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Paper 1. ‘Infamy, Infamy, they’ve all got it in for me.’ 1 Exits in Organisationally Informed CAT Supervision

Sue Walsh, 2019. Paper 1. ‘Infamy, Infamy, they’ve all got it in for me.’ 1 Exits in Organisationally Informed CAT Supervision. Reformulation, Summer, pp.6-8.

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Summary

The delivery of organisationally-informed CAT supervision can be one way of providing thinking tools for staff under pressure. The challenge is how to do this well and with integrity. The focus of this paper prioritises the need to develop better understandings of the psychological relationship between organizational systems and staff minds. It is argued herein that CAT-informed organizational supervision may be particularly valuable in the context of ongoing change and lack of stability to services, constrained resources and high levels of staff anxiety. Integration between aspects of the mentalization literature and cognitive analytic principles is suggested as a way to enable staff to maintain a psychological openness towards their clinical work. It is suggested that narratives and stories can operate as exits in response to harsh organizational experiences. Applying cognitive analytic therapy tools in this way with a particular organisational focus may help us preserve a skilled, but often exhausted, staff resource. This paper and the one that follows work together as a pair. The first, describes the theoretical ideas that have informed the approach; the second, explores the application of these ideas into practice.

Introduction

Kenneth Williams’ quotation from the film ‘Carry on Cleo’ (1960) captures the themes to be explored in this paper. The phrase “Infamy, Infamy, they’ve all got it in for me” suggests that the private ‘I’ (‘in for me’- ‘becoming punitive, critical and punishing towards self), and the external world’ (‘infamy- a sense of public shame and humiliation’) are connected. Staff who are feeling overwhelmed by organizational processes will consistently locate themselves in both positions at the same time. They feel ‘got at’ by clinical work, paranoid and angry (‘in for me’) whilst at the same time feeling threateningly revealed as failing at their work (‘infamy’). It is my suggestion that these two felt experiences are always present for troubled staff when they come to consult a supervisor.

CAT has for some time now been used as a thinking framework to help make sense of the relationship between dysfunctional organizational systems and staff behaviours, using a theoretical framework derived from an understanding of the internal emotional dynamics of the individual (Walsh, 1996, Kerr, 1999). CAT provides a useful framework in which to understand the ways in which client factors and organizational factors come together to undermine or facilitate good clinical practice (Kellett et al. 2014, Shannon et al, 2017). CAT can be used to provide a framework for staff to help deliver improved clinical services by revealing how service users’ reciprocal processes can be re-enacted by the teams or systems around them (Shannon et al. 2017). CAT is therefore able to bring two things into sharper focus. First, it can reveal the staff and organization ‘felt’ relationship, or the organization that pervades the mind of the staff member: for example, the bullying organisation in relation to victimised staff. Second, once the reciprocal patterns that lie between the organisation and staff member are understood then the emotional and behavioural patterns of thought and action that emerge can be made clear. Such procedures are invariably dysfunctional and cyclical and end up reaffirming the core painful relationship between the staff member and the system they work in. For example, if I feel I am being victimized at work I feel unable to get anything right so I become afraid and avoidant and hide/ fail to meet my responsibilities as an employee (I am unable to do my job), which further infuriates the managerial system which ends up dominating and criticizing me and so we go on.

Building upon this work the focus of this paper is to explore CAT specifically as a supervision tool for maintaining the capacity of staff for thinking when they are overwhelmed/professionally challenged by organizational change and threat. As Frank Zappa2 once said “The mind is like an umbrella. It cannot work unless it is open”.

The value of organisationally-informed supervision

Clinical supervision should be more widely construed as an organizational development tool. The core task of supervision is for supervisors to send staff ‘back out there’ by helping them make sense of, and work effectively with, high levels of client distress in challenging work contexts. Too often supervision has become reconstructed as a managerial exchange for monitoring sickness absence, case management or policing adherence to a specific clinical model or Trust protocols. Though these are all useful professional and governance procedures to follow they are not herein defined as clinical supervision. Rather, clinical supervision promotes an understanding of the client’s emotional distress in the context of the relationship with staff. Unfortunately, clinical practitioners are increasingly expected not to require a space to make sense of relationships. Supervision becomes defined as a luxury and something to cut out in times of economic hardship. The task therefore becomes how to provide useful, organizationally informed supervision to staff working in overheated and fragmented systems.

There is limited, but emergent evidence of the positive relationship between therapeutic outcomes and supervisory input (Bambling et al. 2006; Pilling and Roth, 2014; Rousmaniere et. al 2014; Wheeler and Richards, 2007). However, supervision does appear to impact positively upon staff capacity to communicate, helps to strengthen relationships at work and can support the well being of supervisees (White and Winstanley, 2010; O’Connell et al. 2013). O’Connell et al.’s (2013) focus group study with nurses on acute hospital wards found that team supervision boosts positive communicative working relationships and supported nurses to challenge existing practices, which had a perceived positive impact on their reported stress. Supervision seems therefore to maintain a focus on relational factors that positively influence staff wellbeing at work. Maben et al. (2012) argues that to improve patient experience staff well-being should be construed as an antecedent rather than as a consequence of good patient care.

There is a significant body of literature on the processes and underlying theoretical models that inform high quality clinical supervision for clients (Scaife, 2009; Bond and Holland, 2010; Watkins and Milne 2014; Pickvance, 2016). In contrast, very few authors give critical consideration to the value of integrating a relational organizational focus. Hawkins and Shohet’s seven-eyed process model (Hawkins and Shohet, 2012) gives space to consider the impact of the organization on clinical process. CAT takes the next step, which is to provide a meaningful way for staff to understand what is happening between them and their work system.

Mentalization and exits in organizationally informed CAT supervision

Organizational change in health contexts is sadly often experienced as frightening, unthinking, chaotically led; driven by the need for cost improvements rather than the need to maintain the well-being of service users. We know that in the public services, change is often conducted in a fragmented way. Cooper and Lousada (2005) write:

“There are leaks, innuendo, anxiety, favourites, some people do badly as a result, people lose jobs, good things are taken away, things are promised that cannot be lived up to, individuals are scapegoated, vilified. Mostly, it is often experienced as lonely even when you are fighting together with others. Staff often feel diminished by it; are often left sad and scared”.

Of course, the very same processes and feelings are also being reenacted at leadership levels within a health-care hierarchy. Narcissistic or poorly supported leaders can get caught in traps of implementing dysfunctional or perverse change, becoming blind to human reality, getting caught up in unrealistic or psychologically destructive change strategies (Long, 2008, Francis, 2013; Fotaki and Hyde, 2015). Furthermore, overseeing change with an angry staff group is legendarily difficult. However, there is often a commissioning reality to be faced - difficult decisions need to be taken about service redesign and it is at these points of ongoing change implementation that staff often lose the capacity to hold onto a thinking space because the work system becomes suffused with feeling. The consequence of this is that staff may become increasingly unable to maintain the capacity to think about the needs of service users. The issue then is how to help staff hold onto the space to think and make sense of their self in their system, and thereby mentalize their experience.

Mentalization is fundamentally relational – it is `the psychological self ‘(that) develops through being reflected in the mind of another. Allen, Fonagy and Bateman (2008) suggest that mentalization and its functional attachment underpinnings are the key to coming to know oneself and thereby of enabling the individual to come to know the world outside. This dynamic is at the core of how we might understand organizationally informed exits.

“We are mentalizing when we are aware of mental states in ourselves and others - when we are thinking about feelings for example” (Allen, Fonagy and Bateman, 2008).

Understanding the concept of a reciprocal role enactment requires a mentalization of the other’s state of mind in relation to oneself. If we accept that understanding our emotional state is adaptive, it is only so if our feelings can be a) held in mind or mentalized and b) thinking can be maintained, about why one is feeling this way in relation to the other, thus connecting emotions to thinking. Thus “we might best construe mentalizing as thinking and feeling about thinking and feeling”. Allen, Fonagy and Bateman, (2008). The argument progresses herein to coupling thinking and feeling to an organizational reciprocal role enactment as detailed in CAT.

Mentalization can be symbolic, making active use of metaphor or story. More often mentalization is created via working with another to create a narrative made up of coherent parts. We understand as therapists the value of a story, even when that story is about pain and loss. To understand the story is to create a coherency and with coherence emerges a sense that the story can be understood. If a story can be understood one can respond differently to it. Thus the story forms the exit in a CAT informed organizational SDR. The task is to create an emergent narrative. Within CAT theorisation this maintains key conceptual links to making explicit the internalized voices and signs inherent in communication, drawing upon Vygotsky’s work (Stiles, 1997).

Mentalization maintains a self-other focus as does CAT. When CAT works at a systemic level this arises out of the process of being able to understand the system outside self, coupled to an understanding of how self and the system fit together. Mentalization is “attending to mental states of oneself and others, coupled with the implicit or explicit awareness that these mental representations of reality form one of many possible perspectives” (p22 Allen et al 2008). Exits act as a mentalizing process of the emotional distress that results from organisational-staff reciprocal role processes. Losing a sense of organizational mentalization means inevitably that you have lost the sense that there is any other alternative other than to be ‘done to’ by the organization because one is placed in a fixed position, for example of ‘child-like’ helplessness in relation to a neglectful system.

Making explicit or externalizing the felt communication via an exit narrative enables the supervisee a way to think and therefore respond in an externally real way, as opposed to an infantile hurt or terrorized way. However, exits constructed in this way go beyond a specific emotional/ behavioural response sequence. A narrative exit supports a whole picture to develop and reveals one’s part in the story. With this picture emerges the cognitive flexibility and the tools to find ways out. It therefore enables, a moving away from the reciprocal roles of ‘bully- bullied’ or ‘unavailable-anxious which are often at the core of dysfunctional organisational dynamics because one can hold the whole story in one’s mind. In CAT supervision used in this way, we are therefore making narrative links that make explicit the implicit narrative between self and system. This is elaborated on in Paper 2

References, see Paper 2 below.

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Sue Walsh, 2019. Paper 1. ‘Infamy, Infamy, they’ve all got it in for me.’ 1 Exits in Organisationally Informed CAT Supervision. Reformulation, Summer, pp.6-8.

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Paper 2. Applying the Ideas into Practice: Narrative CAT Exits in Organisational Supervision
Sue Walsh, 2019. Paper 2. Applying the Ideas into Practice: Narrative CAT Exits in Organisational Supervision. Reformulation, Summer, pp.8-12.

Incorporating mentalizing skills into Cognitive Analytic Therapy (CAT)
Jane Bradley, 2019. Incorporating mentalizing skills into Cognitive Analytic Therapy (CAT). Reformulation, Winter, pp.39-42.

The 4P’s model: A Cognitive Analytic Therapy (CAT) derived tool to assist individuals and staff groups in their everyday clinical practice with people with complex presentations
Phyllis Annesley and Lindsay Jones, 2016. The 4P’s model: A Cognitive Analytic Therapy (CAT) derived tool to assist individuals and staff groups in their everyday clinical practice with people with complex presentations. Reformulation, Summer, pp.40-43.

Collaborating with Management in the NHS in difficult times
Carson, R. Bristow, J., 2015. Collaborating with Management in the NHS in difficult times. Reformulation, Summer, pp.30-36.

A Hopeful Sequential Diagrammatic Reformulation
Bradley, J., 2012. A Hopeful Sequential Diagrammatic Reformulation. Reformulation, Summer, pp.13-15.

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Paper 1. ‘Infamy, Infamy, they’ve all got it in for me.’ 1 Exits in Organisationally Informed CAT Supervision

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