In this article, Jamie Kirkland, Karen Shannon and Andrea Daykin povide an overview of how applications of Cognitive Analytic Therapy have developed in the forensic field.
People who find themselves in the criminal justice system commonly experience high levels of distress, mental health, trauma and complex interpersonal difficulties/personality disturbance (Pollock, P et al 1994) and risk potential (Shannon, K 2009) There is a need to provide interventions aimed to reduce distress for clients by addressing their clinical problems in addition to the prevention of offending behaviour.
Popular culture is fascinated by crime, though it often takes the perspective of the victim and the investigators. As therapists we are presented with the person, or system, in front of us.
Turning our sights to the "criminal", the Oscar winning film ‘Joker’ invited the audience to understand the backstory of the ‘evil’ Joker, Arthur Fleck. This was to make sense of his violence by looking at early trauma that shaped him. I think this is why the film moved me so much (JK). Much of my work is making sense of the early tragedies that shape future behaviour.
The helping professions try to ‘help’. However, in forensic services the first duty is public protection; not to the client or offender. But it's not really possible to engage in a therapeutic way with someone who has offended without engaging on a more human level. To work in a world of ‘unspeakable acts', the forensic profession must understand the back story. This enables us to build an empathic connection with the offender. We need to do this to work alongside the person and avoid that judging, critical, perhaps even, disgusted stance. We have to seek humanity in sometimes inhumane behaviour.
In this process, the work involves many aspects of that person’s life. But because of the consequences of such offending behaviour our work tends to include many more groups, systems, and voices. There is a risk that the forensic practitioner can become overwhelmed by all of these voices and the many eyes upon an offender. We find ways to address and work with this in our own practice, but in turn we may be called upon to support overwhelmed systems.
CAT helps enormously in this process. This relational model has developed over many years, expanding across more and more areas of our understanding of human behaviour. It provides an understanding of the self, but also the wider world. Writers who practice CAT have continued to extend its reach, offering glimpses of how it can be applied.
Three main texts have been published about CAT in forensic services:
and most recently
You can read many other chapters and articles elsewhere.
Providing CAT therapy to clients in forensic services, clinicians face the challenges of aiming to ensure both public protection, and to also assist offenders with reduction of risk potential. This is often referred to as the ‘the dual relationship problem’.
CAT therapists are therefore subject to wider systemic pressures of political, judicial, media and public scrutiny. These high demands raise frequent moral and ethical issues and systemic re-enactments that impact on therapeutic work.
CAT as a therapy has become increasingly recognised across the full range of forensic settings and security levels, including:
community forensic mental health teams
intellectual disability services
low, medium and high secure hospitals
probation/offender personality disorder pathways Daykin, A et al 2024
prison Willis, A et al 2024
as MAPPA (Multi-Agency Public Protection Arrangements) processes Darajee, R et al 2024, Kirkland, J et al 2024).
There has been development of innovative, diverse practice in CAT across disorders, offence type and age ranges, involving adaptations for different individual and group formats and cognitive limitations.
People who break the law usually have a positive aim. They are attempting to secure some kind of valued outcome in their lives. However they experience a range of limitations in themselves and their environments which prevent them from getting their needs met. Individuals therefore resort to offending; damaging and antisocial ways in attempt to meet their needs (Shannon, K 2009.
As therapists we want to understand how earlier traumatic experiences have shaped clients’ ways of relating, and how these experiences are internalised and result in difficulties such as:
fluctuating levels of dissociation and reflective abilities
limited problem solving
difficulties regulating their emotions and behaviours, and
problems navigating relationships with themselves and others
We aim to work alongside individuals, some of whom have been victims of harm, and who are also perpetrators of harm to themselves and others. As such they can occupy both positions of a reciprocal role e.g. abusing (perpetrator) to abused (victim).
CAT can help a diverse range of offending behaviours , including:
varying levels of severity of violent and sexual offences eg see (Mitzman, S 2010, Manson, K et al 2017
CAT therapy can be time limited (Carradice, A 2013) or 16-24 sessions to address clinical problems and offending behaviour (paper). However, the focus and pace of therapy will be determined by the individual’s zone of proximal development (ZPD) and there may be a need for preparatory or ‘pre-CAT' work’ focussed on engagement (Shannon, K 2016).
Families can also benefit from applications of cognitive analytic therapy e.g.
CAT therapy also focuses on co-presenting issues such as substance misuse or psychosis Morgan, S 2018 CAT can accommodate and complement other therapies and ways of working while being used as an overarching model, to also guide and integrate forensic services (Annesley, P et al 2012, Brown, R. et al 2024 a and b)
At the heart of forensic services is effective risk assessment. CAT provides an opportunity for a collaborative and relational risk assessment incorporating CAT formulation in risk assessment and management plans. This can help inform management plans at both an individual and systemic level Shannon, K 2009 Mitzman, S 2010, Darajee, R et al 2024, Kirkland, J et al 2024).
Criminal justice settings often involve multiple agencies and the voices of professionals and agencies working with the client can predominate in risk assessments . A CAT-informed risk assessment ensures that the voice of the client has more representation in this process. (Kirkland 2015).
We can use the principles from CAT in a versatile range of ways.
As well as working directly with clients, the CAT model can be applied in reflective practice with staff teams (see chapter: Marshall, Yorke et al, 2021).
It can be used as a consultative, case management or supervision tool for professionals who are working directly with clients. For example, the 5 Session CAT care planning approach involves time limited sessions with the client, keyworker and therapist. This approach has been adapted for use on the Offender Personality Disorder Pathways (see chapter: Daykin & Ryan, 2024).
Forensically orientated introductory CAT training has been used to relationally inform a whole clinical workforce of a forensic service, alongside provision of individual psychotherapy by CAT practitioners and CAT informed multidisciplinary risk formulation (Ramm 2010).
CAT has been developed and utilised as an organisational framework in non-mental health/non=forensic settings e.g. homeless services and women’s refuges, and for people who are involved with the criminal justice system. Innovative use of CAT has developed trauma-informed and psychologically-informed environments. This has been achieved via: the formation of relational organisational and service strategies, conflict management, human resources policy and procedures. This approach involves providing CAT training and reflective practice at all levels from Directors, senior managers, support staff and case management for staff and clients Shannon, K et al 2017,Shannon, K et al 2016
A whole system approach was attempted within a forensic service with CAT being used as a primary driver (Marshall & Kirkland, 2021)
Working with clients' experiences of trauma, harm from others, extreme distress and survival can provoke difficult emotions and may elicit vicarious trauma for therapists and other professionals working in this field.
CAT Therapists receive CAT therapy as a key part of their training. This and ongoing reflection and supervision are necessary for working effectively in forensic settings. The provision of the safe, containing space, to normalise feelings elicited, actively reflect on them, is key to limiting the experience of distress or isolation for therapists, and importantly to inform formulated interventions for clients.
In turn CAT therapists often provide supervision and support to other staff working in this area.
Limited research exists on CAT in forensic settings. Published studies often reflect case study examples. These are valuable, but the field would benefit from further research.
If you work in the forensic field and are interested in making links with others using CAT in this area, then there is a CAT and Forensic Services Special Interest Group (SIG) . This is open to open to all those working in forensic services, from CAT practitioners to those interested in learning about the model. You do not have to be an ACAT member to join this group. For more information go to the dedicated page listing ACAT's Special Interest Groups.
