All posts by rhona

Neon lettering against a cloudy blue sky, reading 'understanding'

Beneath the skin: The potential for CAT in helping people who self-harm

In this guest blog, Peter Taylor shares some thoughts on the value of research into cognitive analytic therapy as an intervention for self-harm. His blog also gives early notice of an opportunity for a feasibility trial therapist. This role, part of an NIHR-funded study, involves other therapist/researchers (operating in their NHS roles) linked to Catalyse through other work over the years.

Recently I was party to an online discussion around treating self-harm. A key theme from these discussions was about the challenges in treating self-harm, given that this behaviour was typically a manifestation of a broad variety of different underlying difficulties. This argument is one backed up by the research. Self-harm is a trans-diagnostic phenomenon that can co-occur with a wide variety of different psychological difficulties.

We know that people who self-harm report an array of different functions or reasons for this behaviour. For one person, self-harm may be a form of self-punishment, in response to feelings of shame or guilt. For another, self-harm may be a way to communicate their distress to others when other means of expressing this are not possible. Moreover, self-harm may serve multiple functions, serving a variety of personal needs. The functions that self-harm serves may change over time for that individual. Given the idiosyncrasy of this behaviour, we can see how a therapeutic approach focused on this presenting problem may struggle.

One argument I have seen is that we should not aim to develop interventions for people who self-harm at all, but instead concern ourselves with the associated psychological difficulties. For example, an intervention might instead target anxiety or depression where this is present. Whilst I agree with the principle of moving beyond the behaviour, I also think its important not to completely dismiss the idea of developing interventions that focus on self-harm. There is evidence that therapies that target self-harm specifically may be more effective than those which focus on underlying problems.

In an ongoing trial of a relational therapy taking place in Liverpool, one piece of anecdotal feedback from clients has been that having a therapy that actually talks to the self-harm they experience has been positive and refreshing. In addition, we know that people who self-harm are often disempowered and under-served by our current health care system. They face high levels of stigma, and often struggle to access support. Many fall down the gaps between services.

Instead of dismissing self-harm as a focus for psychological interventions, I see self-harm as an important starting point. In my view, it is a manifestation of deeper distress, unmet needs, and conflict. Therapy should seek to move beneath the self-harm, to map out these underlying patterns and processes. Doing so can be meaningful, respectful, and ultimately more useful to the individual. I believe Cognitive Analytic Therapy (CAT) may be especially well suited to this task. CAT is an approach with collaboration at its heart. Moreover, it takes a ground-up approach to forging a shared picture of what is going on for a specific individual. I think CAT therefore has potential as a therapy for people who self-harm. It does not dismiss the presence and relevance of self-harm in a person’s life. It also avoids the trap of getting hung up on the behaviour, and not what lies beneath it.

However, we need evidence. There is currently very preliminary research concerning CAT and self-harm. CAT has a strong tradition of practice-based evidence. However there is a need for larger clinical trials, to further build on these foundations. Such studies will allow for more rigorous evaluation.

RELATE (relational approaches to treating self-harm) is a National Institute for Health and Care Research (NIHR) funded feasibility trial of CAT for adults who self-harm. It represents an important step in evaluating the suitability of CAT as a way to help people struggling with self-harm. The trial will involve two sites, one in Greater Manchester NHS Foundation Trust (GMMH), and one in Rotherham, Doncaster, & South Humber NHS Foundation Trust (RDASH). The study is due to start in December, and we will be advertising for trial therapists for the GMMH site. If you are a CAT therapist working in GMMH, and have any interest in the role, please do get in touch.

You can contact Peter using the details below.

Dr Peter Taylor, Senior Clinical lecturer & Clinical Psychologist

Division of Psychology & Mental Health| Room 2.33, Zochonis Building| Brunswick Street| University of Manchester| M13 9PL| Tel: 0161 306 0425| Email: peter.taylor-2@manchester.ac.uk| Twitter: @PJTaylorClinPsy

https://www.research.manchester.ac.uk/portal/peter.taylor-2.html

Reflections on a CAT Journey

In this blog, Jenny Marshall looks back over how she became involved with Catalyse. She joined us in 2021 to lead the Personal Reformulation workstream. Jenny has recently started another role with the Practitioner Training team as a core trainer. There have been a number of steps along the way as she’s grown in her readiness to take on such roles. Her blog aims to unpick these, and to encourage others who may be interested in becoming more involved.

I’m writing to say how I have found myself as a member of the Catalyse CAT Practitioner course team. Catalyse have been reaching out for a few years to ensure the continued delivery of the course and other work. This has been prompted by those who started it retiring one by one. I hope this encourages others who may want to contribute to the future of CAT in the North of England to take steps on their journey.

The starting place: CAT Practitioner training

I started my CAT training a number of years ago. Whilst the service plan had always been for me to work towards supervisor status after practitioner training, I gave this little thought at the beginning. Instead, I enjoyed the Practitioner Training run by Catalyse. The long days travelling to Manchester were worth it. It has always struck me how much learning is inspired by being in the presence of others. These days were not only a welcome break from the day to day job but a space to think and develop. They always left me invigorated despite the tiredness from the 6am starts.

A further step: CAT Supervisor training

Years later when I began my supervisor training, I arrived at the residential similarly tired. This time I could attribute it to the early stages of pregnancy, but again had a similar experience. Despite the tiredness, I was alert and engaged when asked what sort of CAT we were. ‘Scaredy CAT’ and ‘Fraudulent CAT’ resonated as I didn’t feel ready to supervise others when there was so much to learn. But knowing this was definitely on my map (high standards, critical and not good enough). So I persevered with trying to hold a ’good enough’ position and I am glad that I did.

The last couple of years have been the toughest for many health professionals and particularly working in the NHS. Holding a relational way of thinking, even in my ability to notice that I was finding it hard to think, helped sustain me. Maintaining space to think relationally with supervisees was challenging but enjoyable. It certainly felt a welcome thinking space for all in the midst of the busyness of the job.

Contemplating Catalyse?

Doing this work, I never envisaged that part of the journey would be taking the step towards contributing to teaching. Nor would I have imagined marking others’ work. I attended the 25 year anniversary event of the Catalyse Practitioner Training Course when there was an active reach out to new people wanting to get involved. Even then, I did not consider I could do it. However perhaps it was then that the seed was planted. Reflecting on this now, I wonder about where I had put the course trainers on the map? Perhaps I had placed them in an ‘unreachable’ place. Had they seemed different, separate and far away from where I placed myself on the map? Despite this, several years later when I was exploring different options for my career, I reached out to Catalyse via Dawn Bennett.

Getting past the snags

I’m not sure what I was hoping for but perhaps this was the start of me ‘dipping my toe in’. Being aware of my own patterns, I know when overwhelmed with anxiety it pulls from me a desire to say ‘I can’t do it’. Over time I have learned to rationalise; ‘can I really not do it or do I just think I can’t?’. However this experience was a gentle but interesting one. Through conversation with Dawn I became aware of the possibilities and the variety of work within Catalyse. There was further ‘dipping my toe in’ by attending a Personal Reformulation meeting and feeling welcome.

One step at a time

I wanted a work/life balance, so getting involved with marking seemed like a good practical fit. Having not done it before though, I was unsure. A buddy system in place helped it feel like a safe and supported way to get started. I was surprised at how interesting it was and how much I learned. Marking was much more of a reciprocal process than I had expected! The biggest hurdle was teaching on the practitioner course. However teaming up with another in trainer pairs enabled me to feel I was ‘held in safe hands’.

I have experimented between safe and comfortable areas and pushing myself with newer territory. It is all a learning experience. It was said to me that if I waited to become an ‘expert’ in this, I might never do it. Perhaps the way to become ‘expert’ (in the loosest sense because we know CAT is not an ‘expert’ model), was to just do it. This resonated, and I was reminded of my journey with reflective practice. I recalled the lightbulb moment of realising that other ‘expert’ facilitators did not know where they were going. Instead, they trusted in the process. This may be similar; trust in the CAT tools, scaffolding and maybe you can’t go far wrong.

Roles for you too?

The world of CAT is expanding. With HEE funding for CAT now established, the value of the model is finally being recognised and invested in. With this comes greater opportunities. We know that we bring our patterns to work and you will bring your own patterns (just like my scaredy CAT and fraudulent CAT). Maybe you have a pattern of jumping straight in or maybe like me you like to dip a toe in and test the water. Whatever your pattern, I would recommend trying it – you never know what might happen or where you will end up.

For our 2022 intake, we are running two cohorts of Year 1 trainees. With an expanded intake, we are particularly keen to expand the pool of those who support the training course. If you’d like to become more involved with Catalyse in any way, then get in touch with us. You can read more about the range of training and other roles at this link.

Save The Date: Two Day Supervisor Training Workshop in November 2022

Thinking of starting your journey as an ACAT-accredited CAT Supervisor? Mark Evans and Sarah Littlejohn are offering a face-to-face two day supervisor training workshop. This will take place on 17 and 18 November 2022 in Manchester. Mark and Sarah will follow the two days with a half day follow-up meeting, online, at a later date. Together these will constitute Part 1 of ACAT’s supervisor training pathway. We’ll post more details of this training shortly once booking is open. Do save the date if you’d like to sign up.

Update: more details and booking options for this event can now be found at this link: CAT Supervisor Training Workshop

Graceful Daisies in July

In this blog, Rhona Brown outlines her forthcoming half day workshop co-led by CAT and systemic family therapist Paddy Crossling.

There is a current push within ACAT for trainers, supervisors and therapists to develop skills and confidence in considering and addressing protected characteristics. Finding ways to more actively take such issues into account in therapy is recommended by UKCP’s HIPC EDI Guidance on teaching Equality, Diversity and Intersectionality in HIPC training organisations. These are shaping how ACAT-accredited training embeds aspects of equality, diversity and intersectionality throughout training and CPD. I’m involved in a working group thinking through how this can progress.

CAT has always been a model that situates the individual in their unique social context. The work of Vygotsky and Bakhtin underscored its radical social model of the self. Ryle and Kerr proposed that training therapies include ‘culture mapping’ to enable practitioners to recognise their own cultural influences and biases. However how realistic this is in each training therapy is another matter. And of course learning and personal development around these issues is life long, as we and the world continue to be fluid and unfinalised.

In contemplating tools to help us in this endeavour, a couple of years ago Paddy Crossling and I explored how we might adapt a systemic family therapy framework. The Social GGRRAAAACCEEESSSS was first proposed and shared by Alison Roper Hall and John Burnham. As a conceptual device they developed it to aid reflection on how aspects of identity impact on our relational exchanges. The letters in the mnemonic refer to Gender, Geography, Race, Religion, Age, Ability, Appearance, Accent, Class, Culture, Ethnicity, Employment, Education, Sexuality, Sexual orientation, and Spirituality. Most recent descriptions include a catch-all additional S for ‘something else’.

These hold some similarities to items included in CAT’s Psychosocial Checklist (PSC), first developed by Yvonne Harris and Janet Toye in 2004. Janet and Rachel Pollard went on to update it in 2006 but it has not been widely adopted in CAT. Like the Psychotherapy File (PF), it primarily centres the relational experience of the client. Neither of these CAT tools necessarily prompt reflection about the self of the therapist. In systemic thinking the lense is broadened to include the therapeutic system, whereby reflection gives way to reflexivity. This refers to the ability to reflect on action and use it to inform future action. The GGRRAAAACCEEESSSS help to scaffold therapist reflection in such a way that it brings to the fore what may be visible, invisible, voiced or unvoiced in our own personhood. This in turn can help us, in our actions, stay open to conversations about the interaction between client and therapist perceptions of our respective social selves.

Therapy, after all, is often about opening up conversations that are often not easy to have, in authentic ways. Inevitably this involves the complex and multifaceted personhood of both parties. Aspects of assumed, perceived and subjective identit(ies) can be powerful mediators of both the therapeutic alliance and rupture. The collaborative nature of CAT starts from a place of humility in its gradual co-construction of shared meaning. Yet understandings are seldom complete. And of course each of us brings a myriad of different life experiences and contextual positionings in the social world.

Finding our way through these can feel uncomfortable and challenging. Without some waymarks we can feel a bit lost. Often, strategies and procedures we employ to feel more safe or secure in our professional roles can powerfully influence the direction therapy takes. In order to hold space for respectful, curious conversations around aspects of identity, we need to feel at ease with uncertainties and discomforts that such exchanges can provoke. Moreover we need to be able to respond helpfully when our clients step into that space with us.

Paddy is on the cusp of retirement from the NHS, following a career spanning some fifty years. She brings much clinical wisdom as a jointly trained CAT therapist and supervisor, and systemic family therapist. Paddy also offers DBT in her busy role in an NHS psychotherapy service. Preparing for our ‘A Graceful CAT’ workshop in 2019 opened up a creative space from which emerged a ‘graceful’ daisy. In addition to the approaching season, this inspired the image we chose to advertise our forthcoming event. In our experiential workshop Paddy and I will provide an overview of these complementary frameworks and introduce this fledgling tool. There will be opportunities for both personal reflection and practice in pairs or small groups. We hope the workshop will provide a safe space for therapists feel more comfortable and confident in working reflexively with similarities, differences and power in the therapy room.

To find out more or book onto this half day in Manchester on the morning of 15th July, visit the “A Graceful CAT: Embedding Social Graces in CAT Dialogue” event page at this link.