Introducing Cognitive Analytic Therapy. Anthony Ryle
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quite arduous undertaking. In many ways it has felt a weighty responsibility to re‐state and update what was essentially Tony's life’s work, although the development of the model was assisted increasingly by various others who are cited in the text. It has also inevitably felt a rather poignant and solitary undertaking at times, despite helpful discussion with various current colleagues, in the absence of Tony’s “larger than life,” innovative, critical, and at times impatient presence and input. It would have been good at various moments to have been able to “chew things over” with him as I and many others would have done in the past.
This revised edition has unfortunately been delayed by the inevitable distractions and intrusions of life, both personal and professional. This has included, sadly, a protracted but morally unavoidable involvement in campaigning in support of “whistle blowers” in the face of some serious incompetence, victimization, and cronyism within and around the NHS in the UK. But I have also been guilty of some procrastination, a tendency to unhelpful over‐inclusiveness, and aspiring to imagined perfect outcomes; all of this Tony with his talents was much better able to transcend, to “see the wood for trees” quickly, and to express his views articulately—if sometimes very forthrightly!
As regards terminology, we have in this revision on the whole, as noted in the previous edition, referred to “patients” rather than “clients,” although we use the term interchangeably. We recognise an increasing tendency and preference among many colleagues, especially non‐clinical, to use the word “client” possibly given some of the arguably paternalistic and disempowering associations of the word “patient.” Possibly in part due to our own medical trainings and background we continue to take a view that the word patient has also an honorable history and associations implying notably a vocational and not essentially commercial responsibility to those who are in distress and are suffering. Indeed, the roots of the word lie in the Latin verb patior (I suffer). In our experience, too, people seeking help from clinicians and other health professionals are not always comfortable with the word client. However, times change and with them connotations and usages of terminology, including of diagnostic “labels” (see Chapter 9), and we recognize it is inevitably hard to know where consensus will lead.
We have also in this edition deliberately drawn back from use of the term “intervention” which we felt has become increasingly and excessively used as a synonym for “treatment” or “therapy.” While the word may make some sense as a high‐level, collective descriptive of treatment approaches, it still to our mind carries unfortunate mechanistic and militaristic echoes at best applicable in health care in, for example a “doing to” public health context, but not we suggest as a description of any collaborative, humane, relationally based treatment, far less psychotherapy. Unfortunately, in an era of increasing “commodification” of health care and of staff it also carries for us a quasi‐commercial and mechanical resonance invoked by phrases such as “delivering interventions” which we felt sat uneasily with our therapeutic position and aims. Again, however, we recognize that word usage changes and it may be our views are effectively already superceded and redundant, and that the word already means something different, perhaps regrettably, to a present generation of health care professionals.
We both sincerely hoped that this reworked and revised edition would be welcome and helpful to a range of people, both fellow mental health professionals and others, and I hope, despite its delayed and rather complicated coming into being, that this will prove to be the case. I very much hope that it may also contribute in some way to a more meaningfully relational and compassionate moving forward for us all much more broadly. This was, I am sure, another deeply felt aspiration and hope on Tony’s part.
Ian B. Kerr—Whangarei, New Zealand–Aotearoa (2020)
Preface to the Second Edition
This book offers an updated introduction and overview of the principles and practice of cognitive analytic therapy (CAT). The last such book appeared over 10 years ago and was the first systematic articulation of a new, integrative model which had been developed over a period of many years. Although there have been two specialist volumes since then (Ryle, 1995, 1997a) it is significant that a restatement of the model and its applications is now necessary. There are many reasons for this. They include the fact that as a young, genuinely integrative model (as acknowledged in the influential Roth and Fonagy report (1996)), it is still evolving and developing both in terms of its theoretical base and its range of applications. In this book, a further exposition of the CAT model of development is given, stressing in particular an understanding of the social formation of the self based on Vygotskian activity theory and Bakhtinian “dialogism.” We also outline an ever‐expanding range of practical applications of CAT as an individual therapy as well as its application as a conceptual model for understanding different disorders and informing approaches to their management by staff teams. This trend has been described (Steve Potter) as “using” CAT, as opposed to “doing” it. Newer or preliminary applications of CAT reviewed here include CAT in old age, with learning disabilities, in anxiety‐related disorders, in psychotic disorders, CAT for self‐harming patients presenting briefly to casualty departments, CAT with the “difficult” patient in organizational settings, and CAT in primary care. In part these also reflect theoretical developments of the model which are also reviewed. Its gradually expanding evidence base is also reviewed, along with some of the difficulties, both scientific and political, inherent in research in this area.
CAT evolved initially as a brief (usually 16‐session) therapy. This was partly for pragmatic reasons and related to the search for the optimum means of delivering an effective treatment to the kind of patients being seen in under‐resourced health service settings. However, it also arose from consideration and evaluation of which aspects of therapy, including its duration, were actually effective. This aspect of research is fundamental to the model and continues to be important in its continuing evolution. We suggest, incidentally, that a brief treatment like CAT, within the course of which profound psychological change can be achieved, genuinely merits the description of “intensive” as opposed to much longer‐term therapies usually described as such, which we suggest might better be called “extensive.”
Despite the effectiveness of brief CAT for very many patients, it is clear that not all patients can be successfully treated within this length of time. However, it is also evident from some very interesting work, with, for example, self‐harming patients but also less damaged “neurotic” patients, that effective work can also be done in a few, or even one session. The length of treatment has thus been modified to adapt to the needs of differing patients. Longer‐term therapy may need to be offered to those with severe personality disorder, longstanding psychotic disorder, or those with histories of serious psychological trauma. Thus, there will be some patients for whom the reparative and supportive aspect of therapy over a longer period of time may be an important requirement. Similarly, more extended treatments may be offered in settings such as a day hospital, where the treatment model may be informed by CAT, as an alternative to offering it as an individual therapy.
A further reason for the present book is the ever increasing popularity of CAT with mental health professionals and the demand from trainees and others for a comprehensive but accessible introduction to it. The rapidly increasing popularity of CAT with both professionals and patients is, we feel, a further indication of the effectiveness and attractiveness of the model. In part, we see this popularity as arising from the congruence of CAT with the increasing demand for “user participation” in mental health services; the explicitly collaborative nature of the model offers and requires active participation on the part of the client or patient. This “doing with” therapeutic position, in addition to being demonstrably effective, appears to be very much more appropriate and welcome to a younger generation of trainees and potential therapists. This “power‐sharing” paradigm has overall, in our view, radical implications for mental, and other, health services.
The CAT understanding of the social and cultural formation of the self also highlights the role of political and economic forces