Psychoanalytic Therapy and Cognitive Behavioural Therapy (CBT)

What is Psychoanalytic Therapy? – A Personal View, Part 10

What psychoanalytic therapy and all these other related therapies do need to be distinguished from however are those forms of psychotherapy and counselling that focus less on treating the person as a whole, and on the conflicts between his emotions within him, and more on his different symptoms in isolation, with the aim of treating them in an analogous way to physical symptoms, like a broken bone or a viral infection. Nowadays the general term for this kind of therapy is cognitive behavioural therapy, or CBT for short.

Psychoanalytic therapy and CBT represent two significantly different conceptions of the mind and of how it should be treated when it shows signs of distress. Psychoanalytic therapy is focused on the person as a whole and sees the various symptoms he is suffering as expressions of the struggles of that person to maintain the integrity of his individuality in the face of the challenges of life. CBT in contrast is focused on the individual symptoms and, traditionally at least, is not interested in the larger story that the individual is living out.

The current popularity of CBT needs to be seen in the context of the history of psychoanalysis, because it arose as a reaction to psychoanalysis and has always defined itself as an anti-psychoanalysis. Without the precedent of psychoanalysis it would not have developed in the way it did, and probably would not have developed at all. Reactivity, as opposed to activity, permeates the philosophy of CBT.

After Freud began psychoanalysis at the beginning of the twentieth century it steadily increased in influence and general acceptance until the 1960s. By at least the 1950s psychoanalysis had become a landmark in contemporary culture, widely discussed and written about, and generally highly regarded. In the twenty years or so after the Second World War it also dominated medical psychiatry, especially in the United States, where it was regarded as the best treatment for most forms of mental illness.

One reflection of the prestige and interest enjoyed by psychoanalysis during this period is the number of films made in these years that feature psychoanalysis or refer to the unconscious mind. The 1950s and early 1960s saw many classic films such as those by Alfred Hitchcock which dramatise psychological themes like memory, sexuality, anxiety, transference relations, paranoia and voyeurism, all of which were first brought to widespread attention by psychoanalysis. 1962 saw the release of John Huston’s biography of Freud starring Montgomery Clift.

These years also saw the publication of Ernest Jones’ great three volume biography of Freud, by a man who knew Freud well and was one of his devoted pupils. To this day Jones’s book remains an indispensable source for the life of Freud and the origins of psychoanalysis and it provides fascinating reading for anyone interested in the history of psychotherapy in the twentieth century.

Jones however is also partisan and perhaps in the long run he did a disservice to Freud by presenting him as a kind of moral paragon that no human being could realistically be expected to represent. Indeed, the student of psychoanalysis might speculate that this over-idealisation of Freud on the part of Jones may have veiled more hostile unconscious feelings. He also uses his biography to settle some personal scores with rivals in the psychoanalytic movement. It was no doubt inevitable that in later decades, especially during the iconoclastic 70s and 80s, Jones’s version of Freud would come in for attack by writers eager to question the “official” nature of the portrait Jones had painted and to argue that the psychoanalytic movement he founded had conspired to hide his failings. Some of these later criticisms were justified, some were overwrought.

In the 1950s however psychoanalysis still enjoyed a dominating position in psychotherapy. It was however also usually expensive and the number of practitioners able to provide it was relatively small. As a result the number of people who had access to it or any direct experience of it was actually quite limited.

While the number of therapists offering psychoanalytic therapy continued steadily to grow, and has continued steadily to grow, from about this time onwards the monopoly of psychoanalysis within secular psychotherapy began to be challenged by committed critics of Freud. They advocated in its place “behaviourist” approaches to psychology and psychological disturbances.

Behaviourism has roots that go back to the beginning of the twentieth century and beyond. It is exemplified by researchers such as Ivan Pavlov (1849-1936), J. B. Watson (1878-1958), and B.F. Skinner (1904-1990). These men were all interested in the way in which the behaviour patterns of animals can be artificially modified by the application of positive or negative reinforcement. They demonstrated that you can, for instance, induce fear of a particular object in an animal by associating that object with a painful experience such as an electric shock. Or, you can induce an animal to press a particular lever if every time it does so it is rewarded with food. This is known as “conditioning” the behaviour patterns of the animal.

The behaviourists believed these principles could be applied to human beings. The claim was, for instance, that one could help an individual overcome an irrational phobia of some thing or some set of circumstances by gradually allowing the individual to become accustomed to those circumstances, and getting him to see that there was no real threat associated with them. In other words, they argued, you could apply conditioning to human beings so as to extinguish undesirable traits of behaviour.

Behaviourism emphasised a belief that scientific methods and procedures that are appropriate for the study of the psychology of other animals should be appropriate for human beings also. The literature of behaviourism is riddled with putative analogies between human behaviour and that of other animals like pigeons, rats, dogs and monkeys.

Psychoanalytic therapy regards mental illness and emotional problems as being rooted in the things that make us unlike other animals, in particular our uniquely developed propensity to think and act in symbolic and associative ways. In contrast, behaviourism takes the view that our emotional problems are rooted in those things that make us like other animals.

For instance, Hans Eysenck, a strong advocate of behaviourism and fierce critic of Freud in the twentieth century, asserted: “The neuroses are essentially disorders of the paleocortex or limbic system [i.e. the more primitive and in evolutionary terms older parts of the human brain]; it is characteristic of neurotic disorders that they can hardly be influenced by processes originating in the neocortex [i.e. the characteristically human part of the brain].” (Decline & Fall of the Freudian Empire, 1985, p.82)

Behaviourism is also marked by an emphasis on the adaptive or reactive aspects of human behaviour and psychology. That is to say, neurotic patterns of behaviour or feeling are regarded as maladaptations to events or circumstances that have been experienced by the patient. They are not looked on as possible attempts by the patient to articulate autonomous needs and aims from inside himself. Thus treatment in the behaviourist tradition is always about modifying responses to externally generated events. It is never about developing a clearer understanding of one’s own needs and aims, as it is in psychoanalytic therapy. For the behaviourist the human subject is always a passive subject, not an active subject.

The CBT therapy that we have today developed out of the behaviourist approach of the 1930s, 40s and 50s. CBT is more nuanced and sophisticated than early behaviourism. In particular, the rather simplistic attempts by behaviourist psychologists to modify manifest behaviour patterns through the imposition of new and altered habits has given way to a recognition of the need on the part of patients in addition to modify their attitudes and feelings.

In other words, by becoming “cognitive”, behavioural therapy has, de facto, recognised the importance of the internal world and experience of the patient, and not just that of his behaviour patterns that can be made manifest to others, and made subject to measurement.

Nevertheless, for the CBT therapists, as for the behaviourists who preceded them, the important task is to distinguish what is “normal” from what is “abnormal” and to help the patient come closer to the former. What is “normal” is identified with whatever is perceived at the time to be the consensus view of what is healthy, good and desirable. What is “abnormal” is identified with whatever is perceived to be the consensus view on what is unwell, bad and undesirable.

The problem with this is that CBT has no way of questioning whatever is the accepted standard for mental health at any given time. It proceeds as if this never changes from one period to another and from one society to another, which is manifestly not the case. Thus the behaviourist view of homosexuality, for instance, was, in the 1950s, as something that should if possible be modified towards heterosexuality. This, notably, was never Freud’s view, who stressed that homosexuality was quite compatible with the highest moral and cultural achievements of man. In the 2020s, the behaviourist attitude towards homosexuality is that it is just another part of what is “normal”, and therefore healthy.

Behaviourism, and the CBT therapy that has succeeded it, because it has no standard of mental health other than what is conventionally accepted at any given time and by any given society, therefore lacks an ethical compass. It must move wherever society moves from year to year and from decade to decade and has no way of questioning that movement. It is, inherently, the servant of convention.

This is the most important reason for the popularity of CBT. It is a style of therapy that tells the patient what it is he needs to do and needs to achieve. Psychoanalytic therapy is different from this. It is a style of therapy that challenges each patient and each individual to find out what is uniquely healthy for him, but not necessarily for anyone else. It is this challenge to discover what is right for oneself, and to achieve a greater degree of emotional autonomy, that is the central ethical core of psychoanalytic therapy. And it is the promise of providing a way of evading this challenge that constitutes the appeal of CBT. CBT is never a threat to the conventional order of things at any given time or in any given place. This is also why it is usually the only kind of therapy that receives government funding. Psychoanalytic therapy in contrast is always ready to question the accepted standards of mental health.

Psychoanalytic therapy takes note of the distinction between what is considered normal, and therefore supposedly healthy, and what is considered abnormal, and supposedly unhealthy. But unlike behaviourism it does not regard this distinction as necessarily authoritative. It takes its point of reference for judging what is healthy from what allows the individual to live a fruitful life, not what the consensus view of society may be on how the individual ought to live and conduct himself. From the outset it takes the abnormality of the human condition within nature as a given and therefore not as subject to normalization. It is concerned to allow develop the unique state of health that is appropriate to each individual.

The aim of psychoanalytic therapy is to help the patient make peace with his inner self. This in turn means that, for psychoanalytic therapy, the emotional health of the patient is, ultimately, defined by the patient himself, though as the result of a dialogue with the therapist.

The aim of CBT in contrast is to help the patient make peace with other people in the outer world. So achieving the particular patterns of behaviour that make the patient’s interaction with the world as trouble free as possible is more important to CBT than is understanding the kind of person Nature intends that individual to be.

It is its stress on adaptation to the world, or more precisely to the consensus view of what the world is, rather than adaptation to the inner self, that characterises CBT and distinguishes it from psychoanalytic therapy. It is this underlying difference of philosophy, rather than any particular method, that is the important distinction between CBT and psychoanalytic therapy.

Tomorrow: (11) Conclusion: Beware of Labels in Psychotherapy

Author: Marcus Bowman PhD

I am a psychoanalytic therapist working in Cork.

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