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Team consultancy using cognitive analytic therapy: A controlled study in assertive outreach

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Abstract

Cognitive analytic consultancy involves mapping the dysfunctional procedures and relationships that exist between team and patient using cognitive analytic theory. The study showed no impact on patient outcomes, but a significant organizational impact in terms of team practices and relationships. Cognitive analytic consultancy offers promise in helping in-patient and community clinical teams manage those patients not suitable for individual or group psychotherapy. The objective of this study was to evaluate the clinical and organizational efficacy of formulation-based consultancy to clinical teams using a randomized control trial methodology. Patients in an Assertive Outreach Team (AOT) were randomized into cognitive analytic consultancy (CAC; n = 10) or treatment as usual (TAU; n = 10). CAC consisted of three consultancy sessions with individual team members to formulate and map the dysfunctional roles and procedures adopted by both patient and team. Subsequent changes to practice were then supported via team supervision. Measures of patient and team functioning were taken across four discrete study phases; (1) baseline team training, (2) case consultation, (3) team supervision and (4) 3-month follow-up. Team members were additionally interviewed before and following the trial. No differences were evident between CAC and TAU in terms of patient outcomes. However, the climate of the AOT significantly improved longitudinally over the course of the trial, with CAC facilitating enhanced clinical and team practices. The results are discussed in terms of methodological limitations, the advantages/disadvantages of team consultation and the potential for the further development of the CAC model.

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... Of these, five were uncontrolled pre-post studies (Berry et al., 2009;Ingham, 2011;Ingham et al., 2008;Maguire, 2006;Revolta et al., 2016), three of which had a descriptive feedback element (Ingham, 2011;Ingham et al., 2008;Revolta et al., 2016). There were three qualitative studies (Christofides et al., 2012;Mohtashemi et al., 2016;Summers, 2006), and two randomised controlled trials (RCT) (Berry et al., 2016;Kellett et al., 2014). One of the RCTs was a mixed method study employing non-blinded randomisation and content analysis of semi-structured interview material (Kellett et al., 2014). ...
... There were three qualitative studies (Christofides et al., 2012;Mohtashemi et al., 2016;Summers, 2006), and two randomised controlled trials (RCT) (Berry et al., 2016;Kellett et al., 2014). One of the RCTs was a mixed method study employing non-blinded randomisation and content analysis of semi-structured interview material (Kellett et al., 2014). ...
... Use of the CASP qualitative study tool indicated that the methodological quality of the three qualitative studies was variable, but generally of fair quality. However, the qualitative part of the mixed method study (Kellett et al., 2014) was poor. The RCT feasibility study (Berry et al., 2016) was also assessed using the CASP for RCT tool and was rated as fair. ...
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Purpose Team formulation, used to understand patient problems and plan care, is a growing practice in adult mental health and learning disability services. The purpose of this paper is to explore definitions applied to team formulation (as distinct to therapy formulation), its underpinning theories, and the inter-relationship between the team and the process of formulation. Design/methodology/approach A database search (main search term of team formulation) of peer-reviewed studies was conducted using PRISMA guidelines. A main and second reviewer conducted quality appraisals and thematic analysis. Data were analysed by convergent qualitative synthesis design using thematic analysis to transform evidence from quantitative and qualitative studies into qualitative findings. Findings Initial searching produced 4,532 papers, 10 of which were eligible for inclusion. Team formulation has no distinct definition. Theories underpinning the practice of therapy formulation emanating from general psychological theory underpin team formulation. Seven studies applied psychological theories to the examination of team formulation. No studies examined the impact of the team on the formulation. Six themes were generated regarding the impact of team formulation on the team; “increased knowledge and understanding”, “altered perceptions, leading to altered relationships, feelings and behaviours”, “space to reflect”, “useful when stuck or challenged”, “perceived increase in effectiveness” and “improved team working”. Research limitations/implications Limited evidence and variable quality compromised the availability of review evidence. Originality/value This is the first review to examine team formulation through the context of the team. The authors argue that a conceptual framework to encompass team inputs, processes and outputs in team formulation practice should guide future research.
... Participants argued that by viewing nonadherence as caused by the AV, via a process of externalization, they were able to appraise clients as deserving of help, thereby remaining compassionate. This is in line with evidence that externalization is commonly employed with AN to this effect (e.g., Wright & Hacking, 2012;Zugai, Stein-Parbury, & Roche, 2018) and that having a framework for understanding promotes less blaming attitudes towards people with AN (Bannatyne & Stapleton, 2017;Crisafulli, Von Holle, & Bulik, 2008;Crisafulli, Thompson-Brenner, Franko, Eddy, & Herzog, 2010) and individuals with other stigmatized mental-health diagnoses such as schizophrenia (Kellett, Wilbram, Davis, & Hardy, 2014) and Personality Disorder (Kerr, 1999). Team discussion of, or training in, the AV may encourage ...
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People with anorexia nervosa (AN) often report experiencing a highly critical inner voice (AV) focused on their eating, shape and weight. There are promising preliminary findings for its role in the treatment of AN and the support of staff is vital for the AV to be embedded in treatment, but their views remain unknown. The aims of this study were to undertake a qualitative exploration of the perceptions of the AV among healthcare professionals (HCPs) in specialist eating disorder (ED) services. A thematic analysis was applied to interviews with 15 HCPs, including nurses, therapists, psychiatrists, healthcare assistants, psychologists and dietitians. Two overarching themes were identified: – “The AV is a vehicle for increasing compassion” and “It's not a one‐size‐fits‐all.” The AV was seen as a means of developing and sustaining compassion, but participants noted that it does not resonate for all clients. All HCPs in this study believed that there was potential benefit in utilising the AV in their work with people with AN, and it is likely that doing so would help to reduce burnout and frustration within clinical teams.
... A semi-structured interview schedule based loosely on one used by Kellett et al. (2014) was developed in consultation with the project supervisor. Questions explored areas including: staff perceptions of presenting problems (e.g., "what problems were going on when your team decided to refer?"); experience of formulation sessions ("What do you remember about the sessions you did attend?"; ...
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Purpose This study aims to explore how care staff working with people with learning disabilities experienced psychologist-facilitated team formulation sessions in a cognitive analytic style (contextual reformulation). Design/methodology/approach Eleven participants attended at least one contextual reformulation session regarding a client their team referred because of challenging behaviour. Post-intervention semi-structured interviews were analysed using qualitative inductive thematic analysis. Findings Five themes were developed: multiple roles and functions of sessions and clinicians; challenging behaviour in relationship; making links – understanding can be enlightening, containing and practical; the process of developing a shared understanding and approach; and caught between two perspectives. Findings suggested contextual reformulation helped staff see challenging behaviour as relational, provided them with the space to reflect on their emotions and relate compassionately to themselves and others, and ultimately helped them to focus their interventions on understanding and relationally managing rather than acting to reduce behaviour. Research limitations/implications Qualitative methodology allows no causal inferences to be made. Ten of 11 participants were female. Originality/value This qualitative study adds to the limited research base on team formulation in learning disabilities settings and specifically that using a cognitive analytic approach.
... Cognitive analytic consultancy (CAC; Carradice, 2013a) provides such an organizational intervention, with the approach grounded in the theory, principles, and practice of cognitive analytic therapy (CAT; Ryle & Kerr, 2002). The purpose of CAC is to enable care dyads (i.e., the care coordinator from the CMHT and the service user) to develop a better/ deeper understanding of the dynamics of their care relationship, and then develop better ways of relating and reciprocating (Kellett, Wilbram, Davis, & Hardy, 2014). The approach of CAC therefore locates difficulties in care dyad reciprocation rather than solely in the client (Ryle & Kerr, 2002). ...
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Objectives This study sought to employ the hourglass model to frame the methodological evolution of outcome studies concerning 5‐session cognitive analytic consultancy (CAC). Design Pre‐post mixed methods evaluation (study one) and mixed methods case series (study two). Methods In study one, three sites generated acceptability and pre‐post effectiveness outcomes from N = 58 care dyads, supplemented with qualitative interviewing. The client outcome measures included the Clinical Outcomes in Routine Evaluation Outcome Measure, Personality Structure Questionnaire, Work and Social Adjustment Questionnaire, Service Engagement Scale, and the Working Alliance Inventory. Study two was a mixed methods case series (N = 5) using an A/B phase design with a 6‐week follow‐up. Client outcome measures were the Personality Structure Questionnaire, Clinical Outcomes in Routine Evaluation Outcome Measure, and the Working Alliance Inventory, and the staff outcome measures were the Working Alliance Inventory, Maslach Burnout Inventory, and the Perceived Competence Scale. Results In study one, the cross‐site dropout rate from CAC was 28.40% (the completion rate varied from 58 to 100%) and full CAC attendance rates ranged from 61 to 100%. Significant reductions in client distress were observed at two sites. Qualitative themes highlighted increased awareness and understanding across care dyads. In study two, there was zero dropout and full attendance. Clients were significantly less fragmented, and staff felt significantly more competent and less exhausted. Potential mechanisms of change were the effective process skills of the consultant and that emotionally difficult CAC processes were helpful. Conclusions Cognitive analytic consultancy appears a promising approach to staff consultation, and testing in a clinical trial is now indicated. Practitioner points • CAC is a suitable method of consultation for care dyads struggling to work effectively together in CMHTs. • Staff feel more competent and clients feel less fragmented following CAC, and the benefits of CAC appear to be maintained over follow‐up time. • CAC processes can be difficult for care coordinator and client, but this is not an impediment to change.
... The suggestion of CAT-informed indirect or consultancy-based work also emerged when participants considered the application of CAT to more extreme or florid states of psychosis. This is consistent with recent work evaluating CAT-informed consultancy approaches for those with experiences of psychosis (Kellett, Wilbram, Davis, & Hardy, 2014) and shows that CAT of psychosis need not be limited to one-to-one therapy. ...
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Objective: There has been growing interest in the use of cognitive analytic therapy (CAT) with those facing experiences of psychosis. However, there is little research on how CAT is best applied to working with psychosis. This study aimed to identify what the key aspects of CAT for psychosis are or whether this approach requires adaptation when applied to those with experiences of psychosis, drawing on expert opinion. Method: An adapted Delphi methodology was used. Items were generated during an initial workshop (N = 24) and then rated for agreement or importance via an online survey by a sample of experts with experience of CAT and working clinically with psychosis (N = 14). Results: Following two rounds of ratings, consensus was reached on most items. Additional comments emphasized the need to be flexible with regard to the varying needs of individual clients. Conclusions: Results highlight the specific relational understanding of psychosis provided by CAT as one of the key elements of this approach. Responses emphasized the need for some level of adaptation to work with psychosis, including greater flexibility with regard to the treatment frame. Practitioner points: When working with experiences of psychosis, aspects of the CAT model, such as session length, pacing, and duration of therapy, are open to change and may require modification. When working with experiences of psychosis, narrative reformulation letters and sequential diagrammatic reformulation (SDR) remain essential to the therapy. This Delphi methodology study essentially relies on opinion. Further empirical research could test assumptions about the most important or therapeutically effective components of CAT in psychosis. CAT is still not widely used in the context of psychosis limiting the pool of experts available for the current sample.
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Background: Formulation and working psychologically with teams is considered a fundamental part of the role of a clinical psychologist. Quantitative studies have found staff find team formulations a positive, useful experience. Aims: This review aims to utilize a Thematic Synthesis to combine qualitative studies on staff experiences of participating in team formulations and explore what benefits staff perceive from the process. The review also aims to provide a thorough quality appraisal of the included research. Method: A Thematic Synthesis was completed on qualitative studies which met the required inclusion criteria. The Critical Appraisal Skills Programme qualitative checklist was used to appraise the included research. Results: The studies included in the review were of a mixed quality, and in some instances there was an insufficient amount of detail to complete an accurate assessment. Overall, seven themes were identified across the studies. Conclusions: The current review highlights the importance of team formulation in general practice for both enhancing staff understanding of service users but also improving professional confidence and validation. The review also highlighted some of the barriers to staff practicing team formulations.
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Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one‐third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD −0.60, 95% CI −1.05 to −0.14; 3 trials, 149 participants), self‐harm (SMD −0.28, 95% CI −0.48 to −0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD −0.36, 95% CI −0.69 to −0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self‐harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD −0.58, 95% CI −1.22 to 0.05, 4 trials, 333 participants). All findings are based on low‐quality evidence. For secondary outcomes see review text. Authors' conclusions Our assessments showed beneficial effects on all primary outcomes in favour of BPD‐tailored psychotherapy compared with TAU. 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This paper reports the development and psychometric validation of a multi-dimensional measure of facet-specific climate for innovation within groups at work: the Team Climate Inventory (TCI). Brief reviews of the organizational climate and work group innovation literatures are presented initially, and the need for measures of facet-specific climate at the level of the proximal work group asserted. The four-factor theory of facet-specific climate for innovation, which was derived from these reviews, is described, and the procedures used to operationalize this model into the original version measure described. Data attesting to underlying factor structure, internal homogeneity, predictive validity and factor replicability across groups of the summarized measure are presented. An initial sample of 155 individuals from 27 hospital management teams provided data for the exploratory factor analysis of this measure. Responses from 121 further groups in four occupations (35 primary health care teams, 42 social services teams, 20 psychiatric teams and 24 oil company teams; total N=971) were used to apply confirmatory factor analysis techniques. This five-factor, 38-item summarized version demonstrates robust psychometric properties, with acceptable levels of reliability and validity. Potential applications of this measure are described and the implication of these findings for the measurement of proximal work group climate are discussed. © 1998 John Wiley & Sons, Ltd.
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This is a comprehensive, up-to-date introduction to the origins, development, and practice of cognitive-analytic therapy (CAT). Written by the founder of the method and an experienced psychiatric practitioner and lecturer, it offers a guide to the potential application and experience of CAT with a wide range of difficult clients and disorders and in a variety of hospital, community care and private practice settings. Introducing Cognitive Analytic Therapy includes a wide range of features to aid scholars and trainees: Illustrative case histories and numerous case vignettes Chapters summaries, further reading and glossary of key terms Resources for use in clinical settings Essential reading for practitioners and graduate trainees in psychotherapy, clinical psychology, psychiatry and nursing.
Article
The phrase primum non nocere ("first, do no harm") is a well-accepted credo of the medical and mental health professions. Although emerging data indicate that several psychological treatments may produce harm in significant numbers of individuals, psychologists have until recently paid little attention to the problem of hazardous treatments. I critically evaluate and update earlier conclusions regarding deterioration effects in psychotherapy, outline methodological obstacles standing in the way of identifying potentially harmful therapies (PHTs), provide a provisional list of PHTs, discuss the implications of PHTs for clinical science and practice, and delineate fruitful areas for further research on PHTs. A heightened emphasis on PHTs should narrow the scientist-practitioner gap and safeguard mental health consumers against harm. Moreover, the literature on PHTs may provide insight into underlying mechanisms of change that cut across many domains of psychotherapy. The field of psychology should prioritize its efforts toward identifying PHTs and place greater emphasis on potentially dangerous than on empirically supported therapies. © 2007 Association for Psychological Science.
Article
This paper presents nine key considerations for improvement in health and social care drawn from recent national and international experience and describes the ways in which some of these ideas are being incorporated into local whole systems intervention.
Article
Summary This paper reports the development and psychometric validation of a multi-dimensional measure of facet-specific climate for innovation within groups at work: the Team Climate Inventory (TCI). Brief reviews of the organizational climate and work group innovation literatures are presented initially, and the need for measures of facet-specific climate at the level of the proximal work group asserted. The four-factor theory of facet-specific climate for innovation, which was derived from these reviews, is described, and the procedures used to operationalize this model into the original version measure described. Data attesting to underlying factor structure, internal homogeneity, predictive validity and factor replicability across groups of the summarized measure are presented. An initial sample of 155 individuals from 27 hospital management teams provided data for the exploratory factor analysis of this measure. Responses from 121 further groups in four occupations (35 primary health care teams, 42 social services teams, 20 psychiatric teams and 24 oil company teams; total Nà 971) were used to apply confirmatory factor analysis techniques. This five-factor, 38-item summarized version demonstrates robust psychometric properties, with acceptable levels of reliability and validity. Potential applications of this measure are described and the implication of these findings for the measurement of proximal work group climate are discussed. #1998 John Wiley & Sons, Ltd.
Article
Assertive outreach has become established as a valuable form of care delivery for the severely mentally ill. Not only does it keep a focus on the most difficult-to-engage patients but it has introduced greater clarity to the organization and evaluation of mental health teams. The model is described, together with its historical and international context, and a realistic assessment of model fidelity issues. Assertive outreach is a labour intensive, 7-day a week service commitment, which aims to support basic survival needs, but is also highly compatible with more sophisticated evidence-based interventions for psychosis. Interventions need to be delivered in a way that is acceptable in the long-term to patients and their families. In assertive outreach this means much more than simply taking the service to the individual. It means engaging in constructive long-term relationships and flexibility in roles and relationships beyond the mere professional. Teams use small caseloads, a team approach and generic working to meet the majority of needs, including practical help and social care, medication and psychological interventions. These interventions, with a review of the supporting research outcomes for assertive outreach implementation, are described.
Article
In multidisciplinary teams in the oil and gas industry, we examined expertise diversity's relationship with team learning and team performance under varying levels of collective team identification. In teams with low collective identification, expertise diversity was negatively related to team learning and performance; where team identification was high, those relationships were positive. Results also supported nonlinear relationships between expertise diversity and both team learning and performance. Finally, team learning partially mediated the linear and nonlinear relationships between diversity and performance. Findings broaden understanding of the process by which and the conditions under which expertise diversity may promote team performance.
Article
Objectives. To investigate clinical psychologists’ accounts of their use of psychological case formulation in multidisciplinary teamwork. Design. A qualitative study using inductive thematic analysis. Methods. Ten clinical psychologists working in community and inpatient adult mental health services who identified themselves as using formulation in their multidisciplinary team work participated in semi-structured interviews. Results. Psychological hypotheses were described as shared mostly through informal means such as chipping in ideas during a team discussion rather than through explicit means such as staff training or case presentations that usually only took place once participants had spent time developing their role within the team. Service context and staff's prior experience were also factors in how explicitly formulation was discussed. Participants reported that they believed that this way of working, although often not formally recognized, was valuable and improved the quality of clinical services provided. Conclusions. More investigation into this under-researched but important area of clinical practice is needed, in order to share ideas and support good practice.
Article
In cognitive-behavioural therapy with children, young people and families, formulation-based practice ensures that interventions are based on underlying causative and maintaining processes. Importantly, however, developmental, attachment, family, systemic and other perspectives must be incorporated into therapy. This paper describes a template for systemic cognitive-behavioural formulation that facilitates incorporation of the necessary range of perspectives including processes more traditionally expressed through other psychotherapeutic modes of working. Case formulation based on this template is sufficiently comprehensive, yet simple enough to derive collaboratively and leads to a distinct clinical process for working with individuals, families and wider support systems. This generic formulation process is appropriate for use across the range of presentations encountered in child and adolescent mental health practice and provides a structure for therapist training. It requires formal evaluation and has implications for future research.
Article
To determine (1) inter-relationships between social network size and quality and therapeutic relationship ratings and (2) inter-relationships between attachment style, team attachment, therapeutic relationships, social networks, and clinical and social functioning. A cross-sectional survey. A sample of 93 people using community mental health teams were assessed on their attachment status, social networks, relationship to the keyworker, attachment to the team, characteristics, and clinical and social functioning. Network size and the number friends and confidants were tested for associations with user- and professional-rated therapeutic relationship. Regression analysis was used to determine variables associated with team attachment. There was no evidence that network size or number of confidants was associated with therapeutic relationship ratings. Therapeutic relationship was strongly associated with team attachment, but of the four attachment dimensions, only preoccupied attachment was associated with team attachment. There is no evidence that therapeutic relationships are associated with the service user's 'affability' or predisposition to form relationships, suggesting that measures of therapeutic relationship and service attachment do measure something distinct about service users' experience of their care. Team attachment and therapeutic relationship measures seem likely to be measuring very similar constructs. It is possible that service users with more preoccupied attachment styles may find it particularly difficult to form positive attachments to services undergoing frequent change.
Article
There are a number of clients that mental health teams (CMHTs) struggle to help. This group often have some form of personality disorder diagnosis. All workers can experience the client's presentation as challenging and this sometimes results in unhelpful repeated patterns between clients and services. Difficulties for this client group include abrupt state shifting, powerful dynamics, difficult/complex relationships with (often numerous) services, symptoms of dissociation, difficulties with emotional regulation and self abuse. Some people with these difficulties can present to services with a number of factors that mean it is hard to work helpfully with them such as having unstable and chaotic lives, experiencing significant ongoing risks from others and often coping day to day by using a variety of harmful strategies such as self-harm, planning suicide and a significant amount of alcohol and/or drug use. The group of clients who experience these difficulties are often assessed as not being able to benefit from individual psychotherapy in the community. Five-session cognitive analytic therapy (CAT) consultancy has been developed as a method to work jointly with mental health workers and their clients to develop a map to understanding their current difficulties, patterns of coping and to guide care planning. This paper describes the steps of 'five-session CAT' consultancy and the skills involved. Copyright © 2012 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGES: Newly evolved approach using CAT to help guide CMHT care planning For people with a diagnosis of personality disorder Who seem unsuitable for individual psychotherapy Because of the nature of their difficulties, mental health teams find such clients difficult to help.
Article
ABSTRACT Given that borderline personality disorder (BPD) is increasingly managed by community mental health teams (CMHTs), an exploration of the effectiveness of the cognitive-analytic model (Ryle 1997a) was undertaken in this context. A young man with a primary diagnosis of BPD was offered a course of cognitive-analytic therapy (CAT) by a member of the CMHT. Therapy was only partially successful, due apparently to the severity of the disorder but also, critically, to the absence of a shared understanding of the disorder by team members as well as other agencies involved. However, the CAT model, involving explicit reformulation, helped educate key members of the team about the disorder and the part they might play in it and to contain the splitting and anxiety provoked by such a patient. In addition, CAT created a reasonably robust therapeutic alliance, with more regular contact and no re-admission during the period of therapy. An extended‘contextual’ reformulation can also offer a means of understanding the difficulties encountered in working with such patients, classically described by Main in‘The ailment’ (1957), and provide the conceptual containment required to work with such‘difficult’ patients.
Article
The need for a measure of engagement with Community Mental Health Services has been identified. This article reports on the development and preliminary psychometric evaluation of a scale, Service Engagement Scale (SES), to measure engagement with community mental health services. Five Community Psychiatric Nurses completed the SES for 66 clients receiving Assertive Outreach services with an ICD-10 diagnosis of schizophrenia. Test-retest reliability of the subscale items and scale total is in the good to excellent range. Validity is supported by good internal consistency and by the criterion group method. Although preliminary psychometric results are promising, further psychometric study is necessary to evaluate the scale's factor structure. The SES appears to evaluate engagement with services, and may therefore be a useful tool to identify areas of concern with clients experiencing engagement difficulties.
Article
Team Tasks, Visions and Objectives Team ParticipationQuality of Decision MakingSupport for InnovationTeam Conflict ResolutionReferences and Further Reading
Article
Patients' perspectives concerning impaired functioning provide important information. AIMS; To evaluate the reliability and validity of the Work and Social Adjustment Scale (WSAS). Data from two studies were analysed. Reliability analyses included internal scale consistency, test-retest and parallel forms. Convergent and criterion validities were examined with respect to disorder severity. Cronbach's alpha measure of internal scale consistency ranged from 0.70 to 0.94. Test-retest correlation was 0.73. Interactive voice response administrations of the WSAS gave correlations of 0.81 and 0.86 with clinician interviews. Correlations of WSAS with severity of depression and obsessive-compulsive disorder symptoms were 0.76 and 0.61, respectively. The scores were sensitive to patient differences in disorder severity and treatment-related change. The WSAS is a simple, reliable and valid measure of impaired functioning. It is a sensitive and useful outcome measure offering the potential for readily interpretable comparisons across studies and disorders.
Article
Treatment non-adherence and service disengagement are commonly attributed to impaired insight. There is evidence that recovery style (i.e. psychological adjustment) may underlie service engagement. We examined whether insight, psychotic symptoms or individuals' recovery style ('integration' v. 'sealing-over') predicts service engagement. Fifty patients with schizophrenia were assessed during acute psychosis and at 3-month and 6-month follow-ups. Measures included recovery style, psychosis symptoms, insight and service engagement. Sealing-over at 3 months following onset of an episode of psychosis predicted low service engagement at 6 months. Neither insight nor symptoms predicted engagement. The clear shift from integration to sealing-over within the first 3 months was independent of changes in symptoms or insight. Sealing-over between 3 and 6 months was associated with improvement in psychosis symptoms. Recovery style contributed more to engagement than did insight, appears to be dynamic in the short term and is orthogonal to insight. Overall, this study demonstrated the importance of addressing psychological adjustment to psychosis as well as illness status when investigating treatment engagement in people with psychosis.
Article
This article describes ways the theory and practice of cognitive analytic therapy (CAT) can contribute to the treatment and management of patients with borderline personality disorder (BPD). CAT, as its name suggests, was derived initially from an integration of conventionally opposed models. From the beginning, it was delivered within a limited timeframe, usually of 16 weekly sessions, extended to 24 in the case of more disturbed patients. Over time, on the basis of clinical experience, conceptual debate, and research, it has evolved into a general theory and has demonstrated itself to be of value over a wide range of conditions and contexts. The evolution of the basic theory and practice of CAT over the past 25 years is summarized, followed by a description of the theoretical developments concerned specifically with BPD. The techniques used in the individual psychotherapy of borderline patients are described in detail and illustrated with case material. The application of methods and understandings derived from individual therapy to staff supervision and the treatment and management of patients in day hospitals, therapeutic communities, and community mental health centers is then considered. A final section describes research contributions to the development and evaluation of CAT with borderline patients.
Article
There is increasing interest in questions about how far the demonstrated efficacy of psychological therapies in research trials can be translated into clinical effectiveness in routine practice. This paper summarises outcome data from several hundred patients treated with CBT in routine clinical practice in a National Health Service psychology service, and compares their outcomes with some of the published research. Although the data have flaws common in ordinary clinical practice (no untreated controls, missing data, uncontrolled pharmacotherapy, etc.), the analyses suggest that CBT in this context is an effective treatment, albeit with probably not quite such good results as it achieves in research trials. Using clinical significance statistics on standardised measures, about half of the sample reliably improved over a course of therapy, including about a third who recovered to normal range.
Article
Mental health teams in different configurations and settings are under increasing pressure to offer formal psychotherapies as well as psychologically informed management to large numbers of 'difficult' patients with severe and complex presentations. This pressure has arisen variously from consumers, governmental agencies and commissioning bodies. Although these teams are an important resource, they receive limited training, supervision or support in models of psychotherapy, especially those incorporating a relational dimension and offering a coherent 'common language'. This commonly results in impairment of collective team function, including the quality and consistency of assessments, and may result in stress, splitting and 'burn out' for team members. This situation is due in part to their burden of casework and responsibility but also to prevailing, largely symptom-based and biomedical, models of mental disorder which tend to minimize the importance of psychosocial dimensions in either aetiology or treatment. Formulating and delivering appropriate, evidence-based and robust models of psychotherapy in generic team settings represents a significantly different challenge from that posed by delivery of psychotherapy in specialist settings. Approaches to this important challenge are discussed and summarized drawing on general considerations and the limited direct research evidence, and are illustrated by a cognitive analytic therapy (CAT)-based training project.
Article
This study sought to explore community mental health teams' (CMHTs) experiences of receiving an innovative introductory level training in cognitive analytic therapy (CAT). CMHTs are important providers of care for people with mental health problems. Although CMHTs have many strengths, they have been widely criticized for failing to have a shared model underlying practice. Inter-professional training which develops shared therapeutic models from which to plan care delivery is, therefore, essential. We have been developing such a training based on the psychotherapeutic principles of CAT. Twelve community mental health staff (six mental health social workers and six community psychiatric nurses) were interviewed by an independent interviewer following the completion of the training programme. The interviews were analysed using a qualitative thematic analysis. The analysis revealed that the programme increased the participants' self-assessed therapeutic confidence and skill and fostered the development of a shared model within the team, although the training was also perceived as adding to workload. The results of this study suggest that whole-team CAT training may facilitate cohesion and also suggest that having some shared common language is important in enabling and supporting work with 'difficult' and 'complex' clients, for example, those with personality disorders. Further development of such training accompanied by rigorous evaluation should be undertaken.
Article
This paper is a description of inductive and deductive content analysis. Content analysis is a method that may be used with either qualitative or quantitative data and in an inductive or deductive way. Qualitative content analysis is commonly used in nursing studies but little has been published on the analysis process and many research books generally only provide a short description of this method. When using content analysis, the aim was to build a model to describe the phenomenon in a conceptual form. Both inductive and deductive analysis processes are represented as three main phases: preparation, organizing and reporting. The preparation phase is similar in both approaches. The concepts are derived from the data in inductive content analysis. Deductive content analysis is used when the structure of analysis is operationalized on the basis of previous knowledge. Inductive content analysis is used in cases where there are no previous studies dealing with the phenomenon or when it is fragmented. A deductive approach is useful if the general aim was to test a previous theory in a different situation or to compare categories at different time periods.
Cognitive analytic therapy for BPD in the context of CMHT: individual and organizational psychodynamic implications
  • Kerr
Applying cognitive analytical therapy to guide indirect working
  • Carradice