Cognitive analytic therapy

The review by Marks (2003) of our book Introducing Cognitive Analytic Therapy: Principles and Practice (Ryle & Kerr, 2002) is both rude and misleading. His reminiscences about a visit to Leningrad in 1966 have nothing to do with the book and we certainly do not see ‘Pavlovian therapy’ (with which we are entirely unfamiliar) as ‘part of cognitive analytic therapy (CAT)’. His objection to the fact that our explicitly integrative model draws on a wide range of sources tells us more about the limitations of his own conceptual framework than about CAT. These limitations are also evident in his inability to understand or unwillingness to mention the key features of CAT, which he seriously misrepresents. These include: (a) focus on ‘reciprocal role procedures’, which are formed though the internalisation of socially meaningful, intersubjective experience and subsequently determine both interpersonal behaviours and self-management; and (b) the practical emphasis on the joint creation of descriptions of these, which serve to enlarge patients’ capacity for self-reflection and change and therapists’ ability to provide reparative, non-collusive relationships.

The reviewer's bias is epitomised in his discussion of one of the case histories in the book (pp. 138–144). While asserting that this ‘patient with obsessive–compulsive rituals’ would have been better served by nine sessions of behavioural therapy or by one session plus computer-aided therapy, he fails to record that the patient was presented precisely to illustrate the limitations of cognitive–behavioural approaches and does not mention that she had previously dropped out of an anxiety-management group and of cognitive–behavioural treatment. Of this she had noted that the more her symptoms were worked on, the ‘more grimly’ she hung onto them. This was not a report of the treatment of obsessive–compulsive rituals, it was a summary of the psychotherapy of a person, an unhappy woman with a history of many years of panic, phobias, obsessive–compulsive behaviours and irritable bowel syndrome. The case was chosen, in part, to demonstrate how focus on presenting symptoms can actually be counterproductive and paradoxically collude with the enactment of underlying reciprocal role procedures in a patient who had come to be regarded as ‘difficult’ and ‘resistant’. This patient's list of ‘target problem procedures’, as worked out with her, included a pervasive need to control both her feelings and other people's behaviours. As is usual in CAT, this formulation, and her therapy, focused on intra- and interpersonal attitudes, assumptions and behaviours (procedures) and paid little direct attention to her symptoms. Therapy included, importantly, work on reciprocal enactments with the therapist. Assessment at termination and follow-up showed major improvements in her life, and psychometric testing demonstrated reductions in symptoms at termination with further reductions at 6-month follow-up.

We think it unfortunate that so obviously partisan a reviewer was selected to discuss a book outside his area of expertise and sympathy and that it was considered appropriate to publish so tendentious a review of the work of colleagues.