What is Psychoanalytic Therapy? – A Personal View, Part 11
Psychoanalytic therapy and CBT are the two most important traditions within psychotherapy. But even here, because labels can be so misleading in this field, in trying to draw distinctions within it, considerable caution is required.
Contemporary CBT is more nuanced than old-style behaviourist psychology, and over time it has also, in spite of itself, come to be influenced, often quite significantly, by the legacy of psychoanalysis and the talking cure in general. It is nevertheless of interest because it is the only important school of psychotherapy that has significant roots outside the tradition of psychoanalysis.
CBT originated as an alternative to psychoanalysis, indeed often in fairly blatant hostility to psychoanalysis. Over the years however it has come more to resemble psychoanalytic therapy, though this is rarely acknowledged. In its origins, CBT had no place for dialogue between therapist and client, dialogue was not seen as a part of the therapy in the way it has always been in psychoanalytic therapy. There is however very little psychotherapy of any kind nowadays, including therapy that calls itself CBT, that does not place some emphasis on the dialogue between therapist and client.
If you go to a CBT therapist you won’t spend as much of your therapy time actually talking with your therapist as you would with a psychoanalytic therapist. If you go to see a CBT therapist you are likely to spend significant time filling out forms and answering questionnaires about your personal habits, something that won’t happen in psychoanalytic therapy. The focus in CBT will be on becoming more aware of how you respond to given everyday situations in your life, so that you gradually achieve greater control over your responses.
Nevertheless you and your CBT therapist may well spend quite a lot of time in conversation. And his consulting room is likely to look similar to that of his psychoanalytic counterpart. Both are more likely to be filled with bookshelves, paintings and works of art than they are with the kind of medical equipment you expect to see in the office of your family doctor. CBT began as a therapy of behavioural manipulation but it has evolved over time into something that is often hard to distinguish from a talking therapy.
However, if you are spending all your therapy time in dialogue with your CBT therapist about your experiences, your feelings, your history, and your hopes and fears, then you are in effect doing some version of psychoanalytic therapy, but for some reason your therapist has decided to call himself a CBT therapist. The most likely explanation for this is that he is working in the public sector, for a public health service, where the label of CBT is always preferred over the label of psychoanalytic therapy.
The label of CBT is preferred in the public sector, in areas where the client is not paying the therapist directly himself, because CBT has always been promoted as a quicker form of therapy than psychoanalytic therapy, which in this context is a euphemism for costing less money. This is why CBT is espoused most energetically by those therapists who work within public health systems around the world, where, inevitably, resources of time and money are particularly scarce. Psychoanalytic therapy, on the other hand, tends to be pretty much the exclusive preserve of therapists who work in private practice, like myself, where the client is paying the therapist directly for his own treatment.
Frequently, clients who are receiving therapy funded by a national health scheme will, once their allowance of paid therapy sessions comes to an end, continue to attend their therapist on a private basis. In other words, therapy that is advertised as CBT not infrequently evolves into something difficult to distinguish from longer term psychoanalytic therapy.
In fairness, however, it must also be said that over the years a lot of psychoanalytic therapy has come more to resemble something a little bit like CBT. Many psychoanalytic therapists will offer practical guidance or suggestions to their client on how to deal with his problems, something that, historically, “official” institutional psychoanalysis frowned upon. This is in spite of the fact that Freud himself never suggested that psychoanalysis was the only valuable method of psychotherapy. For instance in 1905 (in “On Psychotherapy”) he noted:
“There are many kinds and ways of psychotherapy. All are good that lead to the goal of healing. Our usual encouragement: Everything will be fine! With which we are so free with patients, corresponds to one of the therapeutic methods; it is just that with deeper insight into the nature of neurosis we are not forced to confine ourselves to encouragement. We have developed the technique of hypnotic suggestion, psychotherapy through distraction, through exercise, through the provocation of appropriate affects. I disdain none of these and in appropriate circumstances would use them all. … [But] I may assert that the psychoanalytic method is the one that has the most penetrating effect, goes the furthest, through which one can achieve the most extensive change in the patient. If I may for a moment leave the therapeutic point of view I can also say in its favour that it is the most interesting, that it alone teaches us something about the origins and the context of the manifestations of illness.” (ERG 111)
The heyday of “pure” psychoanalysis that was dominant from the 1920s to the 1950s is now long past. Almost all psychoanalytic therapists now acknowledge that analysis of the internal world, on its own, is not enough to cure us, and that we also need emotional support, suggestions and encouragement from the therapist to make practical changes in the way we live.
In public, there is still mutual trading of insults by adherents of the psychoanalytic and CBT schools. In private however both schools have tacitly come to recognise that the other has valuable things to offer when it comes to helping people in emotional distress.
Probably most contemporary forms of psychotherapy and counselling, whatever they may call themselves, now show, at least in terms of practice, the influence to some extent of both these two fundamental points of view.
Nevertheless, the distance between CBT and psychoanalytic therapy remains significant and anyone seeking therapy should be aware of it.
Because the underlying differences of philosophy between the two schools are so deep, all varieties of psychotherapy show a bias towards one or other of them. They are either more inner-directed and psychoanalytic, looking for the guidelines for spiritual and emotional health within the individual, or they are more outer-directed and cognitive behavioural, looking for the criteria of mental health in what society seems to expect and reward.
If you want to assess any therapist whom you do not yet know it is a good principle to ask him whether he tends more towards the perspective of the psychoanalytic school or towards that of the CBT school. No single question will be more revealing of the kind of therapist he is. A carefully thought-out answer, without polemics, will show you have encountered a serious professional who has reflected on the various aspects of the work of therapy and is probably well worth considering as someone to give you help. A therapist who uses his answer to make a rhetorical attack on one or the other school is likely more concerned to adhere to the doctrines of his own school than to think for himself, and is therefore likely to be of limited use as a therapist. A therapist who is evidently baffled by your question is someone who does not understand the implications of his work and should be avoided.
From my own point of view, speaking as a psychoanalytic therapist, the potential danger of CBT is that it can result in a betrayal of the self. It may encourage an adaptation to the world of others that may look like a cure but may in fact lead the individual further away from himself.
The truth is that whether a therapist describes himself as psychoanalytic or as CBT in public matters much less than whether he is intelligent, sensible, sensitive and pragmatic, and focused mainly on the particular needs of his patient, rather than on the tenets of any particular school.