Helping service users to help themselves with cognitive analytic therapy
Mental health nurse Steve Taylor’s dissatisfaction with therapeutic interventions for his clients led him to consider an alternative solution. He began training as a therapist in cognitive analytic therapy – which has been described as a more ‘humanistic’ form of psychotherapy.
I have been working in mental health for around 30 years and, while I recognise the place for pharmaceutical interventions, I’ve always been far more fascinated by the transformational effects that the more relational aspects of the job can have on people’s lives.
During my career, I have observed that most people I have encountered wanted to connect and engage on an emotional level and have a sense that you, as a fellow human being, can empathise with them and their experience.
I have always believed that mental health nurses should have a deep level of understanding about the therapeutic relationship so that they know how to form, sustain and end relationships appropriately – with compassion and sensitivity.
Regrettably, time pressures, staffing problems and sometimes the lack of a developed skill set can reduce the role of a mental health nurse to one where their major function is to screen or monitor symptoms.
‘For some people, it was the first time they could relate their thoughts to their feelings’
Nonetheless, even when I worked in an emergency department (ED) assessing people with mental health problems, I soon recognised that many of them got a huge benefit from the mental health nurse’s ability to be able to talk to them without shame or blame. For some people, it was the first time they could relate their thoughts to their feelings.
I would often see young people coming into the ED who had taken overdoses or self-harmed because of the emotional difficulties in their lives.
The usual clinical pathway was a referral to the mental health team.
‘Surely there must be a better way of dealing with emotional or regulation difficulties than a referral and long wait to see a child and adolescent mental health specialist, who may use medication as the first line of treatment?’
Difficulties become more ingrained
It could take up to three months for the young person to be seen, by which time their emotional difficulties could become more ingrained, self-harming could increase and hopelessness could become more apparent.
Surely there must be a better way of dealing with emotional or regulation difficulties than a referral and long wait to see a child and adolescent mental health specialist, who may use medication as the first line of treatment?
My dissatisfaction with my own shortcomings and the paucity of therapeutic interventions I was able to offer such clients, led me to consider psychotherapy and psychoanalysis as an alternative solution. So, in 2008 I embarked on training as a cognitive analytic therapy (CAT) therapist.
CAT is a form of psychological therapy initially developed in the NHS by the psychotherapist Anthony Ryle during the 1970s and 1980s. It is a time-limited therapy offering 16 or 24 sessions, usually 50 minutes long.
Humanistic style of psychotherapy
CAT is distinctive due to its intensive use of reformulation – listening and retelling of the patient’s story – its integration of psychoanalysis with other, more humanistic styles of psychotherapy and its collaborative nature, involving the patient actively in their treatment. This patient involvement is ideal when working with young people who may be put off by a more authoritarian style of working.
I was able to integrate some of my CAT training into my practice as a senior clinical nurse specialist in liaison psychiatry. When assessing people, I became more interested in their development based on their earlier childhood experiences.
‘CAT was shown to reduce incidents of self-harming behaviour – and to be successful in helping people manage their emotions’
CAT uses object relations-based theory to understand the developments of one’s personality and relationship style. An internalised object/parent who is critical may lead to a person having a critical self that provides their own internal dialogue.
Just over a year ago, I heard about a study completed by the Orygen Mental Health Service in Melbourne, Australia. They conducted a randomised controlled trial of the effectiveness of CAT in reducing symptoms of borderline personality disorder in young people.
Reduce self-harming behaviour
CAT was shown to reduce incidents of self-harming behaviour – and to be successful in helping people manage their emotions (affect regulation management).
I was eager to find out more about their specialist service for young people with emerging personality disorder and discovered they offered a visiting fellows programme.
I looked for ways to get funding to visit the service and in June 2016 I applied for and was awarded a Florence Nightingale Foundation travel scholarship. I was equally surprised and delighted to have been successful in obtaining The Charlie Waller Scholarship, which was specifically for individuals interested in research or promoting good practice in adolescent mental health.
What seemed to impress the panel was the fact that I’d gone from being a nursing assistant in a high secure hospital to becoming a senior clinical nurse specialist in liaison psychiatry, honorary lecturer in mental health nursing, PhD student and psychotherapist.
My visit to Melbourne would also allow me to examine some of my other thoughts about compassion and mental health nursing.
I was given the opportunity to develop links with the Orygen Centre in Melbourne and arranged for a two-week visit in July 2017 where I observed practices, intervention, provision and had the opportunity to speak to the two senior members of the clinical team – a consultant psychiatrist and a consultant psychologist, who were responsible for setting up the service and for developing CAT in Australia.
‘All healthcare professionals who work at Orygen are expected to embark on CAT practitioner training’
Level of dedication
The first thing I noticed about the Helping Young People Early (HYPE) service was the level of dedication of the professionals involved and their commitment to CAT as a modality.
HYPE is an outpatient service offering a combination of CAT therapy plus an Australian version of care coordination. Not only is CAT therapy used on a one-to-one basis with a client and clinician, but CAT provided a language and framework for the whole service.
‘The programme at Helping Young People Early is developed around the standard 16 or 24 sessions, which we also use in the UK’
All healthcare professionals who work at Orygen are expected to embark on CAT practitioner training to ensure clinicians develop an understanding of CAT terms and concepts.
During the clinical meeting every patient was discussed using terminology rooted in the culture of CAT therapy. Obviously as a CAT therapist myself I found it easy to understand what they were talking about when they were talking about clients and the difficulties that they were expecting.
The young people’s difficulties were formulated by the clinicians, which allowed for a CAT intervention to be applied to each individual client.
‘The young people were able to express emotions and feelings in an environment that was supportive, non-judgmental, and holding’
As with all adolescent services, I realised that the uptake was variable. Some young people wouldn’t engage fully and completely, while others would attend one or two sessions and then move on elsewhere (this was explained by the nature of young people who may present as more chaotic or peripatetic).
The programme at HYPE is developed around the standard 16 or 24 sessions, which we also use in the UK.
Adopt shared language
The young people themselves would then be able to adopt a shared language within CAT, where they could attach words, thoughts, and ideas to their feelings, which they would then be able to manage better through identifying what was going on within themselves (such as feeling rejected or angry).
The young people were able to express emotions and feelings in an environment that was supportive, non-judgmental, and holding.
The HYPE service staff believed that by intervening at an earlier age – 14, 15 or 16 – young people would get more benefit from the CAT and the service as a whole, which would then prevent further difficult behaviours or reduce the symptoms of borderline personality disorder.
‘Patients were quick to grasp the shared language of cognitive analytic therapy’
Even during crises, when certain members of the team would carry an on-call bleep, the shared language of CAT would be constantly used between the therapists, psychologists, nurse, and patient to identify what was going on, and help the young person to work on their own coping strategies.
This left me wondering: ‘Why can’t we have something similar in the UK where a relational based psychotherapy is used at the centre of the service, so everyone involved has a shared language and understanding of what is going on?’
Patients were quick to grasp the shared language of CAT. How effective would it be if every young person attended daily and could meet a mental health practitioner who also had training in a relational psychotherapy such as CAT? Clients could quickly learn about their internal worlds and go on to develop better coping skills and affect regulation management.
‘Mapping out’ tool
CAT has some wonderful tools, which can be used in a single session. One such tool is ‘mapping out’. This is the creation of a visual representation of feelings and emotions so that the person, rather than feeling overwhelmed, has a simple diagram in front of them to see what is going on within themselves.
Again, after attending the ED, they could be referred or self-refer to a service where every clinician has a shared language and the young person could attend for a set amount of time. Although this would be expensive at the beginning, after the initial investment in staff and training we would reap the rewards further down the line.
‘If only we could enable commissioning GPs to see that there may be alternatives to the under-resourced model of care for young people and adolescents that we have’
These interventions could be applied in the ED, adolescent services and other areas of adolescent mental health. I know through my own experience of CAT that there is some frustration that other modalities often take precedence.
Cognitive behaviour therapy (CBT) has plenty of success with mild to moderate depression, but we also know that it is less effective with deeper rooted issues, which are relational in their pathology. If CAT therapists were available, they would be highly motivated to move talking therapies away from the standard CBT model that is currently offered.
We know that the government wants mental health first aid in all schools. But we need to take it to another level where we have a shared understanding, a shared language about what it is to be a human being and what it is to have psychological difficulties. A shared language based on object relations theory and other relational psychotherapies.
I would like to have taken a politician and someone from the Department of Health down to the Orygen Service to see for themselves how effective this unique service is. It seems ironic that a psychotherapy with origins at St Thomas’s Hospital in London is being used on a service level on the other side of the world.
‘We know that the government wants mental health first aid in all schools, obviously a good idea – but we need to take it to another level’
If only we could enable commissioning GPs to see that there may be alternatives to the under-resourced model of care for young people and adolescents that we have, which we know for many people means traveling miles from home if they are admitted.
Rather than carrying on with the same model, why can’t we develop something new, but which has already been proven to work elsewhere?