Providing a Clear Way Forward:
Using CAT to Integrate Forensic Services
Into the Future
Conference
4th October 2012
Mark Ramm,
Head of Forensic Psychological Services,
The Orchard Clinic, NHS Lothian
mark.ramm@nhslothian.scot.nhs.uk
Overview



Hard to help offenders/patients
The treatment task
Using CAT formulation to guide:





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Individual therapy
Team working
Risk Assessment
Systemic work
How we are doing this at the Orchard Clinic
Case example
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
Treatment: The methods by which
we deliver therapy
Community
Families
SAFE & SECURE
MEDICATION
GROUPWORK
INDIVIDUAL
PSYCHOTHERAPY
POSTIVE
PURPOSEFUL
ACTIVITY
Prison
Rehabilitation Services
The Forensic Matrix
‘stepped care’
HS
I
Highly specialist
Interventions
Specialist
I
High intensity
interventions
Low intensity
interventions
Information
Formulation
Driven


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
Community
Families
SAFE & SECURE
MEDICATION
RELATIONAL
INTERACTIONS
GROUPWORK
INDIVIDUAL
PSYCHOTHERAPY
POSTIVE
PURPOSEFUL
ACTIVITY
Prison
Rehabilitation Services
There are successful treatments for
Borderline Personality Disorder

Dialectical Behaviour Therapy – DBT


Transference Focussed Therapy –TFT


(Bateman & Fonargy 1999, 2001)
Systems Training for Predictability & Problem
Solving STEPPS


(Glessen-Bioo et al, 2006)
Mentalizing based therapy-MBT


Davidson et al, 2006)
Shema Focused Therapy – SFT


(Clarkin et al, 2007; Levy et al, 2006; Doering et al 2010)
Cognitive Behavioural Therapy -CBT


(Linehan et al, 1993)
(Blum et al, 2008)
Cognitive Analytic Therapy CBT

(Chanen et al, 2008)
Comparisons:
Treatment vs Treatment

Psychodynamic supportive therapy vs
transference-focussed therapy vs DBT (Clarkin et
al, 2007)


“Generally equivalent”
MBT vs Psychodynamic Supportive Therapy
(Jorgensen et al, 2012)
Comparisons:
Specific Treatments vs Good Clinical Care

DBT vs good general psychiatric management
(McMain et al. 2009, 2012)


MBT vs structured clinical management (Bateman
& Fonagy 2009)

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No differences in outcome
Outcome was similar
CAT vs manualised good clinical care (Chanen et
al, 2008)

No major differences in outcome
Conclusions?
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BPD at least can benefit from treatment
These specialised treatments are clearly
better than treatment as usual
Outcome /efficacy does not differ
substantially between specialised
treatments
Specialised therapies have yet to
demonstrate better outcomes than good
tailored clinical care
Conclusions?
It may be that some problem domains
respond to some therapies better than
others
but
 it seems outcome is largely due to change
mechanisms common to all the therapies
and good tailored clinical care

PD and disorders that have their origins in
childhood and adolescence
CAT
Schema F T
DBT
Common
change
mechanisms
MBT
Transference FT
STEPPS
But this does not mean unstructured intervention
Common Change Mechanisms?
A generic supportive therapeutic stance

Structure
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Building and maintaining a collaborative therapeutic
relationship
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Clear conceptual basis – Therapeutic Model
Structure for intervention
Limit setting
validation, motivation, self –reflection
Consistency

Change methods
Creating a Team Culture

Models of working which help teams should include:
 Having a clear common language which is
understandable and makes sense to both patients
and teamworkers
 A stress on the therapeutic relationship
(Roth & Fonagy, 1999)

This results in:
 Improved communication between teammates
 Improved team functioning (minimizing
“splitting”, “buck-passing” and “burn out”
 Improved job satisfaction and team morale
 Improved results and cost-effectiveness
MODEL / FORMULATION
S
T
E
P
P
E
D
C
A
R
E
R
I
S
K
CAT
Schema F T
DBT
Common
change
mechanisms
MBT
Transference FT
STEPPS
M
A
N
A
G
E
M
E
N
T
CAT FORMULATION
S
T
E
P
P
E
D
C
A
R
E
R
I
S
K
CAT
Schema F T
DBT
Common
change
mechanisms
MBT
Transference FT
STEPPS
Because Interpersonal Dysfunction lies
at the core of these patient’s problems
M
A
N
A
G
E
M
E
N
T
CAT FORMULATION
S
T
E
P
P
E
D
C
A
R
E
Patient
CAT
Schema F T
Care staff
Medical staff
DBT
Common
change
mechanisms
MBT
Social workers
R
I
S
K
Families
Transference FT
STEPPS
Applied Health
Professionals
Carers
M
A
N
A
G
E
M
E
N
T
Community
Families
SAFE & SECURE
MEDICATION
RELATIONAL
INTERACTIONS
GROUPWORK
INDIVIDUAL
PSYCHOTHERAPY
POSTIVE
PURPOSEFUL
ACTIVITY
Prison
Rehabilitation Services
 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
Engagement
&
motivation
Core Issues
&
Entrenched
patterns
Skills building
&
strengthening
Consolidation &
integration
Cognitive Analytic Therapy

Integrative
“A theory based on the integration and extension
of ideas and methods used in conventionally
opposed approaches”
(Anthony Ryle)

More than just Cognitive & Psychoanalytic
Cognitive
Behavioural
Psychoanalytic
Developmental
Social
CAT

Distinctive individual psychotherapy
CAT accepted as a distinctive and
independent form of psychotherapy Roth & Fonagy (1996)

An integrated theory of personality and
change
So applicability to a wide range of
situations, problems and settings
How does CAT approach it ?


Relational:
Most distress in human beings is
relationship based
 self and others
 self and self
Dynamic:
Explains how people can act very
differently at different times and in
different contexts
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
CAT
All mental activity, whether
conscious or unconscious, is rooted
in and highly determined by our
repertoire of Reciprocal Roles
RECIPROCAL ROLES
Mother or
Main Other
Other
(Critical &
demanding)
(Critical &
demanding)
SELF
SELF
(Unworthy &
Striving)
(Unworthy &
Striving)
SELF
SELF
(Critical &
demanding)
(Critical &
demanding)
Other
(Unworthy &
Striving)
SELF
(Unworthy &
Striving)
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)
PROCEDURES
Abusing
,
Alternative
Reciprocal
Role/self
state
Abused
e.g. Avoiding
Unmet needs
Negative emotion
Stress
e.g. impress
others
“RIGID” PERSONALITY ORGANISATION
Particular Reciprocal Roles have a dominance and
extreme polarization or there are a limited in number of
Reciprocal Roles.
Self State Disorders


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Disruption of integrating procedures
Deficient and disrupted self reflection
Dissociation of self-states
Some dissociation
normal
Confused, Can’t think,
Unstable
Using CAT formulation to inform
and integrate treatment with
forensic patients

All staff trained in CAT

100 trained in last 3 years

CAT Therapy, Team working, CAT informed
working
CAT KNOWLEDGE
COMMON LANGUAGE
CAT INFORMED
TEAMWORK
CAT MAPS
CAT THERAPY
Trained/supervised staff
Shared Formulation
-
CAT reformulation developed with patient
shared with care team
-
CAT formulation developed by care team
to work with patient
Team working to develop a CAT
formulation to guide therapy

Angry Aggressive Patient

Why is the person like they are?

What is actually happening?

How will we try to improve things?
Perfectly
caring
Abusing
Abandoning
Rejecting
Protecting
Angry
outburst
Abused
Abandoned
Rejected
ANGRY
Seeks perfect
care
Perfectly
cared for
Doesn’t last or
rejected
Protected
NEEDY
Prevented
Needs not
met
Seeks distraction
through excitement
Refuses to ask for
care but expects it
Community
Families
SAFE & SECURE
MEDICATION
RELATIONAL
INTERACTIONS
GROUPWORK
INDIVIDUAL
PSYCHOTHERAPY
POSTIVE
PURPOSEFUL
ACTIVITY
Prison
Rehabilitation Services
CAT and Working as Teams

Benefit to team


Consistent approach, prevent splitting etc
Benefit to patient

Better treatment, breaking the cycle of
damaging responses from others
Application of CAT at many levels –
Integrated Working



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Individual therapy – Formulation, client
focused
Multidisciplinary, team approach
Recovery focussed milieu
Flexible application to mode and modality
of intervention, Stepped care
Collaborative, Service user involvement
Psychologically informed and literate
workforce
Improved relational security
Improved risk assessment
CAT

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: quasiexperimental 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).