Introducing Cognitive Analytic Therapy. Principles and Practice

Isaac Marks

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Reading this book brought to mind a sobering experience from my youth. In 1966, I visited a psychotherapy institute in Leningrad (now St Petersburg). Its doctors said they used ‘Pavlovian’ psychotherapy. How did they do this? They admitted patients, took a detailed history of their upbringing and showed them how current maladaptive behaviours grew out of earlier forms of interaction with family and others which needed revision to become more appropriate to current circumstances. Western psychotherapists using a similar approach might have been surprised to hear that Pavlov was its progenitor. Now Ryle & Kerr see it as part of cognitive analytic therapy (CAT), which takes about 16 sessions. Together with the patient, the therapist writes a reformulation letter that sets out aims in therapy. The patient self-monitors, with the help of a diary, to spot problems as they arise and try to revise them, and rates target problems. The patient and therapist exchange goodbye letters at the penultimate or last session to review what has been achieved or remains to be done, and follow-up is arranged.

Case examples show how CAT assessment is done and reformulation letters and diagrams are constructed. Its use of a goal-oriented approach, diary-keeping, self-ratings and collaboration with the patient overlaps with the practice of behavioural and cognitive therapists. However, a case history of CAT in a patient with obsessive—compulsive rituals (pp. 138-144) highlights how CAT differs from behaviour therapy by exposure and ritual prevention: the ‘ target problem’ procedures did not mention the rituals, the post-treatment rating of improvement did not say whether or not rituals reduced, and a mean of 16 sessions of ‘brief’ CAT exceeds the 9 sessions usual with face-to-face behavioural therapy, let alone the single hour of clinician contact needed with computer-aided behavioural therapy. The authors acknowledge the paucity of controlled trials of CAT. The aim of CAT in early dementia seemed unclear (p. 156).

The authors say that CAT derives its ideas from evolutionary psychology, genetics, developmental neurobiology and psychology, and uses a ‘ Vygotskian perspective’ regarding ‘sign mediation’, ‘ Bakhtinian concepts of the dialogic self’ and ‘Kellyian personal construct therapy, cognitive therapy and psychoanalytic object relations theory’. These supposed roots remind one of the historian's warning of ‘idols of origin’.

A would-be practitioner might learn more from the book's case illustrations than its turgid theoretical digressions, replete with redundant argot. We need not have heard of Vygotsky to know about meaning, intention and signs, or of Bakhtin to know that we are social beings.

The case histories give an idea of what CAT is about, but the book testifies to the long journey ahead before psychotherapy can reach the authors' laudable goal of a lucid language, method and evidence-base shared by all practitioners.