Presentation on theme: "‘Using a Specialist Cognitive Analytic Therapy (CAT) Model for working with People with Learning Disabilities’ Ann Bancroft and Nicola Murphy CAT Practitioner."— Presentation transcript:
1 ‘Using a Specialist Cognitive Analytic Therapy (CAT) Model for working with People with Learning Disabilities’Ann Bancroft and Nicola MurphyCAT Practitioner and Trainee CAT Practitioner,and Clinical Psychologists
2 OverviewThe CAT ModelSuitability of the Cognitive Analytic Therapy (CAT) model for working with People with Learning Disabilities (PLD)Specialising the model for PLDApplications of CAT in PLD ServicesCase exampleSummary and Questions
3 Cognitive Analytic Therapy (CAT) (i) Well-researched, flexible and effective psychotherapy used with a range of client groupsBased on social model of ‘The Self’Key idea is that both poles of adult to child ‘Reciprocal Roles’ experienced during early relationships, become internalised, and form the basis of personality and self-management procedures.
4 Cognitive Analytic Therapy (CAT) (ii) Key features - time-limitation, collaboration, and the active use of the therapeutic relationship.Aim - to identify, recognise and revise procedural sequences (patterns of thoughts, feelings and behaviours) that have become problematic/unhelpful.Increasing diversification of use, including indirect work & working with teams
5 Standard CAT Therapy Individual therapy Fixed sessions – 16, (and 8, 24, 32)Standard processreformulation phaserecognition and revision phaseendingfollow-up
6 Standard CAT (i) Reformulation phase Identification of target problem procedures – traps, dilemmas & snagsTRAPS‘things we cannot escape from….. vicious circles … trying to deal with feeling bad about ourselves, we think and act in ways that tend to confirm our badness’self-fulfilling prophecies
7 Standard CAT (ii) Reformulation phase DILEMMAS‘False choices and narrow options …. If I do ‘x’ then ‘y’ will follow …. Either/or or If/then dilemmas’polarised choices – no middle groundblack and white thinkingSNAGS“….when we say “I want to have a better life, or I want to change my behaviour but…”Hitches/ self-sabotagesthings that get in the way
8 Standard CAT (iii) Reformulation phase Target problem procedures for therapy agreedWritten and diagrammatic reformulation
9 Standard CAT (iv) Recognition & revision phase Oops I’m doing it again!Aim is to recognise recurrences of target problem proceduresTherapist encourages client to make active use of reformulation tools (letter & diagrams) to help recognise repetition of unhelpful patterns in client’s daily life, and within therapy sessions
10 Standard CAT (v) Recognition & revision phase Oops I’m doing it again! I could do something different!Once recognition is achieved then client and therapist work together to develop new, more helpful proceduresThese are added to the diagrammatic reformulation as ‘Exits’ or ‘Ways Out’
11 Standard CAT (vi) Ending Phase & Follow Up Aim is to achieve a ‘good’ and ‘planned’ endingExchange of Goodbye LettersFollow up session to review progress
12 Suitability of CAT for PLD (i) Flexible frameworkEmphasis on collaboration and boundariesUse of ‘Zone of Proximal Development (ZPD)Use of written and diagrammatic materials to supplement verbal communication
13 Suitability of CAT for PLD (ii) Practical therapeutic toolsProvides a vehicle for addressing fundamental Learning Disability Issues in a safe environmentCan be modified according to client need without losing essential elements of the model
14 Specialised CAT for PLD (i) Modifications to the course of therapyPre-Reformulation period to establish relationshipCollaborative completion of Psychotherapy File within sessionsAdaptation of pace of therapy – e.g. Length, frequency and number of sessionsAdaptation of goals of therapy – sometimes ‘Recognition’ is the most appropriate goalCollaborative development of goodbye letters &/or the story of the therapeutic journey
15 Specialised CAT for PLD (ii) Modifications to therapeutic toolsUse of simplified language as appropriateAdapted Psychotherapy File – simplified language version (King, 2005), diagrammatic version (Bancroft, 2009)Pictorial/Symbolised diaries, rating scales, lettersAudio-recorded therapy lettersCreative methods, role play, story work, emotion symbols
16 From this .....‘Fear of hurting others’ Trap, Psychotherapy File 2009 updated versionFeeling fearful of hurting others we keep our feelings inside, or put our own needs aside. This tends to allow other people to ignore or abuse us in various ways, which then leads to our feeling, or being, childishly angry. When we see ourselves behaving like this, it confirms our belief that we shouldn’t be angry or aggressive and reinforces our avoidance of standing up for our rights.
17 To this ...... ‘Fear of hurting others’ Trap, Simplified Version Are you afraid of hurting other people’s feelings? yes/noIf yesDo you hide your feelings and needs inside when you are with other people? yes/no
19 Upset Feelings Dilemma 2009 updated version Either I keep feelings bottled up or I risk being rejected, hurting others, or making a mess.+ ++ 0
20 Upset feelings Dilemma simplified words version I must keep my feelings inside of me.If I do not, other people will not like me.Yes/no
21 Upset feelings Dilemma My version for people with LD YES SOMETIMES NO
22 Snags 2009 updated versionDo you recognise that you feel limited in your life:1. for fear on the response of others: e.g. I must sabotage success, for example 1) as if it deprives others, 2) as if others may envy me or 3) as if there are not enough good things to go around2. by something inside yourself: e.g. I must sabotage good things as if I don’t deserve them
23 Snags simplified words version Do you ever feel that you are stopped from doing good things or having good things because you are afraid of what other people might say or do? yes/noDo you ever feel that you are stopped from doing good things or having good things by something inside of yourself telling you that you are not good enough to have them?yes/no
24 SNAGS – things that get in the way My version for people with LD I want to ….But…
25 Applications of CAT in PLD Services (i) Individual TherapyGroup WorkWorking with carers and staff teamsStaff TrainingSupervisionConsultancy
26 Applications of CAT in PLD Services (ii) Group WorkAdd relational element to traditional group work- e.g. Self-esteem, Anger-managementEncouraging both participants and facilitators to be more aware of Reciprocal Roles in both the content and the process of the group work
27 Applications of CAT in PLD Services (ii) Indirect WorkA questioning relational approach:1. How did you feel?What did this make you want to do?What did you do?What did they do?What happened then?How did you feel?
28 Applications of CAT in PLD Services (iii) 2. How do you think they were feeling?What do you think they wanted you to do?What did they do?What did you do?What happened then?How do you think they were feeling?
29 Indirect Work (iii)Identification of Reciprocal Roles and unhelpful procedures/patterns of behaviourRecognition of repetitions of theseRevision – development of more helpful Reciprocal Roles and procedures
30 Summary and Conclusions (i) CAT is a useful model for working with People with Learning DisabilitiesFlexible framework allows for Specialisation, modifications and adaptations according to individual client need without losing the essential essence of CAT
31 Summary and Conclusions (ii) The model can be used for all aspects of LD work – direct work with individuals, group work, work with carers and professionals, staff training and in consultancy and supervision
33 References (i)Bancroft, A., Collins, S., Crowley, V., Harding, C., Kim, Y., Lloyd. J., Murphy (2008). ‘Is CAT an island or a solar system? The dilemmas in the therapeutic frame when working with people with learning disabilities’. Summer edition, ReformulationCarradice, A (2004). Applying cognitive analytic therapy to guide indirect working. Reformulation Conference Paper,Clayton, P. (2006). “The learning disabled offender and the secure institution”. In P. Pollock, M. Stowell-Smith & M. Gopfert (Eds.), Cognitive Analytic Therapy for Offenders: A new approach to forensic psychotherapy. London: RoutledgeClayton, P. (2001). Using cognitive analytic therapy in an institution to understand & help both client & staff. In Landsberg, G & Smiley, A (Ed.) Forensic Mental Health. USA: Civic Research Institute, Inc.
34 References (ii)Collins, S. (2006). ‘Don’t dis me! Working with young people who have physical and learning disabilities.’ Winter Edition, Reformulation.David, C. (2009). “CAT and people with learning disability: Using CAT with a 17 year old girl with learning disability.” Reformulation 32 (Summer) p21-25.Fisher, C., & Harding, C. (2009). ‘Thoughts on the rebel role: Its application to challenging behaviour in learning disability services.” Reformulation, 32 (Summer) p4-5.King, Ros. (2005). ‘CAT and the therapeutic relationship and working with people with learning disability.’ Summer Edition ReformulationLloyd, J. (2007). ‘Case Study on Z; Not as impossible as we had thought.’ Summer Edition, Reformulation
35 References (iii)Lloyd, J. & Williams, B. (2003). Reciprocal roles and the unspeakable known: Exploring CAT within services for people with learning disabilities. Summer Edition, Reformulation.Lloyd, J. & Williams, B. (2003). ‘Exploring the use of Cognitive Analytic Therapy within services for people with learning disabilities and challenging behaviour.’ J. Lloyd and B. Williams (2004) Clinical Psychology and People with Learning Disabilities 2(2) 4-5.Moss, A. (2007). ‘The application of CAT to working with people with learning disabilities.’ Summer Edition ReformulationMurphy, N. (2008) ‘CAT used therapeutically and contextually for a client with learning disability and Asperger Syndrome.’ Summer Edition Reformulation.
36 References (iv)Murphy, N. (2008) ‘CAT used therapeutically and contextually for a client with learning disability and Asperger Syndrome.’ Summer Edition Reformulation.Psaila, K. and Crowley, V. (2006). Cognitive Analytic Therapy in people with learning disabilities; An investigation of the common reciprocal roles found within the client group.’ Winter Edition. Reformulation.Walsh, S. (1996). Adapting Cognitive Analytic Therapy to make sense of psychologically harmful work environments. British Journal of Medical Psychology, 69: 3-20.