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Cognitive Analytic Therapy for Borderline Personality Disorder

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Title: Cognitive Analytic Therapy for Borderline Personality Disorder


1
Cognitive Analytic Therapy for Borderline
Personality Disorder
  • SPD Network Meeting Aberdeen
  • 4th June 2009
  • Ian B. Kerr
  • NHS Lanarkshire, Department of Psychotherapy,
    Coathill Hospital, Coatbridge,

2
Cognitive Analytic Therapy
3
www.acat.me.uk
4
Cognitive Analytic Therapy Active Participation
in Change Anthony Ryle 1990
J. Wiley Sons
5
Cognitive Analytic Therapy Developments in
Theory and Practice. (1995) Ryle, A. (Ed). (Wiley
Sons) Cognitive Analytic Therapy and
Borderline Personality Disorder The Model and
the Method. (1997) Ryle, A. (Wiley
Sons). Introducing Cognitive Analytic Therapy
Principles and Practice. (2002) Ryle, A.
Kerr, I.B. (Wiley Sons).
6
In the beginning is the relation. -
Martin Buber, I and Thou (1958).
7
Cognitive Analytic Therapy
  • Object-relations informed approach to cognitive
    therapy (including personal construct theory)
    transformed by Vygotskian activity theory and
    Bakhtinian concepts of the dialogic self.

8
Cognitive Analytic Therapy
  • Based on a radically social model of self which
    is seen as fundamentally constituted by
    internalised, socially-meaningful, interpersonal
    experience and is described in terms of a
    repertoire of reciprocal roles and their
    procedural enactments.

9
Cognitive Analytic Therapy
  • Influence in recent years of findings in
    developmental research (e.g Trevarthen) stressing
    the infants capacity for and active
    pre-disposition to inter-subjectivity.
  • Implies the socially and culturally determined
    formation of the self through collaborative,
    meaningful, sign-mediated activity.

10
  • Human beings are biologically predisposed to be
    socially formed. A. Ryle.
  • Bruner, J. (2005). Homo sapiens, a localised
    sub-species. Behavioral and Brain Sciences, 28,
    694-695.

11
Cognitive Analytic Therapy
  • From this perspective it can be argued that there
    can be no such thing as individual
    psychopathology - but only socio-psychopathology.
  • (NB Winnicott- there is no such thing as a
    baby)

12
Infant Observation Research (Stern, Trevarthen et
al) Verbal self from c.18 months meaning (the
relation of thoughts to words), results from
interpersonal negotiations.
(Stern) Ultimately awareness and understanding
of states of mind and intentions of others by
c.3-4 years. (Theory of Mind) Stress on joint,
sign-mediated intersubjectivity ab initio.
Infant characterised predominantly by
joyfulness, curiosity and activity in
companionship. (Trevarthen) Importance of
real experience on development (eg effect of
depressed care-giver Murray). Infant liable
to depression, frustration, shame.
13
Infant Observation Research (Stern, Trevarthen et
al) Early emergent self carers act as
physiological regulators but infant capable of,
and predisposed to, active intersubjectivity and
gradually increasing collaborative playfulness.
(innate motive formation IMF
Trevarthen) Core self by c.6 months agency,
coherence, affectivity, Procedural memory of
interactions with others linked to sense of core
self. (representations of interactions that have
been generalised RIGs Stern) Subjective self
and gradual awareness of the worlds of others by
one year shared framework of meaning and means
of communication (Stern)
14
Infant Observation Research (Stern, Trevarthen et
al) No evidence for early states of fusion. No
evidence for early complex operations such as
splitting or projective identification. No
evidence for dominant, inherent predisposition to
anxiety and destructiveness.
15
Reciprocal role - complex of
implicit relational memory, perception
(including beliefs, values and meanings) and
affect often associated with a dialogic voice
. Repertoire of reciprocal roles seen to
underpin all mental activity whether conscious
or unconscious.
16
Reciprocal role procedure - stable pattern of
interaction originating in early
internalised relationships which determine
current patterns of relations with others and of
self-management. Enactment of a role always
implies another, whose reciprocation is sought
or expected.
17
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18
Vygotsky Activity Theory
  • Concepts of internalisation psychological
    tools zone of proximal development
    (ZPD).

19
Vygotsky Activity Theory
  • Any function in a childs development appears
    twice - or on two planes. First it appears on the
    social plane and then on the psychological plane.
    First it appears between people as an
    interpsychological category and then within the
    child as an intrapsychological category. This is
    equally true with regard to voluntary attention,
    logical memory, the formation of concepts and the
    development of volition. We may consider this
    position as a law n the full sense of the word,
    but it goes without saying that internalisation
    transforms the process itself and changes its
    structure and functions. Social relations or
    relations among people genetically underlie all
    higher functions and their relationships.

20
Lev Vygotsky
  • The very mechanism underlying higher mental
    functions is a copy from social interaction all
    higher mental functions are internalised social
    relationships. These higher mental functions are
    the basis of the individuals social structure.
    Their composition, genetic structure and means of
    action, in a word, their whole nature is
    social.
  • (from The Genesis of Higher Mental Functions)

21
Lev Vygotsky
  • Psychological tools sign-mediating cultural
    artefacts which can influence the mental
    activity of others or of oneself internally.
    Their mastery may require prolonged use and
    practice.

22
Lev Vygotsky
  • Zone of proximal development the gap between
    what an infant can achieve on its own unaided and
    what can be achieved with the active assistance
    of an enabling other - or a peer group.

23
Bakhtin and Notions of the Dialogic Self
  • I am conscious of myself and become myself only
    while revealing myself for another. The most
    important acts constituting self-consciousness
    are determined by a relationship toward another
    consciousness ( toward a thou) not that which
    takes place within, but that which takes place on
    the boundary between ones own and someone elses
    consciousness , on the threshold a person has no
    internal sovereign territory he is wholly and
    always on the boundary looking into himself, he
    looks into the eyes of another or with the eyes
    of another.

24
  • Cognitive analytic therapy
  • Now a mature model of development and
    psychopathology.
  • Increasing amount of work using the model (as
    opposed to simply doing it as therapy) -
    (Potter).
  • E.g. work on re-conceptualisation of self in old
    age and dementia, in psychosis, in consultancy
    work and CAT-informed clinical practice.

25
Basic CAT
  • Behaviour and experience organised by
    procedures.
  • These link perception, appraisal, action
    planning, prediction with action and the
    consequences of the action, which are evaluated
    leading to confirmation or revision.
  • Reciprocal role procedures - to play or enact a
    role is to anticipate or elicit the reciprocal.

26
Basic CAT
  • Reciprocal role procedures are early in origin,
    are general and resist revision.
  • They embody parental and cultural meanings and
    values transmitted by pre-verbal signs and,
    later, language.
  • An individuals repertoire of role procedures
    determines both interpersonal relationships and
    the internal dialogue of thought and
    self-management.

27
Cognitive analytic therapy (CAT)
  • Essentially time-limited (usually 16-24
    sessions).
  • Pro-active, collaborative (doing with), highly
    structured.
  • Aims through extended assessment phase over first
    few sessions at joint description of key problem
    (reciprocal) role procedures by means of written
    (narrative) and diagrammatic reformulations.
    These should also effectively offer a sensitive,
    (micro-) cultural descriptive dimension.

28
Cognitive analytic therapy (CAT)
  • Subsequent work focuses on the enactments, of
    these both outside and during sessions.
  • Use of transference and counter-transference
    understood as enactments of repertoires of
    reciprocal roles.
  • Final summary (goodbye) letters by therapist
    and patient.
  • Labour intensive!

29
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30
Dominic was a young psychology student brought up
and studying in the UK, but of Chinese ethnic
background who had been referred from a student
health service for a psychotherapy assessment
because of difficulties in studying,
depression and a recent self-harm attempt. He
appeared initially withdrawn and
uncommunicative and sat looking at the floor for
several minutes. In response to a general
enquiry about how things were he became angry
about having to go through all this yet again
and anyway what was the point of it all. He
immediately followed this by looking up
and apologising profusely for his outburst saying
that he was wasting my time because he had to get
on with things anyway and there were plenty of
people out there who needed my help more that he
did. Eventually he confided that he felt pretty
fed up and hopeless and could not see his way
forward doing a course that he was not sure that
he wanted to do but had to carry on with in order
not to let his parents down. Again there was
a brief moment of anger at the attitudes of
Westerners towards their parents and older people
in general when discussing the implications of
always having to please his parents. It
appeared that he tended to keep his worries
pretty much to himself feeling you ought to be
able to manage. His worry about not managing
seemed to him compounded by his being gay which
in his original culture, he said, was seen as a
sign of weakness and certainly not something he
could discuss with his family. He did feel
however that a small part of him did want to sort
things out for himself although it was hard to
know how and maybe finish his course and
possibly even become a therapist himself one
day. He agreed that perhaps it was this small
part which had in the end brought him along to
our meeting.
31
(Dominic - possible SDR)
criticising conditionally loving
criticised conditionally loved my fault, am
worthless
briefly self assertive but, feel guilty
and criticised
apologetic strive to perform and please
or,
defiant, rebellious, criticising
depressed ODs
results in emotional isolation, exhaustion, cant
manage confirms worst assumptions
32
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33
CAT recent developments
  • Although initially devised as a time-limited
    therapy for neurotic type out-patient
    populations, the model has been further
    developing to deal with more severe complex
    (e.g. personality, psychotic) disorders in a
    range of modalities/settings.

34
CAT models of severe and complex disorders.
  • Seen to involve deeper levels of damage to the
    self and its processes beyond existence of a
    repertoire of maladaptive RRs/RRPs. This will
    include failure of integration of RRs, impairment
    of self-reflective capacity and of executive
    function. Usually understood as due to
    developmental deprivation/trauma in context of
    biological /neuro-cognitive vulnerability.

35
CAT models of severe and complex disorders.
  • Psychopathology is always seen as rooted in and
    highly determined by repertoire of RRs and
    therefore, critically, to include an
    (internalised and frequently re-enacted)
    relational component.

36
CAT and borderline personality disorder
  • Deficit model of psychopathology.
  • Trauma-induced dissociation rather than
    repression/conflict seen as primary mechanism.
  • In addition to maladaptive reciprocal role
    procedures, describes and addresses multiple
    self states.

37
CAT and borderline personality disorder
  • Postulates different levels of damage to self due
    to developmental deprivation/trauma (possibly in
    conjunction with e.g. poor impulse control, poor
    self-reflective capacity and tendency to
    dissociate)
  • Level 1 Restriction and distortion of the
    procedural repertoire.
  • Level 2 Disruption of integrating procedures.
  • Level 3 Deficient and disrupted self-reflection.

38
CAT models of severe and complex disorders.
  • From a CAT perspective, severe and complex
    disorders could be seen in part as self-state
    and relational disorders.

39
deserve punishment
poor self care, deserve nothing, do nothing
give people a bad time, (e.g. partner)
self harm
neglecting, abandoning
abusing
upsets people, rejected, put down, alone, feel
whole world against me
feel even worse, nothing changes
some relief, but nothing changes
neglected abandoned
OK for a while, but..
abused
self harm
may explode into justified rage
cut off, numb, do drugs
if feel abused
always let down
desperate, unmanageable feelings
seek perfect care - expect too much
caring, trying to help
fearful, fed-up, burnt-out, rejecting
staff
40
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41
Contextual reformulation
  •  Systems based approach using techniques of
    cognitive analytic therapy (CAT) as well as some
    features of family and group therapy.
  •  Permits non-confrontational, collaborative
    mapping of patients self-state and role
    enactments and their effects on others.
  •  Helps establish therapeutic alliance and
    communicates that patient has been listened to
    and understood.

42
Contextual reformulation
  • Educates patient into effects of behaviour and
    staff into patients subjective self-state.
  • Mapping may also be containing and educative for
    staff (especially about splits in team)
  • Permits owning of negative emotions and
    responses which may not feel professionally
    allowed (e.g. anger) by locating these in a
    non-judgmental system of causality.
  • Permits discussion of these difficulties by whole
    team.
  • Stimulates thought about the patients inner
    world beyond getting stuck in negative responses
    (vicious circles) to difficult behaviour.

43
A Fictionalised Case Example Anna - Background
Young woman in mid 20s with a long history of
anorexia and borderline personality
difficulties. Multiple hospital admissions for
emergency treatment of anorexia and for serious
self-harm episodes (overdoses and cutting).
Spent several months in a residential therapeutic
community but discharged to local hospital after
self harming in the wake of her best friends
suicide and her own involvement with a member of
nursing staff. Referred for further assessment
for psychotherapy by despairing local
psychiatrist and community mental health team.
44
Anna - Background
Currently living alone in small flat paid for by
parents in a small town in a very
socio-economically deprived area. Feels very
isolated and rarely goes out - spends lots of
time on the internet where she also obtains
illicit medication (e.g analgesics, thyroxine).
Had previously started university after doing
well at school (was very competitive) but dropped
out in first year because of mental health
problems.
45
Anna - Background
Family background characterised by atmosphere of
tension between parents. Father (an aggressive
alcoholic accountant) very preoccupied with
material wealth and succeeding in life. Mother
tried to keep the peace and not offend or upset
her husband - described as the queen of denial.
Anna forced to attend a distant private school
which she hated and sometimes wouldnt attend due
to sickness. Couldnt tell anyone about this.
Younger sister Mary was less pressured and
somehow more thick-skinned but has also had
problems with anxiety. Tells Anna she should now
be able to pull herself together and get on
with life.
46
Anna - Presentation
At presentation states that sees no point in
living nor any future and that perhaps only a
small part of her wishes to think about any
further attempts at treatment. Part of her would
rather join her dead friend Susan whom she
envies. Appears very wary and rather hostile
towards therapist. (Requests that a painting in
the consulting room which is slightly squint be
straightened up). Relates that she is
still abusing laxatives and medication (e.g.
thyroxine) and eats only liquid baby food. Her
body mass index (BMI) is apparently only about
14. She refuses to see local eating disorder
service who she says dont listen to her or
take her seriously. However agrees to see CPN
intermittently and attend a (different)
psychiatrist for occasional review.
47
Anna - Therapy
In the absence of any more specialist intensive
treatment service locally she is offered, and
agrees to, an initially time-limited (24 sessions
with subsequent review) course of CAT. Remains
worryingly underweight (looks like skin and
bone) although continues to feel overweight and
to believe that this would be disgusting to
everybody including her therapist. Serious
concern about her (cognitive) ability
(concentration and memory) to make use of
therapy. During initial months remains mostly
very gloomy and hopeless about change or about
any future. Attends regularly apart from two
periods when she is re-admitted to hospital
following self harm episodes. One of these occurs
during a period of therapist absence and when CPN
is off ill with no replacement.
48
Anna - Therapy
Supported by regular contact with her mother from
whom she receives some (mostly practical)
support. Has worries about contact with father
whom she rarely sees and about whom she clearly
has strong feelings but about she is reluctant to
talk. Is able to engage with the work of
reformulation which she finds illuminating and
acceptable. This appears to firm up the
therapeutic alliance considerably and to provide
an agreed joint understanding which can be
reasonably referred to. Repeated calls over this
period from other colleagues (eg psychiatrist)
about dealing with her and whether therapy is
working.
49
Anna Reformulation Letter
Dear Anna, This is a letter attempting to
summarise some of the key issues which seem to
have emerged in the course of our initial work
together and to try to think about how they are
impacting on your life at present as well as to
think about what might historically lie behind
them, as we have been doing. I hope that
this will ultimately help you to move on to a
more rewarding future. We have already attempted
to sketch some of this in a diagrammatic form
which I think by your account seemed quite useful
although I think it seemed also quite disturbing
and upsetting in some ways as well. This will
only be my version of what we have been talking
about and is very much open to your feedback or
modification.
50
Anna Reformulation Letter
in looking back over some of the things I have
jotted down over the past few months I am very
struck by the importance for you of not having
other peoples versions of events or their
expectations imposed upon you which does seem
to have been your experience very frequently
throughout your life, both in childhood and more
recently. In fact looking back at our very first
meeting one of the first things you said to me
was that you felt that you had not really ever
been listened to. In looking back over some of
my notes I am also struck by just how painfully
difficult life must seem to you day-to-day and
this was also reinforced by looking through your
psychotherapy file again where you highlighted
some very extreme and difficult states..
51
Anna Reformulation Letter
As well as the unbearable feelings, I have been
very struck by how difficult life must be day to
day with little to do or few real social
contacts, your difficulties with sleep and the
terrible dreams which you sometimes describe and
just generally the panicky feelings which seem
to accompany you for most of the time. We
have talked about various ways you have coped
over the years with these unbearable feelings by
doing controlled overdoses, laxative abuse and
other forms of self-harm such as cutting although
this seems to have become more difficult for you
recently It did seem very striking both from our
chats and the diagram we did that the
consequences of these ways of coping
unfortunately on the whole still leave you, even
if numbed out for a while, ultimately on your
own, unappreciated and often pressurised and
rejected by people again. All of which of course
in a vicious cycle fashion seems to reinforce
your original experiences and keep them going.
These cycles do seem to have acquired quite a
life or their own.
52
Anna Reformulation Letter
I would like to emphasise however how impressed
I have been at you sticking with the work we have
been able to do even if it has been interrupted
by your trips to the ward occasionally or our
other difficulties in getting together
(sometimes mine) and that if the small part of
you which is holding on can continue to keep
thinking together about these issues, reflecting
on them and considering jointly ways of
addressing and challenging them, then it is
perfectly possible that you will be able to move
on to a more fulfilling and meaningful life -
although the path I am sure will not be easy or
straightforward
53
Self States Sequential Diagram - Anna
When I look into the mirror Im not sure who I
see or who is seeing
dont take self seriously, treat self as not good
enough
just carry on as below, dont care for
self, whats the point? (eg blood tests)
emotionally neglecting, disbelieving, not taking
seriously
conditionally loving treating as not good
enough
want to be dead
nothing changes, reinforces original experiences
looked after materially but emotionally
neglected (eg by dad), not listened to or taken
seriously, disbelieved
conditionally loved (real me not
loveable) never good enough (?mentally retarded,
something wrong, never knew how to be good
enough)
exhausted isolated
no change, no result, lose power
sometimes kick furniture, bang head
unbearable feelings, withdraw, cant
tolerate seeing anybody
feel disgusting (anyway) makes a mess, constantly
running, avoids deep thoughts
become ultra competitive (?cultural too)
ill, numb
restrict eating - can be a weapon
pisses people off
restrict eating, cope with laxative abuse
sometimes (more recently) cut or OD sometimes
need to feel punished
(becomes harder to cut deeply)
short lived
sometimes get relief
54
Anna Key Issues (Target Problem Procedures)
  • (1) Because of your experience of being
    frequently criticised, pressurised and only ever
    conditionally loved, you have finished up
    assuming that there is something wrong with you
    (eg missing some chromosome!) and have finished
    up frequently enacting these criticising roles
    towards yourself. This leads you to never
    feeling good about yourself or never trying to do
    good things for yourself which reinforces your
    original experiences.
  • Aim To try to watch out for that
    self-criticising and self-pressurising voice
    and identify it as we have been doing and to try
    to consider whether you really accept its
    validity.

55
Anna Key Issues
  • (2) Because of your experiences of never feeling
    properly listened to or respected, you finish up
    feeling abandoned and alone and often full of
    desperate feelings which you have coped with in
    various ways including self-harm and dietary
    restriction - as well as sometimes perhaps
    behaviour which may have been experienced as
    apparently difficult towards other people.
    This all tends to lead you to be again rejected
    and misunderstood and leaves you still
    unappreciated and with your emotional needs
    unmet, so reinforcing your original experiences.
  • Aim To try to bear in mind when you are feeling
    desperate how it is that these feelings have come
    about and the consequences of your traditional
    ways of coping and try to consider alternatives
    such as communicating calmly to trusted people
    (as we have begun perhaps to do in therapy) how
    you are feeling and what your needs are.

56
Anna - Progress
Continues to attend therapy with apparently
increasing commitment and less wariness and
hostility. Continued collaborative use of diagram
appears to assist containing unbearable
feelings and to reflect on her habitual patterns
of feeling, thinking, and coping. More willing
and able to discuss feelings in relation to
therapist. Towards end of initial contact
finally agrees to discuss feelings about her
father and to address him using an empty chair
approach through which she expresses some
powerful, unresolved, and angry feelings about
the effects of his behaviour on her and her wish
that he would still be able to appreciate this.
This appears to be an important moment which
seems to considerably loosen up her thoughts
and feelings overall.
57
Anna - Progress
Despite this progress, patterns (RRPs) of eating
restriction and laxative and medication abuse
remain a major problem with little change
apparent. Is always tired, finds concentration
difficult and experiences frequent palpitations.
However states is now keen to remain in therapy
and further 24 session course agreed.
Reluctantly agrees to consider seeing a dietician
to address nutritional concerns. Agrees
reduction of various medications is a long term
aim but reluctant to countenance this at present.
Remains socially isolated and lonely and feels
stigmatised by family and others. Recurrently
talks of wishing rather to be out of it all and
appears still a considerable risk of serious self
harm...
58
Anna Overview of Background Issues
  • Problems due to mix of temperamental
    vulnerability (obsessional perfectionism, ?
    dissociation), dysfunctional, intense (nuclear)
    family dynamics (criticising, conditional love,
    not listening to or taking seriously), cultural
    factors (competitive school environment,
    pre-occupation with dieting and appearance).
  • ?Exacerbated and perpetuated contextually by
    doing to, authoritarian approach of many mental
    health services - colluding with her historic
    RRs. Lack of any meaningful attempt at social
    therapy/rehabilitation.

59
Anna Overview of Background Therapeutic Issues
  • Attempt to establish a therapeutic alliance on
    basis of authentic encounter (new RR) - aided
    by collaborative work of joint reformulation
    (offering both insight and empathic narrative
    validation).
  • Aim to generate understandings of the origins of
    relational positions (RRs), of unbearable
    feelings and habitual maladaptive coping
    patterns (RRPs) including dialogical
    underpinnings of these where relevant so
    enabling work on challenging and changing these.

60
Anna Overview of Background Therapeutic Issues
  • Self-reflective capacity and containment of
    unbearable feelings aided by understanding of
    existence of multiple dissociated self-states
  • Importance of jointly acknowledging and
    processing powerful emotions in relation to her
    father.

61
Anna Overview of Therapeutic Challenges
  • RRPs around anorexia very long standing and
    resistant even when obstacles to addressing them
    have been worked on. Will require active
    behavioural approaches.
  • Beliefs around diet and appearance and the
    importance of individual success reinforced by
    cultural norms.
  • Absence of real (joint) community involvement in
    social therapy/rehabilitation. Perpetuates lack
    of any sense of common identity or purpose.

62
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63
CAT Further Applications around PD
  • Brief interventions using standardised CAT
    diagrams in AE.
  • (Sheard, T., Evans, J., Cash, D. et al. (2000).
    A CAT derived one to three session intervention
    for repeated deliberate self harm a description
    of the model and initial experience of trainee
    psychiatrists in using it. British Journal of
    Medical Psychology, 73, 179-196.).

64
CAT Further Applications around PD
  • A CAT framework for understanding and managing
    problematic frequent attendance in primary care.
  • Pickvance, D., Parry, G.D., Howe A. Primary
    Care Mental Health, 2, 165-174.

65
CAT Further Applications around PD
  • Residual PD in the elderly.
  • Sutton, L. et al. (2003) When late life brings a
    diagnosis of dementia and early life brought
    trauma. A cognitive analytic understanding of
    loss of mind. Clinical Psychology and
    Psychotherapy, 10, 156-164.
  • Also, in Cognitive Analytic Therapy and Later
    Life. (2004). Eds Hepple, J. Sutton, L.
    Brunner-Routledge.

66
CAT Further Applications around PD
  • Early intervention studies in adolescents at high
    risk of developing BPD.
  • (Chanen, A.M., Jackson, H.J., McCutcheon, L.K.,
    et al. (2008). Early intervention for adolescents
    with borderline personality disorder using
    cognitive analytic therapy randomised controlled
    trial. British Journal of Psychiatry,193, 1-8.)

67
CAT Further Applications around PD
  • Skills level training for generic mental health
    workers brief CAT-based training in working
    with difficult/PD patients.
  • (Thompson, A.R., et al. (2008). Multidisciplinary
    community mental health team staffs experience
    of a skills level training in cognitive
    analytic therapy. International Journal of Mental
    Health Nursing, 17, 131-137.)

68
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69
CAT-based skills training for a CMHT in working
with complex mental health problems.
  • Emma Warnock Parkes
  • Jenny Donnison
  • James Turner
  • Glenys Parry
  • Ian Kerr
  • Sheffield Care Trust/Sheffield University, UK.

70
CAT-based skills training for a CMHT in working
with complex mental health problems Background
  • Community mental health teams (CMHTs) are
    increasingly central in many services to the
    routine delivery of care for a range of often
    complex and difficult mental health problems,
    including personality disorders.
  • But...

71
CAT-based skills training for a CMHT in working
with complex mental health problems Background
  • Widespread uncertainty about nature of clinical
    models used and their effectiveness.
  • Poor history of effective implementation of
    training programmes (eg family therapy, PSI).
  • Frequent demoralisation, poor job satisfaction
    and burn out amongst team members.

72
CAT-based skills training for a CMHT Background
  • Increasing expectation from consumers for
    psychological treatments for mental health
    problems acknowledged and encouraged in the UK
    by recent DoH guidelines (NIMHE 2003 DoH 2002)
  • Increasing expectation that generic mental health
    workers should offer psychologically-informed
    management and/or treatment to patients with
    complex and PD type problems in wake of emerging
    treatment models (APA 2001 NIMHE 2003 2004NICE
    2009).

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CAT-based skills training for a CMHT in working
with complex mental health problems Background
  • Current paucity of appropriate or effective
    training packages well recognised (NIMHE 2004) as
    is urgent need for their development.

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CAT-based skills training for a CMHT in working
with complex mental health problems Aims
  • To provide CMHT members with a training in a
    common, coherent model to inform routine
    management of complex and difficult patients,
    notably those with PD.
  • To improve overall team function.
  • To improve clinical outcomes for patients.

75
CAT-based skills training in working with complex
mental health problems.
  • Intensive one week training on complex and
    difficult mental health problems (especially
    PD) for generic workers/teams.
  • Aim to inform routine practice rather than
    produce specialist therapists.
  • Based around CAT model of development and
    psychopathology comprising theoretical lectures,
    conceptualisation of clinical material and
    experiential sessions (reflective groups and
    personal reformulations).

76
CAT-based skills training in working with complex
mental health problems.
  • Followed up by experience of treating two cases
    under extended supervision over 6-9 months.
  • Further training/supervision (possibly
    practitioner level course) for those wishing to
    extend experience/expertise.

77
CAT-based skills training in working with complex
mental health problems.
Personal reformulation experience
  • Invitation to explore personal roles (and their
    background if desired) at work in relation to the
    CAT model over a few hours in a confidential
    session with a CAT practitioner from out of
    area.
  • Gives experience of creating and receiving brief
    rudimentary narrative and diagrammatic
    reformulations. Follow up offered if requested.
  • NOT aimed at being therapy.

78
CAT-based team training qualitative evaluation.
  • Questionairre and confidential in-depth
    interviews conducted and evaluated by independent
    researchers (EP and JD).
  • Quantitative evaluation of responses to formal
    questions.
  • Further evaluation of themes emerging from
    interviews.

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Team training evaluation
(i) Experience of training I was hoping it
would extend my skills range and that I could
use it in a focused and structured way in people
that have had lots of different therapies over
the years, who have been stuck or dependent on
the servicepeople who have been labelled as
difficult or challengingit's nice to see a
framework to let them open up and look atwhy
they were entrenched in maladaptive
functioning My understanding was that it would
equip us with the skills of CATso that we could
develop a language to discuss what was going on
with some of our complex and difficult clients

80
Team training evaluation
(i) Experience of training It's created a
great momentum for debate and exploration and a
culture of a single modelled approach that we are
all using and learning at the same timeit has
helped the team bonding, it's created a lot of
banter and debate, jokes and support.a very
satisfying extra. It's comforting to have that
baseline language I dont think that teams will
often have that shared knowledge or shared
understanding of the language "The main thing
is empowering clients the breakdown of the
practitioner-client boundariesit involves
clients, changing the culture, people know
what's happening, it reduces client
dissatisfaction and complaints. I actually
enjoyed the impact that the CAT has on the
client, its been a bit of an eye opener in terms
of their response to it.


81
Team training evaluation
(ii) Impact on team members approach to
work It's improved my confidence as these were
highly anxiety provoking clients - it goes back
to the idea that you have something else to look
at, Im more comfortable taking on a heartsink
personality disorder case knowing that I have
some understanding of CAT "It helps my
assessmentsprovides a clear structure for my
work and my endings with clients

It brings together issues I think
are important within social work alongside
psychological modelsit includes issues of
discrimination, power, it allows for some
understanding of political structure
82
Team training evaluation
(iii) Impact on team function
The CAT model is a common tool
that is often used in team meetings to analyse
difficult cases that people are struggling with.
I think this helps with the way decisions are
made and with understanding why people respond to
difficult clients in the ways that they doBeing
able to discuss it more using a particular model
leads to consensus on how to engage with
someone. nobody is personalising problems,
the team is now a source of strength rather than
being defensive. theres a collective
practice, a collective view of where we are
going, people know the aims. We now have a model
to talk about difficult clients and find out why
we are struggling with people the way that we
are.
83
Team training evaluation
(iv) Impact on level of support and supervision
Very positive, it was tremendous - lots of
knowledge, experience and wisdomdifferent
perspectives from people bringing in different
cases. There has been a shift of focuswe used
to work very differently and think differently
rather than do it, do it now it's am I on the
right track?
84
Team training evaluation
(v) Impact on morale and well being of
members The stress is still around but
actually being more confident and having a joint
position with everybody else in the team helps
you deal with it. The training has lowered my
anxiety levels with regard to working with
complex needs clients, also knowing that we have
something to offer people who are often dismissed
as having untreatable personality
disorders
85
CAT-based skills training for a CMHT in working
with complex mental health problems Conclusions
  • Training is feasible, welcome and helpful to team
    members.
  • Sustained improvements in perceived skills levels
    generalising to routine generic work.
  • Improvement in communication and morale in team.
  • Perceived improvement in team function.
  • Apparent improvement in experience of patients.

86
CAT-based skills training for a CMHT in working
with complex mental health problems What next?
  • Disseminate manualised training programme
    incorporating improvements to other CMHTs in
    service.
  • Controlled evaluation of impact on clinical
    outcomes and patient satisfaction.
  • Assist several team members to further specialist
    CAT psychotherapy level training!

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88
Growing points and challenges
  • CAT now a mature and robust general theory of
    development and psychopathology. Increasing range
    of applications for different conditions and in
    different settings.
  • Contributing to re-conceptualisation of mental
    disorders or aspects of them. Consistent theme in
    such work has been the interpersonal and social
    origins and determinants of human psychopathology
    as well as its current social context.

89
Growing points and challenges
  • However, CAT needs to continue to integrate and
    take account of advances in allied disciplines
    e.g. cognitive and developmental psychology,
    neurobiology, sociology etc.
  • Needs further process and outcome research to
    establish its comparative validity and
    effectiveness (what works for whom?) both alone
    and in multimodal treatment approaches.

90
Growing points and challenges
  • Although CAT emphasises the social and cultural
    formation of self, does the model adequately
    address the need for social therapy and the
    issues of treating psychological damage and
    distress in different cultures and contexts?
  • Could contribute a socio-psychodevelopmental
    dimension to current, often polarised, highly
    individualistic either disease model or social
    inclusion type approaches to public mental
    health initiatives?

91
Thank you!
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