Experiences of receiving cognitive analytic therapy for those with complex secondary care mental health difficulties.

OBJECTIVES: Service users with complex mental health difficulties are more difficult to engage in treatment and drop-out rates are higher, resulting in poorer clinical outcomes. Cognitive analytic therapy (CAT) is widely applied to service users with complex needs and shows promise in terms of engagement and outcomes. The aim of the present study was to examine the 'lived experience' of service users who have been retained in a full course of CAT treatment to provide important insights to why CAT seems to be an engaging psychotherapy, to inform future CAT delivery and practice with clients with complex needs. METHOD: Semi-structured interviews were undertaken with six service users aged between 25 and 47 years who had accessed secondary mental health care services and had received an average of 24 sessions of CAT. Transcripts were analysed using interpretative phenomenological analysis (IPA). RESULTS: The analysis yielded three superordinate themes with subthemes within these. The first superordinate theme referred to changes due to CAT (e.g., insight, tools to cope). The second theme referred to strong emotions evoked by CAT (e.g., feeling frustrated, scared, and upset). The final theme concerned the process of CAT (e.g., endings and therapeutic relationship). CONCLUSIONS: Whilst service users appeared to develop increased insight and acquire skills, there was variance in experiences of sustained and meaningful change post-therapy. The findings suggest adaptations may be required with these service users such as delivering the sequential diagrammatic reformulation (SDR) in a hopeful way and addressing systemic barriers to 'exits' being made. PRACTITIONER POINTS: Overall, service users with complex mental health difficulties describe benefitting from CAT, identifying improved insight and the acquisition of tools to cope. However, therapists need to be attuned to the potential fragility of service users and risk of negative affect, particularly during the reformulation phase. Consideration of delivering the SDR in a hopeful way may be therapeutic. Systemic factors such as service users being pulled to maintain the status quo in their relationships, and lack of support for or resistance to change by important others limit service users from availing of 'exits' from problem procedures. This implicates the need for more attention to systemic and possibly multi-agency working with this group of service users.

The Views of Ex-Police Officers on Child Abuse Case Attrition in the United Kingdom.

Attrition in child abuse cases is of continuing concern. International research has produced evidence to suggest that the form and quality of the evidence available in many child abuse cases is of insufficient quality to allow progression through the judicial system. Recent revelations have led to an increase in public and professional awareness of the prevalence of child sexual abuse, and how this is managed by the legal and social care systems. The aim of this research was to explore the opinions of ex-Police Officers who had direct experience relating to the management of child abuse cases about the factors affecting case progression. Seven ex-Police Officers were interviewed and the transcribed data were thematically analyzed. The five main themes derived from the data were Global Myths, Assumptions, and Misconceptions; Suitability; Resources; Professionals' Attributes; and Working Together. These themes demonstrated that the primary issues indicated by ex-Police Officers were more about relationships between professionals, an understanding of the child's perspective, and their subsequent involvement in the legal processes than simply being related to a lack of resources.

A systematic review of service user's experience of cognitive analytic therapy (CAT).

PURPOSE: It is increasingly acknowledged that understanding of the process and impact of psychotherapy is enhanced by awareness of the experience of service users. Cognitive analytic therapy (CAT) was developed as a time-limited and integrative psychotherapeutic approach. Although reviews have been published on CAT outcome studies, no reviews are currently available on service users' experience of CAT. This paper aims to systematically review and synthesize what is known about service users' experience of CAT. METHODS: A systematic search of HDAS, Cochrane, and Ethos databases was conducted. Following this, fourteen papers were selected for review, appraised using CASP tools, and then thematically synthesized. RESULTS: CAT therapy enabled service users to acquire useful knowledge and skills. Most service users found CAT tools helpful in gaining insight into their reciprocal roles and patterns. However, CAT was experienced by some service users as a painful, frightening, and upsetting process, particularly in relation to the sequential diagrammatical reformulation (SDR) and reformulation letter. The importance of the therapeutic relationship was highlighted, as well as difficulties some service users had with trusting their therapist. CONCLUSIONS: CAT is helpful in supporting service users to understand their patterns and to identify useful coping skills. However, some service users can experience strong emotions in therapy and struggle to trust their therapist. Greater attention to working within the service users' zone of proximal development (ZPD) and engendering hope during the reformulation stage may attenuate some of these risks. Recommendations are made for future research directions. PRACTITIONER POINTS: CAT therapy enables users to develop insight to their reciprocal roles and patterns and helpful coping skills. The service user's ZPD should be worked with when delivering CAT to manage risk of distress and reciprocal role enactments and enhance the working alliance. CAT therapists should explore ways to engender hope by attending to any helpful reciprocal roles, patterns, and exits.

Medicons: toward clinical examination diagrams standardization in medical documentation.

BACKGROUND: Electronic patient records (EPRs) allow efficient and accurate medical documentation. Diagrams have traditionally been used to document clinical signs in patient notes. The interpretation of these diagrams may vary among doctors across a range of specialties, but this has never been tested previously. This study investigated how common diagrams were interpreted and explored the use of digitalized diagrams - Medicons in creating a common language to be used in digital clinical examination proformas. MATERIALS AND METHODS: A cross-sectional survey utilizing a multiple-choice questionnaire was carried out across London hospitals. Seventeen digitalized examination diagrams were included in a multiple-choice questionnaire to test doctors' perception and explore their opinions of diagram usage. The questionnaire was sent to junior doctors in training. RESULTS: A total of 206 responses were received from 31 foundation year 1 trainees, 45 foundation year 2 trainees, 94 core surgical trainees and 36 core medical trainees. Diagrams were interpreted correctly, on average, 75% of the time. The majority of doctors (94%) felt that diagrams facilitated the understanding of clinical examination, documentation of pathologic site (98%) and improved the efficiency of documentation (89.8%). All doctors felt that diagrams may benefit overall medical care provision. CONCLUSION: Digitalizing signs and symptoms in EPR will enhance clinical documentation and may contribute to better patient care. New initiatives need to be employed to increase the use of diagrams - Medicons, as young doctors perceived these to improve clinical documentation. Standardized electronic proformas should be included into EPR to improve the efficiency and accuracy of clinical examination documentation.

Interprofessional education and working in mental health: in search of the evidence base.

AIM: To explore interprofessional attitudes arising from shared learning in mental health. BACKGROUND: Inter-professional education in healthcare is a priority area for improving team-working and communication. Many studies have attempted to evaluate its benefits and challenges, although few emanate from the mental health arena. However, producing evidence to link educational input with clinical outcomes is notoriously difficult. This project attempted to produce evidence for changes in interprofessional attitudes and stereotypes. METHOD(S): Mental health nursing students and clinical psychology trainees participated in inter-professional education. An evaluation tool was designed to evaluate the experience and outcomes, and to consider implications for interprofessional working. RESULTS: There was an increase in clarity regarding roles, approaches and resources, and how to collaborate in practice. There was no significant change in professional identity. Many challenges were identified, including differences in academic level, previous experience, expectations, assessment, motivation and effort. CONCLUSION: Despite the challenges, it remains important to offer collaboration with future mental health colleagues as a foundation for effective team-working. Recommendations are made for creating inter-professional education opportunities for diverse student groups. IMPLICATIONS FOR NURSING MANAGEMENT: Mental health professionals need to work effectively in multidisciplinary teams. Drawing on available guidance, managers should encourage and support team members to undertake shared learning where possible, both within clinical settings and through more formal educational provision. In this way, managers can facilitate collaborative relationships which will pay dividends for the provision of effective mental health care. This project adds to the limited knowledge currently available on interprofessional learning and attitudes within a mental health context.