Tag: Psychoanalysis

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.

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

What is Psychoanalytic Therapy? – A Personal View, Part 9

All of us, whether we are therapy patients or not, have to resolve the question of what is the meaning we are going to give to each day of our lives, and to the rest of our lives. We have to resolve it even if we do so by trying to evade it and just drift along with what seems the easiest course. From moment to moment life ceaselessly imposes on us choices between alternatives. We must all the time make decisions, which means we must all the time decide which values and priorities will govern us, from moment to moment, from day to day, from year to year. The way we make those decisions determines how we end up shaping our lives and whether we feel content with ourselves or not, whether we feel we have achieved the best self that we can, under the circumstances we must work with, or whether we do not.

The psychiatrist Viktor Frankl, who wrote the famous meditation on his experience in the German concentration camps, Man’s Search for Meaning, emphasised possibly more starkly than anyone else the importance of recognising this in psychotherapy. Frankl writes:

Nietzsche’s words, “He who has a why to live for can bear with almost any how“, could be the guiding motto for all psychotherapeutic and psychohygienic efforts regarding prisoners. … It did not really matter what we expected from life but what life expected from us. … Life ultimately means taking the responsibility to find the right answer to its problems and to fulfil the tasks which it constantly sets for each individual. Man’s Search for Meaning, 1959, pp.76-77. Emphasis in original

It is of course not just to the case of psychotherapy with prisoners but with everyone that this applies.

Frankl himself coined the term “logotherapy” for his approach to therapy. Fortunately this is one term that has not passed into general use.

In the decades after World War II there was a great flowering of terms within the general field of psychotherapy and there arose names such as humanistic therapy, object relations therapy, existential therapy, gestalt therapy, and others.

These reflect the cultural upheavals that occurred in the wake of the dictatorships of the 1930s and the war that followed. There was at that time a hunger for new perspectives in most cultural spheres and a sense that the assumptions that had dominated the years leading to the years of tragedy needed to be questioned. This was seen in psychoanalysis and psychotherapy also.

Some of these schools are still around at least in name and you will find slightly different therapeutic emphases in each. Ultimately however they are all variations on the theme of Freud’s original psychodynamic therapy, with an added emphasis on meaning, purposefulness, life goals, and so forth.

In the contemporary field of psychotherapy then, psychoanalysis, psychoanalytic therapy, psychodynamic therapy, existential therapy, humanistic therapy, and a few others, are all now terms between which it is, in practice, impossible to make distinctions that will be found to be consistently reliable.

Finding a therapist who uses one of these titles for his work will not give you any clear indication, before you meet and talk with him, how his approach may or may not differ from a therapist who is using any one of the others. The only meaningful test is to talk with the therapist and see whether you feel he understands where you are coming from and has a good grasp of what you have experienced in life.

Saturday: Psychoanalytic Therapy and Cognitive Behavioural Therapy (CBT)