ICATA Journal
Use of self in teaching reciprocal roles
Cite as: Vasilaki, E., Bradley, J., & Tanfield, Y. (2023). Use of self in teaching reciprocal roles. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 5(1), 131-139. https://www.internationalcat.org/volume-5-8
Int. Journal of CAT & RMH Vol. 5, 2023 / ISSN2059-9919
Abstract
The aim of this small study was to explore the Community Mental Health Team (CMHT) staff experience of attending a one-day relational training informed by Cognitive Analytic Therapy concepts (Reciprocal Role Procedures (RRP)) and other tools such as CAT mapping. The training placed particular emphasis on applying relational skills in day-to-day practice. Fifteen CMHT staff attended the training and completed a feedback questionnaire. Following this, six CMHT staff agreed to participate in a 30-minute semi-structured interview. The areas covered by the interview included questions about views of training, reflections on participants’ ability to draw Reciprocal Roles (RRs), supervision, and everyday practice. Interviews were analysed using thematic analysis and a double-blinded research approach. Besides indicating that CAT relational skills-based training was perceived as valuable, the findings highlight that the trainer’s willingness to use ‘self ’ has a positive impact on the participating staff ’s ability to engage in reflective practice. Barriers to self-reflection were also highlighted. The findings are discussed in relation to previous research but also in relation to implications on delivering relational based training to CMHTs. Future research ideas as well as limitations of the present study are also explored.
Keywords: community mental health staff, Cognitive Analytic Therapy, self-reflection, training, barriers, appropriate self- disclosure.
Introduction
Community Mental Health Team’s (CMHTs) adopt a multi-disciplinary model of working, with an aim to meet the complex needs of individuals with mental health difficulties. This comes with advantages but also with some potential challenges.
Previous studies have shown positive results on staff ’s ability to work with ‘complex’ presentations, whenever Cognitive Analytic Therapy (CAT) concepts were applied (Thompson et al, 2008; Jones & Annestey, 2018; Clinkscales et al., 2018). The key element among these studies was that their training days and or reflective groups were guided by the concepts of Reciprocal Role Procedures (RRPs) and the use of Sequential Diagrammatic Reformulation (SDRs) (Ryle, 1991).
In CAT, RRPs are understood as other to self, self to self and self to other. They help map out relational procedures (Ryle, 1991) which are sequences combining perception, knowledge, aim-directed actions, and affect (Ryle & Fawkes, 2007). RRPs are thought to be developed and internalised during early life and individuals will have a repertoire of RRPs, some adaptive and some less adaptive (Ryle, 1991). Clinkscales, Tan, Jones (2018) argue that developing this relational understanding with service users can be beneficial to teams. The CAT model has been used as a consultation tool to aid reflective practice, and or service-care delivery. Research has shown that skills-based training, informed by CAT, can support staff to develop a shared and common language that can help them to work with complex clients and make better use of consultation sessions (Thompson et al 2008). Several challenges can arise when CMHT staff are invited to engage in reflective practice informed by CAT thinking. These may include the lack of a shared language, different training backgrounds but also tensions arising from the invitation to shift awareness onto self as well as on the other (Westacott, 2017). These challenges can affect the quality of reflective practice but also how well staff engage and apply relational thinking in their day-to-day practice.
The Study
Aims
The current small-scale study was conducted within an NHS Community Mental Health Affective Disorders Team (CMHT). The service typically works with service users with severe mental health difficulties, and it is defined by a multidisciplinary team-based approach. The present study aims are a) to explore staff’s subjective experience of receiving a one- day relational training informed by CAT key concepts, and b) to explore how staff have experienced the invitation to reflect on their own reciprocal roles.
Overview of the Training Day
Reflecting on previous examples of brief relational and CAT informed training courses (e.g., Thompson et al 2008), a one-day training course was developed. The aim was to support multidisciplinary CMHT staff to learn about RRPs, practice relational mapping (draw RRPs) and to learn how to use them with the aim to understand complex relational dynamics. The content of the training included a) learning about the concept of RRs and b) practice skills such as learning to draw/map RRPs as identified in client’s histories.
The CMHT staff were supported to engage with the content of the training by the trainer (second author) sharing her personal life story while mapping relevant RRs. The trainer also shared a personal example of how those RRs were re-enacted in a therapy session with a client (consent to share information anonymously was ascertained). The aim of this was for the trainer to ‘model’ personal engagement with the self to self simultaneously with the self with others interaction of reciprocal roles.
Materials for the study
A semi structured but open-ended interview schedule was adapted and developed from the work of Thompson (2008) and Hunter (2015). The areas covered by the interview included open ended questions about CMHT staff views on how they did experience the training, and their reflection on being invited to learn how to draw RRs.
Participants and Procedure
Fifteen CMHT staff participated in the training day. They received an information sheet and consent form to participate to the current study. NHS ethical approval was obtained. Out of the fifteen who attended, six staff responded to the researcher’s invitation to participate on an approximately 30 to 60 minutes interview. A total of six participants (five community mental health nurses and one psychiatrist) were interviewed. The interviews took place at the participant’s work base. The mean number of years for which participants had been qualified was 11 (range eight to nineteen years). Participants were all experienced in working with complex presentations and in a community setting. Of the six participants interviewed, only one had attended an introduction to CAT training in the past.
Analysis
Qualitative data was collected by six participating staff, via 30-60 minutes semi-structured interviews. The anonymised transcripts and ‘quotes’ from the evaluations were analysed using thematic analysis (Braun and Clarke, 2006), and by using a double-blinded research approach. The first author (EV) engaged with reading the transcripts multiple times and organised the data into themes and subthemes using the method of coding. The third author (YT) also followed a similar process independently. The phase of agreeing on the overarching themes was conducted by both first (EV) and third (YT) author.
Results
From the analysis of the six 30 minutes semi-structured interviews, three main themes emerged:
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3 Rs (Reformulation, Recognition and Revision)
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CMHT staff part of the ‘relational dance’
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Barriers to relational thinking on day-to-day practice.
Theme 1. The 3 Rs Reformulation, Recognition and Revision
All six staff described feeling ‘stuck’ with service users and stated that the teaching day has helped them to use the time to think through the roles and relationships underlying the feelings around being stuck.
‘. . . clients where I felt stuck with, clients where they felt like we were failing them, and where team members were experienced different feelings. . . it has been helpful to pause and think of those in the training day. . .’ (P2)
All six staff were able to develop an understanding of their clients early relational patterns (3Rs: Reformulation) and as a result, to feel less entangled with unhelpful feelings and reactions (e.g., taking less personally, service users challenging reactions). This has enabled staff (five out of six) to feel more able to reflect on their own personal reactions, to notice both poles of reciprocal roles, and to consider re- enactments (3Rs: Recognition).
‘. . . well, the particular client I talked about, was sensitive to feeling let down by services when she rang for support and certain phrases staff used. . . it was helpful to understand her past. . . think about her ‘bad’ map. . . how we unintentionally may end up in her ‘bad’ map. . . ’ (P3)
Further, by engaging in a non-judgmental, self-reflective and compassionate ‘dialogue’, all six staff commented on how this has helped them to support clients to develop alternative and healthier ways of relating, both with services and others (3Rs: Revision).
‘. . . As a team to recognise where this distress is coming from and how it is being maintained, I think. . . it has been helpful when we had people who we felt stuck with, the training day and supervision gave us the opportunity to rethink the person. . . and to end up changing the treatment plan or how we approach what we do with this client. . . (P1)
Theme 2: CMHT staff ‘part’ of relational ‘dance’
This theme highlighted how community mental health staff received and experienced the invitation to reflect and draw their own reciprocal roles as part of the training day and to engage in a CAT mapping activity. The process of self-reflection is often familiar to psychological therapists and psychology staff in general but not necessarily to non-psychology staff. All six staff commented that the invitation to reflect on their own reciprocal roles was hard but valuable.
‘. . . so we need to reflect on our personal stuff. . . on our self- drawing my own map. . . it was not easy. I did not know how to do it – I have never done it before. . . ’ (P6)
‘. . . it is hard. . . really hard. . . thinking about yourself. . . and your own stuff. . . ’ (P4)
All six participants valued the trainers non-judgmental and compassionate relational approach built around appropriate self- disclosure when they were invited to engage in self-reflection.
‘. . . it is stressful for some staff, and they may become defensive and for this reason, I feel that when the trainer shared personal examples of RRs that were played out in therapy with a client, this helped me to be more open to self-reflection and think about how my own relational patterns may come out in my work and how I can avoid this and or why and how I may be joining the maps of some of my clients. . . (P2)
‘. . . seeing the trainer doing hers. And sharing her own store. It was quite helpful but intense. . . ’ (P6)
Theme 3: Barriers to ‘relational thinking’ on to day-to-day practice
Four participants commented on some pitfalls to the use of their relational thinking in day-to-day practice. Some of these barriers include lack of time, pressures, and lack of capacity.
‘. . . pressure of workload, we have lost staff and we do not have time. No time to think.’ (P4)
‘. . . the challenge of not having time. You know when you are really busy. . . is one of those things. . . that puts off people.’ (P1)
This theme highlights how obstacles often arise from the system in which CMHTs operate from and how this has a negative impact on their ability to engage in reflective practice.
Participants also highlighted other barriers to reflective practice. Specifically, participants commented on the systemic issues that often characterise NHS teams and appear to act as obstacles in staff ability to slow down and engage in relational reflective practice.
Discussion
This small scale study comes with limitations. It was intended to be a multi-site study across different teams but was cut short by the arrival of COVID which was frustrating having got through the lengthy process of research clearance. It is based on only six interviews and might best be considered as a research note. The present study’s findings whilst small scale highlight that CAT relational skills-based training for the participating CMHT staff is perceived as valuable as well as having a positive impact on their ability to engage in reflective practice.
The first step that was identified was the value of ‘slowing down’ and having time for self to think together. The study indicates that CAT mapping and RRPs can be a useful tool to support CMHT staff to engage in reflective practice.
The second step, linked to how the training day was delivered. The following ‘training’ invitations were helpful a), to engage in a compassionate understanding of their service users’ life story and to understand how RRPs are developed (3Rs, Reformulation), b) to learn to recognise RRPs (3Rs, Recognition) and c) to begin to consider alternative healthier ways to relate with their service users and ultimately to avoid re-enactments (3Rs, Revision) through attention to one’s own feelings.
The study also may suggest that how training is delivered may play a role in increasing CMHT staff’s Zone of Proximal Development (ZPD, Vygotsky’s 1978) when learning to practice the 3Rs. CAT places significant emphasis on the concept of scaffolding (Bruner, 1986: 77). Bruner’s theory of scaffolding was influenced by Vygotsky’s (1978) theory of the ZPD. Learning needs to happen within the learner’s ZPD (Vygotsky, 1978). Scaffolding is defined as what a good teacher provides to the child when she/he tries to learn a new skill and they are not ready to learn it independently (Nehmad, 2017). In a similar way, Nehmad (2017, p. 23) states that all good supervision and teaching should take place within the person’s ZPD, where the facilitator acts as ‘external mental function’ for the learner.
The qualitative data may tentatively indicate the trainer’s ability to ‘model’ the relational approach by using ‘self’ while teaching the use of RRPs and the 3Rs can increase CMHT staff ZPD and readiness to engage in relational reflective practice. We are left wondering whether trainers’ willingness to disclose personal examples are important in supporting CMHT staff to be less guarded and more likely to engage in reflective practice. Whilst each trainer and training situation is unique, trainers’ willingness to self-disclose can help CMHT staff to stretch themselves within each other’s zones of proximal educational development and engage more fully in meaningful learning. More research is needed into when and how to make appropriate use of modelling self-disclosure both to illustrate the cognitive and emotional aspects of reciprocal role ideas and to model the risk, safety and trust of personal engagement.
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