On Learning From Our Patients: Reformulating CAT Training

Robert Marx, Joanne King, Kylie, Mary Wilson-Verrall, Karen Spencer and Annabel J McDonald, 2017. On Learning From Our Patients: Reformulating CAT Training. Reformulation, Winter, pp.13-18.


Introduction

I remember the humbling moment.  I was sitting in a meeting with some colleagues.  We were discussing one of the key priorities of the Education and Training Department’s strategy objectives – to ensure that every training programme hosted by Sussex Partnership NHS Foundation Trust (which includes the Brighton CAT Practitioner course) should be co-produced by service users.  I was sitting opposite the director of the CBT training programme trying to explain the reservations I and some of my CAT colleagues had to involving service users in the CAT training: 

 ‘What would happen to the transference?’  ‘Wouldn’t you just get idealisation or denigration?’  ‘It would disturb the therapy if you did it whilst the therapy was ongoing, and there would be so many complications about contacting patients after they had gone through the ending and you had closed the case.’  ‘You’d be asking patients to open up their material all over again – it could be very distressing for them.’

 As I was explaining the possible objections, I could feel myself losing faith in my own narrative and by the end, the CBT course director looked at me, visibly appalled:

 ‘Don’t you think they should make these decisions?’ she said.

The literature was clear. There had been almost two decades of public policy advocating for Service User (SU) involvement in the planning and delivery of care – for example ‘Patient and public involvement in the New NHS’ (DH, 1999) and ‘Creating a Patient-led NHS’ (DH, 2005).  More recently, the ‘Five year Forward view’ (NHS England at al., 2016) states that ‘co-production with experts-by-experience should…be a standard approach to commissioning and service design’. Finally, the report, ‘Nothing about us without us’ (NIP & NSUN, 2015) which was funded by the Department of Health states that ‘where possible, training should be shared by and with service users, carers and professionals taking part in an involvement process’.

 Many professional bodies have long been on board with the principle of SU involvement.  In 2005, the Royal College of Psychiatrists declared SU involvement mandatory in training (Fadden, Shooter & Holsgrove, 2005); the following year, the Chief Nursing Officer demanded greater partnership between SUs and nursing educators (DH, 2006) and in 2010, the British Psychological Society published guidance published on SU partnership for clinical psychology training programmes (BPS,  2010).

 The involvement of SUs in service provision and training fits well with CAT.  We are used to considering issues of power in therapy. For example, we say that CAT ‘actively promotes a collaborative and power-sharing therapeutic relationship’ (Brown, 2010) and that ‘psychotherapy is a two-way conversation whose successful outcome usually depends on the patient having an opportunity to repair the therapist’s misunderstandings’  (Jenaway, 2011).  Why would training be different?  How could we be engaged in a collaborative ‘doing with’ SUs as opposed to ‘doing for’ (Ryle and Kerr, 2002, p.2) with no SUs involved in the training process?  By not involving SUs in training, are we not privileging the voices of trainers, trainees, ACAT and UKCP, the literature and evidence base, but not those for whom the whole therapeutic enterprise is set up?  This could be especially problematic when the research suggests that therapists and patients may have very different perceptions of what the helpful and unhelpful elements of therapy are (e.g. Llewelyn, 1988).

Plan

We wrote to all local CAT therapists and told them about our plan to involve SUs in a teaching session, asking for their help.  We asked them if they had anyone with whom they had fairly recently finished CAT who might be interested in participating in an upcoming training session on the Practitioner training.  We fairly quickly had a group of five.  Four of the five had had individual CAT and one had had group CAT.  Four were women and there was one man. All had been seen in the NHS in secondary or tertiary care services. One had finished therapy a couple of years previously and I discovered on the day that one was just finishing with a recent follow up session just completed. 

 I wrote to all five in advance with a session plan.  They arrived on the day an hour before the start of the session and had time talking on their own as a group and then with me. We re-considered the plan for the session and discussed any concerns.  Two of the five unexpectedly knew each other from work.  They decided to continue but  agreed certain boundaries around what they would and would not say in front of each other.  There was some nervousness. I explained that the trainees had all had their own CAT and had just done an exercise that morning about their experiences of their own therapy. 

I  introduced the context and purpose of the session and we agreed ground rules (including respect, confidentiality and the freedom to not answer any questions or to feel any pressure to say anything anyone was uncomfortable saying); the SUs each had 5 minutes to say whatever they wanted about their personal context for coming into therapy; then they had about 20 minutes discussing their experience of CAT in front of the trainee group; and the last 30 minutes or so would were spent in a dialogue between the trainee and SU group. 

After the session, the SU group had lunch together and de-briefed.  Each person agreed that the session had been a positive and, in fact, therapeutic, experience. The person who had just recently finished her CAT was gratified to see how much progress others had made who had completed CAT longer ago, commenting that ‘the best is still to come’.   Others were missing their CAT and appreciated the sense of support and re-connection with CAT.  Another felt that it was normalising to hear how others had struggled with adversity in their lives. There was a shared sense that it was positive to be able to help future CAT therapists to be effective. 

We had a very interesting discussion about payment.  One SU said she had received the therapy for free and wanted to give something back for free.  Someone else was concerned about the effect on benefits and so preferred no payment. Another felt it was important to accept payment as this was valuing; and as the staff were mostly being paid to be there, why shouldn’t they receive payment. 

I suggested we write this piece.  Everyone was invited to stay on for the afternoon session on ‘personality disorder’ and one person did this.

I  separately spoke to the trainee group and invited any of them to write a letter response with their experience of the session.  Their written evaluation of the day, reviewed subsequently, was very positive with all Likert ratings for different aspects of the day falling between 4.3 and 4.7 on a scale of 0-5.  Comments included:  ‘Having previous CAT clients in was very enlightening’; ‘SU experience was brilliant’; ‘very thought provoking’; ‘open and honest’; ‘SU participation was really useful and powerful’; ‘superb day’. Trainees also commented they liked the inclusion of SUs into the presentation on personality disorder. There was one suggestion that SUs should not disclose their histories as this trainee felt it created a sense of ‘them’ and ‘us’ as the trainees were not asked to disclose anything about themselves.  (The SU group were also not asked to disclose anything but chose to do so).

Exchange of letters

This was my letter to the SU and trainee group:

Dear group,

I haven’t always been an advocate for doing what we did at the CAT practitioner training last week. I had my reservations.  I guess I was concerned that the experience might be distressing for you and wasn’t convinced it would be helpful for the trainees.  Sometimes, these kinds of innovations can feel a bit faddish, tokenistic and more about being seen to be politically correct than actually being helpful.  Or maybe it just takes time to adjust.  I think I still feel that way about the term ‘service user’ so forgive my continued use of the term ‘patient’ – I hope this doesn’t offend.  In the months before we did the session, my uncertainty about involving you in the teaching was confirmed by some colleagues, most of whom were initially uncertain too, and one of whom was rather opposed. 

However, together with my uncertainty was a growing sense of feeling inspired by this idea of trying to break down the barriers between ‘us’ and ‘them’, between so called ‘helping experts’ and the ‘helped’, and so changing some of the sources of knowledge on which we drew to inform how we become CAT therapists.  I think this fits really well with the CAT ethos.  In starting to feel inspired by the idea, I think I was reflecting on some of my own experiences of having been a patient and how some of my therapists, helpful as they all were, may have sometimes been guided more by theoretical and received ideas of what works more than by what I needed; and of course, I have been guilty of doing this too as a therapist myself. Sometimes, we rationalise certain ways of acting by telling ourselves they are necessary for our patients when actually they are more ways of protecting ourselves as therapists.  It can be hard to see what these blind spots are until someone shows you. 

So when we put out the call to CAT therapists to see if they wanted to be involved in suggesting this teaching session to their former patients, I had no idea if anyone would reply or even if I would get a lot of hostile responses.  Our administrator, who has been fantastic in helping make this event happen, said that of all the things she has done over the years for the course, this felt like this had the most potential to go wrong. 

My uncertainty continued through the months of us emailing right into the morning of the teaching actually when I could not be sure who would show up or what would happen.  In the meeting we had just before you led the session, one of you was unsure you’d have anything to say.  I was also wondering if it would all dry up and tried to think of contingency plans in case it finished long before the 90 minute session was up. 

But actually we had a great discussion in that hour before the teaching session started.   When we went up to the teaching room where the trainees were, I later discovered how nervous some of you were.  I shared your nervousness.

In the first section of the session, you each took 5 minutes to say something about yourselves and what brought you to therapy.  It was powerful and moving and I was in awe of your courage to be so open with a group of people you had never met. 

Then you all talked together in front of the trainees.  You raised some important points about how difficult it was to get the right service.  One of you talked of how you fell through the cracks between primary and secondary care, being deemed ‘too severe’ for primary care and not ‘severe enough’ for secondary. You then had to fight for a service that should have been simply provided to you.  You thought the therapy should be available at a much earlier stage.  Another one of you talked about how you had received psychological help that had not helped at all (‘the woman just looked at me’; ‘you walked away with an open wound’) over a period of years, before you came to CAT.   By contrast, your experience of CAT was that it offered an explanation of ‘how I destroy and heal myself’ and was more ‘personal’. 

You explored what were the most therapeutic aspects of the CAT you had.  You said that the individual person of the therapist and the relationship between you were crucial.  You found it ‘amazing’ to be able to feel able to be so safe, trusting and open with someone.   You had some thoughts about what a good therapist was – someone who does what works and does not push through the ‘standard’ model if it isn’t working for someone – for example, understanding that you might not want to talk one week or might need to do something creative rather than verbal. However, the group CAT may have been a little different in that it was not all just about the therapist and patient, but about all the group members. You all recognised that you had to be at the right point in your life to do the work, and that that required a huge commitment. 

In terms of the CAT tools – the map and the letter mainly – you generally felt both were important.  Most, but not all of you, described the diagram as really helpful although you also said that you could feel ‘trapped’ by looking at this ‘washing machine’ that seemed initially confusing with no way out.  So exits were very important and so was making the map your own, for example by colouring it or re-doing it your way.  One of you gave an example of having internalised the map, you could bring it to mind in a challenging situation and use it to stop yourself acting destructively. 

You talked about the impact of hearing the letter – feeling ‘spaced out’ and ‘sick’ - how that was a turning point for you that affected some of you more than anything else.  You were worried about being judged but the affirmation of the letter was really helpful. 

 You reminded us how ‘daunting’ it was to simply end the therapy and called for either a face to face or online forum where you could continue to talk with people who had had CAT.  Another idea was for the therapist to be available by email after the therapy had ended or to have a ‘weaning off period’ and/or an annual review, although one of you thought the work you had done at the end of the therapy prepared you to do the work on your own after the therapy had ended.   

None of you seemed to find the Psychotherapy File and other questionnaires you were given at the start of the therapy at all useful.  You said you were not in a position then to say anything about what your thought or felt, that you just felt ‘blank’.  

I feel that you taught us a great deal in that session.  For me personally, you reminded me how bewildering the start of therapy can feel, how much more important the safety and trust in the relationship are than the technical aspects of CAT, especially the questionnaires, and how daunting and not necessarily therapeutic it is to end suddenly.  You have made me think about what ongoing support might be helpful and possible after people finish CAT and I plan to continue this conversation with colleagues, and hopefully with you.   It was also really inspiring to hear how much this CAT approach has made such a positive difference and helpful to be reminded of this when the pressures of the NHS may cause us to lose sight of what is most important. 

Finally, thank you so much for trusting us with your openness and honesty and generosity. 

Best wishes,

Robert

There were two responses from the SU group:

 

Dear Robert,

Thank you for inviting me along to the training day, I am a big fan of CAT therapy and I felt privileged to participate with the therapists and patients.

The day was enjoyable I felt comfortable and it was a warm, friendly and safe environment.

I felt the communication flowed very well in terms of us (patients) talking openly and easily about our experiences, it was interesting how different and unique our paths had been but we all shared the universal benefits of CAT which included getting to learn and understand ourselves on a deeper level thanks to the CAT therapy.

I guess the ‘us and them’ situation is inevitable to a certain extent, however, it didn’t stand out too much because I find the CAT approach is very human with a strong compassionate ethic within it.

I felt very fortunate as a psychology student and a frontline mental health worker with a strong recovery to experience the day training from the two perspectives of patient and therapist.

I enjoyed Jane’s presentation in the afternoon although I did find the film upsetting and emotive which I was expecting as I was warned of upsetting scenes, I did shed a few discreet tears and managed to control my emotions quite well. I especially liked listening to the therapists ask and answer questions after the film, it was interesting to see how CAT is taught to professionals.

Thank you for the opportunity to share my ideas and reflect again on CAT it was truly inspiring for me as I hope to develop my skills as a therapist in the future and be of benefit to others. The mind map is one of my favourite components of CAT which I found most insightful and helpful, however it represents my cognitive functions in the past and stops at 2013/14 and I feel my map has grown in 2-3 years and I wish there was a way for extending the map as the individual progresses in their recovery, otherwise there is a concern one may feel they are stuck in that cycle of thinking / behaving for the unseeable future.

Learning how to create virtuous circles and practice them either through a computer app or forum would be a great way for the patient to carry on with CAT work after the treatment is finished.

We talked about creating a gentle safe ending after the intense work load is finished, I think maybe a casual CAT drop in for clients to reflect with one another on their experiences could possibly make the ending less abrupt or an intro to an on-line forum or sign post to another self-help group for after care especially if the patient has a substance misuse problem as well as a mental health issue; for example Pavilions, SMART group, AA, NA, Coda Anonymous, hearing voices group or survivors network, whatever is most suitable for the individual if they have a dual diagnosis.

Please let me know if I can help in any way in the future, it has been a pleasure.

Kind Regards,

Jo

And:

Dear Robert,

Thank you for your letter regarding the CAT teaching session, first of all I just wanted to say thank you for inviting me to attend. CAT therapy has really helped me over come so many obstacles in my life and I’m happy to be able to give back in anyway.

For me I had mixed emotions when I first agreed to attend. I was excited and a little nervous I didn’t really know what to expect. When we first arrived I really liked that we all sat down as a group before meeting the trainees. I found this calmed my nerves a little, getting to know all the other speakers I found really interesting it was good to see how CAT therapy had helped other people.

When it came to going upstairs to where the trainees were I found this very intimidating to start with as we had to walk in to the room they was all sitting in and it felt like we were walking into the lions den to be honest, I would have felt a little more comfortable if they had come in to the room we had been sitting in.

When we entered the room and sat down I really liked that fact that we were handed the same hand-outs as the trainees and made to feel like part of the group this helped ease my nerves a lot. I personally wasn’t too keen on the little talk we did between ourselves in front of the trainees as we were talking and they was just watching us, I’m not sure if this is because we had already had a talk between all of us so it was hard to know what to talk about and I felt it didn’t have much structure so kept going of topic a little. We also kept talking over each other at some points and I feel like some of the group didn’t really get to put their point of view across at times.  For me personally I would have found it easier if maybe you had two of us with a group of maybe five or 6 trainees to be able to sit and talk in smaller groups.

Overall I really enjoyed the teaching session and found it very helpful for myself so I really hope the trainees found it just as useful.

Many Thanks

Kylie

There were three letters back from trainees in the group: 

 

Dear Robert,

Thank you for organising and inviting ex CAT patients into our practitioner training day. I must say I felt very excited in seeing this on our outline for the day and, in thinking  more about it, I was surprised this has not been done before. It seems a “no brainer” that you would not open this out to patients that have been through CAT to give an account of their experiences of therapy. So, it’s great this happened.

I was curious to see how it would go and whether enough support would be in place as I was aware this may stir up emotions for those that came to tell us about their experiences. As the group walked in to the room I felt nervous for them and I wondered what it must have felt like walking into a room full of CAT trainees. I know some of their feedback was they felt a bit like being on trial walking in with us all already sat there. They said their preference would be to have us walk in with them already sat. I agree with this.

You invited each person to talk about their experience of CAT and then this followed with a joint dialogue of our experiences of having the therapy. It was a really moving experience to hear a little about what led them to therapy and their experience of it. I was struck by their bravery and openness and I felt privileged to hear what was shared. 

The group asked us about our own experience of having CAT.  I felt exactly the same as they described, how scary it can feel, how important it is to feel heard, to feel safe and to trust your therapist, and how sudden and difficult the ending of therapy can feel.

The whole experience felt very inclusive, without barriers. It was inspiring and of great value.

I really hope you continue the conversations with the group’s ideas of further support following finishing CAT and that this experience happens again for the next intake of trainees. It’s been very thought provoking.

Best wishes

Mary

And:

Dear Robert,

Thank you for putting together such a rich training day which provided an opportunity for us, as trainee CAT practitioners, to be able to meet together with such an inspiring group of CAT patients.

When we discuss ‘moments’ within therapy I feel this also applies to the generous, courageous and honest contribution made by the patient group who offered up ‘themselves’ and shared their combined experiences of CAT therapy. I hope that with their help I will continue to develop and remember them when working collaboratively with patients with a renewed respect to the importance of creating a safe, trusting and open relationship which can be flexible to what the patient needs at any one time. I was particularly moved by the expressed power of maps, both emotionally and visually, and how they can helpfully ‘pop up’ in the mind at times of stress. I was also moved by the conveyed sadness and difficulties managing the ending of therapy.

I felt immensely privileged and grateful to have been a part of this inclusive training experience, and hope that subsequent trainees and patients can benefit similarly in the future. The opportunity reinforced why I feel so passionate about the collaborative aspects of CAT, and it was so positive that the group of patients also spoke about how they felt it was a worthwhile experience for them.

With best wishes,

Karen

And finally:

Dear Robert,

I am writing to say how much I valued the visit, to our teaching session, of past and current CAT patients.  It was extremely valuable to hear their views about the therapy and their enthusiasm made me feel genuinely privileged to be training as a CAT practitioner.

It was interesting to see how the five patients had largely similar views about CAT.  Their strongest opinion seemed to be a criticism of the abrupt nature of ending therapy.  They suggested that it would be useful to experience more follow-up sessions and were enthusiastic about there being more contact between patients after therapy - perhaps in the form of a support group which might be supervised or possibly not.  There was also a feeling of frustration shared by some of the patients that they had not received such valuable therapy earlier in their lives, they suggested that this could have saved them from years of unhappiness and poor function.  Each patient appeared to have felt a very close bond with their therapist which seemed to embody the trusting and caring relationship which we had, as a group, identified as vital in our own experiences of therapy.  I found it very valuable to have thought about our own values in our personal therapy prior to meeting the patients. 

One manner in which views differed between the visitors was their response to their reformulation letters.  This was sometimes a moment of revelation and finally feeling understood.  However, for others, it was a dreadful shock to see their lives caricatured in a couple of pages displaying a depth of negative experience.  The provision of the SDR appeared more broadly positive with patients tending to view it as a very positive tool.  Again, there was a feeling of reluctance to terminate therapy with one visitor suggesting that there should be ongoing support to keep the SDR relevant as they introduced changes to their lives.  It was unclear whether she was suggesting using it to map new problems or whether she wanted it to convert to a ‘happy map’ and display successful patterns of interactions.

On the negative side, I note that all attendees had experienced positive effects from their therapy and feel that this was thus unlikely to be a group representing the broad range of CAT experience.  It would be valuable to see a wider range and hear the reasons for negative responses.  I understand that such patients might be less willing to be helpful but wonder whether a more representative sample could be contacted by using the responses to quality questionnaires provided at the end of treatment.

Thank you very much for arranging such a helpful and interesting training experience.  It will contribute to the relationship that I strive to build with patients as well as emphasising their vulnerability.  It has made me more sensitive to the effects that we can have on our patients.  It has also provided me with valuable food for thought about the possibilities of providing forms of ongoing CAT support.

With best wishes,

Jinny

Discussion

This seemed to be a highly valued session.  I was very pleased that the trainees appreciated and valued hearing about CAT in this way and I think it was inspiring to hear so directly about how effective CAT can be.  What was more of an unexpected and happy surprise was to hear from the SU group how much they got from doing this at a number of levels: for example, reversing some of the power imbalance and meeting human to human, being valued enough to teach and seeing how valued their contribution was, the therapeutic benefits of meeting together as SU group, and the growth in confidence in being able to do this.  This session also had value as a statement about who and what we as CAT professionals value and whose voices we want to learn from. It felt like more of a ‘doing with’ rather than ‘doing to’ or ‘doing for’ in a training context.

 

 

Recommendations

There were useful ideas about how to do this session again if we have the opportunity.  I would hope that next time:

•             The design of the sessions would be more comprehensively co-produced now that this group knows the ropes

•             The trainees would be invited would be invited to disclose something of their own experience so that it feels more equal.  One way of doing this next time if we get the chance may be to be all together as a SU and trainee group from the beginning of the day, participating together in the exercise on the therapeutic elements of our personal CAT therapies, which only the trainees did this time. 

•             We could have small groups instead of, or as well as, the goldfish bowl exercise

•             We could find one or two people with a less positive experience of CAT to offer more of a critique.

There was also food for thought about possible changes, or changes in emphasis in the way we deliver CAT;

•             To consider follow up support after the end of therapy  - for example, by being invited to join a CAT group, having a drop in and setting up an online forum. These all have challenges to them but are also all worthy of exploration. 

•             To pay particular attention to the issues around starting and ending therapy, and in using maps and letters

•             To remind ourselves of the centrality of a trusting and flexible therapeutic relationship

•             To question whether even a well worked through ending with a follow up is necessarily therapeutic

•             To think twice about whether or how to use the Psychotherapy File at the start of therapy. 

Acknowledgments

Thanks to Gavin Lockhart for his scholarly knowledge of the policy background, to Lydia Turner for changing my mind about SU involvement in training, and to Adrian Whittington for guiding the strategic vision within which this took place.  Thanks to my CAT supervisor, James Low, and to my CAT trainer colleagues, Jane Blunden and Val Coumont, for their support with this venture.  Above all, thanks to the ex-CAT patients, who made the training session possible through their courage and generosity, and who led it so movingly.  

References

British Psychological Society (2010).  Accreditation through partnership handbook: guidance for clinical psychology programmes.  Leicester: British Psychological Society. 

Brown, R. (2010).  Situating social inequality and collective action in Cognitive Analytic Therapy. Reformulation, winter, 28-34.

Department of Health (2006).  From Values to Action: the Chief Nursing Officer’s Review of Mental Health Nursing.  London:  HMSO.

Department of Health (2005).  Creating a Patient-Led NHS. London: HMSO.

Department of Health (1999). Patient and Pubic Involvement in the New NHS.  London: HMSO. 

Fadden, G., Shooter, M. & Holsgrove, G.  (2005).  Involving carers and service users in the training of psychiatrists.  Psychiatric Bulletin, 29, 270-274. 

Jenaway, A.  (2011).  Whose reformulation is it anyway?   Reformulation, Winter, 26-29.

Llewelyn, S.P. (1988).  Psychological therapy as viewed by clients and therapist.  British Journal of Clinical Psychology, 27, 223-227.

 National Involvement Partnership (NIP) and National Survivor User Network (NSUN) (2015).  Nothing about us without us. London: NSUN.

NHS England, Care Quality Commission, Health Education England, Monitor, Public Health England & Trust Development Authority (2016).  Five Year Forward View. Downloaded from https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

on 25th October 2016.

Ryle, A. & Kerr, I.B. (2002).  Cognitive Analytic Therapy: principles and practice. Chichester: Wiley.

Full Reference

Robert Marx, Joanne King, Kylie, Mary Wilson-Verrall, Karen Spencer and Annabel J McDonald, 2017. On Learning From Our Patients: Reformulating CAT Training. Reformulation, Winter, pp.13-18.

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