Book Review: Cognitive Analytic Therapy and Later Life by Sutton and Hepple

Ardern, M., 2004. Book Review: Cognitive Analytic Therapy and Later Life by Sutton and Hepple. Reformulation, Summer, pp.28-29.


I read this book not as a Psychotherapist but as a middle-aged Old Age Psychiatrist with a particular interest in psychodynamic therapy with older people. I have heard Dr Hepple (a fellow Old Age Psychiatrist) speak before on Cognitive Analytic Therapy (CAT) with older people, and his philosophy has greatly impressed me. His refreshing challenges to the stereotypical view of old age held in Western Society are underpinned by his training in the CAT model. Although I have not met the co-editor, Laura Sutton, I looked forward to delving into the book and was somewhat flattered to have been asked.

The book is divided into two parts. Part I: ‘Ageing, ageism and CAT: the theoretical and psychological context of psychotherapy with older people’ sets the background. Here one learns of the evolution of CAT by its founder, Anthony Ryle, from object relations and cognitive theories. The relevance of ageism in hitherto constricting theorists is discussed, moving then on to the practical application of CAT to older people in the clinical sphere. Part II focuses on a deeper examination of the psychological tasks which confront ageing people. In particular it explores narcissism, borderline states, depression and dementia. This redresses the imbalance of a purely biological view of old age and shows how CAT may be applied to troubled individuals and the systems within which they may become swept up.

There are advantages and disadvantages in drawing together several authors in one book. On the one hand scope and comprehensiveness are broadened. However differences in style can sometimes sit uncomfortably together. To some extent books such as these become like a patchwork quilt. Inevitably some chapters stand out and make their unique impact on the reader’s overall impression. The reader’s own motivation is of course crucial. Mine was to see if this book taught me something new that would be relevant to my work with older people finding difficulties with the latter part of their lives. Since I am not trained in CAT, could I successfully integrate aspects of the model into my everyday encounters? And would I recommend it to colleagues?

The foreword and introductions map out the scope of the book. This proved a necessary guide since chapter 1 felt hard going. Sutton and Leiman’s ‘The development of the dialogic self in CAT’ required real effort to get through. To me it was too detailed in its attempts to introduce the basic tools of CAT while simultaneously describing Ryle’s evolving conceptual framework. In the film ‘Amadeus’ the inexpert Austrian emperor, clearly not very comfortable with Mozart’s music, accused him of composing ‘too many notes’. Perhaps I am similarly naïve, but there did seem to be too much to take in by way of an overture.

Chapters 2 and 3 entitled ‘Ageism in therapy and beyond’ (by Jason Hepple), and ‘Why do so few become elders?’(by Mark Dunn) were completely different in their ability to convey material in an engaging and convincing way. Here the reader is really asked to reflect on the prejudicial processes at work in our culture and how services and individuals unconsciously conspire to exclude older people from real understanding. The older person himself is no more free from these misperceptions than the rest of us. Fortunately we are all (in contrast to Freud’s opinion) all capable of change. These ideas lay the foundations for CAT which depends upon the unravelling of interpersonal and contextual meaning. The concluding chapter of part I then uses clinical examples to flesh out how CAT works in practice. By now I found myself ready to grasp how the tools (Sequential Diagrammatic Reformulation, snagging etc) are actually applied.

Part II has another helpful introduction, drawing attention to the vulnerabilities of personality make-up in facing the vicissitudes of later life. As a psychiatrist with experience in a psychodynamic approach I found myself on familiar territory here. Nevertheless the opening chapter to part II proved a disappointment. Although an erudite analysis of King Lear (as an example of the fragility of the extreme Narcissist facing his own twilight years), it seemed to me to be unnecessary; as if the editors had felt compelled to stitch a rare piece of silk into this quilt. To my mind it was worthy of a separately published paper to further develop the writing of Noel Hess on the same subject.

Chapter 6 by Madeleine Loates describes the case of a 70 year old man referred by an exasperated psychiatrist for failing to respond to counselling or antidepressants. The fourteen session CAT is examined in detail, for me demonstrating the particular power of the reformulation and goodbye letters. This is a courageous aspect of CAT which would be an anathema to most psychodynamic therapists. Chapter 7 is a collaborative one between a Cognitive Behavioural Therapist (CBT) and a CAT therapist. With clinical examples components of CAT are synthesised with CBT in the treatment of the effects of distant trauma. The final two chapters show CAT applied to dissociative states, couples and the impact of severely mentally ill older people on their carers. These are extremely relevant to the role of the Old Age Psychiatrist and multidisciplinary team, adding a new dimension to conventional approaches and reframing the psychodynamic terms of containment and transference.

Apart therefore from a few quibbles (mostly about the fact that chapter 1 sets an off-putting tone to the beginner), I have learnt much from this book. It seems that the editors have succeeded in taking the reader right back to basic principles and beyond. One is left with a healthy self-questioning about the proper place of older people in our society, the reluctance of psychoanalysis to move on from the Eriksonian model of ‘integrity versus despair’, and the influence of our own personal anxieties on our practice. CAT is presented as a humane, three-dimensional treatment option with exciting potential applicability to NHS services. It combines theoretical rigour with flexibility, yet on the face of it is plausibly efficient and cost-effective enough to be of interest to purchasers of health care.

As psychological therapies become more mature then boundaries become blurred between one and another. For example the behavioural concepts of ‘modelling’ and ‘reinforcement’ are surely enacted, but unspoken of, on the psychoanalytic couch. In this book the authors demonstrate yet again that it is the relationship between the patient and therapist which is probably the most beneficial factor of all. What a pity that the National Service Framework for Older People disregarded all psychological treatments; at the same time purporting to ‘root out age discrimination’. This reminds me that my own service was funded on an initiative called (unashamedly) ‘the Rising Tide’ denoting the malignant creeping menace of older people threatening to overwhelm services. According to Hepple I would appear to be working within a metaphorical Thames barrier.

Although this book does not set out to be a ‘manual’ it is one that every Old Age Psychiatrist might read. In my opinion its eloquent clinical realism will resonate with the multi-facetted predicaments of our older patients and the institutions we inhabit. Not only should it broaden the clinician’s professional horizons but perhaps his personal ones too.

Dr Mark Ardern - Consultant in Old Age Psychiatry.

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Cognitive Analytic Therapy and Later Life
Eds. Jason Hepple and Laura Sutton. Pub. Brunner-Routledge 2004. 232 pages. £16.99

Full Reference

Ardern, M., 2004. Book Review: Cognitive Analytic Therapy and Later Life by Sutton and Hepple. Reformulation, Summer, pp.28-29.

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