providing a clear way forward: using cat to integrate forensic services mark ramm, head of forensic...
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Providing a Clear Way Forward: Providing a Clear Way Forward: Using Using CAT to Integrate Forensic CAT to Integrate Forensic
ServicesServices
Mark Ramm, Mark Ramm, Head of Forensic Psychological Services, Head of Forensic Psychological Services, The Orchard Clinic, NHS LothianThe Orchard Clinic, NHS [email protected]@nhslothian.scot.nhs.uk
Into the Future Conference
4th October 2012
OverviewOverview Hard to help offenders/patientsHard to help offenders/patients The treatment taskThe treatment task Using CAT formulation to guide:Using CAT formulation to guide:
Individual therapyIndividual therapy Team workingTeam working Risk AssessmentRisk Assessment Systemic workSystemic work
How we are doing this at the Orchard How we are doing this at the Orchard Clinic Clinic
Case exampleCase example
Hard to help Forensic PatientsHard to help Forensic PatientsSome Types:Some Types:
Uncontrollable affect Uncontrollable affect (lack ability to self regulate)(lack ability to self regulate)
Can’t think, Don’t think Can’t think, Don’t think (Lack insight re: internal (Lack insight re: internal states of self and others) states of self and others)
Confusion Confusion (Things just happen)(Things just happen)
Too split up, Moving target Too split up, Moving target (Flipping)(Flipping)
Too aggressive / rejectingToo aggressive / rejecting
Too needyToo needy
Low Motivational readinessLow Motivational readiness
‘‘Defend’ against problem/othersDefend’ against problem/others
Don’t think there is problemDon’t think there is problem
Don’t change, Revolving door patientsDon’t change, Revolving door patients
Treatment: The methods by Treatment: The methods by
which we deliver therapywhich we deliver therapy
GROUPWORK
INDIVIDUAL
PSYCHOTHERAPYPOSTIVE
PURPOSEFUL
ACTIVITY
SAFE & SECURE
Rehabilitation ServicesPrison
Families
MEDICATION
Community
The Forensic MatrixThe Forensic Matrix‘stepped care’‘stepped care’
HSI
Specialist I
High intensity interventions
Low intensity interventions
Information
Highly specialist Interventions
Formulation Driven
But less specific about how you hold the But less specific about how you hold the whole thing together (Psychology, whole thing together (Psychology, Occupational Therapy, Social Work etc)Occupational Therapy, Social Work etc)
Or about the how to use of the Or about the how to use of the therapeutic relationship outside therapeutic relationship outside particular individual or group therapies particular individual or group therapies
GROUPWORK
INDIVIDUAL
PSYCHOTHERAPYPOSTIVE
PURPOSEFUL
ACTIVITY
SAFE & SECURE
RELATIONAL
INTERACTIONS
Rehabilitation ServicesPrison
Families
MEDICATION
Community
There are successful treatments for There are successful treatments for Borderline Personality DisorderBorderline 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 (Clarkin et al, 2007; Levy et al, 2006; Doering et al
2010)2010) Cognitive Behavioural Therapy -CBTCognitive Behavioural Therapy -CBT
Davidson et al, 2006)Davidson et al, 2006) Shema Focused Therapy – SFTShema Focused Therapy – SFT
(Glessen-Bioo et al, 2006)(Glessen-Bioo et al, 2006) Mentalizing based therapy-MBTMentalizing based therapy-MBT
(Bateman & Fonargy 1999, 2001)(Bateman & Fonargy 1999, 2001) Systems Training for Predictability & Systems Training for Predictability &
Problem Solving STEPPS Problem Solving STEPPS (Blum et al, 2008)(Blum et al, 2008)
Cognitive Analytic Therapy CBTCognitive Analytic Therapy CBT (Chanen et al, 2008)(Chanen et al, 2008)
Comparisons: Comparisons: Treatment vs TreatmentTreatment vs Treatment
Psychodynamic supportive therapy vs Psychodynamic supportive therapy vs transference-focussed therapy vs DBT transference-focussed therapy vs DBT (Clarkin et al, 2007) (Clarkin et al, 2007) ““Generally equivalent”Generally equivalent”
MBT vs Psychodynamic Supportive Therapy MBT vs Psychodynamic Supportive Therapy (Jorgensen et al, 2012)(Jorgensen et al, 2012)
Comparisons:Comparisons:Specific Treatments vs Good Clinical Specific Treatments vs Good Clinical
CareCare DBT vs good general psychiatric DBT vs good general psychiatric
management (McMain et al. 2009, 2012)management (McMain et al. 2009, 2012) No differences in outcomeNo differences in outcome
MBT vs structured clinical management MBT vs structured clinical management (Bateman & Fonagy 2009)(Bateman & Fonagy 2009) Outcome was similarOutcome was similar
CAT vs manualised good clinical care CAT vs manualised good clinical care (Chanen et al, 2008)(Chanen et al, 2008) No major differences in outcomeNo major differences in outcome
Conclusions?Conclusions? BPD at least can benefit from BPD at least can benefit from
treatmenttreatment These specialised treatments are These specialised treatments are
clearly better than treatment as usualclearly better than treatment as usual Outcome /efficacy does not differ Outcome /efficacy does not differ
substantially between specialised substantially between specialised treatmentstreatments
Specialised therapies have yet to Specialised therapies have yet to demonstrate better outcomes than demonstrate better outcomes than good tailored clinical care good tailored clinical care
Conclusions?Conclusions? It may be that some problem It may be that some problem
domains respond to some therapies domains respond to some therapies better than others better than others
butbut it seems outcome is largely due to it seems outcome is largely due to
change mechanisms common to all change mechanisms common to all the therapies and good tailored the therapies and good tailored clinical care clinical care
PD and disorders that have their PD and disorders that have their
origins in childhood and adolescenceorigins in childhood and adolescence
Common change mechanisms
CAT
Schema F T DBT
Transference FT
MBT
STEPPS
But this does not mean unstructured intervention
Common Change Common Change Mechanisms?Mechanisms?
A generic supportive therapeutic stanceA generic supportive therapeutic stance
StructureStructure Clear conceptual basis – Clear conceptual basis – Therapeutic ModelTherapeutic Model Structure for interventionStructure for intervention Limit settingLimit setting
Building and maintaining a collaborative Building and maintaining a collaborative therapeutic relationshiptherapeutic relationship validation, motivation, self –reflectionvalidation, motivation, self –reflection
ConsistencyConsistency Change methodsChange methods
Creating a Team CultureCreating 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 Having a clear common language which is understandable and makes sense to both patients understandable and makes sense to both patients and teamworkers and teamworkers
A stress on the therapeutic relationshipA stress on the therapeutic relationship (Roth & Fonagy, 1999)(Roth & Fonagy, 1999)
This results in: This results in: Improved communication between teammatesImproved communication between teammates Improved team functioning (minimizing Improved team functioning (minimizing
“splitting”, “buck-passing” and “burn out”“splitting”, “buck-passing” and “burn out” Improved job satisfaction and team moraleImproved job satisfaction and team morale Improved results and cost-effectivenessImproved results and cost-effectiveness
MODEL / FORMULATIONMODEL / FORMULATION
Common change mechanisms
CAT
Schema F T DBT
Transference FT
MBT
STEPPS
STEPPED CARE
RISK
MANAGEMENT
CAT CAT FORMULATIONFORMULATION
Common change mechanisms
CAT
Schema F T DBT
Transference FT
MBT
STEPPS
STEPPED CARE
RISK
MANAGEMENT
Because Interpersonal Dysfunction lies
at the core of these patient’s problems
CATCAT FORMULATION FORMULATION
Common change mechanisms
CAT
Schema F T DBT
Transference FT
MBT
STEPPSSocial workers
Care staff
Medical staff
Families
Applied Health Professionals
STEPPED CARE
RISK
MANAGEMENT
Carers
Patient
GROUPWORK
INDIVIDUAL
PSYCHOTHERAPYPOSTIVE
PURPOSEFUL
ACTIVITY
SAFE & SECURE
RELATIONAL
INTERACTIONS
Rehabilitation ServicesPrison
Families
MEDICATION
Community
We need an overarching formulation and We need an overarching formulation and reformulation to plan the type, level, timing, reformulation to plan the type, level, timing, order and length of interventionsorder and length of interventions
CAT as a ‘relational model’ is particularly CAT as a ‘relational model’ is particularly applicable because we need to work throughapplicable because we need to work through therapeutic relationships across the whole therapeutic relationships across the whole processprocess
FormulationFormulation
Core Issues & Entrenched patterns
Skills building & strengthening
Engagement & motivation
Consolidation & integration
Cognitive Analytic TherapyCognitive Analytic Therapy IntegrativeIntegrative
““A theory based on the integration and A theory based on the integration and extension extension of ideas and methods used in conventionally of ideas and methods used in conventionally opposed approaches”opposed approaches” (Anthony Ryle)(Anthony Ryle)
More than just Cognitive & PsychoanalyticMore than just Cognitive & Psychoanalytic
CognitiveCognitiveBehavioural Behavioural Psychoanalytic Psychoanalytic Developmental Developmental SocialSocial
CATCAT Distinctive individual psychotherapyDistinctive individual psychotherapy
CAT accepted as a distinctive and CAT accepted as a distinctive and independent form of psychotherapy - independent form of psychotherapy - Roth & Fonagy (1996)Roth & Fonagy (1996)
An integrated theory of personality and An integrated theory of personality and changechangeSoSo applicability to a wide range of applicability to a wide range of situations, problems and settingssituations, problems and settings
How does CAT approach it ?How does CAT approach it ?
Relational: Relational: Most distress in human beings is Most distress in human beings is relationship basedrelationship based
self and othersself and othersself and selfself and self
Dynamic: Dynamic: Explains how people can act very Explains how people can act very differently at different times and in differently at different times and in different contextsdifferent contexts
DEVELOPMENTDEVELOPMENT
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 experienceForms joint understandings with others
Forms concepts about others
Formation of Relationship templatesFormation of Reciprocal Roles
CATCAT
All mental activity, whether conscious or unconscious, is rooted in and highly determined by our repertoire of Reciprocal Roles
RECIPROCAL ROLESRECIPROCAL 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)
BALANCED PERSONALITY ORGANISATIONBALANCED 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)
PROCEDURESPROCEDURES
Abusing
Abused
Unmet needsNegative emotion
Stress
e.g. Avoiding
,
e.g. impress others
Alternative
Reciprocal
Role/self state
““RIGID” PERSONALITY ORGANISATIONRIGID” PERSONALITY ORGANISATION
Particular Reciprocal Roles have a dominance and extreme polarization or there are a limited in number of Reciprocal Roles.
Self State DisordersSelf State Disorders Disruption of integrating proceduresDisruption of integrating procedures Deficient and disrupted self reflectionDeficient and disrupted self reflection Dissociation of self-statesDissociation of self-states
Confused, Can’t think, Unstable
Some dissociation normal
Using CAT formulation to Using CAT formulation to inform and integrate treatment inform and integrate treatment
with forensic patients with forensic patients
All staff trained in CATAll staff trained in CAT
100 trained in last 3 years100 trained in last 3 years
CAT Therapy, Team working, CAT CAT Therapy, Team working, CAT informed workinginformed working
CAT KNOWLEDGE COMMON LANGUAGE
CAT INFORMED TEAMWORK
CAT THERAPYCAT MAPS
Trained/supervised staff
Shared FormulationShared Formulation
- CAT reformulation developed with patient CAT reformulation developed with patient shared with care teamshared with care team
- CAT formulation developed by care team CAT formulation developed by care team to work with patientto work with patient
Team working to develop a CAT Team working to develop a CAT formulation to guide therapyformulation to guide therapy
Angry Aggressive PatientAngry 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?
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
PreventedRefuses to ask for
care but expects itNeeds not met
GROUPWORK
INDIVIDUAL
PSYCHOTHERAPYPOSTIVE
PURPOSEFUL
ACTIVITY
SAFE & SECURE
RELATIONAL
INTERACTIONS
Rehabilitation ServicesPrison
Families
MEDICATION
Community
CAT and Working as TeamsCAT and Working as Teams
Benefit to teamBenefit to team Consistent approach, prevent splitting etcConsistent approach, prevent splitting etc
Benefit to patientBenefit to patient Better treatment, breaking the cycle of Better treatment, breaking the cycle of
damaging responses from othersdamaging responses from others
Application of CAT at many Application of CAT at many levels – Integrated Workinglevels – Integrated Working
Individual therapy – Formulation, client Individual therapy – Formulation, client focusedfocused
Multidisciplinary, team approachMultidisciplinary, team approach Recovery focussed milieuRecovery focussed milieu Flexible application to mode and Flexible application to mode and
modality of intervention, Stepped caremodality of intervention, Stepped care Collaborative, Service user involvementCollaborative, Service user involvement Psychologically informed and literate Psychologically informed and literate
workforceworkforce Improved relational securityImproved relational security Improved risk assessmentImproved risk assessment
CATCAT Ryle A. & Kerr I.B. Introducing Cognitive Ryle A. & Kerr I.B. Introducing Cognitive
Analytic Therapy (2002) John Wiley & Sons Analytic Therapy (2002) John Wiley & Sons
RCT’s for PD RCT’s for PD
Chanen A.M., Jackson H.J., McCutcheon, l.K Chanen A.M., Jackson H.J., McCutcheon, l.K et al. (2009) Early intervention for et al. (2009) Early intervention for adolescents with borderline personality adolescents with borderline personality disorder: quasi-experimental comparison disorder: quasi-experimental comparison with treatment as usual. with treatment as usual. Australian and New Australian and New Zealand Journal of Psychiatry, Zealand Journal of Psychiatry, 43, 397-40843, 397-408
Prof Sue Clarke, RCT of CAT vs TAU for PD As Prof Sue Clarke, RCT of CAT vs TAU for PD As presented at a recent conferences presented at a recent conferences (submitted to B. J. Psych). (submitted to B. J. Psych).