Staff experiences of Cognitive Analytic Therapy in secure settings
Research type
Research Study
Full title
Exploring Multi-Disciplinary Team (MDT) Experiences of Cognitive Analytic Therapy (CAT) as a Systemic Consultation Tool in an Adult Forensic Service.
IRAS ID
123588
Contact name
James Reilly
Contact email
Research summary
Purpose and design:
Cognitive Analytic Therapy (CAT) is a time-limited, integrated approach which draws on ideas from psychoanalytic and cognitive theories with the aim to be a coherent model of formulation, or ‘reformulation’ as it is referred to in CAT (i.e. a psychological understanding of the individual's presenting problems)and treatment (Ryle, 1979). On a simple level, CAT for offenders can highlight the relational component of the offender-to-victim roles, for example the exploiting/manipulating offender to the exploited/duped victim. Moreover, the relationship enactments (referred to as Reciprocal Role enactments) can manifest within the therapeutic relationship (e.g. premature termination of therapy) but may also manifest within the setting or the system in which the offender is being treated (e.g. the erotomanic delusional attachment to a member of staff). CAT for offenders aims for the offence committed to be understood as the outcome of patterns of thinking, perceiving, feeling, relating and acting which are able to be changed (Pollock & Stowell-Smith, 2006). One of the key aims of CAT is to offer a non-collusive therapeutic relationship (Ryle & Kerr, 2002).Caplan (1970) defined consultation as “a voluntary, non-hierarchical relationship between two professionals who are often of different occupational groups and is initiated by the consultee for the purpose of solving a work-related problem.” More recently, following the publication of the “New Ways of Working” (British Psychological Society, 2007) consultation skills are becoming increasingly recognised as an essential role of a clinical psychologist. Given the relational underpinning of CAT as an approach, in particular in highlighting reciprocal role enactments within the therapeutic relationship and the wider system, there has been a growing work which applies CAT to indirect ways of working, including the role of consultation (Carradice, 2004). Furthermore, psychodynamic and psychoanalytic orientated therapists working in forensic services commonly apply dynamic principles during consultation to think about the offender within the complexities and dynamics of a staff team and the systems (i.e. ward or institution) in which the offender is being treated (McGauley & Humphreys, 2003).
Research has shown CAT to be an effective approach in the treatment of a variety of clinical populations (Clarke & Llewelyn, 1994; Cowmeadow, 1994; Denman, 1995) including the treatment of personality disorders (Ryle & Marlowe, 1995; Ryle, 1997) and within the forensic population (Pollock & Kear-Colwell, 1994; Pollock, 1996; Pollock, 1997; Pollock & Belshaw, 1998; Pollock, 2001a &b). It is often difficult for teams to hold in view that the patient is both a perpetrator and a victim and can lead to ‘split’ within a team, thus potentially affecting the team and the care received by the patient (Withers, 2008). However, research exploring the use of CAT with offenders has highlighted an increased understanding in the offenders representation of themselves in relation to their victim (Pollock, 1997) and also the offender's motivation for committing the offence (Pollock & Belshaw, 1998). Furthermore, the understanding of patterns of thinking and behaving in response to self-other and self-self enactments has been shown to help staff ‘hold’ patients at times of distress (Cox, 1976; Dunn & Parry, 1997) and therefore predict the risk potential and inform the clinical management of the offender (Pollock & Kear-Colwell, 1994; Pollock, 1996, 1997).
Research has shown that often staff teams who work with complex and challenging clients tend to be inadequately resourced (Kerr, 1999) thus leading to a split in staff teams (Ryle & Kerr, 2002) high expressed emotions and re-enactments of roles which contribute to the maintenance of the clients difficulties (Dunn & Parry, 1997). Dunn and Parry (1997) demonstrate how developing a reformulation with clients and sharing this in consultation with the staff team helped with increasing understanding of the clients difficulties and has gone on to inform the care planning of the client. In a similar way, Ryle and Kerr (2002) describe the benefits when reformulation can be utilised through consultation with the staff team when a service user is too ill or too ‘stuck’ to participate themselves. Research also suggests that sharing or collaboratively developing reformulations with staff teams allows staff and clients to make sense of previously challenging and confusing behaviours (Walsh, 1996) and can help predict the transference and counter transference reactions (Dunn & Parry, 1997). In turn, this helps to contain staff anxieties about future behaviours (Kerr, 1999; Ryle & Kerr, 2002). By sharing the formulation in consultation it is suggested that staff can then respond to clients in a more helpful, adaptive way, thus improving the care a client receives (Ryle & Kerr, 2002).
Despite CAT being used in consultation within forensic services, there is a lack of research investigating this. Furthermore, although there appears to be a growing emphasis on the use of psychological consultation, there remains paucity in the research investigating the experiences of the consultees. The proposed research would be grounded in the evidence base for the utilisation of consultation and the evidence which suggests that CAT is effective in the treatment and management of the forensic population. The proposed research has the potential to inform the delivery of psychology services within forensic services and thus the delivery of care to patients. The present study will aim to address the gap in the literature by addressing the following aims; to identify whether CAT increases staff understanding of i) patients' behaviour, ii) the clinical presentation of the patient, iii) the clinical management of the patient, iv) the offenders risk and v) relational aspects of working with the patients and other patients.
Recruitment:
The external supervisors of the study (who work within the psychology deprtment at Ashworth Hospital) will identify patients who have received direct or indirect Cognitive Analytic therapy from an existing psychology department working list. The list consists of patients who have completed therapy within the last 6 years (this is the avergae stay of patients in the hospital) and those who are in therapy. From the list of identified patients, the external supervisors of the study will create a list of members of staff who are involved in the patients' care team. The external supervisors would have access to all of this information within their current job roles. The researcher will not have access to the names of patients. The researcher will send e-mails with information of the study attached to the members of staff identified in the first instance. Dependent upon response rate, paper copies of the study information will also be sent to the wards of which the members of staff work.Inclusion/exclusion:
To participate in the study, staff members must have been involved in a CAT informed consultation either by contributing to the development of a reformulation or by the reformulation being shared with them in a consultation session.Consent:
Participants are requested to opt-in to the research study by completing an opt-in sheet. Informed consent will be sought prior to commencing any data collection. Participation (or not wishing to take part) in this study will remain confidential and such information will not be passed on to their place of work. Participants will be asked to complete a consent form prior to interviews being conducted. All participants will have the information about the study for a minimum of 24 hours prior to giving consent and interviews taking place. Participants are given the specific opportunity to ask the researcher questions at 2 time points; at opt-in stage and at first face to face meeting with the researcher. Participants will be informed that they have the right to withdraw at any time; however, their data will be unable to be disposed of after completion of the interview due to participants data being anonymised.Risks, burdens and benefits:
All data will be collected anonymously from participants, by using a numerical coding system. Participants will be asked to use non-identifiable information when discussing clients and colleagues in order to preserve anonymity. Data will be stored in line with Mersey Care and the University of Liverpool Data Storage/Destruction Guidelines, the Medical Research Guidelines and the Data protection Act (1988). There are no expected adverse effects from participating in this study. For those wishing to discuss the research further they can contact the external supervisors of the study at the service(all relevant details will be included on the information sheet)and debriefing sessions will be facilitated. There is a potential risk of accidental disclosure of confidential information about a patient or member of staff. The researcher will follow Mersey Care and site specific policies and procedures regarding any risk and/or safeguarding concerns which are raised as part of the interviews. Interviews will take place in a private room either inside or outside of the secure service on the Ashworth hospital site. Participants will be given the choice of venue to ensure that they feel comfortable in their surroundings. Interviews can be arranged to coincide with the start and finish of work shifts to ensure that participants and the service are not inconvenienced. There are no anticipated risks for the researcher during the study. The researcher will follow the Institute of Psychology Health and Society safety guidelines for personal safety whilst working off campus. The researcher will have access to regular supervision from supervisors.Benefits:
The study will give the participants time to reflect on their clinical practice.Conflict of interest:
The principle researcher that will conduct the semi-structured interviews with the members of staff, transcribe some of the data and conduct the analysis has no managerial responsibilities to the staff and/or patients at the hospital. The principle researcher will be on placement with the service but will have no clinical responsibility for any of the clients discussed. Participants will be informed of the principle researchers position in the study and in the service. External supervisors of the study may potentially work or previously worked with the participants. In order to manage these potential conflicts of interests, participants are requested to complete 'opt-in' forms in order for the researcher to approach them regarding the study. Furthermore, the principle researcher has devised the interview schedule, will conduct the interviews and analyse the data. Participants will be informed that their responses will remain confidential and their opinions will not impact on their job role, providing that any risk or safeguarding concerns are not raised. Participants will be informed that choosing to participate (or not) will remain confidential. Participants will also be made aware that they will not be disadvantaged if they choose not to participate or withdraw from the study. The principle investigator of the service, who has no responsibilities to the service or supervisors involved, will also oversee all of the data analysis to reduce conflict of interest.REC name
North East - Newcastle & North Tyneside 1 Research Ethics Committee
REC reference
13/NE/0241
Date of REC Opinion
8 Aug 2013
REC opinion
Favourable Opinion