Reflecting on Risk To Others

Next month, Jenny Marshall and David Harvey are coming together to lead a CPD day on using CAT Concepts in Working With Risk of Harm To Others in Leeds. We caught up with them about their interest in this work and their thoughts on why CAT is well placed to support staff working with people who may pose risk to others.

In your work roles as CAT consultants in forensic settings, you’ve both worked a lot with staff teams rather than just directly with clients.  What drew you to this?

David: It just made more sense to me. The settings and contexts were complex with high levels of emotion for staff too. So, I could see how it important it was for staff well being. It was also a chance for me to learn from the staff teams too about their ideas and ways of approaching risky challenges and complex clinical work. I feel an increasing sense of wanting to support, nurture and look after staff who are coming into this line of work so it helps me channel that too.

I could also see how the relationships in a person’s day to day life with staff were so important. They were vehicles for modulating or increasing emotion (and so risk). So the consultancy work seemed like a clear way to help service users have the best chance of change, recovery and living in the least restrictive setting possible. Although an hour a week of therapy can be helpful, it’s not always enough.

Risk is an issue that can create anxiety in us all.  What do you think helps us to think, as well as feel, in situations that make us feel concerned about risk?

Jenny: This is such a great question and really encapsulates some of the challenges in working with risk. Of course we will all try to manage difficult emotions in a range of ways. At times, and for some of us, this is by not feeling. Suppressing our emotions might lead to an overemphasis on thinking, intellectually. Or else making judgements. And at other times emotion might dominate. That can feel overwhelming and it’s easy to neglect more rational thought.

In working with risk, we need to balance both. I find the observing eye in CAT helps with this and a map can help us to hold different perspectives in the team about risk. This bigger picture can then be used as information to inform our understanding of risk, as opposed to ending up as conflict in teams. It’s easy for this to happen if we don’t “hover” above these different styles of relating. 

In your experience, what are some of the main pushes and pulls for staff assessing and trying to respond to risk of harm to others?

David: I think Laura Hamilton’s see saw model captures the control versus care dilemma beautifully. It really is a great example of CAT taking complex theory and making it accessible. It’s a bridge to having meaningful conversations and joint thinking to help address issues in real life practical ways.

I think that the roles of neglecting-neglected have perhaps had less attention in the wider and CAT literature. We know that omission of care, attunement or boundaries can be just as harmful in the past and the present as the commission of harmful relational acts. Karen Shannon’s chapter on CAT and men with aggression is a great way to start holding these neglectful relational patterns in mind in relation to risk. I have just finished a book chapter about we can use CAT to spot the pulls of overlooking and potentially neglecting important aspects of running high quality mental health services so watch this space!

How does CAT support work with teams in ways that other approaches don’t?

Jenny: Where do I start?! There are some great chapters in the reflective practice book which really highlight this. My co-editor Jamie Kirkland did a great chapter on helping the helpers, and there was also David’s chapter on leadership.

If I was to pick a couple of points, I think CAT really allows us to hear multiple voices and perspectives. This is so key to teamwork, where different voices can be seen as valuable, not threatening. CAT also allows us to hold the hurt or more vulnerable position alongside the part that can hurt others. This allows for a richer understanding of risk.

Finally CAT allows us to explore interactions in a way that considers the impact of what we all bring:- my patterns, others’ and the system or wider culture. These interactions can prove so helpful in our understanding of risk. Importantly, this gives voice to frontline staff who often spend the most time with those service users, patients or prisoners. 

CAT would see risk as a very relational thing, with many aspects embedded in relationships in the past, the present and a person’s relationship with themselves. Where amongst these do you see the most potential for change and shifts?

David: Two things spring to mind. The first is when something live happens in a therapeutic relationship between you and a client who has posed a risk of harm to others and you work through it with the person using CAT tools as scaffolding. This feels like a real leveller to me. Two people, neither of whom have the answer, trying to work something out together. It’s almost always these moments that stand out for me and clients when therapy comes to an end and where the learning is deepest for both of us.

The second is using CAT theory to help someone make sense of their personal history and life adversity and how this relates to risky behaviour. The CAT tools open up this as an explanation, not an excuse. A person can then hold compassion for themselves and also be quite rightly accountable for their own risk management. It is one of the things that makes me feel the saddest really – when someone hasn’t had the chance to go at their pace and make sense of how their own adversity has led to risky behaviours. So being able to offer that feels really important for me.

If you could give three top tips for team wellbeing and staff retention in high risk settings, what would they be?

David: Mmm…well there is no one right way of doing things when we are trying to help other people and it can be stressful! I would go with:

  1. Try and find ways that are psychologically safe enough to talk about what is really going on in relationships, kindly but honestly. When relational tangles get complex try and find ways to feel confident enough to lean into it a bit. Slow things down and think about what’s possible together. CAT is fantastic at helping us do this
  2. Watch out for outrage and indifference in yourself and others – try not to get too consumed by either. I first heard this from Sue Walsh when she spoke at a supervisor training event about ten years ago and it has stayed with me! Both could be signs something is going on that might need a bit of attention for the well-being of those involved and for high quality forensic care
  3. Asking people what they think, want or need can be so important and often overlooked. I think it is a way to help us all feel more heard, connected and attuned and it usually makes the job much easier!
You have both written about, and specialised in, developments using CAT ideas that can enrich the work of non-CAT professionals – such as reflective practice (Jenny) and leadership (David).  How do you see these approaches helping staff and teams who work with risk of harm to others?

Jenny: Again there is much we could say but reflective practice allows for us to hold the complexity of working with risk. At the same time it helps us consider why we feel stuck, what we don’t know, and more importantly how we might play a part in it all. Only by tolerating this uncertainty can we be curious. With this we can arrive at a deeper understanding of risk. 

David: Those who have formal leadership within their job role heavily shape workplace culture and when working with risk of harm to other these cultures can easily become charged with destructive or harmful patterns. Through CAT’s relational and practical tools we can quickly start to decipher some meaning from what initially seems confusing. This is the focus of my chapter on CAT & leadership in the forthcoming Oxford Handbook of Cognitive Analytic Therapy to help leaders start to see possible ways forward based on a deeper understanding of the issues. Where risk is a core feature of the work, then we need to help people do this as thoughtfully but as responsively as possible, and that is what our teaching day is all about. 

What question about this training day have I not asked you that you really want to be asked?!

David: “Will attendees enjoy the day?”. Because they will! It’s easy to forget that in this line of work most of us enjoy learning, clarifying, (re)gaining insight, finding ways to recalibrate and refocus on helping others. Jenny and I have a good time working together. We’re a bit like chalk and cheese in some ways but we compliment each other! And when teaching together we all usually have a good time too.

Jenny and David’s CPD day takes place on 8 September in Leeds. For more information and booking options, visit the page at CAT Concepts in Working With Risk of Harm To Others