1. “Using CAT” as opposed to “Doing CAT”: Adapting Cognitive Analytic Therapy for use within a Forensic Patient Setting Katie Gilchrist, Higher Assistant Psychologist Co delivery: Katherine Crosby, Katie Downsworth & Kristy O’Hare, Higher Assistant Psychologists Roseberry Park Hospital

2. Overview What is CAT? ‘Using’ CAT The Adapted Approach Case example - Isobel Mapping the moment with staff Patient life history Creating an overarching map demonstrating key roles Recognition of key areas within reformulation The creation of a ‘relationally informed’ care plan Conclusion Reflection References

3. What is CAT? Cognitive Analytic Therapy (CAT) is a time limited therapy which encompasses cognitive and psychoanalytic thinking along with the social model of the self Ryle (2002) depicts that an individual’s pattern of relating to others and their ability to self manage is developed from childhood experiences Aims to increase relational awareness

4. ‘Using’ CAT CAT typically involves working alongside the client in a 1:1 manner This is not always possible – difficulty engaging in therapy, anxiety, mental health state Potter (1999) explored ‘using’ CAT rather than ‘doing’ CAT. He wondered ‘can CAT be used with only an introductory grasp of its principles and methodology?’

5. The Adapted Approach Evolved following the implementation of CAT training within our service From this, individuals were given the opportunity to apply for additional skills training Aim of additional skills training was to use CAT as a reflective practice for frontline staff To enhance relational awareness on the ward and to develop greater insight and understanding of ward based interactions (Marshall, Freshwater and Potter, 2013)

6. Case Example - Isobel Woman in her forties Lost her brother as a youngster Bullied at school & aggressive toward others Thoughts of harming others, sought assistance No immediate response led her to commit arson Little progress on the ward, perceived to be ‘stuck’ Fearful and anxious of progressing – displaying increasingly dependent behaviour

7. Mapping the moment with staff Isobel seeking constant reassurance, asking staff to brush her hair Explored staff responses and how it made them feel: ‘do for her, mothering  overwhelmed, frustrated’ ‘try and promote independence  frustrated, worn out’ All staff felt that Isobel would feel reassured and secure by their actions But actually mapping showed Isobel was likely to feel pushed and rejected

8. Patient life history Ryle & Kerr (2002): any reciprocal roles identified with staff should relate to a common reciprocal role internalised in childhood Early experiences of separation and anxiety could have led to a dependency on others to care for her, creating a mothering reciprocal role Long periods in hospital could have led to a fear of being alone Influence current coping strategies of needing reassurance, wanting to be mothered and to be in a safe environment

9. Creating an overarching map demonstrating key roles CAT map displayed the key reciprocal roles that staff entered in to with Isobel It highlighted subtle differences in the way staff interacted with Isobel and demonstrated Isobel’s perception of the interaction It showed reciprocal roles that were unhelpful and this allowed for exit points to be made Exit points are more helpful ways of working, e.g. lets do this together

10. The map

11. Recognition of key areas within reformulation Reformulation allowed staff to identify Isobel’s childhood influences, current coping strategies, roles they were being pulled in to and areas for intervention It raised awareness of Isobel’s behaviour and gave an understanding for the behaviour displayed on the ward

12. The creation of a ‘relationally informed’ care plan The care plan reflected the dynamics Isobel entered into personally, with staff and with the ward environment Isobel’s zone of proximal development was recognised (Vygotsky, 1978) The importance of consistent staff responses was highlighted The need to promote independence in a supportive way was demonstrated

13. Conclusion An awareness of the CAT map led to a non blaming, non mothering approach that fostered Isobel’s independence Isobel was unaware of the changes in staff interaction but began to present with more autonomous behaviour This led to a move to a less intensive ward

14. Reflections A common language helped the staff to unite in working with Isobel CAT created a more psychologically informed environment Staff were able to become attuned to Isobel’s behaviour There was a reduction in staff splits as a consistent approach was adopted It allowed others to think trans-diagnostically and therapeutically

15. References Marshall, J., Freshwater, K. & Potter, S. (2013). Adaptations of a CAT skills course. Reformulation, Winter Potter, S. (1999). A Personal View of CAT. Reformulation, ACAT News Winter 103, 1-4 Ryle, A. & Kerr, I. (2002). Introducing Cognitive Analytic Therapy: Principles and Practice. West Sussex: John Wiley & Sons Ltd. Vygotsky, L. (1978). Interaction between Learning and Development. In M. Gauvain & M. Cole (Eds.), Readings on the Development of Children (pp. 29-36). New York: W. H. Freeman and Company

16. Thank you for listening katie.gilchrist@nhs.net