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Initial experience of a CAT skills certificate level training for a community mental health team working with complex and â€˜difficultâ€™ mental health problems (including personality disorders).

de Normanville, J. and Kerr, I., 2003. Initial experience of a CAT skills certificate level training for a community mental health team working with complex and â€˜difficultâ€™ mental health problems (including personality disorders).. Reformulation, Spring, pp.25-27.

Initial experience of a CAT skills certificate level training for a community mental health team working with complex and ‘difficult’ mental health problems (including personality disorders).

Although CAT is becoming increasingly popular both in terms of its range of clinical applications and its appeal to (mostly) health service workers as a specialist therapy training, it is clear that a major challenge for the model is to become more broadly used as a common and unifying language within mental health services at large. This urgent challenge is most evident in engaging and working with patients who are in some way or other ‘difficult’ (see discussion in Ryle and Kerr 2002). Increasingly, both patients referred into the system and those referring them (e.g. GPs) expect more rigorous treatment as opposed to the historic case management approach. Given the complexity and difficulty of very many of these patients referred into secondary and tertiary level services (many would qualify diagnostically for some form of personality disorder) this work represents a huge and frequently demoralising challenge to such workers and their teams. The need for more effective treatment approaches (and trainings in them) for such ‘difficult’ patients at both a specialist and generic level has been stressed in the recently-published Department of Health guidelines for the treatment of personality disorders (NIMHE 2003)

With these challenges in mind a new ‘skills certificate’ in CAT aimed at this group of workers was proposed to and approved by the training committee last year. The aim of this was to provide a ‘good and thorough enough’ working introduction to the CAT model to enable generic workers to helpfully inform and improve their practice both at an individual but also, importantly, at a common team level. This training initiative has parallels with longer introductory and team-based trainings being run elsewhere (e.g. by Dawn Bennett in Blackburn and the day hospital based training being run by James Low at Guy’s Hospital). The structure and content of this level of training will be described in further detail elsewhere but in summary, the proposal was to offer an intensive week’s teaching on the CAT model of development and psychopathology, on the ‘nuts and bolts’ of therapy, the applications of CAT to different clinical issues and problems (especially the concept of the ‘difficult’ patient), consideration of process research with reference to CAT, practice on identifying RRPs and reformulating, and experiential sessions and discussion groups. Prior to this all participants would be expected to attend a confidential half-day ‘personal reformulation experience’ with a therapist from outside the city to explore what it was they brought to the work. This was considered to be of great importance in flagging up the importance of our (reciprocal) interactions and enactments in any therapeutic situation given that it was not feasible to expect participants to undertake a formal therapy themselves. Finally, all participants would be then expected to undertake two cases for formal CAT under supervision over a period of six months or so after the training in order to consolidate and extend their working knowledge of the model.

Some limited funds had been made available locally in Sheffield to support such training initiatives, and so this training was proposed and offered on a pilot basis to one of the well-established community mental health teams (CMHTs) in the city by members of the CAT North training group. This project and its impact on the team will be the subject of a formal qualitative research evaluation but some preliminary and more subjective impressions of this experience may be of interest at this point.

This team had, on earlier exploration, expressed collective enthusiasm to undergo this training. Although most generic mental health workers might be anticipated to welcome any contribution to improving their skills and effectiveness, we suggest that it is important that participants would actively welcome any such training and prepare for it. This team is responsible for a large caseload (about 25 cases each) and a continuing stream of referrals of patients with ‘non-psychotic’ (i.e. more severe neurotic and personality type problems). Team members are also responsible for manning a duty system for urgent referrals and the approved social workers have statutory duties under the Mental Health Act. They also attend team meetings, personal routine case supervision and have liaison duties with different primary care groups. This is an experienced team of social workers and community mental health nurses with an average of about 20 years experience amongst the 10 core staff. Many have some other experience or training in psychological therapies (e.g. CBT or systemic therapy). All these team members participated in the training, together with a forensic social worker, GP vocational trainee and another social worker who had some involvement with the team. A major stress in this project was on training a whole team rather than one or two isolated individuals within it, given the well-recognised potential problems associated with this scenario. Following the initial training week, team memers were allocated to one of several weekly supervision groups under an external CAT North supervisor (Debby Pickvance) or, for one of them, the team psychiatrist (IK)

Experience so far of the training initiative
Different members of the team have inevitably, six months on, been able to progress to differing extents with CAT cases given different levels of other commitments. However, globally the general feedback so far has been very positive as regards both the initial training and the experience of consolidation and extension of skills through undertaking formal cases for therapy. Likewise the personal reformulation experience was well received by virtually all with no apparent adverse effects and some were stimulated to think about doing more. A major issue that has inevitably arisen is the impact on workers’ case loads and commitments given the extra work involved in taking on a CAT case and attending supervision. This has required a very firm commitment from the team manager to free up half a day a week, which, in the face of other routine and urgent commitments, is not a trivial undertaking. Without exception participants have found this a difficult pressure to manage and it has largely limited them to taking on one case at a time, thus extending the period of training beyond the six months initially envisaged. This issue will clearly require emphasis in any further ‘rolling out’ of this training package. Despite this the team has appeared positive about the impact of the training on their work and would recommend it to other teams provided they did not underestimate the commitment needed.

The quality of therapy appears to the supervisors to be fully comparable to that achieved by new trainees on practitioner courses so far, although this awaits evaluation using more formal outcome measures (all patients are being assessed using CORE, GHQ and the PSQ). It should be noted that most of the patients are challenging and complex and are certainly not the ‘worried well’. However, in the context of the project they are receiving arguably better care although they are not ideal beginners’ cases. Despite initial anxieties about doing therapy, team members have persisted and done well with individual patients with the considerable assistance afforded by the containing structure of the model and of supervision.

Some of the more interesting and important effects of the training are, encouragingly, apparently at a general team level. This is manifest in a different individual approach to case work and an interest in deeper interpersonal issues and their enactments which appears to be permeating through the team’s generic work and in general discussions of cases. This has been evident in the use of CAT terminology in routine work. This diffusion has also been evident in patient responses. For example, one patient brought a CAT reformulation to care coordination meetings. One other patient reported that in many years experience of mental health services she had never been ‘worked with’ in this way before. On a lighter note team meetings have began to be interspersed with CAT-based humour around various enactments by team members. More seriously, this appears to be serving an increasingly important function in maintaining focus, particularly with ‘difficult’ patients, on sometimes collusive and unhelpful reciprocal enactments. The use of the model and its terminology seems thus so far to be serving a remoralising and unifying function, which was one of the key issues being addressed in the project. Interestingly this unifying function appears to be welcome by team members from different professional backgrounds e.g. nurses and social workers. The CAT model of development with its emphasis on a very social concept of the self appears welcome to their previous conceptual frameworks and professional values. This is clearly important in offering such training and appears to confirm the perception that CAT seems in a general way to be appealing to the values of the current generation of mental health professionals. However some team members have expressed some anxiety and caution about attempting to become therapists and about retaining a sense of their existing professional identity. Nonetheless most have expressed interest in continuing their 1:1 therapeutic work f team resources and overall Trust service policy and priorities permit.

Discussion
It certainly appears that the impact of the skills training package has been positive both in terms of the team’s skills and the clinical outcome for the clients seen. Not only do there appear to be positive outcomes for the CAT clients but the thinking and CAT work is percolating into the general work that the team undertakes. Currently the training appears to be helpful to such teams with the caveat and recognition that it requires a significant amount of time for a robust CMHT to prepare for and take it on. In preparation for this training, staff were consulted at length and fully collaborated with in developing the training and in the evaluation and proposed dissemination of the package. The need for clear support in terms of workload management likewise cannot be over emphasised. Nonetheless the project appears so far to have been experienced as a welcome, rewarding although also challenging and labour-intensive development.

Clearly the effectiveness of such a training package requires further formal evaluation both in terms of patient outcomes following 1:1 treatment and also, from the point of view of this project perhaps more importantly, in terms of overall team function. This is currently the subject of a qualitative research evaluation. This initial experience will of course inevitably have been coloured by the research allegiances of those participating and evaluation of its generalisability as it is ‘rolled out’ to other sectors in the city will be very important. At the very least however, as a general aim for the future, if such trainings can help teams to manage patients better and not become involved in unhelpful and sometimes damaging reciprocal enactments, then this would be an important achievement. Helping team members cope, at present often in conceptual and practical isolation, with their own levels of stress in working with ‘difficult’ patients would also be an important outcome.

Clearly uptake of such training initiatives, possibly in a range of health service settings, will require a political commitment to improved quality of care from consumers, colleagues (including senior managers) and politicians which is beyond our immediate influence. We would argue however, that by demonstrating how significant improvements can be made in routine mental health services by means of relatively modest investments in training (when ‘relatively little can achieve a lot more’ to paraphrase a well-known title), it may be possible to challenge received assumptions about acceptable care as well as to offer serious support to those attempting to provide it.

Jim de Normanvill

Ian Kerr

Jim is Team Manager and Ian is Consultant Psychiatrist and Psychotherapist, West Sector CMHT, The Yews, Worrall Rd, Sheffield S35.

References

Introducing Cognitive Analytic Therapy: Principles and Practice

(2002). Ryle, A. and Kerr, I.B., John Wiley, Chichester.

Personality disorder: No longer a diagnosis of exclusion. Policy implementation guidance for the development of services for people with personality disorder. National Institute for Mental Health in England (www.nimhe.org.uk).

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