Falchi, V., 2007. Using CAT in an assertive outreach team: a reflection on current issues. Reformulation, Summer, pp.11-17.
In my current job as psychiatrist in an assertive outreach team (Sheffield), I deal with psychotic patients who are considered to be “resistant” and “non compliant” to the ordinary facilities that psychiatric sector teams can offer to them. They are considered patients difficult to treat and engage, and they require intensive and assertive support from a specialised multidisciplinary team like us, in order to prevent future relapse and consequent hospital admissions. In this paper, I will try first to put CAT in the context of other available psychotherapies for psychosis. Then I will try to underline the CAT understanding of psychosis and related issues, and how CAT can be applied from a theoretical and a practical point of view to my clinical environment. I will emphasise, in particular, how CAT can contribute to a better understanding of the patient’s problems, how CAT can help us understand staff dynamics in relation to the patients, and so help staff manage patients in a better way, and overall how it can improve the quality of care of psychotic patients.
There is some evidence-based literature about treatment of psychotic people using individual psychodynamic psychotherapy, cognitive behaviour therapy (CBT), and counselling. The more salient of these studies are summarised below.
Individual Psychodynamic psychotherapy for schizophrenia
Few controlled clinical trials of individual psychotherapy for psychosis exist. Malmberg and Fenton (2002) find no evidence to support any positive effect of psychodynamic, insight-orientated therapy for schizophrenia and comment that the possibility of negative effects seems never to have been considered. It is also noted that individual psychodynamic psychotherapy has a high drop-out rate. Recently, the NICE guidelines state that individual psychodynamic psychotherapy is contra-indicated in schizophrenic patients.
CBT and supportive counselling in psychosis
CBT has been used in recent years in the treatment of psychosis. The CBT model of psychosis views psychotic phenomena as highly convoluted expressions of normal experience (Rector&Beck, 2000). CBT treats patients more empirically and with a shorter-term focus than traditional psychodynamic interventions. Fenton (2000) compared the psychodynamic approach to the CBT approach for psychosis. His study found positive outcomes for psychodynamic therapy with psychotic patients, when the therapy focused on the specific and current problems adversely affecting the patient’s functioning. This conclusion began a move away from treatment founded upon psychogenic aetiology, towards problem solving and cognitivebehavioural interventions.
Eells (2000) tells how the largely disappointing efforts of the psychodynamic approach in the past have tempered today’s treatment methods, which are more modest and pragmatic in their aims. These methods are viewed as part of a comprehensive package of psychosocial interventions that assume a diathesisstress model, in which pharmacology performs an important function. Advantages of CBT over supportive counselling appear to hold in recent papers also, (Tarrier et al, 1999) where researchers found significant improvements in respect to a reduction in positive symptoms, whereas supportive counselling performed similarly to routine care. Both CBT and supportive counselling proved equally as effective in producing small, nonsignificant improvements in negative symptoms.
In contrast to the approaches of Wiersma et al.( 2001) and Tarrier et al. (1998), Kuipers et al. (1997) developed a more investigative, schema-focused approach, which involved eliciting the detail of the client’s own interpretation of their problems, with particular attention paid to the development of delusional ideas and hallucinations from their first emergence over time. Such intervention is focused on the development of coping strategies, training in problem solving and relapse prevention. The aims of therapy were ambitious, in that they included a reduction in both frequency and severity of psychotic symptoms, a reduction in depression, anxiety and hopelessness. An increase in social functioning has only been applied to positive symptoms, and effect sizes are modest (Barrowclough, 2004). Fewer trials demonstrate benefits in terms of negative symptoms. Even when a positive outcome has been found, the evidence base does not generalise to populations with high levels of co-morbid conditions (e.g. personality disorders etc.).
CAT and the understanding of psychosis
As pointed out above, the CBT approach for psychosis works on psychotic symptoms (in particular positive symptoms) and aims to reduce the degree of distress associated with psychotic experiences. However, this approach does not allow the patients’ problems to be understood from an interpersonal perspective, and enactment of specific reciprocal role procedures (RRPs) in the therapeutic sessions cannot be addressed. As a consequence of that, the therapist might “collude” with patients during and between sessions. For example, the therapist can be seen by the patients as being coercive or controlling, or patients might feel neglected or not listened to by the “busy therapist”.
In contrast to CBT, the CAT approach works on an interpersonal level and looks at the interpersonal origin of the psychopathology of psychosis. CAT, therefore, is able to help patients gain an understanding of “what is going” between them and the therapist on a relational level and to use this in a therapeutic way. Kerr (2001) has pointed out that individuals with neuro-cognitive impairment may have difficulties in processing information and interacting with people and this can lead, early in development, to hostile, critical, or neglectful reactions from others. From a CAT perspective, all such experiences would be seen to be internalised as increasingly maladaptive reciprocal roles. This would increase the individual’s psychological vulnerability and contribute to further stressful interpersonal difficulties.
The internalisation of a maladaptive repertoire of reciprocal roles and the consequences of their enactments is a principal focus of therapy in CAT.
CAT understands psychotic symptoms and phenomena to represent the muddled, amplified, or distorted enactments of RRPs as well as their associated dialogic voices. Internalised voices in psychotic states would be seen in CAT to represent distorted, exaggerated, and alien phenomena. These internal enactments have been described as “internal expressed emotion” (Kerr, 2001), and they represent a major focus for
therapy in this model for psychotic disorders, both schizophrenic and bipolar affective. Overall, psychosis represents an extreme version of being “out of dialogue” both with the internal and the external world (Ryle, 1997). For patients suffering from psychotic disorders, diagrammatic mapping will involve the recognition and description of dissociated “self-states”, each of which is seen to embody one RRP. Therapy also aims to help the patient to be able to reflect on those at a meta-procedural (or “meta-cognitive”) level. CAT also aims to create with the patient a coherent and meaningful account of their difficulties and experiences in an educational and supportive manner. The reformulation, created jointly in therapy, often comes to function as reassuring and containing tool for patients and for therapists.
CAT understanding of staff dynamics in relation to psychotic patients
Along with the CAT research around psychotic patients, there has been in recent years, an increased interest in applying CAT principles within staff dynamics and organisation. Frequently, patient enactments of extreme and disconnected RRPs cause difficulty for staff attempting to work with such patients. Such difficulty often manifests as staff “collusion” with, for example, either needy or angry patient enactments, leading to possible reciprocal enactments of over-involved or hostile reactions by staff.
The CAT model is thought to be an adequate and coherent approach for enabling staff to understand psychotic patients and to respond appropriately (Kerr, 2001). Both clinical experience and the theoretical model suggest that working specifically with patients on their repertoire of RRPs and self-state disturbances, and mapping them out along with their associated dialogic voices, can be beneficial for the patient, as well as family, friends, and staff.
Description of the team
I work as a psychiatrist in the Assertive Outreach Team in Sheffield (SORT), and we have a caseload of 150 patients, who generally have been referred to our team from the psychiatric sector teams in Sheffield. The criteria for referral are:
The team works within a multidisciplinary framework. Care coordinators directly responsible for the care of the patients are generally social workers and psychiatric nurses. Doctors and clinical psychologists give a psychological / medical understanding to the difficulties of the above patients.
Occupational therapists and care workers are also involved in the day to day management of these patients. On a weekly basis we have client reviews and the problematic issues about patients are shared with all team members. The philosophy of the Assertive Outreach Team is to treat patients in the community as much as we can, and hospital admission is seen as the last option, when patients become unmanageable in the community.
Description of the patients
All the patients have a primary diagnosis of psychotic illness (mainly schizophrenia and schizo-affective disorders), and a considerable number of them also have co-morbidity, most commonly personality disorder and substance misuse.
All the patients share a certain degree of the following features:
Because of the poor compliance, patients are generally seen at home.
Application of CAT in my clinical practice.
CAT principles can be applied in my setting in two different ways:
How can CAT principles be applied to my clinical environment?
Within the team, as well as within similar psychiatric settings, staff make use predominantly of the medical model in order to conceptualise the patient’s difficulties and in order to direct treatment. In this context, CAT is a valuable tool that can give staff a different perspective of the client’s difficulties, and can give them new tools (e.g.: contextual reformulation, use of the self, transference and counter-transference issues etc.) that can be integrated in their own way of working with clients.
1) CAT can help build a contextual reformulation, as a way of summarising and understanding the complex history of our clients in the client review meeting.
Quite often our clients have a very long and complex psychiatric, personal, and forensic history, and it is sometimes difficult to extract from their chaotic life-story what is important for us to know in order to help them. CAT reformulation, in this respect, can be very useful and informative because it can give, in a concise and comprehensive way, a clear account of the patient’s story and difficulties; it can also highlight recurrent patterns of dysfunctional behaviour and try to explain them in terms of the enactment of dysfunctional RRPs.
With knowledge of the patient’s main important historical RRPs, CAT can elucidate the current difficulties of the patient in relating to others and engaging with the therapist.
CAT can also, to a certain extent, make some predictions on how to maintain and reinforce the therapeutic alliance, and this is particularly important in our client group, with their wellestablished history of non-compliance with psychiatric services.
It is quite common in our client group to find some of the following pieces of past personal history and recurrent patterns of behaviour:
As a consequence of the above, they have internalised “neglecting/dismissive to neglected/dismissed”, “not understanding to not feeling understood”, “abandoning to abandoned”, and they desperately want to find an ideal carer.It’s not uncommon, as a pattern of behaviour, that when very distressed, these patients overdose or call Police/Ambulance/Fire-fighters, which may lead sometimes to distress and the concern of other agencies involved in their care.
Patients who internalised “criticising to criticised”, tend to believe in what other people have repeatedly said about them. So the voice of the other becomes their own internal voice. This can be a considerable source of stress for the patient, and it has been called “internal expressed emotion”. It is not unusual that, on top of the above stressful mechanism, patients experience on a daily basis the “external” expressed emotion coming from family/friends. This “criticising to criticised” reciprocal role plays an important part in the content of psychotic phenomena. In fact it is very common for these patients to experience auditory hallucinations in the form of “people saying they are bad” or “people saying nasty things about them”, “people commenting that the patient is useless” or asking the patient to kill himself/herself.
In addition, the “controlling to controlled” reciprocal role plays a predominant role in the psychopathology of some psychotic patients. For example, a very characteristic feature of schizophrenia is the so called “passivity phenomena”: patients think people insert or broadcast their thoughts, “somebody” can make their body move and cause their actions, “somebody” make them feel the way they feel etc.
2) CAT principles of using transference and countertransference issues in order to understand client’s problems, in the client’s review meeting.
Quite often different professionals working with the same client within the team have different feelings and opinions about the client. The principles of CAT can be used as a way of analysing the way the patient relates to different people in the Team. Transference and counter-transference issues can be brought to the client’s review meeting as a forum of discussion in order to a have a shared understanding of how the patients make us to feel and how we feel and respond to them. This can help to prevent the splitting that sometimes is present in staff members in relation to a particular patient and his/her problems.
3) CAT principles of using the staff ’s countertransference to help staff to understand their own feelings and using that to help the patients.
Particularly recurrent in our caseloads are themes around:
Staff who try to “rescue” difficult patients. This is often in response to needy or demanding patients, or patients seeking an ideal carer. It can result in staff sometimes over-investing time and energy to try to improve the patient’s psychological and social life. Awareness of this issue can avoid the so called “burn-out syndrome” and lead to an improved staff attitude towards the patients in terms of motivation and morale.
Staff “feeling lost” in the chaotic history of patients, and feeling overwhelmed by the complicated previous forensic, drug and personal history. Awareness of this issue can help staff to “contain” patient’s problems and to set clear boundaries. Staff feeling like “giving-up” on patients with whom they have spent so much time and energy and have seen very limited rewards in return. Staff feeling useless in relation to the patients who are not improving, or who are resistant to engaging with services, or who are sabotaging any effort that staff try to put in place. This can lead to staff feeling angry or disappointed with themselves or towards the patients. It is important for staff to recognise the above therapist-patient dynamic in order not to reciprocate in a collusive way with what patients enact, either consciously or unconsciously, in the relationship.
In my experience, I noticed how sometimes it is so difficult for some professionals to admit to themselves the “bad feelings” that sometimes they might have about their patients. They might feel guilty or ashamed because they might believe, on a conscious or unconscious level, that mental health professionals are not allowed to have bad feelings towards patients. The discussion of counter-transference may also help staff release and share their emotions when they feel overwhelmed by unbearable feelings towards patients. They can, thus, use their own feelings to have a better understanding of the patient and to use that in the therapeutic alliance.
CAT can be used with psychotic patients and the general principles of CAT practice can be used with this group of patients as it has been already applied with other patient groups. In particular CAT can help these patients in the following areas:
Main problems and consequences in delivering CAT with psychotic patients
Inevitably, because of the profound difficulties and impairments that such patients have in their lives, there are some important issues that have to be considered when treating psychotic patients; the following issues seem to be particularly relevant:
Poor motivation and poor compliance issues
Most of our patients have numerous residual symptoms of schizophrenia (negative symptoms such as apathy, severe social withdrawal etc.) that prevent them starting or continuing with therapy. A considerable amount of work must be spent engaging these patients in all possible, appropriate ways (e.g. having assessment in bars, in the park, even on the street sometimes, or more often at home etc.). It takes a very considerable amount of time to build-up a trusting relationship with them, and therapy may be considered only when, a “basic engagement” with the service as a whole has been established.
Complex issues around patient-therapist relationship
Because most of our patients have a previous history of aggression, or a forensic history, it is not advisable to see them on a 1:1 basis. For this reason, for some of these patients, the possibility of starting an individual therapy have to be balanced with the risk associated in having a close, one to one relation with them.
The patient’s views about the Team as care-provider
Because most of our patients have had a long history of compulsory hospitalisations, a certain proportion of them see the “health system/health worker” as intrusive and coercive. From their point of view, the health system can be seen as an antagonist; it is the agency that has been responsible for taking their freedom away for a long time and on numerous occasions in the past, it is the system that told them what to do and what not to do. It is very common for patients to re-enact in the relationship with the team-worker some previous dysfunctional role-procedures, the most common of which may be “abusing to abused”, and “not understanding/criticising to not understood/criticised”. In using CAT with these patients, the therapist needs to be aware of how such issues might crop up in the “here and now” relationship and must be able to use them in a therapeutic way.
The conflicting dual roles of the therapist
Like other professionals on the team, I have a specific role in the care of the patient. It can be difficult from the point of view of the patient, to distinguish between our role in our core profession and our role as therapist. As a consequence of that, the patient may not feel free, within the therapeutic relationship, to express in a neutral environment his/her own feelings and thoughts. In using CAT with psychotic patients, the role of the therapist needs to be addressed early in therapy, and appropriate boundaries need to be set.
Principles of adjusting CAT to “very difficult” patients
Using CAT with psychotic patients is really a new and challenging territory where, for all the reasons explained above, it feels as if CAT will have to be sensibly adjusted to the patients’ problems and needs. The following “adjusted” solutions can be seen as ways of dealing with some of the problems related to working with damaged psychotic patients:
The need to be flexible with patients in terms of delivering CAT in the home setting, or in a different place, in the way the client might be comfortable to work with. This will clash inevitably with some basic principles about therapy setting (e.g. consistency in place and time for therapy etc.) Because motivation and compliance of our patients are generally quite poor, prior to starting therapy, a considerable amount of time should be spent with patient to work in increasing motivation towards change.
The need to have flexible sessions in terms of frequency and length of session. These must be adjusted according to the client’s level of distress at that time and the degree of cognitive and personal impairment the client might have as a consequence of their chronic illness.
The need to have two therapists for each client, or alternatively to consider one therapist to be chaperoned by another member of staff, in order to overcome the very important issues around legal matters (e.g. risk of violence, risk of allegations etc). Inevitably, this will raise issues on how the third person in the room might influence transference and counter-transference phenomena.
It would be advisable for the therapist to be an independent professional within the team, not involved in any other activities with the patient eligible for therapy. In doing so, the patient will have the chance to receive therapy in a neutral context, not directly related to the team work.
There should be flexibility also in terms of missed sessions and poor attendance, because this issue is the very core difficulty of these patients. This inevitably leads to some important ethical issues as I will discuss in the next section.
Inevitably, when working with psychotic patients, there are some important ethical and philosophical issues that crop up in the day to day delivery of psychiatry and psychotherapy services. These can be summarised as follows:
Assertiveness versus intrusiveness
With our group of patients, motivation and engagement with the service fluctuates considerably and it is sometimes difficult to think how we can best help the patient at a certain moment in time. We generally see motivation and ability to make choices as part of the freedom that every individual has, and we take for granted that all individuals should be responsible for the choices they make. In our experience, motivation and the ability to make choices are quite often impaired in our clients because of their longstanding mental disorders. They lack, we might say, the fundamental prerequisite to be free. Because of this, we sometimes need to act in their best interest. We come to a crucial dilemma, to which it would be very difficult to find an answer: Should we be proactive with psychotic patients, prompting them to receive psychotherapy and treatment, in order for them to find the freedom they don’t possess? Or should we consider their poor interest/willingness for change as the
way they are, and go along with their decisions?
Confidentiality issues in therapy and the duty of the therapist to share information with other members of the team
It is a well established philosophy of multidisciplinary teams that all information about the patients be shared within the team, and this is believed to increase their general understanding of the patients. This is because professionals within the team take for granted that confidentiality doesn’t apply when we discuss the patient’s difficulties in team meetings. But how should we behave when we have to discuss psychotherapy issues within the team? On the one hand, we are aware that therapy sessions are strictly confidential in nature, but we are also aware of the “need for the other people to know” in order to help the patient in a better way. How can we balance these two important issues: the patients’ need for other people not to know, in order to be free to talk in therapy, and the team’s need to know about the patients, in order to understand/help them?
Valerio Falchi, MA, MD, MRCPsych, CAT practitioner
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