Psychotherapies and the space between us

Public domain image from pixabay. Click for source.There’s an in-depth article at The Guardian revisiting an old debate about cognitive behavioural therapy (CBT) versus psychoanalysis that falls into the trap of asking some rather clichéd questions.

For those not familiar with the world of psychotherapy, CBT is a time-limited treatment based on understanding how interpretations, behaviour and emotions become unhelpfully connected to maintain psychological problems while psychoanalysis is a Freudian psychotherapy based on the exploration and interpretation of unhelpful processes in the unconscious mind that remain from unresolved conflicts in earlier life.

I won’t go into the comparisons the article makes about the evidence for CBT vs psychoanalysis except to say that in comparing the impact of treatments, both the amount and quality of evidence are key. Like when comparing teams using football matches, pointing to individual ‘wins’ will tell us little. In terms of randomised controlled trials or RCTs, psychoanalysis has simply played far fewer matches at the highest level of competition.

But the treatments are often compared due to them aiming to treat some of the same problems. However, the comparison is usually unhelpfully shallow.

Here’s how the cliché goes: CBT is evidence-based but superficial, the scientific method applied for a quick fix that promises happiness but brings only light relief. The flip-side of this cliché says that psychoanalysis is based on apprenticeship and practice, handed down through generations. It lacks a scientific seal of approval but examines the root of life’s struggles through a form of deep artisanal self-examination.

Pitching these two clichés against each other, and suggesting the ‘old style craftsmanship is now being recognised as superior’ is one of the great tropes in mental health – and, as it happens, 21st Century consumerism – and there is more than a touch of marketing about this debate.

Which do you think is portrayed as commercial, mass produced, and popular, and which is expensive, individually tailored, and only available to an exclusive clientèle? Even mental health has its luxury goods.

But more widely discussed (or perhaps, admitted to) are the differing models of the mind that each therapy is based on. But even here simple comparisons fall flat because many of the concepts don’t easily translate.

One of the central tropes is that psychoanalysis deals with the ‘root’ of the psychological problem while CBT only deals with its surface effects. The problem with this contrast is that psychoanalysis can only be seen to deal with the ‘root of the problem’ if you buy into to the psychoanalytic view of where problems are rooted.

Is your social anxiety caused by the projection of unacceptable feelings of hatred based in unresolved conflicts from your earliest childhood relationships – as psychoanalysis might claim? Or is your social anxiety caused by the continuation of a normal fear response to a difficult situation that has been maintained due to maladaptive coping – as CBT might posit?

These views of the internal world, are, in many ways, the non-overlapping magisteria of psychology.

Another common claim is that psychoanalysis assumes an unconscious whereas CBT does not. This assertion collapses on simple examination but the models of the unconscious are so radically different that it is hard to see how they easily translate.

Psychoanalysis suggests that the unconscious can be understood in terms of objects, drives, conflicts and defence mechanisms that, despite being masked in symbolism, can ultimately be understood at the level of personal meaning. In contrast, CBT draws on its endowment from cognitive psychology and claims that the unconscious can often only be understood at the sub-personal level because meaning as we would understand it consciously is unevenly distributed across actions, reactions and interpretations rather than being embedded within them.

But despite this, there are also some areas of shared common ground that most critics miss. CBT equally cites deep structures of meaning acquired through early experience that lie below the surface to influence conscious experience – but calls them core beliefs or schemas – rather than complexes.

Perhaps the most annoying aspect of the CBT vs psychoanalysis debate is it tends to ask ‘which is best’ in a general and over-vague manner rather than examining the strengths and weaknesses of each approach for specific problems.

For example, one of the central areas that psychoanalysis excels at is in conceptualising the therapeutic relationship as being a dynamic interplay between the perception and emotions of therapist and patient – something that can be a source of insight and change in itself.

Notably, this is the core aspect that’s maintained in its less purist and, quite frankly, more sensible version, psychodynamic psychotherapy.

CBT’s approach to the therapeutic relationship is essentially ‘be friendly and aim for cooperation’ – the civil service model of psychotherapy if you will – which works wonderfully except for people whose central problem is itself cooperation and the management of personal interactions.

It’s no accident that most extensions of CBT (schema therapy, DBT and so on) add value by paying additional attention to the therapeutic relationship as a tool for change for people with complex interpersonal difficulties.

Because each therapy assumes a slightly different model of the mind, it’s easy to think that they are somehow battling over the ‘what it means to be human’ and this is where the dramatic tension from most of these debates comes from.

Mostly though, models of the mind are just maps that help us get places. All are necessarily stylised in some way to accentuate different aspects of human nature. As long as they sufficiently reflect the territory, this highlighting helps us focus on what we most need to change.

10 thoughts on “Psychotherapies and the space between us”

  1. I totally agree, a very simplistic article. I’m extremely fond of Integral Family Systems therapy over CBT, but I’d avoid Freudian psychoanalysis like the plague. In the Boston area, IFS is increasingly common, although still used by a small minority of therapists. I recommend it to everyone. It’s helped me more than CBT. At least one good-sized study shows IFS to be superior to CBT in treating PTSD.

  2. In 1998 I was diagnosed with PTSD. I was recommended for EMDR but I received 40 1 hour sessions of psychological therapy. The therapist at this time would not go deep enough into my past. This therapy did not resolve my problems as I found out in 2010 when I had a mental breakdown and was again diagnosed with PTSD for the same trauma as in 1998.

    This time I received 16 sessions of CBT and again the therapist seemed to avoid going near the trauma I experienced concentrating more in trying to make me think differently about it. It didn’t work. I asked to be put on a waiting list for EMDR which took 2 years.

    In the meantime I paid for psychoanalysis from a therapist who lead me through my problems and was very influential in helping me. It helped that she knew what body memories were, and the difference between implicit and explicit memories. I a now having the EMDR, after what must be the record waiting time of 17 years.

    From my experience I would say it doesn’t really seem to matter what therapy you get, it is the therapist that makes the difference.

  3. >> “Is your social anxiety caused by the projection of unacceptable feelings of hatred based in unresolved conflicts from your earliest childhood relationships – as psychoanalysis might claim? Or is your social anxiety caused by the continuation of a normal fear response to a difficult situation that has been maintained due to maladaptive coping – as CBT might posit?”

    Or is your anxiety caused by an overactive fear response? See Reinforcement Sensitivity Theory (RST).

    The field of psychology suffers from lack of an overarching theory (a la evolution in biology). The conscious mind is grounded in nature, nurture, and cognitive appraisal.

    Neuropsychological therapy needs to continue to develop rich methods for determining areas of need and appropriate interventions for each.

  4. I thought this line at the end of the article was good:

    “What happens in therapy,” Pollens said, “is that people come in asking for help, and then the very next thing they do is they try to stop you helping them.”

    But that’s the point of CBT: to slowly change the web of beliefs that support unhelpful behaviors. That doesn’t imply there aren’t hidden variables, including self deception, nor is it a comprehensive theory of how the mind works (methods which address other aspects of self knowledge may very well be complementary). Knowledge about specific disorders is important because what is often the case with problems like e.g. body image or anxiety is the symptoms are a manifestation of life long patterns of thinking and behavior. Narrow treatment of symptoms through surface level domain specific exercises will miss why patients are resistant to change.

    I don’t doubt that it’s possible through talking to work through some problems (just as it’s possible to arrive at some insights by doing non analytic philosophy or narrative based fieldwork in anthropology) but what often happens in a pschoanalytic approach is the expensive sessions are wasted in circular discussion due to the unsystematic nature of talk therapy (it should be mentioned that CBT can also devolve into retrospective rumination if sessions aren’t sufficiently structured to provide meaningful intervention)

    The Guardian article leans on a false dilemma as if there weren’t other alternative explanations for why CBT effectiveness has declined. It is a legitimate concern that it’s oversold as a quick and easy solution. Therapy is expensive which puts downward pressure on the number of sessions. With fewer sessions the patient is put in a position where they are expected to learn skills similar to expecting someone to learn critical thinking by teaching a few lessons about logic, fallacies and biases. While that can lead to some immediate progress and relief not everyone has the background to become competent enough to apply those skills or the determination or support in planning and following through on exposures.

    Patients who treat the cognitive lessons like it’s a method of pure reason to make headway on so that they can get on with living later will find it less effective than patients who properly place it in a life long process of learning through experience and thinking (the structure, concepts, and exercises in therapies are merely an aid)

  5. Whilst it’s true that the Burkeman article is simplistic, I feel that the present rejoinder replicates this simplicity in another form. Namely, it supposed that CBT and psychoanalysis are essentially up to the same thing (especially with ‘sensible’ psychodynamic treatments!) and can therefore be compared on strengths and weaknesses.
    It’s quite proper to reject the notion of CBT as ‘empirical’. Its epistemological standards are pure garbage, and its theory is one that would have embarrassed any 19th Century philosopher. Its theory of mind is untenable. Nevertheless, CBT is not funded particularly because of its ‘evidence’ but because of its ideology. Analysts can play the empirical game just as well, if not better that the CBTers – see Fonagy, for instance – but the fundamental difference between the two is ethical rather than empirical.
    To elaborate, CBT is technocratic, psychoanalysis is transferential. CBT is authoritarian, with the expert clinician teaching the patient correct thinking through directive methods. CBT does not require its clinicians to undergo any therapy of their own (unlike psychoanalysis) so the likes of Ellis or Beck never need doubt the veracity of their ideas, or the motives behind their interventions. CBT is only sustainable under conditions of philosophical and political ignorance, and is explicitly designed to be cheap and standardised. As such, it is essentially applied neoliberalism, and we ought not to be surprised to find it used in workfare (for instance). Ellis’ ‘philosophy’ is basically that of Ayn Rand but without the money fetishism.
    In short, psychoanalysis is not CBT but with a better theory and more detailed treatment. It’s a different ethical approach, aimed at subjective desire and enjoyment, and absolutely singular in its approach to people. CBT is a project of socio-political pacification and control, a method of discipline and surveillance. Consequently, to say that CBT has ‘worked’ means something totally different to saying that psychoanalysis has ‘worked’, and in my view, we should object to a CBT that works as much as we should reject one that doesn’t.

    1. Well, both don’t work very well (see effectiveness literature) , effects are quite the same (see Dodo verdict). So what?! The main difference is that psychoanalysis is more time consuming and more expensive. “fundamental ‘ethical’ differences” – OMG!

      1. The ethical differences are real, since the two approaches are aiming at entirely different things. Psychoanalysts believe that people are essentially divided, and help them to learn about those divisions. Beck and Ellis think your problems derive from weakness and stupidity, and want to tell you how to think.

  6. I am no expert but to me CBT echos the mantras I grew up with in an Ayn Rand reading household. All the things CBT says to do are exactly what my parents told me to do. I now view it as a form of abuse.

    My parents split when I was two and I have a brother 11 years my senior that always challenged my father. I had a lot of anger but was always told I was being irrational and to focus on the positive. I was never allowed to feel my pain and thus never allowed myself to grieve. When I gave a voice to my pain it was considered irrational and completely ignored unless I adopted the “proactive” voice they deemed acceptable.

    The abuse I received in my family is based off of Randian Ideology and CBT to me, looks like abuse institutionalized in the name of “science.” I find CBT deeply offensive and its adherents belligerent folk drunk on ego. I hope they choke on it.

  7. What a refreshing perspective on therapy. Thank you so much for exposing the shallow difference and economic structures that are behind who chooses what.

  8. the essence of CBT, boiled down to its core, is a set of technologies that foster training skills to reduce problematic psychological symptoms. PD, at its core, is about gaining insight into one’s identity and relationship patterns in a way that fosters deeper awareness and more adaptive living.

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