Introducing Cognitive Analytic Therapy. Anthony Ryle

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СКАЧАТЬ psychotherapy must consider these issues if not resolve them. We believe that this is an area where the CAT model may have something to offer. Any model of psychotherapy should be able to generate some meaningful account of cultural and ethnic diversity as manifest in the range of individuals and their problems who may, or may not, experience them as “mental” problems, or present for “treatment” (see, e.g., Bhui & Morgan, 2007; Burman, Gowrisunkur, & Sangha, 1998; 2007; Dalal, 1992; Krause, 1998; Kirmayer, 2005; Mills, 2014; Paris & Lis, 2013; Tseng, 1999). In some cultures, emotional distress may be experienced and present as somatic symptoms, in some as overt anxiety or depression. In others, including our own, distress may also be “repressed” through, for example, “coping” or “soldiering on” role procedures. Expression of distress may vary considerably over time within a given culture. A century or so ago in Europe, for example, “hysterical” or “conversion” disorders were more common, at least in certain classes, as addressed by authors such as Charcot, Janet, and Freud (see e.g., review by Schwartz, 1999).

      Another example of how culture is manifest in terms of self‐identity is evident in the ways in which meaning is ascribed to gender. The diversity, increasing understanding, and cultural acceptability of variously gender‐related “identities” is a clear, and in the West still rapidly changing, example of how understandings, cultural values, and morals are internalized and enacted. These issues require an appropriately sensitive and flexible model to address them. (Some of these issues are addressed further in Chapter 9.) We would argue that some form of “culture mapping” should be at least implicit within any model of psychotherapy and that psychotherapists should ideally aim to be free of normative cultural values. Although this represents an important aim it can clearly never, by definition, be fully achieved given our own varying cultural formation. But CAT's practice of collaborative reformulation does aim to reflect on and make joint sense of what each patient brings to therapy, including their cultural assumptions and formation, and including in relation to our own. Every CAT diagram should in fact represent effectively a “micro‐cultural” reformulation. Consideration of these issues led to a renowned cultural psychologist such as Bruner to suggest that Homo sapiens should be considered as a “localized species” (Bruner, 2005).

Studies of Infant Development

One important influence on CAT has been the body of literature which has emerged over the past couple of decades from the observational work of infant researchers and developmental psychologists, notably Stern (2000, 2010), Murray (1992), Trevarthen (1993), Aitken and Trevarthen (1997), Tronick (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 СКАЧАТЬ