1. Providing a Clear Way Forward: Using CAT to Integrate Forensic Services Mark Ramm, Head of Forensic Psychological Services, The Orchard Clinic, NHS Lothian mark.ramm@nhslothian.scot.nhs.uk Into the Future Conference 4 th October 2012

2. Overview Hard to help offenders/patients Hard to help offenders/patients The treatment task The treatment task Using CAT formulation to guide: Using CAT formulation to guide: Individual therapy Individual therapy Team working Team working Risk Assessment Risk Assessment Systemic work Systemic work How we are doing this at the Orchard Clinic How we are doing this at the Orchard Clinic Case example Case example

3. Hard to help Forensic Patients Some Types: Uncontrollable affect (lack ability to self regulate) Can’t think, Don’t think (Lack insight re: internal states of self and others) Confusion (Things just happen) Too split up, Moving target (Flipping) Too aggressive / rejecting Too needy Low Motivational readiness ‘Defend’ against problem/others Don’t think there is problem Don’t change, Revolving door patients

4. Treatment: The methods by which we deliver therapy GROUPWORK INDIVIDUAL PSYCHOTHERAPY POSTIVE PURPOSEFUL ACTIVITY SAFE & SECURE Rehabilitation ServicesPrison Families MEDICATION Community

5. The Forensic Matrix ‘stepped care’ HSI Specialist I High intensity interventions Low intensity interventions Information Highly specialist Interventions Formulation Driven

6. But less specific about how you hold the whole thing together (Psychology, Occupational Therapy, Social Work etc) But less specific about how you hold the whole thing together (Psychology, Occupational Therapy, Social Work etc) Or about the how to use of the therapeutic relationship outside particular individual or group therapies Or about the how to use of the therapeutic relationship outside particular individual or group therapies

7. GROUPWORK INDIVIDUAL PSYCHOTHERAPY POSTIVE PURPOSEFUL ACTIVITY SAFE & SECURE RELATIONAL INTERACTIONS Rehabilitation ServicesPrison Families MEDICATION Community

8. There are successful treatments for Borderline Personality Disorder Dialectical Behaviour Therapy – DBT Dialectical Behaviour Therapy – DBT (Linehan et al, 1993) (Linehan et al, 1993) Transference Focussed Therapy –TFT Transference Focussed Therapy –TFT (Clarkin et al, 2007; Levy et al, 2006; Doering et al 2010) (Clarkin et al, 2007; Levy et al, 2006; Doering et al 2010) Cognitive Behavioural Therapy -CBT Cognitive Behavioural Therapy -CBT Davidson et al, 2006) Davidson et al, 2006) Shema Focused Therapy – SFT Shema Focused Therapy – SFT (Glessen-Bioo et al, 2006) (Glessen-Bioo et al, 2006) Mentalizing based therapy-MBT Mentalizing based therapy-MBT (Bateman & Fonargy 1999, 2001) (Bateman & Fonargy 1999, 2001) Systems Training for Predictability & Problem Solving STEPPS Systems Training for Predictability & Problem Solving STEPPS (Blum et al, 2008) (Blum et al, 2008) Cognitive Analytic Therapy CBT Cognitive Analytic Therapy CBT (Chanen et al, 2008) (Chanen et al, 2008)

9. Comparisons: Treatment vs Treatment Psychodynamic supportive therapy vs transference-focussed therapy vs DBT (Clarkin et al, 2007) Psychodynamic supportive therapy vs transference-focussed therapy vs DBT (Clarkin et al, 2007) “Generally equivalent” “Generally equivalent” MBT vs Psychodynamic Supportive Therapy (Jorgensen et al, 2012) MBT vs Psychodynamic Supportive Therapy (Jorgensen et al, 2012)

10. Comparisons: Specific Treatments vs Good Clinical Care DBT vs good general psychiatric management (McMain et al. 2009, 2012) DBT vs good general psychiatric management (McMain et al. 2009, 2012) No differences in outcome No differences in outcome MBT vs structured clinical management (Bateman & Fonagy 2009) MBT vs structured clinical management (Bateman & Fonagy 2009) Outcome was similar Outcome was similar CAT vs manualised good clinical care (Chanen et al, 2008) CAT vs manualised good clinical care (Chanen et al, 2008) No major differences in outcome No major differences in outcome

11. Conclusions? BPD at least can benefit from treatment BPD at least can benefit from treatment These specialised treatments are clearly better than treatment as usual These specialised treatments are clearly better than treatment as usual Outcome /efficacy does not differ substantially between specialised treatments Outcome /efficacy does not differ substantially between specialised treatments Specialised therapies have yet to demonstrate better outcomes than good tailored clinical care Specialised therapies have yet to demonstrate better outcomes than good tailored clinical care

12. Conclusions? It may be that some problem domains respond to some therapies better than others It may be that some problem domains respond to some therapies better than othersbut it seems outcome is largely due to change mechanisms common to all the therapies and good tailored clinical care it seems outcome is largely due to change mechanisms common to all the therapies and good tailored clinical care

13. PD and disorders that have their origins in childhood and adolescence Common change mechanisms CAT Schema F T DBT Transference FT MBT STEPPS But this does not mean unstructured intervention

14. Common Change Mechanisms? A generic supportive therapeutic stance Structure Structure Clear conceptual basis – Therapeutic Model Clear conceptual basis – Therapeutic Model Structure for intervention Structure for intervention Limit setting Limit setting Building and maintaining a collaborative therapeutic relationship Building and maintaining a collaborative therapeutic relationship validation, motivation, self –reflection validation, motivation, self –reflection Consistency Consistency Change methods Change methods

15. Creating a Team Culture Models of working which help teams should include: Models of working which help teams should include: Having a clear common language which is understandable and makes sense to both patients and teamworkers Having a clear common language which is understandable and makes sense to both patients and teamworkers A stress on the therapeutic relationship A stress on the therapeutic relationship (Roth & Fonagy, 1999) (Roth & Fonagy, 1999) This results in: This results in: Improved communication between teammates Improved communication between teammates Improved team functioning (minimizing “splitting”, “buck-passing” and “burn out” Improved team functioning (minimizing “splitting”, “buck-passing” and “burn out” Improved job satisfaction and team morale Improved job satisfaction and team morale Improved results and cost-effectiveness Improved results and cost-effectiveness

16. MODEL / FORMULATION Common change mechanisms CAT Schema F T DBT Transference FT MBT STEPPS STEPPED CARE STEPPED CARE RISKMANAGEMENTRISKMANAGEMENT

17. CAT FORMULATION Common change mechanisms CAT Schema F T DBT Transference FT MBT STEPPS STEPPED CARE STEPPED CARE RISKMANAGEMENTRISKMANAGEMENT Because Interpersonal Dysfunction lies at the core of these patient’s problems

18. CAT FORMULATION Common change mechanisms CAT Schema F T DBT Transference FT MBT STEPPS Social workers Care staff Medical staff Families Applied Health Professionals STEPPED CARE STEPPED CARE RISKMANAGEMENTRISKMANAGEMENT Carers Patient

19. GROUPWORK INDIVIDUAL PSYCHOTHERAPY POSTIVE PURPOSEFUL ACTIVITY SAFE & SECURE RELATIONAL INTERACTIONS Rehabilitation ServicesPrison Families MEDICATION Community

20.  We need an overarching formulation and reformulation to plan the type, level, timing, order and length of interventions  CAT as a ‘relational model’ is particularly applicable because we need to work through therapeutic relationships across the whole process Formulation Core Issues & Entrenched patterns Skills building & strengthening Engagement & motivation Consolidation & integration

21. Cognitive Analytic Therapy Integrative Integrative “A theory based on the integration and extension of ideas and methods used in conventionally opposed approaches” (Anthony Ryle) (Anthony Ryle) More than just Cognitive & Psychoanalytic More than just Cognitive & Psychoanalytic Cognitive CognitiveBehaviouralPsychoanalyticDevelopmentalSocial

22. CAT Distinctive individual psychotherapy Distinctive individual psychotherapy CAT accepted as a distinctive and independent form of psychotherapy - Roth & Fonagy (1996) An integrated theory of personality and change An integrated theory of personality and change So applicability to a wide range of situations, problems and settings

23. How does CAT approach it ? Relational: Relational: Most distress in human beings is relationship based self and others self and others self and self self and self Dynamic: Dynamic: Explains how people can act very differently at different times and in different contexts

24. DEVELOPMENT DEVELOPMENT Babies are born attuned to interact with others Each baby has its own genetic predispositions The baby interacts with carers who are massively influential - Attachment issues The infant internalises its experience Forms joint understandings with others Forms concepts about others Formation of Relationship templates Formation of Reciprocal Roles

25. CAT All mental activity, whether conscious or unconscious, is rooted in and highly determined by our repertoire of Reciprocal Roles

26. RECIPROCAL ROLES RECIPROCAL ROLES Mother or Main Other (Critical & demanding) SELF (Unworthy & Striving) SELF (Critical & demanding) Other (Unworthy & Striving) SELF (Critical & demanding) SELF (Unworthy & Striving) Other (Critical & demanding) SELF (Unworthy & Striving)

27. BALANCED PERSONALITY ORGANISATION A Reciprocal Role is a block of procedural knowledge about how to ‘do’ a particular relationship and what to expect from it (Denman 2001)

28. PROCEDURES Abusing Abused Unmet needs Negative emotion Stress e.g. Avoiding, e.g. impress others Alternative Reciprocal Role/self state

29. “RIGID” PERSONALITY ORGANISATION Particular Reciprocal Roles have a dominance and extreme polarization or there are a limited in number of Reciprocal Roles.

30. Self State Disorders Disruption of integrating procedures Disruption of integrating procedures Deficient and disrupted self reflection Deficient and disrupted self reflection Dissociation of self-states Dissociation of self-states Confused, Can’t think, Unstable Some dissociation normal

31. Using CAT formulation to inform and integrate treatment with forensic patients All staff trained in CAT All staff trained in CAT 100 trained in last 3 years 100 trained in last 3 years CAT Therapy, Team working, CAT informed working CAT Therapy, Team working, CAT informed working

32. CAT KNOWLEDGE COMMON LANGUAGE CAT INFORMED TEAMWORK CAT THERAPY CAT MAPS Trained/supervised staff

33. Shared Formulation - CAT reformulation developed with patient shared with care team - CAT formulation developed by care team to work with patient

34. Team working to develop a CAT formulation to guide therapy Angry Aggressive Patient Angry Aggressive Patient Why is the person like they are? Why is the person like they are? What is actually happening? What is actually happening? How will we try to improve things? How will we try to improve things?

35. Abusing Abandoning Rejecting Abused Abandoned Rejected Perfectly caring Protecting Perfectly cared for Protected ANGRY NEEDY Angry outburst Seeks perfect care Seeks distraction through excitement Doesn’t last or rejected Prevented Refuses to ask for care but expects it Needs not met

36. GROUPWORK INDIVIDUAL PSYCHOTHERAPY POSTIVE PURPOSEFUL ACTIVITY SAFE & SECURE RELATIONAL INTERACTIONS Rehabilitation ServicesPrison Families MEDICATION Community

37. CAT and Working as Teams Benefit to team Benefit to team Consistent approach, prevent splitting etc Consistent approach, prevent splitting etc Benefit to patient Benefit to patient Better treatment, breaking the cycle of damaging responses from others Better treatment, breaking the cycle of damaging responses from others

38. Application of CAT at many levels – Integrated Working Individual therapy – Formulation, client focused Individual therapy – Formulation, client focused Multidisciplinary, team approach Multidisciplinary, team approach Recovery focussed milieu Recovery focussed milieu Flexible application to mode and modality of intervention, Stepped care Flexible application to mode and modality of intervention, Stepped care Collaborative, Service user involvement Collaborative, Service user involvement Psychologically informed and literate workforce Psychologically informed and literate workforce Improved relational security Improved relational security Improved risk assessment Improved risk assessment

39. CAT Ryle A. & Kerr I.B. Introducing Cognitive Analytic Therapy (2002) John Wiley & Sons Ryle A. & Kerr I.B. Introducing Cognitive Analytic Therapy (2002) John Wiley & Sons RCT’s for PD Chanen A.M., Jackson H.J., McCutcheon, l.K et al. (2009) Early intervention for adolescents with borderline personality disorder: quasi- experimental comparison with treatment as usual. Australian and New Zealand Journal of Psychiatry, 43, 397-408 Chanen A.M., Jackson H.J., McCutcheon, l.K et al. (2009) Early intervention for adolescents with borderline personality disorder: quasi- experimental comparison with treatment as usual. Australian and New Zealand Journal of Psychiatry, 43, 397-408 Prof Sue Clarke, RCT of CAT vs TAU for PD As presented at a recent conferences (submitted to B. J. Psych). Prof Sue Clarke, RCT of CAT vs TAU for PD As presented at a recent conferences (submitted to B. J. Psych).