Abstract
Ryle challenges the assumptions of many authorities concerning the length of therapy required for the majority of patients with borderline personality disorder (BPD). The model of therapy he has called cognitive analytic therapy (CAT) limits the duration of treatment for BPD to 16–24 sessions. Ryle suggests that clinically significant changes are achieved by just over two thirds of patients in this time and that the majority of patients do not require further treatment. Given the cost of longer treatments his model deserves careful consideration.
Cognitive analytic therapy has developed over the last 15 years from Ryle's early integration of personal construct psychology and object relations theory. Its mature form incorporates understandings from object relations theory, attachment theory, and the work of Vygotsky on the social and cultural formation of mind. The ‘cognitive’ in the title refers to the active identification of thought patterns that have kept the patient stuck in maladaptive behaviours and interpersonal interactions. It is interesting to note that research designed to measure and describe change in psychodynamic psychotherapy provided information critical to the development of CAT. Ryle discovered that the collaborative work carried out by patient and therapist to identify and describe what had brought the patient into treatment had a powerful therapeutic impact. This collaborative endeavour came to be called the ‘joint descriptive reformulation’ and became a defining feature of CAT.
The most useful feature of this joint descriptive reformulation for patients with BPD, according to the CAT model, involves the descriptions of shifts between different ‘self states’ which are more or less dissociated from each other. This dissociation is said to reflect the failure to develop higher-order integraling and self-reflective [1] functions as a result of adverse early life experiences. The realities of the borderline patient's life experiences, frequently of cruelty, abuse and neglect are taken fully into account by practitioners of CAT. Indeed, Ryle's trenchant criticisms of certain psychoanalytic models of BPD focus on their failure to take these experiences sufficiently into account. His view is that patients with BPD have a fragmented sense of self and of relationships with others, not through defensive splitting but through a developmental failure of integration.
While acknowledging that psychoanalysis, self psychology, cognitive therapy and dialectical behaviour therapy have all made significant contributions to the understanding of BPD, Ryle argues that the CAT model provides a more comprehensive understanding and more rapidly effective treatment.
The book provides a clear account of the theory and practice of CAT for patients with BPD. There are criticisms to be made. Some readers will find the constant use of acronyms annoying and will regret the frequent necessity to refer to previous pages to rediscover what the acronym means in words. The index is among the most inadequate I have seen. Some readers will want more research-based evidence of the efficacy of CAT for patients with BPD. However, experienced clinicians among the readership will be heartened that the research so far involves unselected outpatients with BPD, and thus does not suffer from doubts about how far generalisations can be made to the clinical world of real patients.
The most important omission in this work is that no information is provided about the outcome of CAT months or years after the treatment. Such information is crucial, particularly in the borderline group of patients.
Ryle acknowledges the lack of available evidence of the effectiveness of CAT from controlled trials, but on the basis of ongoing research evaluation, suggests that clinically significant change can be achieved in two-thirds of patients using this modality. He adds that comparative trials involving CAT await funding, and the cooperation of practitioners using a different treatment method. Clinicians treating patients with BPD will hope that the funding becomes quickly available, and that it includes funding for long-term follow-up.
Ryle acknowledges that, given the complexity of the psychopathology of patients with BPD, it is unlikely that one mode of intervention would suit all patients. He acknowledges that for some, the prolonged regressive and ambivalent dependencies of many long-term therapies and psychoanalysis may be of value. As he says ‘maybe those few patients who cannot recover with the combinations of the various active methods described above need real, intensive care'(p. 160).
It is possible to envisage a future in which an active therapy like CAT, if proved effective in comparative trials and on follow-up, is made available as a first line of treatment for patients suffering BPD. Delineation of the characteristics of those borderline patients unlikely to respond to the more active methods will emerge over time, a prospect Ryle envisages. Those patients who fail to respond to the more active methods, or who fit into the group of patients unlikely to respond, could then, perhaps have longer term treatment provided, without accusations of indulgence and overservicing which currently plague such treatments. Studies of the efficacy and outcome of these longer-term treatments, while difficult, are not impossible. Questions about which therapy for which patient with BPD could then receive more accurate answers than those currently available. Work in this direction has already been carried out [2], but more still needs to be done.
All who treat patients with BPD should read this book. They will be challenged to think about the work they are doing, to justify their use of technique and the theoretical framework they employ.