cognitive analytic therapy for borderline personality disorder spd network meeting aberdeen 4 th...

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,

Cognitive Analytic Therapy

www.acat.me.uk

“Cognitive Analytic Therapy:Active Participation in Change”

Anthony Ryle 1990 J. Wiley & Sons

“Cognitive Analytic Therapy: Developmentsin 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).

‘In the beginning is the relation’.

- Martin Buber, ‘I and Thou’ (1958).


• Object-relations informed approach to cognitive therapy (including personal construct theory) transformed by Vygotskian activity theory and Bakhtinian concepts of the dialogic self.


• 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.


• Influence in recent years of findings in developmental research (e.g Trevarthen) stressing the infant’s 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.

• ‘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.


• 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…’)

Infant Observation Research (Stern, Trevarthen et al)

Verbal self from c.18 months: meaning (the relation ofthoughts to words), results from interpersonal negotiations. (Stern)

Ultimately awareness and understanding of states ofmind 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.


Early “emergent self” – carers act as physiological regulators but infant capable of, and predisposed to,active intersubjectivity and gradually increasingcollaborative 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 ofothers by one year; “shared framework of meaning and means of communication” (Stern)


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.

‘Reciprocal role’ - complex of implicitrelational memory, perception (includingbeliefs, values and meanings) and affect– often associated with a dialogic voice .

Repertoire of reciprocal roles seen to underpin all mental ‘activity’ whetherconscious or unconscious.

‘Reciprocal role procedure’ - stable patternof interaction originating in early internalisedrelationships which determine current patternsof relations with others and of self-management.

Enactment of a role always implies another,whose reciprocation is sought or expected.

Vygotsky & ‘Activity Theory’

• Concepts of ‘internalisation’; ‘psychological tools’ ; ‘zone of proximal development’ (‘ZPD’).

Vygotsky & ‘Activity Theory’

• ‘Any function in a child’s 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.’

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 individual’s 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`)

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.

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.

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 one’s own and someone else’s 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’.

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.

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.

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 individual’s repertoire of role procedures determines both interpersonal relationships and the internal dialogue of thought and self-management.

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.

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!

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, depressionand a recent self-harm attempt. He appeared initially withdrawn and uncommunicativeand sat looking at the floor for several minutes. In response to a general enquiry abouthow things were he became angry about “having to go through all this yet again” andanyway “what was the point of it all”. He immediately followed this by looking up andapologising profusely for his outburst saying that he was wasting my time because hehad to get on with things anyway and there were plenty of people out there who neededmy 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 wantedto do but had to carry on with in order not to let his parents down. Again there was abrief moment of anger at the attitudes of Westerners towards their parents and olderpeople 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.

(Dominic - possible SDR)

criticisedconditionally loved‘my fault’, ‘am worthless’

*criticisingconditionally loving

apologeticstrive to perform and please

results in emotional isolation, exhaustion,can’t manage – confirms worst assumptions

‘depressed’ODs

or, defiant, rebellious,*criticising

briefly self assertivebut, feel guilty and*criticised

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.

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.


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.

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’.

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.


From a CAT perspective, ‘severe and complex’ disorders could be seen in part

as ‘self-state and relational disorders’.

neglectedabandoned

neglecting,abandoning

‘cut off’,‘numb’,do drugs

‘OK’ for a while, but..

feel even worse,nothing changes

poor self care,‘deserve nothing,do nothing’

seek perfectcare - expecttoo much

abused

abusing

always let down

desperate,unmanageablefeelings

self harm

some relief, butnothing changes

deservepunishment

self harm

if feelabused

may explode into ‘justified’rage

upsets people,rejected, put down,alone, feel ‘wholeworld against me’

give peoplea ‘bad time’,(e.g. partner)

staff caring,trying to help

fearful, fed-up,burnt-out, rejecting

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 patient’s self-state and role enactments and their effects on others.

• Helps establish therapeutic alliance and communicates that patient has been listened to and understood.

Contextual reformulation

• Educates patient into effects of behaviour and staff into patient’s 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 patient’s inner world

beyond getting stuck in negative responses (‘vicious circles’) to difficult behaviour.

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 friend’s 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.

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.

Anna - Background

Family background characterised by atmosphere of tensionbetween 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 wouldn’t attend due to ‘sickness’. ‘Couldn’t 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.

Anna - Presentation

At presentation states that sees no point in living nor anyfuture and that perhaps only a small part of her wishes to think about any further attempts at treatment. Part of herwould 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 isslightly squint be straightened up). Relates that she is stillabusing laxatives and medication (e.g. thyroxine) andeats only liquid baby food. Her body mass index (BMI) isapparently only about 14. She refuses to see local eatingdisorder service who she says don’t listen to her or takeher seriously. However agrees to see CPN intermittentlyand attend a (different) psychiatrist for occasional review.

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.

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’.

Anna – Reformulation Letter

Dear Anna,

This is a letter attempting to summarise some of the key issues which seemto have emerged in the course of our initial work together and to try to thinkabout how they are impacting on your life at present as well as to think aboutwhat might historically lie behind them, as we have been doing. I hope that thiswill ultimately help you to move on to a more rewarding future. We have alreadyattempted to sketch some of this in a diagrammatic form which I think by youraccount 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….


…in looking back over some of the things I have jotted down over the pastfew months I am very struck by the importance for you of not having other people’sversions of events or their expectations imposed upon you which does seem tohave 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 bylooking through your psychotherapy file again where you highlighted some very extreme and difficult states…..


… 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 havetalked about various ways you have coped over the years with these unbearablefeelings by doing controlled overdoses, laxative abuse and other forms of self-harmsuch as cutting although this seems to have become more difficult for you recentlyIt 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 oftenpressurised and rejected by people again. All of which of course in a viciouscycle fashion seems to reinforce your original experiences and keep them going. These cycles do seem to have acquired quite a life or their own….


…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 andconsidering jointly ways of addressing and challenging them, then it is perfectlypossible 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…

Self States Sequential Diagram - Anna

conditionally loving treating as ‘not good enough’#

conditionally loved(‘real me not loveable’)

never good enough(?mentally retarded, something wrong, never knew how to be good enough’)

emotionally neglecting,disbelieving*,not taking seriously*

looked after ‘materially’ but emotionally neglected (eg by dad),not listened to or taken seriously,disbelieved

want to be dead

unbearable feelings, withdraw, can’t tolerateseeing anybody

become ultra competitive(?cultural too)

restrict eating,cope with laxative abuse

sometimes (more recently)cut or OD – sometimes need to feel punished #

sometimes get reliefshort lived(becomes harder to cut deeply)

feel disgusting (anyway)makes a mess,constantly running, avoids deep thoughts

nothing changes,reinforces original experiences

exhaustedisolated

don’t take self seriously,treat self as not good enoughjust carry on as below,

don’t care for self,‘what’s the point’?(eg blood tests)

‘When I look into the mirror I’m notsure who I see or who is seeing*’

sometimes kick furniture, bang head

restrict eating- can be a ‘weapon’

pisses people off

ill, numb

no change, no result, lose power

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.

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.

Anna - Progress

Continues to attend therapy with apparently increasingcommitment 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.

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...

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.

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.

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.

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.

CAT: Further Applications around ‘PD’

• Brief interventions using standardised CAT diagrams in A&E.

– (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.).


• 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.


• 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.


• 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.)


• 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 staff’s experience of a ‘skills level’ training in cognitive analytic therapy. International Journal of Mental Health Nursing, 17, 131-137.)

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.


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...



• 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.

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; 2004;NICE 2009).



• Current paucity of appropriate or effective training packages well recognised (NIMHE 2004) as is urgent need for their development.

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.

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).


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.


health problems.

• 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.

Personal reformulation experience:

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.

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 ordependent on the service…people who have been labelled as difficultor challenging…it's nice to see a framework to let them open upand look at…why they were entrenched in maladaptive functioning”

“My understanding was that it would equip us with the skills of CAT…so that we could develop a language to discuss what was going on with some of our complex and difficult clients”


(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 time…it 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 don’t 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 boundaries…it 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”.


(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, I’m more comfortable taking on a heartsink personality disorder case knowing that I have some understanding of CAT”

"It helps my assessments…provides a clear structure for my work and my endings with clients”

“It brings together issues I think are important within social work alongside psychological models…it includes issues of discrimination, power, it allows for some understanding of political structure…”

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 strugglingwith. I think this helps with the way decisions are made andwith understanding why people respond to difficult clients in the ways that they do…Being 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.”

“…there’s 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.”


(iv) Impact on level of support and supervision

“Very positive, it was tremendous - lots of knowledge, experience and wisdom…different perspectives from people bringing in different cases.”

“There has been a shift of focus…we used to work very differently and think differently: rather than ‘do it, do it now’ it's ‘am I on the right track?”


(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”


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.

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!

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.


• 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.


• 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?

Thank you!

cognitive analytic therapy for borderline personality disorder spd network meeting aberdeen 4 th...

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