Clive Turpin, 2019. Follow Up in CAT. Reformulation, Summer, pp.26-28.
Follow up: what, when and how?
This article has been in my mind for a long time, influenced by little in the way of written guidance, conversations with others, particularly trainees, and my own interests in this aspect of therapy. This has also been informed by the impact of follow-up sessions with personal reformulation sessions (see Catalyse website listed below) and the feedback shows how highly valued they are.
During my CAT training, and more specifically through providing follow up sessions, I began to reflect on the benefit of these and started to incorporate them into my work within a self-harm team. We were delivering very brief therapy of four to six sessions to people that presented to A&E with any form of self-harm or an attempt to kill themselves and introduced a follow up about a month after the final therapy session. The follow up enabled some further space to reflect after an intense piece of work.
Due to the therapy being brief, I was quickly building a lot of experience on the impact of the follow ups although I did not think at the time to formally record this in any way, so my comments are anecdotal over a period of 7 years. The positive impact and influence of the follow up struck me and I reflected on why I seemed so surprised about this and how I’d not thought about it before. I reasoned this as something new that came into my awareness and how often in busy services when working at full capacity creativity outside of sessions can get stifled.
Continuing my work in psychotherapy, I’m curious how we approach follow ups: introduce them; and when; and explore the purpose. The aspect that resonates most strongly for me is providing a space to increase someone’s confidence in themselves to be their own therapist and continue with the awareness and developments established through therapy. I want to take the opportunity to share my experience and reflections given the limited written resources available on the topic and have focused this around frequently-asked questions.
What’s written about follow up in CAT?
In CAT Theory and Practice, Ryle (1995) refers to a semi-structured post-therapy interview used at Guy’s Hospital CAT clinic which focuses on reviewing target problem procedures (TPPs) or the map to establish how accurately it’s been remembered, used, and seeking detail of revisions. Any problems or life events should be discussed and it also suggests dual ratings of change on five point scales. A second follow up is suggested if difficulties remain or supported further with two or three ‘top-up’ sessions.
Further guidance by Ryle (1997) states that for a 16-session therapy one follow up is offered and in 24 session, it’s four. The time frame for these vary, generally a single follow up is about 3 months after the last therapy session and with four, they’re often after 1, 2, 3 and 6 months. This is not presented in an arbitrary manner, however given the lack of writing on the subject these suggestions can be taken somewhat literally, although the structure makes some sense of a growing duration between sessions.
When is the option of follow-up discussed?
There are different approaches to this and it will be strongly informed by the work in the room. At times, it will be important to have a clear ending and then present the option of a follow-up at this point. However, this can also be complex and difficult to fully engage with if there is considerable anxiety and distress relating to the ending and loss and the knowledge of a follow-up can help someone feel more comfortable to fully explore the ending. This presents another situation of being thoughtful of someone’s Zone of Proximal Development towards ending and how this might inform decisions.
Given that the additional follow ups with a 24-session therapy were established to help create a more manageable ending it makes sense that these are described either at the beginning of therapy when setting the frame or when entering the ending phase to support establishing a good enough ending. Naturally practice varies, I generally introduce the option of follow up whilst in the ending phase as we increasingly talk about the gains of therapy being maintained and developed whilst remaining mindful to snags.
What’s offered and when?
Further to the guidance above, I now approach the time frame by starting a conversation with ‘what will be most helpful to you?’ and explore different options as a guide to work from. This might include exploration of shorter and longer time frames before a single follow up and initial feelings towards this. A starting point for up to four follow ups could be the present guidance or taking the approach of four sessions over a period of a year. After some initial uncertainties, I generally find that through conversation we quite quickly establish a sense of what will be most helpful.
Many processes are occurring whilst approaching ending, and there is something important for me during the period to promote influencing or taking charge of what happens next, which introduces and encourages a different form of agency and focus. We discuss a general sense of the preferred time frame and agree the date for the first follow up with the view of seeing where things are up to at that point. Sometimes the following session is at a similar time frame or shorter and other times extended to get increasingly longer and firm up greater confidence. If however there’s been a wobble in confidence or an unexpected event that has taken priority in the session we might explore the benefit of an additional session.
I’ve also used an approach of ‘banking’ sessions to draw upon, which takes charge of when they will most helpfully be used and can provide a different form of safety net and integration. This is a part of therapy for me that holds a different form of collaboration and suggest that it benefits from maintaining a similar degree of flexibility and negotiation.
What’s the focus in the follow-up?
Primarily, follow-up provides a space to further consolidate the work of therapy and reflect on any snags that might have returned or arisen and a chance to get hold of them before becoming established or re-established. The map is likely to be a prominent tool of reflection and revision on further exits and snags, whilst also attending to continuing integration. The letters, along with the map, also remain useful tools as prompts and reminders of what’s been explored and established, as well as being forms of transitional objects (often heard as the therapist’s voice as they were read). In addition to this, there are many ways of keeping therapy, therapist and the space in mind, which might include checking-in during the therapy time, holding imagined conversations and an encouraging and supportive voice.
This focus can vary greatly, at times it can be busy with stories of further change and success and exploring how this has occurred and identifying the ‘active ingredients’ or a focus on repeated struggles and many of the things that exist between.
With multiple follow-up appointments, the focus might take an overall approach of firming up greater independence and increased confidence in being one’s own therapist. I’ve found it useful at the end of each session to reflect on what was helpful and how this can be incorporated and integrated. It can also be helpful to differentiate between a felt need for the therapist and an acknowledgement that the reflective space is a key element, although cannot be separated from the relationship that has developed over time.
I sometimes experience that people can approach the follow up like a news update, which in itself can present a lot of information. I find it helpful to start by exploring what someone wants to get from the session and how they’d like to use the time that might include successes and new developments or making sense of some of difficulties and challenges.
I favour more flexibility with follow-up appointments and it’s been my experience that for the majority of those I’ve worked with this enables us to remain attentive to their needs whilst maintaining a creative approach and most importantly collaborating on what will be helpful.
The four follow up appointments after 24 sessions were established to recognise the difficulty that more, so called complex, people have with endings whilst often managing feelings of rejection or abandonment. However, there can still remain a lot of feelings and anxiety ahead of the final follow up and this is the real end. I’ve had conversations in therapy on this issue, ‘so this isn’t actually the end’ and they’ve been right in many ways. It is however an end of the weekly therapy, which naturally is an ending and significant change. Sometimes that final goodbye at the end of follow up can feel the hardest, a final letting go or sense of being left.
There’s growing use of ‘letters to myself’ that hold a theme of compassion and encouragement that can be effective at times of emotional pain and distress, doubt and uncertainty. It’s another way of developing new self-to-self relationships when initial connection to healthy roles might be a challenge. This could extend the work and reflection of a goodbye letter and attending to the on-going work in progress and maintaining words of encouragement. I’ve incorporated a similar approach with exit cards that include notes to self.
For further consideration
Whilst working within the Self-Harm Team we offered the option to call us if someone felt that things were deteriorating rather than wait until something became more established or enter a crisis, after all it’s a common pull to soldier on. It has frequently been my experience that others can panic at this offer or provision, which is counter to my experience.
I recall a conversation with Greg Carter who was visiting from Australia and presented his research - Postcards from the EDge (Carter et al, 2005). In the study, people that presented to the ED (Emergency Dept) with self-poisoning were sent eight automated postcards over a 12-month period post-discharge acknowledging that they had not re-presented and if needed they could call one of two named clinicians on the numbers provided. Some of the feedback was that although it was known the cards were automated they still had meaning and people felt they were being held in mind and that alone had a significant impact. I view this as similar to knowing that an option exists - most, if not all of us, need some form of anchor, whatever shape or form that it takes, and for some this holds great meaning. This has been important to me for a long time, although rooted in my previous work, the presence remains current and it was interesting to read an article in Reformulation (Marx et al, 2017) exploring an option of emailing post therapy that might serve a similar purpose.
Remaining mindful of the potential complications with this, such as reliance on the therapist to help navigate through difficult times, will be important. Continuing to be creative in the face of (NHS) restrictions and the knowledge of long waiting lists can be challenging. Like many things in life, it’s striking a balance, prevention has always been more human, sensible and ‘efficient’ rather than responding to later distress and ‘crisis’.
I’m interested in people’s view on this and how others approach follow-up and this latter issue.
Maybe this highlights a need to do some structured work and possible research on the impact of follow-up and if anyone is interested in this and collaborating on something then please get in touch at firstname.lastname@example.org
Carter, GL; Clover, K; Whyte, IM; Dawson, A, H; Este, C, D (2005). Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self-poisoning. British Medical Journal, Volume: 331, Issue: 7520: p805.
Marx, R; King, J; Kylie; Wilson-Verrall, M; Spencer, K; and McDonald, AJ. On Learning from Our Patients: Reformulating CAT Training. Reformulation, Winter 2017, p13-18.
Ryle, A (1995), Cognitive Analytic Therapy: Developments in Theory and Practice, Ryle, A (Ed): Wiley: Chichester.
Ryle, A. (1997). Cognitive Analytic Therapy and Borderline Personality Disorder: The Model and the Method. WIley: Chichester.
Ryle, A and Kerr, I, (2002). Introducing Cognitive Analytic Therapy: Principles and Practice. Wiley: Chichester.
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