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I am very grateful to the Editor for publishing, alongside my paper ‘Addiction to the death instinct?’, the commentary by Ann Scott, and grateful to her for the tone and contents of her remarks. The opportunity to respond in turn to the points she raises gives me the chance to spell out more positively the agreements and disagreements between CAT and Psychoanalysis.
It is clear that CAT can treat many more patients per therapist or per budget than can either psychoanalytic psychotherapy or psychoanalysis. But this would be of no interest if it were shown to have no lasting, humanly valuable effects. We have accumulated enough experience to know that this is not the case, even with patients with border-line and narcissistic personality disorders of the type discussed in Joseph's paper. Most of what I say here will refer to this group. Who can benefit in what ways can only be clarified by careful research and we are currently accumulating a series of such patients treated with 16-24 sessions and to be followed up for as long as possible. The therapies are being audiotaped with the aim of documenting the process and relating it to outcome. It would be excellent if a group of psychoanalytic therapists would undertake a parallel study.
To move on to theory, yes, it is my belief that ‘damage comes primarily “from outside”’ or, more precisely, from the interpersonal field in which the individual is formed. This does not deny that we are born with different potentials for love and hate and different thresholds to harm. But having assessed around 200 borderline patients in the course of my life I am angered by the scant attention paid to actual life experience in the accounts of most psychoanalytic authors. In the face of the abuse, torture and neglect suffered and, in most cases, at least partly remembered by these patients, it is insulting and misleading to explain their destructiveness and damage in terms of ‘ego weakness’ or a large dose o