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Smith, Jak 2022. CAT in Neurorehabilitation: Developing a model through team consultation. Reformulation 55, p 21 - 27
Overview
For millennia human beings have been sketching and using maps as a way to navigate the unknown landscapes. With rapid advances in technological medical treatment in neuro-rehabilitation, the landscape of possible outcomes has never been so unknown. There is a dominant lens within neurological services which I feel prioritises objective out-come, at the potential overlooking and neglect of personal experience and subjectivity. I feel CAT attends to this imbalance, as a model concerned with integration and what it means to be human. In this article, I present an outline of what CAT has to offer neurorehabilitation, illustrated through an example of CAT-informed consultation with a clinical team. The details of this case have been anonymised to protect the identity of those concerned. Themes highlighted in this article may present similarities in other clinical teams I have been part of, given the nature of what I intend to cover.
CAT in Neurorehabilitation
The pivotal role of the therapeutic alliance – the relationship in which we are being treated – is well understood in psychotherapy to be a central predictor of engagement and thus clinical outcome, across different psychotherapy models with varying tools and modes of enquiry (Luborsky et al, 1988 and Bordin, 1994). This crucial insight is increasingly recognised in physical treatment for example, for the use of CAT in poorly controlled diabetes (Fosbury, 1996), and in the helpful application of CAT in asthma care (Walsh et al 2000). Furthermore Johnson and McCown (1997) are noted to argue for the birth of a new profession, integrating neuro-psychology and family therapy (systemic) practice.
Healthcare is fundamentally a relational process between patient, clinician and often family members. Many authors acknowledge that neuro-rehabilitation is a relational process, considering how injured brains are always in relation to other brains (Frith 2003).
In CAT we work collaboratively with the patient/client or team, which can help us to make sense of this space between the parts. We seek to understand relational patterns and procedures that occur in any given moment and we approach this using co-created, visually tactile tools such as a map. The aim of a map is to promote change and growth, through increased insight, awareness and a capacity to reflect, in a distinctly relational style, towards integration and collaboration. In this way, relational (CAT) mapping attends to both the biomedical and neurological empirical, together with lived experience and subjectivity, in a more holistic approach.
Mapping depicts the familiar dynamics that can unknowingly keep us stuck. McCormick (2012) helpfully points out that these patterns are often ‘the only way we have known how’ and CAT offers an opportunity to approach an individual neurorehabilitation journey from a truly collaborative and relational position from the outset. However, neurological and neuropsychology services have not typically been associated nor grounded in relational thinking. Bowen, et al (2018) note that indeed it has been the opposite for the most part, with a common definition being the study of mind-brain-behaviour relation-ships, with the mind being very firmly rooted in an individual’s cranium. This contrasts with understandings from modern developmental neuroscience that our the development and functioning of our minds are fundamentally relational (Trevarthen, 2017).
My work as a psychological therapist has spanned a regional NHS level one Centre for Neurorehabilitation and Neuropsychiatry, and private practice supporting care packages for neuro-rehabilitation. With my clinical background informed by psychodynamic therapy and now current work being heavily informed by cognitive and behavioural models, CAT and its integrated approach offered something new and valuable. Patients regularly brought relational difficulties as the central concern to therapy, including adjustment to disability, life with a brain injury or identity and relationship issues (including intimacy and dependence) following injury. These sit somewhere between mind and body paradigms, interacting with one another and the broader social landscapes.
In the regional centre, access to psychologically informed interventions was acutely limited although the needs of patients’ and their family members, often brought lots of expectation and complexity to the treating team. A central challenge in neurorehabilitation is the fine balance between managing expectation and maintaining motivation, which can sometimes set up an all or nothing dilemma of Either ‘liberation/success’ or ‘loss/ defeat’ for both patient and clinician.
Team consultation using CAT mapping can help colleagues understand such conflicts, and how this might play out in rehabilitation if not acknowledged in the early stages. I hope the following example acts as a springboard, opening a developing dialogue, towards a model of CAT in Neurorehabilitation, a field that offers a unique opportunity to think closely about the relational process between mind and body, self and other.
Referral
I received a referral from a case manager to join a newly forming multidisciplinary team (MDT) who were experiencing difficulties in delivering a complex care package. The patient, whom I have named Mark, lived with a 24hr care and support team. Other members of the MDT included a specialist physiotherapist and occupational therapist. Mark was fairly new to this case management company, having had a number of previous care packages break down for multiple reasons. He lived with a long term neurological condition, which brought a high level of physical dependence and need. There were no known cognitive difficulties serious enough to impact upon his active engagement in his care package. He was deemed to have mental capacity; communication and his speech could vary in relation to levels of fatigue, pain and emotional arousal.
There was a certain anxiety that surrounded this case, which brought a pressure to provide help. At one point the phrase ‘can you wave your magic wand?’ was used, although a jocular comment, I was aware of the real clinical need this disguised. Phrases like this can often be heard in neurorehabilitation and readers may remember times when they have felt a similar invitation to deliver something quite magical – and may even be able to tell a story of a time when it happened.
Resisting the magician’s role, I suggested we approach this together - the first invitation to the collaborative approach of CAT and doing with. The team was beginning to struggle with the pressures and expectations that were thought to be coming from the patient who was described as demanding and controlling. I noticed the team felt angry towards the patient, and they helpfully acknowledged getting caught up in psychological games like ‘well if she did this then…’ or ‘he knows this already’ and ‘yes but… it doesn’t matter what we do, it’s not enough’. I saw these frustrations overlap with signs of burnout, which can also be understood as secondary traumatic stress (Figley, 2002). Some authors have referred to compassion fatigue, such as Bride (2007) who outlines how it can have a substantial impact on staff and may develop into unhelpful and even harmful relational patterns.
Neurorehabilitation teams are often working with high levels of physical complexity, psychological distress, need and dependence, following traumatic injury. Often MDT staff have little, if any, or support available to consider the psychological dimensions of the work.
I therefore agreed to offer a team consultation using CAT as a framework to guide the process, influenced by the consultation model described by Carradice (2013). I use the 3 R’s of CAT reformulation, recognition and revision, and work to facilitate the process of joint mapping towards a rapid map (Sequential Diagrammatic Reformulation) that can be used to navigate the challenges, risks and unpredictability of neuro-rehabilitation work. The map is central to the team intervention, with the aim of underpinning the way the treatment intervention is delivered. The map grows and changes with the process and journey of the patient, whilst metaphorically holding and containing the treating clinicians on the same page, aiming for a stance of doing together. The hope is that it promotes new learning, offering insight and opportunity to try something different, while reducing fear of getting it wrong. In consultancy we are aiming for doing with not doing to, with the aim of avoiding the problematic dynamics that can result when a psychological practitioner is drafted in to join a MDT at a crisis point.
The Target Problem (TP) is the overarching difficulty that gets in the way of us achieving the aims and goals of treatment. In this case the team agreed the following TP:
TP – ‘We fear getting it wrong, as it may result in something catastrophic.’
This emerged from a discussion of the hopes and fears of the team consultation, but hinted at the team’s noticing of the patient’s unarticulated and unformulated fears. It allowed us to develop three clear aims for the work:
1 – To bring together and retain a team that works collaboratively and alongside the patient.
2- To promote the patient’s growing independence in their individual and collective therapies.
3- To support one another and to understand the complexities of this package.
Reformulation (phase 1 – Risks and Repeating Patterns)
Prior to commencing a team consultation, it can be valuable to offer a a psychoeducation session on CAT for an overview and brief understanding of the key concepts of Reciprocal Role Procedures (RRPs) and Target Problem Procedures (TPPs) – the patterns and dynamics we are going to map together. A secondary gain of this is an opportunity for the MDT to come together as equals from diverse backgrounds, starting a journey alongside one another as a team wholly together, which refuses hierarchy and power inherent in professional role difference. It also offers insight into the groups’ readiness or zone of proximal development (Vygotsky 1980). Alongside this, there needs to be agreement about contracting, time, duration, boundaries and small group work, offering a framework that can help to contain emotional unrest, as we sit together for the first time.
The reformulation phase is the foundation of what is to come, and it is a busy, often intense and exhausting stage for both the clinicians and facilitator. It is offered as a reflective space, marked by a non-judgemental stance, holding a curiosity to understand one and others emotional difference and felt experience, as individuals and as a team. It offers permission for the MDT to pause, name and connect, with the subjective nature of this work. For example – we notice the language which team members bring into the reflective space, and invite a deepening understanding of the meaning and felt expression, of those words.
This fosters safety, attending to the fear of getting it wrong or striving to get it right. A non-judgmental curiosity, creates a space in which the team can begin to notice, observe and name their interactions [self to self]; [self to other] and [other to self].
Validation arises from hearing a colleague describe something similar, whilst also opening space to reflect on the meaning of that collectively. It also opens the door to different perspectives. A skill for facilitators is to contain the MDT and to monitor the process to ensure it does not become a hot bed of emotional distress with verbal attacks; contempt or rage. A further skill is getting the group to talk, as in many MDTs, roles and responsibilities challenge the sense of psychological safety, not to mention that this work can be highly emotive when we pause for a moment, sometimes leaving us without words.
I may suggest that as they talk I will write key words or phrases down, bringing together the themes in an attempt to shape up common patterns and procedures, whilst indirectly modelling a relational approach to co-creating. The team began to name their relational experience with the patient, namely anger, powerlessness, control and a fear of defeat which they associated with loss, if they give up and left the MDT or requested a change in worker. This speaking to the procedural pattern of soldiering on that we identified early on in, during our initial conversations of hopes and fears.
Words flow when given space to name them, which enables us to shape up the difficult relational patterns that may be less conscious and avoided or unspoken in health ‘care’ settings (See figure 1 – RR1 and RR2). Mapping then opens up space to explore the felt experience and how the team manage such relational patterns.
In time there was shared recognition of the emotional experiences associated with being trapped, feeling powerless or not good enough/ letting others down. People experienced these roles in different ways, but collectively no one felt comfortable.
Naming this discomfort and adding it to the map (the unmanageable feelings of loss and defeat – see figure 1) allowed us as a team to reflect on the sense of powerlessness the patient might experience, living with a significant disability and dependence. It allows us to zoom out adopting CAT’s observing eye position, encouraging the team to hover over and see the relational enactments between Team – Patient as [Other to Self] [Self to Self].
Figure 1: Initial draft team map
This increased awareness and ability to notice and observe those relational patterns we are beginning to map together, enabled the MDT to shift perspective into a more curious and reflective position. Sketching these patterns invited a deepening dialogue, as one team member reflected on feelings of guilt having felt anger/contempt towards the patient. Mapping can give birth to something more than CAT: it can cultivate a therapeutic attitude, as the map acts as a vehicle for expression of feelings, thus aiding a sense of reconnection and empathy Potter (2010).
In these moments of relational encounter, I observed the team coming together, supporting one another which one later reflected on being more free to think (a potential exit from the role of trapped/no choice – or soldiering on but feeling increasingly frustrated and burdened).
With increased psychological safety and trust, formed through the process of reformulation and joint activity, the team began to take safe and manageable risks, naming that they often found themselves “giving more”, despite “knowing what I’m saying is probably wrong” – an example of early recognition and a reminder that the process of neurorehabilitation is not a predictable algorithm, thus inviting relational thinking.
This led to a further RRP - the coping pattern – of ‘Liberating - ideal/perfect care to Liberated- Never getting it wrong’ (RR3). The team reflected on how this could (unknowingly) contribute to and maintain the pressures and expectations.
At this stage of the reform-ulation we are beginning to make sense of the relational patterns that are present and how this can contribute to and maintain the difficulties that are experienced. Central to this is an understanding that the core pain, experienced by both the team and the patient was a deep sense of loss and defeat which must be avoided. This reflected a wish (of patient and staff) to be liberated from the psychological discomforts, with a focus to regain total independence, which overlooks the unavoidable increase in dependence when living with a significant disability.
The team recognised that loss and limitation brings powerful emotions to the surface that are difficult to acknowledge for both patient/client and clinicians who may not feel skilled or appropriately trained, to respond effectively to the distress being expressed (verbally or non-verbally). The team noticed that this can lead to an emphasis on achieving physical or objective goals that, on the one hand, had provided a number of special achievements and temporary relief, but also acknowledged this has been at the neglect of emotional and psychological needs.
At this stage a complete map was in draft form (Figure 1), and I agreed to share and circulate this to the team, along with general notes of themes and reflections. Included in this were some of those examples of recognition and an intro-duction to revision, inviting the team to think and reflect on potential exits they had noticed in the session. We met again for phase 2 one week later.
Recognition (phase 2 – reflecting and responding)
We commence by offering space for the team to pick up on anything missed last week, and to think together about their experience and understanding of where we had reached, including the central task of using the map for recognition and revision.
Much of this session is facilitated via the map. The team has hold of it and has been invited to think closely about the relational patterns they experience in themselves and with the patient. It is often a welcome relief to engage in this session as ‘light bulb moments’ are brought to the session from the week prior. I am often encouraged to hear my colleagues talk about how they used the map and reflections to inform their individual clinical work. Thus the map is complementing their clinical experience and offering an alternative where those patterns seem to keep them stuck, despite their best efforts to work in line with clinical guidance and the neurorehabilitation evidence base. As noted earlier, the relational aspect of healthcare includes the relation between objective treatments and subjective experience.
The team now seems able to shift perspective and describe exits, including: stepping back, inviting the patient to respond, boundaries, trying something different, and having a consistency across the team (as facilitated by the map).
A further developing exit was a growing awareness that the patient and team could mirror a parent/child relationship which echoes how we are at risk of enacting such patterns given that we meet patients at a point of increased vulnerability, dependence and need (Jones et al 2017).
Naming this allowed the team to clarify their role as facilitators rather than parents, which helped them to step back and share responsibilities. Again this is aligned to the CAT approach of doing with others.
Central to those developed exits was a need for more open and regular communication between team members. This from the naming of a rupture where a team member had felt overlooked and not listened to. Although the process of reflecting and sharing individual experience and anxieties was not always comfortable, the team commented on the value of having a space to reflect and express together. They described a strong sense of knowing and understanding each other’s individual roles and responsibilities as we nudged things along towards our individual and collective goals.
We agreed to meet for our final session several weeks later to revisit how the team carried forward what we had done together, consolidating the learning and holding an openness to explore and discover together.
Figure 2: Team map with exits
Revision (Phase 3 revising and reflecting)
The emphasis of this session was to provide a space in which the team could speak about their experience of the revised approach towards the treatment and care plan being offered. Outside of the session the team had took it upon themselves to review care plans, incorporating in this regular opportunities for reviews and
an open dialogic approach. They spoke with me about a sense of not feeling as responsible which in turn had provided opportunity for the patient to ‘grow’ in their independence, across the range of therapies. People shared examples, and the process seems to have shifted from a doing to approach (the expert with answers) toward doing together (facilitator with expertise and curiosity).
The team noted some of their key exits as working alongside each other and supporting one another (exit 2 on Figure 2), trying out new things (exit 6), therapeutically challenging (exit 5), and pushing where it moves attributed to Tony Ryle’s ‘push where it moves’ clinically, encouraging a more collaborative and shared position (exit 1). The central relational process of this team consultation was something of ‘exploring to discovering’, which encouraged the team to acknowledge the loss and limitations (exit 3). Providing a safe space for the team to reflect, recognise and revise, freed them up to take appropriate and measured risks without causing harm, offering fertile ground for growth and development (exit 4). Hearing the team describe this reminded me of the zone of proximal development (ZPD) and how greatest learning takes place when we are at the edge of the ZPD.
Further to the team’s observations, the patient had commented directly on their sense of ‘feeling safer’ and the patient’s extended support and family commented positively on the ‘team’s strength and ability’. In reviewing the work, the team described growing changes in the subjective interactions between self and other, towards a more collaborative, reflective, attuned and relationally informed approach. It is my understanding that the team continue to work together and use the map as a way to navigate the unchartered landscape filled with future uncertainties which they continue to explore, in the quest of neurorehabilitation.
Conclusions
Having worked across inpatient, community and private neurorehabilitation services, offering psychological interventions to both individuals and teams, I believe CAT and its emphasis on integration and doing with, in a relationally informed approach that sits within the ZPD of each individual and within the wider ZPD of the clinical MDT team, can offer significant contributions to this specialist field.
Working with teams and systems, providing a reflective space, towards understanding both the objective and subjective nature of complex care and neurorehabilitation, appears to increase team work, and improve treatment outcome and satisfaction (for patient/client and clinician) as outlined in this case example and the illustrated through the consultation model in figure 3.
Figure 3: Consultation model (CAT in Neurorehabilitation)
Conducting team consultations has reaffirmed the need for regular reflective practice in neurorehabilitation. The application of this model provides a relational framework, allowing for complex relational patterns and dynamics to be described, in a clear accessible language, for a range of clinicians, many of which have no psychological training. Authors such as Kurtz (2020) highlight the increasingly fast paced world that we live in and how there is not enough time to think. Reflective practice is a necessity, as a corrective, to this increased pace and demand that accompanies the technology boom, something we have all witnessed over the past decade. Whilst the digital age and its features in medical settings have brought many, often profound benefits to the lives of individuals who suffer neurological conditions, including brain injury, stroke and progressive conditions such as multiple sclerosis, there is a risk that we unconsciously overlook, the subjective and lived experiences of clients and clinicians, where easy answer or certainty cannot always be found.
The subjective experience of feeling overlooked has featured regularly in my work with individuals and so it seems necessary to develop relationally informed models, not only for the benefits of what I have outlined above, but as a potential exit to this pattern (Overlooking to Overlooked). Embedding such models, may help to minimise less conscious, cultural and societal patterns, towards a more integrative approach, working collaboratively to hold in mind the many relational possibilities between the physical and psychological dimensions in healthcare.
Whilst reflective practice is not new, the unique aspect of mapping in CAT, clearly compliments the process, in that it brings together the varying parts of a neuro-rehabilitation team, including the patients unique experience. The versatility of this model, offers rich opportunity across the various clinical settings in neurological services and I look forward to sharing more of my experience, as I continue to develop and apply the model of CAT in Neurorehabilitation.
With thanks to Dr Steve Jefferis CNTW CAT Service Lead
Correspondence:
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