CBT and Psychodynamic Psychotherapy
Christian Jonathan Haverkampf, M.D.
Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy, the less intensive form of psychoanalysis, are arguably the most prominent and well-researched schools of psychotherapy, apart from interpersonal therapy (IPT) models.
Essentially all psychotherapies go back to the revolutionary concept of the ‘talking cure’ in the late nineteenth century, the use of communication as an instrument of healing. CBT and psychodynamic psychotherapy as descendants from the same concept should be viewed as complimentary rather than as substitutes. Technical approaches from both can be helpful in individual situations.
Keywords: CBT, psychodynamic psychotherapy, Communication-Focused Therapy, CFT, communication, psychotherapy, psychiatry
Table of Contents
Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy, the less intensive form of psychoanalysis, are arguably the most prominent and well-researched schools of psychotherapy (see Lambert and Bergin, 1994), apart from interpersonal therapy (IPT) models.
Essentially all psychotherapies go back to the revolutionary concept of the ‘talking cure’ (Breuer et al, 2000) in the late nineteenth century, the use of communication as an instrument of healing. CBT and psychodynamic psychotherapy as descendants from the same concept should be viewed as complimentary rather than as substitutes. Technical approaches from both can be helpful in individual situations.
The late nineteenth century with new discoveries in biological medicine and neurology and the emergence of Darwinian evolution provided the background for psychoanalysis. Psychoanalysis regards the mind as a complex yet structured system that produces and is affected by communication and meaningful information, not unlike individual cells in an organism. The patient’s free associations are reflected upon by patient and analyst to explore and resolve intrapsychic conflicts and their defences, which cause ‘neurotic’ symptoms, such as anxiety, OCD, depression. Symptoms contain not only hints of repressed feelings and emotions, but also information about the patient’s authentic wishes and desires for individual growth.
CBT delivers a more action-oriented and problem-focused approach, in which treatment plans and goals are formulated without a prior analysis of the meaning of the symptoms. CBT goes back to a merger of the behaviourism based on studies on conditioning and learning and studies into cognitive processes by students of Freud , who believed cognitive processes to be closer to consciousness than their mentor. CBT focuses on an understanding of the mechanisms of present thoughts and behaviours rather than their pathogenesis. Both, however, teach their patients to become experts in their respective skills.
In psychodynamic theory, the development stages in childhood play an important role, as do other past experiences, which are largely organised around interpersonal relations. In CBT, the focus is on conscious processes and the present. Psychoanalysis assumes that communication phenomena between therapist and patient allow insight into partly unconscious intrapsychic processes, which are organised in a structured system (such as the tri-partite model of ego, superego and id) .
From a CBT perspective, distorted thought processes and maladaptive behaviours are direct causes of mental health symptoms (Hollon and Beck, 1994), in psychodynamic theory they are ‘only’ symptoms and not to be confused with the underlying causes. In CBT, logic, for example in the form of the Socratic dialogue, can be used to identify and discard false beliefs that cause unwanted thoughts and emotions (Beck at al, 1979). Psychodynamic therapy enables reason (the ego) to break down the defences, which protect from underlying conflicts.
In CBT, unhelpful thought patterns are made clear in the beginning (assessment phase), which, however, requires a norm of ‘helpful thinking’ (Fancher, 1995). In psychodynamic psychotherapy, what is ‘helpful’ depends on the individual and has to be worked out in the exploratory process.
Both therapeutic approaches are growing organically, though unfortunately with less than optimal cross fertilisation. Emotional, motivational and relational aspects have been added to CBT. Neural networks and neural computation models are used in psychodynamic research (Peled, 2008), as well as in the cognitive sciences which underlie CBT. The neurosciences , infant research , neurobiology , attachment psychology and other fields have contributed significantly to psychodynamic theory.
Treatment in CBT is usually shorter, often below twenty sessions, and with longer inter-session intervals. There is an evidence-based short-term psychodynamic psychotherapy (STPP) which, however, has in a meta-analysis shown to be “significantly” less effective than the longer version (LTPP) (Leichsenring and Rabung (2008).
Both therapies transfer skills. In CBT the therapist is “very active” (Hofmann, 2011) and the approach is highly structured (Gatchel, 2008) , often with homework and including an initial assessment, education on the course of therapy (Hofmann, 2011), a reconceptualization of the problem, skills acquisition, skills training, generalisation and maintenance, and another assessment. In psychodynamic psychotherapy, patients learn in the therapist-patient interaction to gain insight into their unconscious dynamics and to become their own analysts.
Since CBT assigns lower priority to the specific thought content and the communication dynamics between patient and therapist and defines problems more narrowly, psychoeducation and ‘manualisation’ are easier to integrate, particularly in clearly defined situations, such as drug addiction (Carroll, 1998) . CBT also lends itself better to conduct therapy over a distance (Weiss et al, 2012; Himle et al., 2006) , including the use of e-mail therapy (Vernmark et al, 2010). Computer programmes (CCBT) can make therapy available to millions of previously underserved populations.
Both, CBT and psychodynamic psychotherapy have proven their effectiveness in numerous studies and large meta-analyses. However, direct comparisons of the effectiveness of CBT and psychodynamic psychotherapy can be flawed by design if the two therapies are complementary and conceptually related. Bram and Björgvinsson (2004), for example, have successfully integrated exposure-response prevention into their psychodynamic therapies. Measuring success in completed therapy phases seems equally problematic, but is still often used.
CBT is likely to deliver quicker results in motivated patients with clearly defined symptoms, low resistance levels and relatively intact personality structures (with the exception of borderline personality disorder and DBT). Psychodynamic psychotherapy may have advantages in dealing directly with personality disorders, which are traditionally derived from psychodynamic models.
Leichsenring and Leibling (2003) demonstrated in a meta-analysis a better long-time effectiveness of psychodynamic psychotherapy than CBT, while CBT on its own has shown to prevent relapses in the long-run (Driessen et al, 2013). Much of the apparent diversity in opinion may depend on the specific diagnosis in question.
CBT may have higher drop-out rates (Cuijpers et al, 2008; Whittal et al, 1999). Motivation seems more external in CBT (see Haddock et al, 2012) than in psychodynamic psychotherapy with its emphasis on the therapeutic relationship and the integration of the more recent motivational systems research (see Lichtenberg at al, 2016). Adding these psychodynamic elements in CBT therapies may lead to better outcomes.
In psychodynamic theory, the anxiety underlying OCD is a result of conflicting dynamics (including emotions), often with a strong relationship component. A conflict may arise in an unstable relationship to an important other, such as a primary caretaker in early childhood, as the feelings of love for the idealised mental representation of the other (longing for attachment) and the frustration, sadness and/or abandonment about the reality of this person’s unpredictability or unreliability cannot be resolved by the child. Higher levels of aggression and distrust in other people have indeed been found in OCD (Moritz, 2011), and infant research has demonstrated how the interaction between primary caretaker and child can affect the child’s evolving sense of self and feeling of secure attachment . Obsessive thoughts and compulsive rituals are aimed at temporary relief from the heightened anxiety in present situations which trigger the situational and associated emotional memory systems of previous situations . Awareness of the underlying emotional conflict, which manifests through the symptoms, helps the patient to recognise, identify the ‘free-floating’ anxiety in the past experience, which reduces the anxiety from experienced emotional uncertainty and the OCD symptoms in the present.
The cognitive-affective schemata of newer developments in psychodynamic theory have considerable overlap with CBT concepts of the effect of learned cognitive schemata. From a CBT perspective, obsessive thoughts are otherwise ‘normal’ negative thoughts which may be misinterpreted as personally significant (Rachman, 1997) or as a potentially dangerous situation for which the patient feels responsible (Salkovskis, 1985), response patterns which are largely learned (Taylor and Jang, 2011). Compulsive rituals are efforts to control these intrusive thoughts. After performing the rituals, individuals usually report a temporary decrease in their obsessional distress (Rachman and Hodgson, 1980), which negatively reinforces these behaviours, a mechanism similar to CBT models on addiction.
Exposure and Response Prevention (ERP) tries to break this cycle of negative reinforcement, in which the patient is repeatedly exposed to an anxiety-provoking thought or situation stimulus, but the self-calming ritual is reduced or suppressed. The anxiety may increase in the beginning, but then reach a peak and fade away. Exposure necessarily leads to an involvement of the patient’s emotional memory and an emotional processing of the anxiety (Foa and Kozak, 1986), which seems a point where CBT and psychodynamic psychotherapy again intersect. Basically, both approaches try to give patients a greater sense of positive control over their lives.
Freud considered the internalisation of object loss as a normal part of life, and depression as a reaction formation in the face of a particularly severe super-ego , which holds in check our basic desires and wishes (the ‘id’) with the help of conscious cognitive functions (reason, the ‘ego’). In CBT, the super-ego could be compared to the messages we learn over time and the believes we construct of how we ‘should’ live our lives. And similar to the concept of limited cognitive resources in CBT, the rational ‘ego’ function in psychodynamic theory may get overwhelmed in stressful and traumatic situations and become unable to reconcile the super-ego and the id, leaving an unresolved emotional conflict, which the ego (reason) needs to defend against. Loss and the emotions associated with this conflict (such as anger, sadness or helplessness) are important themes. Anxiety and avoidance have been shown to be greater in people with more insecure attachment (Bateman & Fonagy, 2012), who are often more dependent and self-criticising, eliciting responses from others that confirm their fears of rejection and abandonment (see Blatt, 1974; Blatt, 1992). The negative emotions then lead to a ‘withdrawal’ from one’s own emotions (repression), reminiscent of learned helplessness in CBT. Awareness of the underlying dynamics and their origin in the past, helps the patient to understand and integrate them in the present.
In CBT, thoughts, behaviours and feelings are directly interrelated, which can lead to a circularity that is in psychodynamic theory ‘impossible’. Negative thoughts can lead to depressed feelings, which again lead to negative thoughts and ‘depressed’ behaviour, such as social withdrawal, reinforcing the depression. Maladaptive cognitive patterns, such as negative thinking about oneself and one’s experiences (McGinn, 2000), increase the vulnerability for depression. In learned helplessness, for example, the sense of low self-efficacy brings about behaviour that just reaffirms the low self-efficacy.
In the cognitive aspect of CBT, a person learns to recognize and turn negative automatic thoughts into realistic beliefs. More realistic beliefs lead to more adaptive thoughts and less depressed feelings. Patients are taught to deconstruct problems into the actual situation, and the thoughts, feelings and behaviours that occur before, during and after the situation, an external correlate to the internal deconstructive process in psychodynamic psychotherapy. In Mindfulness CBT (MCBT) the emphasis is on experiencing one’s thoughts as mental events rather than interpreting them as representations of oneself or reality. This detachment from negative thoughts and feelings is also useful in preventing relapse (Teasdale, 1999).
The aim of psychotherapy is not merely to eliminate suffering (WHO, 1946), but to help patients develop as humans. The primary tool is communication, in CBT to provide information that generates change and in psychodynamic psychotherapy to reveal the information that brings about change. There are synergistic effects from using both. Zipfel et al (2014) showed in a large sample of anorexic patients, that CBT was associated with weight gain, while psychodynamic psychotherapy with lower relapse rates at the 12-month follow-up. McFall and Wollersheim (1979) in an early study successfully used a combination of CBT and psychodynamic psychotherapy in anxiety . Given the widely-perceived need for multimodal approaches , it is difficult to comprehend that this should not apply to the most important therapeutic models we have. In ancient Greece, knowing oneself (γνῶθι σεαυτόν, “know thyself”) and the process of the Socratic dialogue were inextricably linked. Psychodynamic psychotherapy and CBT should be viewed as complementary rather than substitutes.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at firstname.lastname@example.org or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.
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