Introducing Cognitive Analytic Therapy. Anthony Ryle
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(1998, 2007), Brazelton and Cramer (1991), Reddy, (2008), Hobson, (2002), Gratier and Trevarthen, (2008), Braten, (2009), Apter and Williams, (2018). The field overall, along with many of its considerable implications for psychotherapy, is extensively reviewed by Trevarthen (2017). Many of the findings emerging from this fascinating body of work have illuminated in unexpected ways our understandings of early infant experience, abilities, and development. In particular, they have contradicted and disconfirmed many of the speculative ideas developed previously within the psychoanalytic tradition. This work describes an infant busily engaged from birth in a process of recognizing, remembering, and interacting with significant others, notably the mother, capable of perception, and demonstrating an increasingly dominant intersubjective focus. Many of these early processes have been described in terms of a fundamental “communicative musicality” apparently underpinning, pre‐verbally, all human interaction (Malloch & Trevarthen, 2009). This has important implications for the modality and effectiveness of any subsequent therapy (Compton‐Dickinson & Haakvoort, 2017; Malloch & Trevarthen, 2009; Trevarthen, 2017). An important feature of this developmental process is a collaborative playfulness which, from the beginning, is imbued with social meaning and makes use of signs, as in Winnicott's famous “transitional object.” The developmental importance of play, its role in creativity as well as its relevance to therapy, was stressed historically in the object relations tradition by Winnicott (1971). These issues have been further emphasized and explored by later writers such as Trevarthen (1993, 2017) and Meares (2005) and, from a CAT perspective, parallels with the work of Winnicott have been noted by Leiman (1992). The psychological predisposition to behave in these ways has been described by Aitken and Trevarthen (1997) as an innate or “intrinsic motive formation” (IMF), and also as implying the inherent psychological existence within infants of a “virtual other” (Braten, 2009). These studies demonstrate a rudimentary, pre‐verbal, sense of self existing from birth. This sense of self is developed and transformed in the context of a constant interaction with others, resulting eventually in a capacity for self‐reflection and a subtle awareness of others. This culminates normally in the development of an empathic, imaginative understanding of others (a “theory of mind”) by the age of 3 to 4 years (see also Povinelli & Preuss, 1995). These observations refute earlier theories which suggested “fused” or “symbiotic” states in early development; rather than “fusion,” the presence of an exquisite, active intersubjectivity between baby and mother is now stressed.
The predominant affects reported in these studies of infants and children are those such as joyfulness and curiosity, albeit tempered by intermittent frustration, shame, or depression (Stern, 2000; Trevarthen, 1993, 2017). These observational studies provide no evidence for such postulated entities as a “death instinct” or any innate dominant predisposition to destructiveness or to pervasive, endogenous anxiety. They also refute the idea that infants can undertake the complex, mental operations such as “splitting” or “projection,” as postulated by Kleinian writers. The damaging effects of insecurity and of externally generated anxiety on infant development are, however, stressed in this literature, and CAT would regard this as a critically important developmental issue. Such damage would include the effects of maternal depression and other ways in which the infant's need for interaction are denied (Apter & Williams, 2018; Murray, 1992, Trevarthen, 2017). Some of these effects are described in the disturbed patterns of attachment behavior observed in the “strange situation” experimental tests as developed by Ainsworth (Ainsworth, Blehar, Waters, & Wall, 1978 and see overviews in Cassidy & Shaver, 2016; Mooney, 2010). These observational studies overall confirm the importance of real, social experience in the formation of mind or of the Self. They also confirm the Vygotskian emphasis (see below) on the importance of a competent, caring, and enabling other in development and on the active, collaborative participation of the infant in this process (see also Boyes, Guidano, & Pool, 1997; Cox & Lightfoot, 1997). These findings have important implications for the way in which therapy, or any treatment, is offered to those with mental health problems.
Stern (2000) concludes his survey of the implications of observational research for a model of development by insisting on the primacy of experience over fantasy, as follows: “It is the actual shape of interpersonal reality, specified by the interpersonal invariants that really exist, that helps determine the developmental course.” This assertion has major implications for certain forms of psychodynamic psychotherapy. In some of these, the traditional aim to construct, by interpretation, the unremembered past and the implicit requirement to find evidence for the effects of such entities as the Oedipus complex or for a “death instinct” have deflected attention from the indirect evidence for, or memories of, childhood experiences presented by patients. But even the increasing emphasis in some parts of the psychoanalytic tradition on “here and now” interpretations of transference or on a “something more than” approach recognizing the importance of “implicit relational knowledge” (Stern et al., 1998) have remained apparently constrained by these traditional requirements of psychoanalytic theory and practice (Ryle, 2003).
Preceding and parallel to many of these developments in infant psychology was the pioneering body of work by John Bowlby, (also a psychoanalyst), that became known as attachment theory (AT). Although Bowlby's development of AT initially provoked considerable hostility from, and was neglected by, the psychoanalytic community, it has by now been enthusiastically embraced by many (Schwartz, 1999). Many of the more implausible aspects of psychoanalytic theory were derived from the attempt to construct a model of personality based on drives embodied in conflicting structures, or internal objects (seen in some accounts as largely arising from endogenous psychic impulses) within some “mental apparatus.” Bowlby offered a more acceptable biological basis in ethology, suggesting in particular that experiences and behaviors related to attachment and loss could be seen as examples of complex innate behavior patterns found throughout much of the animal kingdom. This revision, easily linked with some versions of object‐relations theory and in Bowlby's view constituting a version of it (Bowlby, 1988), drew attention to the profound importance of the quality of real experience and of the infant's bond with the mother. This constituted a radical and humane revision of contemporary psychoanalytic theory despite its being received with much hostility and misrepresentation at the time (Schwartz, 1999). The theory was developed using cognitive psychology concepts to describe the early formation of internal “working models of relationships” responsible for the subsequent shaping of relationship patterns. Workers in the AT tradition have also carried out important research describing how the form and content of parents' recollections of childhood are linked to the patterns of attachment displayed by their own children. From a CAT perspective, Jellema has offered a series of thought‐provoking papers on the importance of an AT perspective particularly in considering personality‐type disorders (Jellema, 1999, 2000, 2002). However, in its initial form a least, in seeking a respectable scientific base in biology, AT largely ignored what is essentially human, namely the formative role of culture and its meanings and values, and from Bowlby's “working models of relationships” on, has largely adopted restricted, cognitivist assumptions. The creation and maintenance of other self processes and the transmission of social values in the mother–child relationship were not explicitly considered. It appears that AT was enthusiastically over‐extended in an attempt to account for all aspects of development (including the generation of “theory of mind”) and psychopathology. In our view, and that of many others (Aitken & Trevarthen, 1997; Brown & Zinkin, 1994; Gilbert, 1992; Leiman, 1995), this theory, although important, described only some of the factors involved in healthy growth and development. Although the issues that attachment theorists stress are important, in particular loss and attachment throughout the life cycle (Bowlby, 1988), AT does not, in itself, at least in its earlier formulations, appear to offer an adequate account of the complexity and subtlety of development or of psychopathology. However, in recent years, the scope of AT has itself broadened very considerably with the result that its field of study appears now almost synonymous with, and to include, most other domains of developmental psychology (for overviews see Cassidy & Shaver, 2016; Mooney, 2010).
The Contribution of Vygotsky's Ideas
Many of the criticisms made of classical psychoanalytic theory and practice during the evolution of the CAT model, and many features of the specific methods employed,