Response to Anthony Ryle

My starting point in responding to Anthony Ryle's provocative critique of Betty Joseph's ‘Addiction to near-death’ is Dr Ryle's closing comment: ‘one year in analysis uses enough professional time to treat ten patients in this category with CognitiveAnalytic Therapy’. A debate in this area is particularly welcome because it brings together two widespread concerns: one theoretical, one about resources; I should like to suggest a third term for discussion, absent from Ryle's paper: the lastingness of psychic change. For it seems to me that this is a pivot around which to explore questions about resources and treatments of choice.

But first, some comments about Dr Ryle's presentation of Joseph. It is true that the reader has to take quite a lot on trust. Betty Joseph's patient is a theorised patient. And, in my view, Dr Ryle is right to ask the question that one would ask of any clinical approach: what mobilises the patient's capacities? It is also a bullseye to speak of hyperbole in the presentation of the patient's psychic life. But there are some unresolved theoretical issues, too. Ryle tells us what has been discarded from object relations but not what has been retained (I wish he had); and CAT's theorisation of a division of the human personality would have been helped by an unpacking of the steps by which the (to my mind) rather functionalist, benign account of role procedures gives way to a more nuanced picture of a self at odds with itself. And I hope I am not caricaturing CAT in concluding that psychic damage comes primarily ‘from outside’ (the stress on adverse circumstances). So we have a view of human relationships in which even severe disturbances of mental functioning can be modified by the provision of a task-oriented therapeutic setting in which the therapist and patient agree on a new, shared language and set of procedures that will initiate and reinforce change.

At its heart, however, Joseph's paper is concerned with the question of refusal: the refusal