Kate Freshwater, Tilait Tanweer & Wendy Walker, 2017. Where Should We Keep Reformulation Letters?. Reformulation, Winter, pp.8-12.
The storage and confidentiality of Reformulation Letters and other therapy tools in CAT is a sensitive and important issue and one that can evoke a number of different views and practices. From our NHS clinical experience, clients often consent for their SDRs/CAT maps to be shared with the wider clinical team in order to aid understanding. The maps provide a summary without the depth of personal information that is usually contained within Reformulation and Goodbye letters. Therefore CAT letters may pose more challenges with regard to ownership and storage. The bottom-line for most Practitioners would be that the client owns their letter and is given a copy. Client feedback around this issue can vary from finding it helpful to share their letters with others (including health professionals involved in their care) to those who feel that their reformulation letters are private and exposing and that sharing their letters is too risky and would require careful thought (Hamil 2008). Caldicott (Department of Health, 1997) clearly outlines the right of the patient to privacy and confidentiality and to expect the health and social care system to keep confidential information safe and secure, but the devil is in the detail. Many CAT therapists will have other internal “voices” in mind such as:
• the NHS trusts’ policies and procedures that regard all written information about the client as the property of the Trust and to be placed on the person’s record
• the voice shouting loudly that the Reformulation letter belongs to the client and it is their choice what to do with it
• the voice of joint ownership (client and therapist)
• the voice of the threat of litigation which recommends a copy is kept by the therapist/organisation.
These potentially conflicting internal voices highlight the struggles for many CAT therapists working in the current context of the NHS regarding the crossover between the therapeutic and the legal – the latter often seen to dominate. One of the dangers is that the Reformulation letter could be read by someone without clinical experience who could interpret it to their own ends though able to argue that what they are doing is entirely legitimate. If the Reformulation letter is seen as “public” in some way and accessible to others then the clinical benefit to the client may be hindered by the loss of confidentiality. In addition CAT therapists may experience added pressure in writing letters if having to bear in mind “how might this be read in court?” (Welch, L. 2014, personal communication). Indeed, many CAT therapists use headers on their letters to minimise misinterpretation such as “This letter is a therapeutic tool, not to be considered outside the context of cognitive analytic therapy”.
We are writing this from a work setting in which we and our CAT colleagues feel passionately about developing relational thinking within mental health services. Staff frequently report the CAT model to be an accessible tool to aid this process. It could be argued that sharing the client’s Reformulation letter with other involved staff is a helpful way of developing a deeper understanding and empathy. However, it could also be argued that the Reformulation letter is primarily a therapeutic tool for the client and not a form of communicating to others, with its very privacy enabling clinical depth and containment. There are many other methods for developing relational thinking – such as mapping with staff groups, encouraging staff to write a “no send” reformulation letter from a staff mapping/formulation session, or clients choosing to share their maps or TPP summaries.
Brown (2010) provided a helpful review of good record-keeping in CAT, with clear distinction between CAT materials depending on its authorship and addressee. It suggests that Reformulation and goodbye letters, written by the therapist to the patient as part of the therapy could be placed on the file subject to the patient’s consent and right of amendment. The underlying assumption here is that “the Reformulation letter belongs to the patient and this should normally take precedence over any other considerations. Therefore if they do not wish it to go on the file they should be allowed to retain it”. Brown (2010) describes that a process of negotiation may be appropriate in some cases for the therapist to ask the client if parts of the letter can go on the file – with the therapist noting in the record that the patient was given a fuller version but declined for it to become part of the file. This process of discussion and negotiation with clients is close to the collaborative spirit of CAT and Brown states that it should only be over-ridden in exceptional circumstances (e.g. in forensic settings and/or when the person lacks capacity) when the therapist may feel it necessary to record some/all of the letter in the shared clinical record without the client’s permission. Thinking with clients as to who they wish to see their reformulation letter can generate helpful further discussion regarding the boundaries of therapy, the implications of sharing new self-awareness with others, and sometimes the wish to protect or hurt others with the content of letters (Hamil 2008).
The challenges for many CAT therapists working within NHS trusts involve a delicate balance between the needs of the client, therapist, other staff involved in the client’s care, and the employing Trust. One of the authors previously practised as the letter belonging to the client, with no copy held by therapist /organisation if the client so chose – contrary to Trust policy. However, she was left vulnerable as she had no copy of the Reformulation letter to refer to when a complaint was made to the Trust by the partner of a client. The partner was unhappy about the way she, and their relationship difficulties, had been described in the letter. The therapist’s practice then changed to a copy of the letter held on the paper record, but protected from wider electronic access.
The introduction of the electronic record is also a source of professional and ethical concern for the CAT therapist. Although guidelines on the use of electronic records are provided by the British Psychological Society (2011), this document provides no absolute position. Instead clinicians are encouraged to reach independent decisions which are informed by the advice of the Trust Caldicott Guardians, the Society’s Code of Ethics and Conduct, and relevant Health Professions Council standards. It is advised that the risks of sharing and storing information are considered in relation to the wishes, needs and interests of the individual service user.
The revised NHS Care Record Guarantee (Department of Health, 2011) and the Confidentiality NHS Code of Practice (Department of Health, 2003) assert the importance of only sharing information on a need to know basis, offering choice to patients to limit how information is shared, with a discussion about the possible impact of such restrictions on clinicians’ abilities to provide care and treatment, and only making records available to people who have a right to see them. However, the Care Record Guarantee also states that where technology allows, an audit trail will enable recording and identification of anyone who has accessed records without good reason. This highlights the reality that many electronic records systems are widely available to many, without the capability to restrict access through ‘sealed envelopes’.
This paper came about as a result of the CAT clinicians in a NHS mental health trust having struggled with the tensions around good record keeping in CAT for some time and a wish to share current practice and stimulate discussion. The authors vary between them in their views and practice, and have practiced differently in different settings which can also depend upon the practicalities of access to storage.
In some ways, the introduction of the electronic record (in our setting PARIS) for activity recording helped to clarify that some documents were inappropriate for such recording (e.g. therapeutic tools, psychometric tests) and our Trust recognised the need for a paper file for their storage. For some years, there was agreement that an additional paper file (for psychology/psychological therapists, known as “the green envelope”) could be held for documents inappropriate for both the electronic record and the wider team paper file. Many CAT therapists were using these to store reformulation letters whilst sharing an appropriate summary of the formulation on the electronic record, with client consent, to aid staff/team understanding and treatment. However, this practice had recently been challenged by a CMHT manager, with objection to these records being kept separate to the shared team paper record. As a result of discussion and advice from our information governance department, we are beginning to use a new system. This involves CAT therapists (and other psychological therapists) using a large purple envelope called “Secure-Stor+” (Cardea LP24343) for therapeutic documents inappropriate for sharing with the wider clinical team, such as Reformulation letters. These can be placed inside and the envelope is sealed at the end of therapy – with a contents list on the front. Clear reference to the existence of the documents and their location is made on the electronic record in addition to an appropriate negotiated summary of the formulation, key reciprocal roles, TPPs etc, with client’s consent. Once sealed, the envelope is attached to the existing team paper file in order to keep records together. If no paper record exists for the client, then the envelope becomes the paper record and is archived. It is early days and the system is by no means fool-proof but we hope it reduces the likelihood of people “happening to see it” without good reason when looking through notes. We also hope it will offer more balance of the positions of the need to protect these highly sensitive documents from unnecessary circulation/breaches of confidentiality as well as the need to keep a record of our therapeutic work should there be a future enquiry/complaint.
In order to find a solution to the storage problem, we asked 31 staff in our mental health care NHS trust who are CAT trained or training for their opinions and practice with regard to the storage of RF letters and other therapeutic tools. These include psychologists, psychological therapists, nurses, and OTs who work in a variety of settings and specialties including inpatient CAMHS, Older Peoples Services, Forensics, Adult community teams, inpatients and tertiary services.
14 CAT therapists responded to the study. They were contacted via the CAT therapist network by email and asked to report their current storage of CAT therapy resources and provide any thoughts or views regarding this issue. Participants were informed their replies would be treated as confidential. In an attempt to maintain the anonymity of participants, it was requested all replies be sent to the trainee clinical psychologist conducting the survey, who was independent to the network.
A Summary of CAT Therapist Storage of Therapy Resources
Storage of Therapy Resources Number of Clinicians
Purple Envelope 3
Green Envelope 5
Shared Paper File 3
Patient-informed Storage 1
Process Notes 1
*A total of 14 replies received however 1 participant did not state their current storage method.
Thematic Analysis based on the framework provided by Braun and Clark (2006) was used to analyze clinician’s thoughts and views regarding the storage of CAT therapy resources.
Four main overarching themes were identified: current practices; implications of sharing; tensions and uncertainty. Each theme identified along with sub themes is discussed in more detail below.
Table of Themes
Current Practices Therapist practice and patient views
Implications of sharing CAT resources Benefits
Therapist practice and patient views Several therapists informed their patients of the way in which they had planned to store CAT therapy materials. Although some therapists spoke of pre-determined storage plans some also described their practice as flexible. For example, one therapist stated ‘I tell patients I am doing this’ (restricting the wider care team’s access to therapy materials). ... occasionally people respond to this by saying that they do not mind if others see their letter, in which case I discuss with them whether they want to share it’. Others described offering patients an explicit choice and described their practice as patient led. Some therapists highlighted patients who valued restricted access to their therapy resources. For example one therapist reported ‘I do know from conversations with clients that they appreciate that the letters and SDRs are not shared within the team’.
A majority of therapists made reference to restricting the wider care team’s access to CAT therapy resources by opting to store materials separately from the general patient record. Some therapists explicitly stated that their practice intentionally avoided the use of the electronic record system. For example, one participant reported ‘I do not put letters on PARIS’ as the system was viewed as ‘accessible to so many’. However others explained how they made reference to therapy resources in the patient general record and used the electronic system to summarize reciprocal roles or formulations. Based on therapist’s accounts, the purpose of restricting access was to maintain confidentiality.
Several therapists identified the availability of resources as one factor which influenced the way in which CAT therapy materials were stored. For example, one clinician stated ‘I do not have a filing cabinet of my own so there was no way I could store my own files separately’. Another clinician stated ‘I have tried to obtain purple envelopes … but our admin staff have not been successful in obtaining these’.
Implications of sharing CAT resources
Several clinicians discussed the potential benefits of sharing aspects of CAT therapy resources with the wider care team. Such benefits included aiding a patient’s care if they returned to service at a later date or managing risk. One therapist spoke of how ‘there may be risk issues which would make it in the client’s best interest if the material were available, for example if there were procedures on the SDR which could inform care or help with risk assessment.’ Another therapist described their experience of sharing elements of a SDR as ‘helpful’ when relational patterns were being re-enacted on an inpatient ward. One therapist stated she felt appropriate access to therapy material may be in the interest of the therapist should a complaint be made and they needed to demonstrate good practice. All therapists emphasised the importance of seeking patient consent before sharing CAT therapy resources.
The risks of sharing or making CAT therapy materials more accessible were highlighted by some therapists. One therapist described concerns regarding the content of therapy letters being taken out of context ‘I may use a metaphor meaningful to the client, but this could be misconstrued by others.’ Others shared concerns about storing CAT therapy resources in the electronic patient record and the risk to patient confidentiality. For example one therapist stated ‘the very nature of the way information is shared and stored on PARIS means it is accessible ... I do get concerned at times that with such processes there is a risk of more information about a patient being exposed than necessary.’
Several therapists described feeling uncertain about the way in which CAT therapy resources should be stored. One therapist explained how the use of multiple folders (i.e green and purple) ‘could lead to potential confusion.’ Another described seeking advice from colleagues. With regards to the sealed purple envelope, some therapists stated they were uncertain in what context and when they should be opened. To manage this uncertainty one therapist reported ‘I do think there would need to be guidelines around the circumstances in which this envelope could be opened in the future and the contents used.’
Therapists acknowledged the underlying tensions associated with storage of CAT therapy resources. These tensions were described in the context of adhering to the Trust record keeping policy and maintaining a patient’s confidentiality. For example one therapist stated ‘I feel at times it is a fine balance maintaining patient’s privacy and being mindful to not leave them in a position of being exposed whilst keeping to Trust policy on record keeping.’ Others described tensions between respecting patient choice but protecting their own practice. One clinician described a past clinical experience in which they had destroyed a therapy letter on request of the patient but felt vulnerable by not holding on to a copy if a future legal issue or complaint had arisen.
The above results were shared with CAT clinicians in two CAT network meetings. This generated further discussion and recognition of potential reciprocal roles that were being enacted between therapist and client in the process of deciding where CAT letters/diagrams should be stored.
It was recognised that an exposing – exposed reciprocal role existed between some CAT clinicians and the wider care team and/or legal professionals, not just the patient and the care team. CAT clinicians described the risks of being exposed with regard to their therapeutic letters being misinterpreted outside of the therapeutic context, particularly with regard to use of their own emotional reactions within letters or use of client’s sometimes brutal and harsh metaphors (such as one reformulation letter referring to “the bitch state” which was the client’s label for her rage state). Concerns were raised that a therapist’s therapeutic writing style/freedom of expression may be limited during the writing of the reformulation letter if the contents were potentially to be shared more widely. All CAT therapists involved in the survey reflected the importance of protecting patient confidentiality with regard to the potential risks of exposing the private content of CAT letters and maps (also reported by Hamil, 2008) and the majority were restricting access by the wider care team. Thus, our discussions acknowledged the importance of protecting the privacy and safety of the therapy space and therapeutic tools for BOTH the client and therapist.
We debated the possible reciprocal role of overprotective / controlling to over-protected / no choice, between some CAT clinicians and clients. For instance, although with the best intent, some clinicians seemed to be making assumptions about the fragility of the client and their needs without having an open discussion about choice of storage location. One clinician who described the decision about storage as being patient led had been surprised at the willingness of some clients to sharing information (maps) when they had been consulted. However, we also acknowledged the importance of appropriate authority/protection to feeling protected in our relationships with clients – for example if a client was asking for their CAT letter to be stored on the electronic record, we would want to explore their motives/expectations for this and possibly caution with regard to our knowledge of the fallibility of the electronic system around protecting confidentiality and the problems of getting it off again if they changed their minds.
We are proceeding with a process that is not solely “patient led” but we hope it is mostly led by the best interests of the patient. We have rules or boundaries – such as the Trust’s Record Keeping Policy which states that a record has to be kept and the Trust CAT Lead’s guidance that CAT letters are not to be stored on the electronic record and that the minimum requirement is storage in the “Secure-Stor+” envelopes. However, we advocate that these processes are made clear to clients, with discussion, negotiation where possible and informed consent if a client should choose to share any of the CAT resources more widely within the clinical team. For example, a client may wish to share their SDR with the clinical team and have this stored within the shared paper record, or a client might decide for their TPP summary from their reformulation letter to be entered onto the electronic record. This process of sensitive discussion and consideration parallels the importance of careful and considered reflection with clients regarding anyone else they might choose to share their letters and maps with, with regard to their hopes, expectations and possible consequences (Hamil, 2008). To aid more informed discussion with clients about storage issues, we are planning to include a “storage of CAT therapeutic tools” paragraph in our Trust “What is CAT?” information leaflet. This will state the Trust’s position of a copy having to be held on record (but “protected in the “Secure-Stor+” envelope and not placed on the electronic record) to prompt discussion at assessment or early in the therapy process in case this would be a reason to not engage in therapy.
Feedback from the CAT clinicians in this survey reflected confusion and uncertainty about the new storage process (“Secure-Stor+” envelopes). This was unsurprising given that it was a recent change to processes and that different services and settings had differing systems and storage resources. However, the feedback was a helpful prompt for our Trust CAT Lead to write a storage guidance document, ratified by The Head of Psychology and Head of Information Governance, and then disseminated widely to aid clarity of process and communication. We also hope to audit client feedback regarding their opinions on storage of CAT therapy tools and what they choose with regard to storage options within the boundaries of our work setting. This will be an important next step given that the client’s voice is missing from this small study.
We are keen to hear about how others manage these tensions, particularly within the settings of NHS trusts.
We would like to thank the CAT clinicians in our trust for their involvement in this survey, and the support from our Head of Psychology and Information Governance department to enable us to find a compromise solution with the “Secure-Stor+” envelopes.
We are also grateful to Lawrence Welch for comments and advice on an earlier draft and to Jan Mead for her advice and support.
Address for correspondence
Kate Freshwater, CAT Service, TEWV NHS Foundation Trust, Wessex House, Falcon Court, Preston Farm, Stockton-on- Tees,TS18 3TS. email@example.com
Braun, V. and Clarke, V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology, 3 (2). pp. 77-101. ISSN
Department of Health (1997) The Caldicott Committee: Report on the Review of Patient-Identifiable Information
Department of Health (2003) Confidentiality : NHS Code of Practice
Department of Health (2011) The Care Record Guarantee: Our Guarantee for NHS Care Records in England
British Psychological Society (2011) Guidance on the use of Electronic Health Records.
Brown, H (2010). Confidentiality and Record Keeping in CAT therapy. ACAT Reformulation. Summer.
Hamil et al (2008). Letters in CAT: The patient’s experience. Psychotherapy Research. 18(5) 573-583.
Welch, L. 2014, personal communication
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