance framework
Marie-Anne Bernardy-Arbuz, 2017. CAT and the “Incredible Years” programme: Towards a CAT parenting guidance framework. Reformulation, Summer, pp.22-31.

Developing a CAT understanding of Anti-Social Personality Disorder (ASPD)
Kerry Manson, Sunil Lad and Marisol Cavieres, 2017. Developing a CAT understanding of Anti-Social Personality Disorder (ASPD). Reformulation, Summer, pp.42-48.

Embodiment as a creative resource in working with split and “borderline” clients
Tim Sheard, 2017. Embodiment as a creative resource in working with split and “borderline” clients. Reformulation, Summer, pp.34-41.

Our relationship with our bodies: Reflections from bariatric surgery and the wider cultural context
Dr Jenny Bowe, 2017. Our relationship with our bodies: Reflections from bariatric surgery and the wider cultural context. Reformulation, Summer, pp.63-65.

The experience of staff practising “Five Session CAT” consultancy for the first time: Preliminary findings.
Kate Freshwater, Jennifer Guthrie and Alison Bridges, 2017. The experience of staff practising “Five Session CAT” consultancy for the first time: Preliminary findings.. Reformulation, Summer, pp.59-62.

‘Seeing the unseen’. Supporting organisational and team working at YMCA Liverpool with multiple complex clients. The use of Cognitive Analytic concepts to enhance service delivery
Karen Shannon, Sean Butler, Claire Ellis, Judith McLaine, and Julian Riley, 2017. ‘Seeing the unseen’. Supporting organisational and team working at YMCA Liverpool with multiple complex clients. The use of Cognitive Analytic concepts to enhance service delivery. Reformulation, Summer, pp.5-15.

“IAPTrogenic effect?”: CAT theory as a tool to consider potential systemic patterns of iatrogenic harm within the context of Improving Access to Psychological Therapies (IAPT) Services
Chris Barry, 2017. “IAPTrogenic effect?”: CAT theory as a tool to consider potential systemic patterns of iatrogenic harm within the context of Improving Access to Psychological Therapies (IAPT) Services. Reformulation, Summer, pp.51-58.

“Never-ending hurt”: How CAT can help inform the management of chronic pain
Dr Melanie L Davis, 2017. “Never-ending hurt”: How CAT can help inform the management of chronic pain. Reformulation, Summer, pp.16-21.

“Resilience in the face of change” – 23rd National ACAT Conference, the benefits of working with over 65s – our reflections on why the evidence base is so limited
Dr Sarah Craven-Staines and Dr Tamsin Williams, 2017. “Resilience in the face of change” – 23rd National ACAT Conference, the benefits of working with over 65s – our reflections on why the evidence base is so limited. Reformulation, Summer, pp.32-33.


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