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Fuller, D., Draper, M. and Lawes, P., 2024. Reflections on Running a CAT Group in a Personality Disorder Service. Reformulation, Winter, p.31-34.
INTRODUCTION
As CAT practitioners working within a tier 3 group-based personality disorder service, we had asked ourselves was there a place for CAT within our service. Up to that point, the specialist service offered STEPPS (Systems Training for Emotional Predictability and Problem-Solving), Mindfulness and activity groups as the main interventions. STEPPS is a twenty week group programme for people with diagnoses of EUPD (Emotionally Unstable Personality Disorder) that combines cognitive behavioural elements with skills training and is systems based. That means that the systems around the person such as family members, significant others and health care professionals are also taught how best to interact with the person to enable the intervention to work. The STEPPS programme combines a weekly psychoeducational group with individual reviews called 'reinforcement'.
We wondered if CAT would work within the existing model, adding a therapy to an existing skills-based intervention. We had seen that CAT was an effective therapy for personality disorder outside of the specialist service in individual work, but wanted to explore if the tools and techniques transferred well to a group setting.
Personality disorders are a major cause of long-term functional disability and are among the most common disorders in clinical practice affecting up to 50% of out-patients (Zimmerman, Cherminski and Young, 2008).
Ryle (2004) describes the ways in which the theory and practice of CAT might contribute to the treatment of BPD, and subsequent studies suggest that CAT is an effective treatment for people with this diagnosis (Clarke, Thomas & James, 2013). NICE guidelines once again have listed CAT as evidence-based treatment for personality disorder. While CAT is usually provided in an individual format, increasingly it is being used in groups in a variety of settings as described by Hepple & Bowdrey (2015), Martin, Byrne, Conon & Power (2021) and Calvert, Kellet & Hagan (2015) .
We started discussing the concept of a pilot group within our tier 3 service. Initial planning involved brainstorming potential barriers. These included the fact that we already knew the members who would be attending the CAT group and they knew us in different roles, would this affect the therapy? Members had come through a service where STEPPS lingo and model was the thread that had run through all parts of treatment. The group rules in activity groups did not allow discussion of past trauma while in group. Would this shift in boundaries be manageable? How would the structure of individual CAT translate to a group and would group members receive the same 'value for money' as they could have with individual therapy?
In this article, we describe the process of setting up a pilot CAT group and reflect upon our experience of facilitating a therapy group for clients within a specialist personality disorder service. We aim to provide enough detail so that others could pilot similar groups.
Recruitment
Group members were selected from the membership of a tier 3 personality disorder service. It was a prerequisite to have completed a STEPPS programme and not have undertaken another formal therapy in the previous 12 months. We met candidates individually for an interview where CAT, and the planned course of the therapy group was explained. Overall, we were looking for people with a recurring TPP (trap/dilemma/snag), and who demonstrated some curiosity as to their procedures and reciprocal roles.
Group structure
We ran 22 group sessions in all as part of the pilot. We debated how to maintain the CAT process of 'recognise, reformulate, revise' within a group session that ensured that all members came with us on the therapy journey. We made the decision that the first six sessions were designated 'psycho-educational'. We felt that this would allow members to settle into the group and provide a safe way to start developing a relationship with other group members. Each psychoeducation session lasted 90 minutes with a break. The remaining 16 sessions were exploratory, lasting 75 minutes that just ran through.
The reformulation process was woven through those first sessions, while juggling the introduction of theoretical concepts and the components that need to be present in any psychotherapeutic group.
In session 1, after some questionnaire measures, the group did a warm-up exercise followed by co-production of a group agreement. We ended this session with a 'hopes and fears' exercise. The remaining five psycho-ed sessions used a format of: a check-in, some CAT theory inviting reflection and examples from their everyday lives, and a check-out to capture how they were at the end of group, and that they were safe to leave. The psychotherapy file was given out in session four, and by session six the members had each identified a target problem that they wanted to focus on.
It was interesting that we really did not know initially where the land would lie between individual and group maps. However, it was agreed by the group that a group map would be developed. While both group members and facilitators were apprehensive about how this would work, it soon became clear that this large map was a crucial and core part of the group - both physically (on the floor between us) and as an anchor point for discussion.
In the same vein, rather than separate reformulation letters, we wrote a group reformulation letter which was read out to the group.
Before the last session, each member was asked to write a goodbye letter to the group, and the facilitators did the same. Letters were shared in the final session.
DISCUSSION:
Psychoeducation
In hindsight, we now realise that the psychoeducation sessions were an unnecessary safety net that we felt was needed prior to exploratory sessions. It became apparent that members were keen to get on with 'therapy proper'. When introducing a topic, they would relate distressing events from their lives that were real and important rather than the psychoeducational topic that had been planned. We ended up attending to the material presented in those initial weeks and put the psychoeducation on the back burner. Those initial sessions therefore became richer and moved the group process on considerably.
Group vs individual maps
Although the group were encouraged to create and share personal maps, we developed a single group map that encapsulated their common themes - one that could be added to, altered and discussed as the therapy progressed.
We began by mapping individual TPPs on a whiteboard and then transferred common reciprocal roles, alongside traps, dilemmas and snags, onto large sheets of paper. As therapy progressed this scruffy map lay between us and became a focal point that we referred to as we talked. We used a template of the longed for, 'ideal' place at the top, and the most feared, 'core pain' at the bottom. In the middle lay the 'battleground' of the 'here and now' everyday challenges that the group experienced. It seemed that some of the most valuable conversations between members took place in relation to the group map, and towards the end of therapy some positive reciprocal roles (validating-validated, listening-heard, accepting-accepted) were added that showed possible exits from their procedures.
The theme of being understood and attended to individually came up in various forms throughout the group, and it seemed that a longing for individual recognition - for 'my story' not to be lost - remained until the end. Despite this tension, we feel that the group map was invaluable; that is was an essential part of what made this a group, rather than an individual therapy.
Reciprocal Roles
The theme of group versus individual was there throughout and perhaps for us as facilitators as well. The idealised roles of 'perfectly caring to perfectly cared for' was prominent in the therapy. It seemed to be present in a request for the equal allocation of space and time for each member.
Whilst the group found common ground in their traumatic histories, it was harder to support each other when it came to current, everyday problems. Rather, they would look to the facilitators to address each person's issues separately. We would in turn try to bring other members into the discussion, but this seemed to leave them feeling unattended to.
The theme of perfect care also emerged via the topic of handouts, a few of which were distributed in the first session. The members felt this was inadequate, and this perceived lack of support by providing them with something tangible, was experienced as evidence that the facilitators did not really care about the group.
As therapy progressed, the idealised pole seemed to diminish. The group was more cohesive and seemed to need less of the facilitator's input. However, in the penultimate session withholding care re-emerged. Now the facilitators were seen as not having done enough to make things better, our goodbye letter to the group was dismissed as 'patronising' because it didn't demonstrate our knowledge of each individual's struggle, and therefore, therapy had not worked. There was a strength in having three co-facilitators to weather this storm and we reflected that this support would not have been possible in individual therapy.
Target Problem Procedures
While each group member identified target problems, some struggled to recognise their enactment in the here and now. For most, it felt that their difficulty in revision related to a snag; namely, that things could not change because of their overwhelming history of trauma and neglect. The difficulty of revision is a common theme in individual CAT, but seemed to be exacerbated in a group as members supported each other in their belief that, in the face of such damage, change was not possible. Ironically, this sharing and understanding formed the majority of the exits that we were able to put on the map (understanding/understood and validating/validated).
Length of therapy
Overall, there was a focus on reformulation, with some recognition in later sessions. However, it seemed difficult to move towards revision and exits in the time available. We wondered if a longer therapy might have allowed members to more fully acknowledge their capacity to inhabit the top part of their reciprocal roles - e.g. punishing/bullying/critical. These dynamics, evident in the room, were perhaps too disturbing to broach in the time available, and in preference, the group would talk of their past - a shared history of trauma was their strongest bond and perhaps felt safer than the present. It also reflected the complexity of presentations that are found in a tier 3 service.
Being Heard
The power of CAT as a group intervention was evident in the group's capacity to validate each other's story and the trauma within. There was a touching empathy in listening to each other, in bearing witness to what they had endured and now carried with them through life. It felt that by sharing, naming and placing their experiences on the map, the burden was also shared. This validation felt stronger than that experienced in an individual therapy, with the enactment of a more powerful group reciprocal role; Listening to Being Heard.
Letters
Another way in which this 'Listening and Being Heard' role emerged was through letters. In the reformulation letter we acknowledged the histories the members of the group shared with each other and how "The power of the group lies in the common humanity you all experience." We used the letter to challenge the group to name difference; to enable therapy to move forward from the 'norming' stage. We felt that in doing so a seed had been planted that allowed more meaningful discussion to grow in later sessions.
The goodbye letter outlined the exits that had been discussed, namely; accepting support that is freely given, using the observing eye, distancing, acceptance and validation of experience, responding proportionally, trying something different, and reality testing. We also acknowledged how well the group had worked together; "Working with the three areas; the core pain, the battle ground and the idealised place, we were able to find reciprocal roles and emotional states that resonated with everyone, but also had some individual meaning". We talked about the next step of practicing new ways of being outside of the group. Initially reviled, eventually this letter was received in the spirit it was written, and each member shared a letter to the group. These letters were especially moving when naming the value they placed on the CAT group, and on each other, and in doing so they acknowledged the feelings of loss that endings bring. We reflected on the different emotions we and the group had gone through in reading a receiving these letters. There was an initial dismissal of the content which was difficult to hear(when we put so much work into writing them!). However, it was clear that part of the dismissal was a way of telling us that the group would be missed and its true value shone through in the members' goodbye letters to us and each other.
CONCLUSION:
The group intervention took place in a tier 3 specialist service for people with diagnoses of personality disorder. Overall, we concluded that a CAT group could be an effective treatment for this group of service users.
Were we to run it again we would probably follow the model used in individual CAT therapy, whereby, instead of six delineated psycho-ed sessions, the educative component of CAT would be interwoven with the initial reformulation sessions. We learnt to trust the CAT process and that the reformulation sessions provides the scaffolding needed i.e. CAT encourages the use of mapping from the outset, and diagrams and maps are a powerful way to educate the group on CAT theory and techniques.
Considering the complexity of this client group and the additional work required for a group map, we feel that a longer group (more sessions) would be better, and may allow a group to move from recognition to revision.
The group map emerged as the most powerful part of the therapy and we would encourage future group facilitators to resist the temptation to have individual maps, but encourage them to create a group map as part of the process.
While we were encouraged by the CAT group we had developed, we acknowledge that the low numbers make it difficult to provide evidence of success. Further CAT groups with people with Complex Emotional and Relational Needs are required to explore if group CAT is a more effective form of treatment than individual CAT for this client group.
References:
Calvert R., Kellet S., & Hagan T., (2015). Group cognitive analytic therapy for female survivors of childhood sexual abuse. British Journal of Clinical Psychology, 54, 391–413.
Clarke S., Thomas P., & James K., (2013) Cognitive analytic therapy for personality disorder: randomised controlled trial. The British Journal of Psychiatry, 202, 129–134.
Hepple, J., Bowdrey, S., (2015). Cognitive Analytic Therapy in an Open Dialogic Group - Adaptations and Advantages. Reformulation, Winter, pp.16-19.
Martin E., Byrne G., Conon G., & Power L., (2021). An exploration of group cognitive analytic therapy for anxiety and depression. Psychology and Psychotherapy: Theory, Research and Practice, 94, 79–95
Ryle A., (2004) The contribution of cognitive analytic therapy to the treatment of borderline personality disorder. Journal of Personality Disorder, 18(1), 3-35.
Zimmerman M., Cherminski C., & Young D., (2008) The Frequency of Personality Disorders in Psychiatric Patients. Psychiatric Clinics of North America, 31, 405–420
Author information: Dr. Mark Draper - Clinical Psychologist, Deirdre Fuller - CAT Practitioner & Occupational Therapist , Pat Lawes- CAT Practitioner & Occupational Therapist.
Contact details:
mark.draper@spft.nhs.uk, Deirdre.fuller@spft.nhs.uk, Patricia.lawes@spft.nhs.uk