Letters in cognitive analytic therapy : the patient's experience
"Written words don't fade, they endure through space and time, bearing
witness to the work of therapy and immortalising it"
(Epston, 1994: p31)
Aim: This study explored how the therapeutic letters, which are used as a
standard procedure in Cognitive Analytic Therapy (CAT), contribute to the therapy from
the perspective of patients.
Background: CAT is a structured, time-limited psychotherapy (Ryle & Kerr,
2002). Letters form an important part of the reformulation and ending stages in CAT.
However, little is known about the impact these letters have on the therapeutic process
and how they are used from the perspective of the patient. Exploring the meaning and use
of letters may further our understanding of this process, as well as giving value to
Method: Semi-structured interviews were used to elicit eight participants'
perspectives of how the letters in CAT contributed to their therapy. A thematic analysis
based on certain grounded theory principles was used to analyse the interview transcripts.
Results: The analysis of participants' accounts suggested that the letters in CAT
contributed to therapy through a process of `connecting' patients in varying degrees in
the following four ways to: `understanding and awareness of self', `relationship with
therapist', `perception of the structure and process of therapy', and `communicating self
with others'. CAT theory has addressed many of these findings. However, the dilemmas
and risk associated with the letters, such as re-invoking painful emotions by re-reading
them and whether to share them with others, pervaded patients' accounts, offering a more
complex understanding of the part the letters played, beyond those currently proposed by
Discussion: It is proposed that it is the letters' ability to tap into patients'
experience of connecting and relating, internally and externally, and the difficulties
entailed in this that makes them such potentially powerful therapeutic tools. Clinical and
theoretical implications and suggestions for future research are also discussed