Whilst I value my CBT orientation and training, I am also a psychoanalytic practitioner and always work between the two approaches. I have speculate ld how might it be possible to reconcile both modalities in a practice? Would there be a conflict between the two ways of considering psychological problems?  

So, what’s the difference between a CBT approach to resolving psychological problems and a psychoanalytic approach? And is there any way in which you might be able to combine and/or integrate them in a practice? 

My first encounter with CBT was back in 2004 but it wasn’t an entirely successful one. I didn’t quite appreciate its value then and promptly started my formal training as an psychoanalyst and psychotherapist which took place over a number of years. But I finally came back to CBT recently. So, what’s my take on CBT? On Psychoanalysis? And on how to reconcile them in a practice? 

CBT is a ‘here and now’ way of dealing with psychological problems.. The basic principle of the cognitive model is that “dysfunctional thinking is common to all disturbances” (Beck, 2020, p.4). The philosophical root for this principle is the concept of rationalism which proposes that the explanation for one’s feelings and behaviour lies in what someone thinks and, critically, believes: “It is because one believes something to be true – whether or not it is in fact true – that affects one, rather than there being some unknown cause” (Mansell & Taylor, 2011, p.10). There are three levels of cognition – consciousness, automatic thoughts, and schemas (or core beliefs), with CBT treatment working at all three levels (Wright, 2006). Beck (2020) states that the “cognitive model suggests that it is the interpretation of a situation faced by the individual expressed in these automatic thoughts and images that influence one’s emotion, behaviour, and physiological response” (p.210).

A central theme in CBT is shifting the focus of the client to the present, with the aim of helping the client to focus on present concerns and to develop skills so that they can be more effectively managed (Mansell & Taylor, 2011). There is empirical evidence that clients who use these skills consistently experience better life outcomes, even in the face of adverse life circumstances (Vittengli et al., 2019, cited in Beck, 2020). 

Psychoanalysis, on the other hand, is a “certain way of understanding the unconscious (process)” (Dor, 1998, p.1). The way we might understand the unconscious is to distinguish it from our active memory – a bit like the difference between RAM in a computer and its hard disc. All of our life experience is stored in our personal hard disc, but only a small portion of our life is available in our conscious processes. A psychoanalytic practice will often look at the “there and then” of experience, and in so doing surface thoughts and memories from the past. Here’s a useful introduction to the subject. https://nosubject.com/Psychoanalytic_treatment 

The business of psychoanalysis is to join unconscious and conscious processes to help us work better and have better relationships. This is achieved by the production of language in the therapeutic encounter and freely associating with what we say. But how this is achieved is also due to the relationship with the therapist (the transference’) whereby “the unconscious processes described by Freud are dependent on the psychic dimension of language and on the fulcrums that sustain it in the transference” (Dor, 1998, p.2). Freud (1958) did not place any time frame on the length of a psychoanalytic treatment, whereas CBT work can often be completed in a short and defined time period.

The emphasis on the unconscious process and transference, along with the timeframe for treatment are, in my view, the key differences between CBT and psychoanalysis. But I believe that these two approaches to resolving psychological problems can be combined on occasions. For example, Judith Beck (2020) makes an important point that there are times when a focus on the past may well be needed in certain circumstances including when the client desires it, when progress in treatment is slow and when it is helpful for the client to understand the root cause of their problems. And this brings us naturally into the realm of the psychoanalytic which might be described as dealing with how the “there and then” of life and his intrudes into our daily life.

Freud (1958) also makes reference to the idea of “introductory sessions” where the transferential relationship is established. This often can take quite a long time during which the introduction and application of CBT approaches and techniques can be helpful and valid. I often find that various CBT and Mindfulness techniques introduced in a psychoanalytic treatment can be of great help for people who are looking for an early and practical way of reducing distress.

But the most important way in which the CBT and psychoanalytic approaches merge in my practice is in the early stages of the work where I ask the patient to help me to understand where they locate the root of their problems. Is it in cognitive distortions in the “here and now“ or or does it lie in disruptive patterns in early life and challenges in formative relationships in the “there and then”? Or can it be a mix of both by which we can pay attention to both aspects of our functioning?

I’m very pleased to work with both aspects of the individual and to consider the possibility that the patient will typically know themselves best what lies at the root of their problems that bring them into therapy.

References

Beck, J. S. (2020). Cognitive behavior therapy (3rd ed.). Guilford Press.

Dor, J, (1998). Introduction to the Reading of Lacan (The Unconscious Structured like a Language). Other Press, New York.

Freud, S., 1958. On Beginning the Treatment. The Standard Edition of the Complete Psychological Writings of Sigmund Freud, 12.

Mansell, W. & Taylor, J.L, (2011). What Is CBT and what isn’t CBT?. In W Dryden & R. Branch (Eds.),The CBT handbook (pp.5-24). Sage. 

Wright, J. H. (2006). Cognitive behavior therapy: Basic principles and recent advances. Focus, 4(2), 173-178.

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