Psychoanalysis and Cognitive Behaviour Therapy—Rival Paradigms Or Common Ground?1

Home , Behaviour therapy, Cognitive therapy

Int. J. Psychoanal. (2001) 82, 431

PSYCHOANALYSIS AND COGNITIVE BEHAVIOUR THERAPY—RIVAL PARADIGMS OR COMMON GROUND?1

JANE MILTON, L ON DON

The author suggests that contemporary enthusiasm for cognitive-behavioural therapy re- flects our longing for swif t, rational help for psychological suff ering. C ompetition for funding threatens the psychoanalytic presence in the public sector. The psychoanalytic and cognitive-behavioural models are contrasted, and the relative richness of the psychoanalytic paradigm outlined. The author suggests that a cognitive model is commonsensical, but less complex, with less pot ential ex planatory and t herapeutic power. S he discusses how the analytic st ance is always under pressure t o ‘ collapse’ into simpler modes, one of which resembles a cognitive one. This also occurs inevitably, she argues, when attempts are made to ‘integrate’ the two models. Cognitive and ‘integrated’ treatment s nevertheless have the advantage that they are less intrusive and hence more acceptable to some patients. Selected empirical process and outcome research on cognitive and psychoanalytic therapies is discussed. Brief psychotherapies of either variety have a similar, modestly good outcome, and there is some evidence that this may be based more on ‘dynamic’ t han ‘cognitive’ elements of treatment. Formal outcome studies of more typical psychoanalytic psychotherapy and of psychoanalysis itself begin to suggest that these long and complex treatments are effective in the more comprehensive ways predicted by the model.

INTRODUCTION debate about it, as it appears to be linked with a serious devaluation and erosion of the psy- Cognitive behaviour therapy (CBT), relatively choanalytic perspective in health-care services new to the psychotherapeutic scene, is hailed worldwide. with great hope and enthusiasm as a means of I will compare and contrast the two clinical rapidly alleviating mental distress. Its practice paradigms, the psychoanalytic and the cogni- is seen in some quarters, for example the UK tive-behavioural. I will show how CBT practi- public sector, a s provid ing a n alternative to tioners are beginning to rediscover the sam e psychoanalytically orientated therapy that is phenomena that psychoanalysts earlier faced, more ratio nal, q uick and efficient, an d and are having to change and deepen both their regarded as of proven efficacy. This is similar to theory and practice accordingly, and to modify the early idealisation of p sychoanalysis, an d their expectations. Th ese red iscovered phe- may prove relatively short-lived. However, psy- nomena concern unconscious p rocesses, th e choanalysts need to take careful h eed of th is complexity of the internal world and the intrin- phenomenon, and be p repared to engage in sic d ifficulties of p sychic change. The m ain

1 An earlier version of this paper was presented at a conference of the same title, organised by the Association for Psychoanalytic Psychotherapy in the NHS on 3 March 2000 at St Anne ’s College, Oxford. 432 JANE MILTON originator of CBT, Aaron Beck, in his recent methodology again collapse into the cognitive book about work with personality-disordered one, with a loss of potential therapeutic power. patients (Beck et al., 1990), talks at times in a This is worth exploring in view of the huge cur- way reminiscent of the early Freud. Early psy- rent enthusiasm for so-called ‘integrated’ treat- choanalysis was itself more ‘cognitive’, and had ments such as ‘cognitive analytic therapy ’. to evolve to meet the challenges encountered in One oft-quoted argument for offering CBT the psyche. We may find that CBT technique rather t han psych oanalytic treatments to continues to become m ore ‘analytic’ as time patients in the public sector is that there is so goes by, and that accompanying this the need much more empirical research evidence for its for longer and more complex training of thera- efficacy. It also on the surface appears cheaper, pists, inclu ding su bstantial personal analysis, as it is brief and needs less training to apply. It will be rediscovered. At least one major CBT is worth noting first of all that where patients training co urse in th e U K in fact already re- have freedom to choose, in the private sector, commends that trainees seek personal psycho- only a minority opt for CBT, most patients pre- therapy. ferring dynamic therapies. The alleged superior The st ance of the therapist in CBT is a efficacy of C BT is also questionable empiri- socially acceptable one, which makes immedi- cally, and I will look briefly at the ou tcome ate intuitive sense. The psychoanalytic stance is research field in this connection. much harder to swallow, and is ma intained against the resistance of both the analyst and the patient. I will suggest that there is a con- COMPARING PSYCHOANALYTIC AND stant tendency for ‘decomposition ’ or collapse COGN ITIVE-BEHAVIOURAL THER APY into something simpler during psychoanalytic work. The a nalyst is p ushed co nstantly from History of the split from psychoanalysis without and within either into being more ‘cognitive’ or into a simpler counselling stance —in such ways the analytic stance is frequently in The biographical context for Freud ’s ideas is danger of being lost and having to be refound. widely known, with important links between When it can be achieved, the advantage is that the ideas and Freud ’s personal experiences and through the disco mfort and tension of t he his self-a nalysis. A similar context for Beck ’s striving for analytic neutrality and abstinence, ideas is less well-known and is worth outlining. more distu rbance becomes available in the Aaron T. Beck began as a psychoanalyst, grad- room, within the therapeutic relationship itself, uating from the P hiladelphia Psychoanalytic to be worked with and p otentially trans- Institute in 1956. He became disillusioned and formed. CBT is far less disturbing and intru- impatient with the psych oanalytic culture in sive. It is worth noting that although it forfeits which he found himself over the following de- potential therapeutic power, it may be accepta- cades—in his view unfocused, resting on dubi- ble to some patients in a way that psychoana- ous theoretical foundations and insufficiently lytic therapy is n ot, pro tecting pr ivacy a nd located in the patient ’s current reality. Psychoa- defences that the individual has good reasons nalysis was very much the dominant, authori- for wishing to preserve. tative culture in psychiatry (a situ ation A second, related point is that ‘integration ’ radically different from that in the UK then or of analytic and cognitive methods in my view now). Beck, in opposition to this establishment inevitably produces something more cognitive model, fo unded first a ‘cognitive theory ’ of than analytic. O nce cognitive or behavioural depression, then derived a brief therapeutic parameters are in troduced by th e th erapist, I approach. Perhaps, as is not uncommon, inno- will argue that an analytic stance essentially vation arose through the combination of a par- ceases to exist, and the analytic paradigm and ticular personality and a rather rigid or too- PSYCHOANALYSIS AND COGNITIVE BEHAVIOUR 433 comfortable state of affairs in p sychoanalysis involved a card-so rting test. T he fa ct that at one place and time. depressed subjects did not react negatively to Beck’s biographer (Weishaar, 1993) n otes success in the task showed, Beck thought, that that Beck is open about having developed his they d id not have a need to suffer, a nd thus theory and technique not just through his clin- went towards disp roving th e psych oanalytic ical work, but, like Freud, through introspec- theory that depression was d ue to ‘inverted tion and analysis of his own neurotic problems. hostility’. Many p sychoanalysts m ight ques- Born in 1921, the youngest of a sibship of five, tion this as a research paradigm for psychoan- Beck was accord ing t o family mythology th e alytic concepts, isolated as it is from the context one who had ‘cured’ his mother by being born. of a close interpersonal relationship. However I Elizabeth Beck had been depressed since the think it illustrates how great the conceptual dif- loss of her first child, a son, in infancy, followed ferences som etimes a re b etween practitioners later by the death of a young daughter in the of the two treatments, which can lead to major 1919 influenza epidemic. Described as a pow- difficulties in communication. erful m atriarchal figure, over shadowing th e Beck began to develop a cognitive theory, quieter father, she remained an explosive per- and from that a cognitive therapy (CT) of son, whose unpredictable and irrational moods depression. H e was in fluenced by K elly ’s the you ng A aron fo und troubling. Sh e is (1955) p ersonal construct theory an d by the described as having been ‘overprotective ’ of her idea that the patient could become his or her youngest son , who spent months in hospital own ‘scientist’ of the mind. He was also influ- with a life-threatening illness at the age of 8. enced by the ideas of Adler, Horney and Stack- Beck describes the way he systematically Sullivan. Beck communicated with Albert Ellis desensitised himself to a serious ‘blood/injury who was ind ependently developing R ational- phobia’ during h is med ical training, treating Emotive therapy, which shares some but not all his fea rs o f h eights, tunnels, p ublic speaking of its featu res with cognitive therapy (Ellis, and ‘abandonment ’ with similar sorts o f 1980). Beck, t ogether with Ellis and Donald behavioural and cognitive strategies. He also Meichenbaum (see e.g. Meichenbaum, 1985), described curing himself of ‘moderate depres- is regarded as one of the ‘founding fathers ’ of sion’. He is lukewarm about the effects of his cognitive behavioural th erapy (CBT), a n training analysis. Weishaar quotes a colleague, umbrella term which covers this broad thera- Ruth Greenberg, as referring to Beck ’s restive peutic approach, and which, in the UK at least, rebelliousness about the psychoanalytic estab- is now used more or less synonymously with lishment. G reenberg su ggests t hat being his CT. ‘Behavioural ’ acknowledges the contribu- own authority and being in control of himself tion of learning theory and classical behaviour were o f overr iding im portance to Beck, and therapy. I will continue to use the term CBT in would have made th e a nalytic training very this paper. problematic for him. Early theories underpinning CBT were rela- In the decade following his qualification as tively simple, with little emphasis on the precise an analyst, Weishaar relates how Beck carried mechanism of symptom causality, simply that out empirical research into depression. things h ad been ‘mis-learnt’ through child- Through examining th e dream s o f h is hood experience. The emphasis was rather on depressed patients, he came to the conclusion the way symptoms were currently maintained that hypothesising wish-fulfilment and hidden and underpinned by ‘negative cognitions ’, motivation was u nnecessary, and indeed in which were in turn generated by maladaptive time he came to dispense with the idea of an internal ‘schemas’—deep cognitive structures unconscious in Freud ’s sen se at all. He also organising exp erience and behaviour. (I n used more standard experimental psychology recent years ‘schemas’ are seen in increasingly procedures in his research . One exp eriment complex ways). Beck believed that discovering 434 JANE MILTON and challenging negative cognitions was a sim- Socratic dialogue) and then through carefully pler, shorter path to change than psychoanaly- planned homework involving observations and sis, and made more theoretical sense. He saw possibly beh avioural tasks. T his hypo thetical himself as shifting away from the ‘motiva- patient will be referred to again later. tional’ psychoanalytic model to an ‘informa- The u sual practice is to offer b etween ten tion pro cessing ’ one—he d irected attention and twenty sessions of treatment, with follow- away from ‘why’ on to ‘how’ distressed psycho- up refresher sessions. Training required for the logical functioning operates. therapist is relatively brief, no t requiring, for example, any personal therapy. Beck, however, The cognitive behavioural paradigm stresses that it is far from enough for the therapist simply to learn a set of techniques —he/she In its classical form (Beck, 1979; Hawton et needs to have an overall ‘cognitive conceptual- al., 1989; Moorey, 1991) CBT is a short-term, isation’, and to have well-developed interper- structured, problem-solving method by which sonal skills and sensitivity. Weishaar notes that a patient is trained to recognise and modify the Beck’s treatment manual for depression fails to maladaptive, conscious th inking an d beliefs capture the heart of his own empathic thera- that are, it is argu ed, maintaining his or her peutic style, as seen on videotapes. This obser- problems and distress. This treatment/training vation will be returned to later, when discussing is done first by educating the patient in the cog- what factors may really be therapeutic in CBT. nitive model of emotion, often with the help of written material. The patient is then helped to Comparing the psychoanalytic paradigm recognise negative automatic thoughts, th en encouraged to use a process of logical challenging and reality-testing of thoughts, both in the Contemporary psychoanalytic conceptuali- session and in t he fo rm of b etween-session sation and clinical technique m ostly d iffers homework. from that of 1950s P hiladelphia. Beck, wh o A vital feature of CBT is the sympathetic, was sceptical about classical drive theory, and collaborative therapeutic relationship, in which the stro ng em phasis h is p sychoanalytic col- the therapist tries to be an inspiring and imagi- leagues then placed on childhood reconstruc- native trainer in self-help skills. The patient is tions, m ight (or m ight not) h ave found a encouraged to become a scientific observer of relatively active, ‘here-and-now ’-based object- himself and his or her thoughts, and to start to relations approach more to his taste. Although question the logical basis on which beliefs —for familiar to most rea ders, I will lay out the example, beliefs about being unlovable, or a basics o f this co ntemporary p sychoanalytic failure—are held. Sessions are structured and clinical paradigm so as to contrast it with the directive, with the patient and therapist focus- cognitive one. I approach th is, I should say, ing gen eral complaints down on to sp ecific from the traditional ‘positivist’ rather than an negative cognitions which can then give rise to intersubjective ‘constructivist ’ paradigm—that experimental tasks to be carried out, and the is, I see the primary object of study and discov- outcome monitored. Thus a depressed patient ery a s b eing th e in ner world of t he p atient. is found, for example, to have core beliefs that While acknowledging the biases caused by our no one is interested in her, and that everyone ‘irreducible subjectivity ’ (Renik, 1998), I agree else is having a better life. These core beliefs are with Dunn (1995) that this does not reduce us found to generate day-to-day thoughts like ‘no to total ign orance. Thus I see th e an alyst as one talks to me at parties ’, and ‘other people doing his o r her best, with an imperfect and have much more interesting jobs ’. Such beliefs biased observing instrument, to strive towards can be specifically tested out both during dis- understanding of the internal wo rld of th e cussion in session s (often through a sort of other. PSYCHOANALYSIS AND COGNITIVE BEHAVIOUR 435 The C BT stan ce is in tuitive and socially The analytic stance will frequently be lost, acceptable—indeed it is a specialised form of a and have to be refound, as the analyst is subtly familiar tutorial relationship. The psychoana- pulled into fulfilling the patient ’s unconscious lytic stance is counterintuitive and less socially scripts (Sandler, 1976; Joseph, 1985). There will acceptable—much harder to swallow for both be constant invitations, which the analyst will analyst and patient. The therapist offers close often partly accept, to become more prescrip- empathic attention, but leaves the agenda to tive, or educational, more partisan, more emo- the p atient ’s free associations, beco ming tionally reactive and so on. One could say that involved with the p atient as p articipant- the patient tries all the time to get the analyst to observer in an unfolding relationship. The ana- be a different sort of therapist —whether this is lyst often has powerful wishes to respond natu- more of a humanistic counsellor, a gestalt ther- rally to the patient, to explain and to reassure. apist, a guru, a teacher or, what I think is quite Giving way to such impulses relieves the ana- common, the patient unconsciously nu dging lyst—it makes him or her feel nicer and kinder. the a nalyst into providing a weak version of In particular, it spares t he a nalyst the moral cognitive therapy itself. All these th erapies, reproach intrinsic in being the negative trans- including cogn itive therapy but with the o ne ference figure (Milton, 2000). The paradox is exception of psychoanalytic therapy, use thera- that although the an alyst is apparently being peutic stances th at come more n aturally because they are specialised forms of ordinary more ‘real’, this is illusory. He or she has in fact, by fit ting in with the patient ’s pressures, social contact. So it is always hard work, and work against the grain, to observe the collapse remained a transference object, and it is th is of the analytic stance, work it through in the familiar, relatively weak figure that the patient countertransference, and re-establish its coun- is left with externally and internally (Feldman, ter-intuitiveness and complexity again. 1993). C ollapse o f th e a nalytic stance has In CBT, the set up is such that the patient removed the p otential for the an alyst to and therapist talk together about a disturbed become a truly su rprising an d n ew o bject patient they mostly only hear reported, and try (Baker, 1993). This is a new object for internal- to think, with the sensible patient in the room, isation, who can bear and reflect on the ways to make him or her feel, and be, more rea- patient’s p rojections, rather th an quickly d is- sonable. Th e ration al p art o f th e self is owning them. strengthened, in order to get on top of the dis- The a nalytic precepts of n eutrality and turbance. This m aintains, even strengthens, a abstinence do not as we know refer to coldness, division in th e p ersonality between rational but to a striven-for personal un obtrusiveness and irrational, co nscious a nd unconscious. that allows th e a nalyst to become clothed in Analytic conditions, by co ntrast, a llow d is- whatever the patient needs to bring. By reduc- turbed aspects of the patient to come right into ing the extraneous ‘noise’ from one’s own per- the room, with all their passion and irrational- sonality, a clearer field is provided for locating ity, loving, hating, destroying and so on. The this. ‘Live’ emotional exp eriencing is allowed patient is encouraged to project, challenge, dis- to occur, som etimes frau ght, anxiety-provok- rupt, complain, involve the analyst in myriad ing or painful fo r analyst, patient or both. ways in the psychic drama. Primitive and dis- However, by activatin g d istorted internal turbing p hantasies, involving both body and object relationships in a live way, they are mind, may come to light. potentially able to be explored and gradually The an alyst, th en, has the a dvantage of a altered by exp erience. In contrast to CBT, much greater range o f or ientations to the change pro moted by p sychoanalysis work is patient, and aspects of the patien t, than the relatively independent of the conscious aspects cognitive therapist ha s. L inked to this, a n of insight. important but particularly intrusive feature of 436 JANE MILTON psychoanalysis is the analyst ’s frequent orien- and questioned at a much d eeper level. The tation towards what happens in the therapeutic patient’s envio us misery may prove linked to relationship from an observing ‘third position ’. childhood feelings of exclusion from the par- This triangularity can arouse the primitive feel- ents’ relationship and from the mother ’s rela- ings of oedipal exclusion which Britton (1989) tionship with other siblings. The ‘other room’ describes. T he an alyst ’s reflect ive, in depend- from wh ich one by defin ition is always ently thinking mind can seem an infuriatingly excluded (Britton, 1998) may, for many people, private, superior place where an excluding sort become id ealised in a way th at empties their of ‘mental intercourse ’ takes place. It is easier own life of meaning, and halts the process of and more comfortable to flatten the triangle, to separation and independence. This deep sense discuss things that are already visible, from a of ‘oedipal exclusion ’ may b e linked to both shared position, or to get together to discuss childhood deprivations and a particular diffi- someone else . T he ‘collaborative colleague ’ culty with tolerating sepa rateness a nd differ- stance of CBT, together with a setting that does ence. CBT is unlikely to reveal or to be able to not invite live manifestation of distu rbance, address such complex dynamics. can avoid tr iangularity almost com pletely. I It is certainly true that psychoanalysts rea- think this is a key issue in the difference. The son with their patients, explain to them, make psychoanalyst deliberately takes the risk at practical suggest ions, an d so on. Often, for times of precipitating the patient ’s narcissistic example, I think this happens at the end of a bit indignation or even rage, by speaking openly of painful or stormy work in the transference. about things he or she sees that the patient can- A narcissistic aspect of the p atient has b een not see, or half-sees and wants to keep hidden. finally understood and integrated (in Kleinian Although th is is un comfortable for both, it terms, for example, a move towards the depres- means narcissistic parts of the personality are sive p osition) and the p atient is tho ughtful, activated and may become gradually modified curious and collaborative about what has hap- and integrated. pened and how it relates to current and past To consider now the case of the hypothetical relationships. I think this is often the organis- depressed patient mentioned above who comes ing a nd contextualising ph ase o f a piece of for help feeling no one is interested in her, and work, which is in many ways a final ‘cognitive’ that other people are having better lives. A psy- phase. At other times, though, I think analysts choanalyst she co nsults will not a ctively become ‘cognitive’ as a short circuit, to avoid a encourage her to challenge and test this belief painful but necessary bit of emotional experi- outside the room. Instead, a neutral, unstruc- encing. Thus a self-observing eye is needed, so tured settin g will be p rovided, in which t he the analyst can question whether he or she is patient may quickly experience the analyst as beginning to sound very reasonable and sensi- uninterested, involved in his or her own ble, trying to persuade the patient of some bit thoughts, and speaking from a superior and of reality , or push the p atient into certain privileged position —the analyst, like the peo- action. One migh t ask oneself at this p oint ple she meets outside, she believes to be having whether there is a wish to be seen as a good, a much better and exciting time with other peo- blameless o bject —in which case it is wo rth ple, while she is left alone with an inferior sort wondering what form the b ad object would of life. By not encouraging and reassuring, the take at this point that would feel so unbearable. analyst may quickly find him or herself the tar- It might also be that there is a larger picture to get of this patient ’s miserable resentment. The be seen in the transference and countertrans- nature a nd source of t his resen tment will ference that is being missed. I will illustrate this become clearer, allowing it to be u nderstood latter possibility with the case of Mr A. PSYCHOANALYSIS AND COGNITIVE BEHAVIOUR 437 M r A still not done a nything ab out the p roject. I would sometimes feel pushed beyon d endur- A 45-year-old man who was still living with ance at this stage . If I could not contain my his parents, working in a clerical job far below countertransference, I would hear myself mak- his capabilities, Mr A came to analysis for help ing a rather sharp and impatient interpretation to move on. He intermittently would come to a about M r A’s passivity. In response, he would session in a particularly thinking and construc- become either very weak and demoralised, or tive mood, wanting help with a particular plan alternatively subtly excited and mocking. H e for change—such as learning to drive, applying would typically report d reams at times like for a new job, buying his own flat and so on. I these, in which someone was pursued or intim- would feel encouraged and pleased for him, idated by gangsters or con men —it was often because he really was miserably stuck. I would unclear which side he was on in these dreams. join him in trying to analyse his difficulties with By repeatedly working through these situa- these tasks, lin king th ings in , when I could, tions with Mr A, I came to understand a com- with the transference relationship and trouble- plex internal situ ation in which he was b oth some past relationships, in an ordinary sort of trapped by , and took revenge u pon, a mon- way. In subsequent sessions Mr A would have strous internal figure which was partly a ver- become very anxious and doubtful about the sion of a very abusive stepmother. I came to see change. He would start to spin it all out —he my ‘cognitive’ impulses as part of a larger pic- would have a form to fill in but leave it at work, ture in which we as an analytic couple enacted or lose it; he would tell me about a necessary a sado-masochistic scenario that both trapped phone call being put off, an d so on, making Mr A but also fulfilled a wish and need for a sure I knew every stage of the postponement. timeless in fantile-like dependence on archaic He would still seem to want help with his fears. objects. In phantasy, he seemed to have lodged The nature of the scene-setting followed by the himself inside me, projecting his active mind in delays was such that I was often left with a very a very wh olesale way. Movement could o nly strong sense of thwarted desire. occur at times when I could get outside the sit- At first I would find myself full of sensible uation, see the whole picture, and interpret it in and practical ideas a nd strategies for helping a non-retaliatory way that Mr A could become Mr A to challenge his fears, and (with a guilty really interested in, and concerned about. This sideways look towards my own analytic super- ego) I would slip into making interpretations work used to test my analytic capacity to the which were rea lly disguised practical sugges- full, but it eventually enabled Mr A to experi- tions, like ‘it is interesting that you don ’t seem ence his own mind more fully. This meant him to feel that you could …’ At this stage we would having to face and mourn his own situation, enter, as I came to see, a ‘cognitive’ mode that internal and external, and experience his rage, was ultimately unproductive. Mr A would pas- guilt, sadness and ultimately his own consider- sively seem to accept my cognitive and behav- able strength. ioural suggestions, bu t con tinue to let the In my work with Mr A I was thus periodi- project slide. As Mr A became flatter and more cally nudged into doing fragments of a weak passive, I would find myself more a nd more version of CBT. This illustrates what I mean by lively. I would now perhaps analyse his resist- ‘collapse’ of the analytic stance into something ance in terms of his rebellious attitude to me, or simpler and more apparently common-sense. It to his d isowning an d projection of h is m ind will inevitably occur in our work from time to into me, or maybe in terms of his internal con- time, and it needs h ard work in the counter- flict. Nothing wo uld happen —that is, M r A transference to notice and rebuild the tension would still report to me flatly or hopelessly, or and complexity inherent in productive analytic sometimes a tinge tr iumphantly, that he ha d work. 438 JANE MILTON Comparing modes of learning in the only to a very limited extent. Unconsciously his psychoanalytic and cognitive-behavioural childhood fury about being left out of his par- paradigms ents’ bedroom and their smugly exclusive relationship, lead ing to a ph antasy o f vio lent We know that both psychoanalysis a nd intrusion into his mother ’s body, means that he CBT involve learning. The main sort of learn- superstitiously fea rs he will damage the ing h oped fo r in psychoanalysis is lear ning woman, and/or provoke attack from an inter- from emotional experience. This may be, for nal nightmarishly vengeful phantasy couple. example, find ing that one ’s wor st fea rs in a Having said this, cognitive therapists argue relationship are not confirmed, or, when they cogently for the efficacy of CBT in combating are, that the exp erience can be sur vived and vicious cycles of symptom generation. Thus thought about. CBT therapists also hope their someone who suffers from panic attacks which patients will learn from experience. The whole are ultimately generated, say, by fearful uncon- point of h omework experiments is th at the scious phantasies is often then subject to fur- patient can test out distorted preconceptions ther sp iralling hypo chondriacal fear at the outside the session. Some cognitive therapists, feelings of breathlessness and palpitations gen- nowadays, may even say to the patient, ‘and erated. CBT can be very helpful in modifying can’t you see how you ’re doing it with me too? ’ such positive feedback loops in symptom gen- The analytic patient can, however, learn some- eration. However, one would predict a less rad- thing quite subtle and complex through under- ical and enduring effect from CBT than from standing, con tainment, rep eated experiment psychoanalytic work which would aim in such and sustained experience within the therapeu- a situation to address structures earlier in the tic relationship, that (for example in Mr A ’s causal chain. case) giving up a dependent, sado-masochistic Psychoanalysis has shed light on some bar- way of relating involves both some loss and a riers we have to learning. Learning certain fun- new sort of loneliness but also a new freedom damental tr uths ab out self an d others is a and independence of thought and action. complex process —both sought after but also Implicit in CBT is that if one pays attention desperately hated and resisted (Money-Kyrle, to modifying th e p atient ’s con scious distor- 1968). It is hard to give up feeling omnipotent, tions of reality, or ‘dysfunctional assumptions ’, the centre of the universe, rather than depend- over a brief period, the deeper structures gener- ent on others, a nd fully to know we are the ating such assumptions will dissipate, o r product of a couple who came together outside become far less powerful. P sychoanalysts are our control, and have minds that are separate more sanguine about this. A patient Ms B may and different from ours. This involves the trian- be relieved and encouraged to find as a result of gularity I h ave referred to. P sychoanalytic a courageous h omework exercise that her research shows how very active a part we play actual fam ily are pleased about her applying in what we learn or mis-learn all our lives, and for promotion at work. However, after a short that this is th e p roduct of b oth environment remission she rema ins p lagued and seriously and constitution. An implicit message in much inhibited in her life by a nightmarishly carica- CBT (but mostly not in psychoanalytic) writ- tured inner maternal figure who is weak, ill and ing is th at somehow th e therap ist sh ould b e reproachful if h er daughter leaves her own able simply to transcend and transform the depression and self-doubt behind —it feels at a patient’s m aladaptive internal sch emas by deep level as if she is ‘abandoning’ the mother. being a good, reasonable person. This view of Another patien t Mr C, who fears (he kn ows human nature sees th e ap plication of reaso n irrationally) that sexual intercourse will some- and the right external conditions as sufficient how damage either himself or the woman, may for healing. The assumption is that the patient be able to reality-test his fears behaviourally is simply a good and reasonable victim of mis- PSYCHOANALYSIS AND COGNITIVE BEHAVIOUR 439 understanding an d neglect. Most psychoana- at different times and places. A bstinence and lysts, in contrast, see man as subject to complex neutrality th at harden in to rigidity and arro- internal co nflicts and strong tend encies gance may prompt some a nalysts to espouse towards u nreasonableness —all needing to be ‘human warmth ’ and experiment anew with understood and addressed in detail. This dif- gratification of th e p atient ’s infan tile wishes. ference in philosophy, o ften unstated, has The p itfalls o pened up by such an approach important clinical implications. carried to extremes may then in turn provoke a The facto rs th at psychoanalysts su ggest countermovement. Partial collapses of analytic make learning so difficult may mean that cer- tension in one direction or another may become tain patients will simply not be able to tolerate institutionalised in particular approaches. One the so rt of k nowing and understanding that analyst’s collapse may be another ’s flexible and psychoanalysis offers. They will neither want it innovative experiment, a nd the d ebate thus nor be accessible to it. In such cases it would be launched may be creative within psychoanaly- arrogant (as well as pointless) for a psychoana- sis, p roviding necessa ry challenges to stagna- lytic therapist to attempt to impose such treat- tion. Moves t owards more ‘reasonable’ and ment. A patient must be free to choose a socially acceptable approaches may also be less collaborative, less ambitious and more directly creative, and related to analysts ’ own inevitable educational approach that will not threaten ambivalence about analysis an d impatience needed defences. In a good assessment, one will with its slowness; its failure to live up to earlier, hopefully be able to gauge how much intrusion idealistic expectations. a patient welcomes or is prepared to tolerate. This will mean for example that psychoanalytic psychotherapists in the public sector, funded to ‘INTEGRATION’ OF PSYCHOANALYTIC AND work only o nce a week with ver y distu rbed COGN ITIVE THER APIES patients, may find themselves introducing more cogn itive parameters, and in effect col- A number of psych otherapists b elieve you lapsing the a nalytic stance. This co llapse at can combine all the advantages of the different least pa rtially deprives the patient of a full techniques with out lo sing p ower. T hus fo r opportunity to work in the negative transfer- example ‘cognitive-analytic therapy ’ (CAT) ence—to project the very worst things in his or (Ryle, 1990) is a brief, flexible approach where her internal world into the therapeutic relation- the patient is encouraged to think about them- ship. Thus one does limit the scope of the work selves and their relationships and to formulate that can be done. A therapist might judge with and monitor, with the therapist, what is habitu- a particular patient that this is wise, a s th ese ally going wrong. The therapist may use classi- terrible things might simply not be able to be cal CBT approaches such as encouraging the contained within the limited setting available. patient to keep a symptom diary a nd make However, I think it is always worth questioning homework experiments, while at the same time this, and for the therapist to ask him or herself interpreting t ransference phenomena as t hey whether it is really the patient being spared or arise. The patient ’s resistances to diary keeping the th erapist —is o ne u nderestimating the and other ta sks o ften (for example) quickly patient’s capacity to bear things, and avoiding provide material for work in the transference. an attack the patient really needs an opportu- CAT sessions are less structured than classi- nity to make? cal CBT sessions, and unconscious as well as There may be clinical reasons for knowingly conscious m eanings are certa inly so ught, but collapsing the tension of the analytic stance in CAT has certain hallmark structural features. this way with particular patients, but collapse There is, as in CBT, read ing m atter for the may also be part of ongoing debates and dia- patient, and stress on early collaborative writ- lectics within the profession of psychoanalysis ten formulation of the problems. The formula- 440 JANE MILTON tions can be referred back to when problems oedipal exclusio n dynamic can be avo ided or arise in the transference relationship or when swiftly collapsed by the rea dy availability of difficulties outside are discussed. Another writ- cognitive escape routes —again, triangularity is ing task is that both patient and therapist are bypassed. However C AT, like CBT, will for supposed to write each other ‘goodbye letters ’ these reaso ns b e m ore accessible and user- expressing their views about the therapy as it friendly o n initial con tact, and will engage a comes to an end. Ryle (1995) describes CAT as greater variety of patients. a very u seful an d safe first in tervention for I think another linked and important limita- patients referred for outpatient psychotherapy tion of both CAT and CBT, as compared with (in the UK health service). the an alytic approach, is th e therapist ’s non- Ryle (1995) regard s th e tra nsference as a neutral alignment in CAT and CBT with the ‘hardy plant ’ arising whatever one d oes, a nd ideal of ‘progress’. Through the introduction of certainly not requiring the therapist to be inac- explicit tasks, pressure and expectation on the tive. He regard s t he co llaborative stance of patient is implicit from the outset, in however CAT as less p otentially dangerous than psy- gentle and understanding a form it might be choanalysis, wh ich he sees as p lacing t he couched, to conform and to improve. I think patient in quite a powerless p osition (Ryle, this m akes goo d CBT and CAT both more 1994). I agree with Ryle that bad psychoanaly- paternalistic than good analysis, an d intro- sis has more potential for harm than bad CAT. duces a subtle moral restrictiveness through its This is because conditions are created such that very reasonableness and friendliness. the ‘hardy plant ’ of transference can flourish in Questions have also been raised (e.g. Scott, a much fuller, often more disturbing way, much 1993) about the rather functionalist and benign as the pot plants of colder climes become the model of the mind and of internal relationships bushes an d trees of th e trop ics. In addition, which underpins CAT (and indeed to my mind many plants will not even germinate outside CBT). The possibility of truly establishing and the tropics, and there will be important aspects maintaining a task-orientated therapeutic alli- of th e tra nsference and countertransference ance in d eeply t roubled and self-defeating which will not come to light at all in the setting patients seems too easily assumed. I think it is of CBT or CAT, which, in spite of superficial important for the therapist to be aware of the appearances to the contrary, I think have a fun- limitations of an approach such as CAT, and to damental similarity to each other an d differ- be sensitive to some patients ’ longing and need ence from a psychoanalytic approach. T he for something mo re an d different. As indeed therapist’s a ctive assertion of the ben ign col- with psychoanalysis, there is a danger of parti- league/teacher stance in CAT, as in CBT, and san idealisation of one ’s own approach, with- the structured nature of the work, help to limit out appreciation of both its advantages and its the patien t ’s regression , and the n ature a nd limitations. intensity of the transference. This makes them on the wh ole safer therapies fo r relatively unskilled therapists to perform. TH E REDISCOVERY OF TRANSFERENCE AND However, I think the sa me factors wh ich RESISTAN CE IN CBT limit the potential for harm and abuse to the patient in CAT and CBT also limit the poten- I have argued that CAT (and other similar tial power for good of the treatments, precisely ‘integrated’ approaches) may be much nearer because they restrict the nature and depth of in their conceptualisation to modern CBT than the tr ansference and countertransference. In to psychoanalysis, in spite of their attention to both, a limit is put on the power and stature, the unconscious and use of the transference. I both positive and negative, which the therapist think this is becoming more obvious as CBT can potentially have in the tra nsference. The moves into the treatment of personality disor- PSYCHOANALYSIS AND COGNITIVE BEHAVIOUR 441 der, and becomes itself more experiential and early ‘pressure tech nique ’, wh en he wo uld emotive and concentrates more on the thera- insist that the patient tell him what was in their peutic relationship. Beck himself ha s recen tly mind, however much they would prefer not to. stated that CBT is an ‘integrative therapy ’ par Freud describes (Breuer & Freud, 1895) how it excellence (Beck, 1991). is oft en the mo st significa nt things th at are Cognitive theory is evolving into something withheld from the physician , t hough the less m echanistic and more ‘constructivist ’— patient insists th at they a re in significant. In concerned with how th e p atient constructs other ways, too, I think CBT can be seen as rec- reality. This moves from an idea of the therapist reating earlier forms in the history of psychoa- imposing their own ‘rationality ’ on the patient. nalysis. After all, at first Freud tried to cure A number o f authors (e.g. Power, 1991) have patients using a simple cathartic method, and noted a ‘psychoanalytic drift ’ in the practice of his initial attempts at dealing with transference cognitive therapy, just as there was a ‘cognitive were by exp laining it to th e patien t as a n drift’ in the p ractice of b ehaviour therapy. archaic residue. Something a bit more object-related is seeping Giving a wealth of ca se exam ples, Beck into schema theory also, via a flourishing o f describes how treatmen ts h ave to be lo nger, interest in Bowlby ’s id eas ab out attachment and sometimes more t han once a week. His amongst cognitive theorists (e.g. Liotti, 1991). therapeutic optimism is m ore gu arded than According to Weishaar (1993), there is active before, an d he talks of th e d ifficulty of debate amongst cognitive theorists at the researching th ese lo nger-term more com plex moment as to ‘whether clinical deficits are cog- treatments usin g th e con trolled trial fo rmat, nitive or interpersonal in nature ’ (p. 125). How- suggesting that one sh ould valu e sin gle case ever, in spite of this apparent ‘analytic drift ’, I studies a nd clinical experience much more. differ from Bateman (2000) in believing that (This m ight strike psychoanalysts, wh o are the cognitive clinical paradigm remains funda- often criticised for doing ju st this, a s a bit mentally different from the psychoanalytic ironic.) He talks about the importance of get- one, a nd that true r approchement is mo re ting to know about the patient ’s total life, and apparent than real. An examination of the way exploring their childhood, and not just focus- modern CBT therapists modify their technique ing d own too much, or too prematurely, on will, I hope illustrate, this. cognitions an d tasks. H e stresses the impor- Alongside evolut ion in th eory, therapists tance of here-an d-now a ffective experience, (e.g. Beck et al., 1990) now suggest modifica- and the use of experiential techniques. tions to standard CBT technique when work- Beck points o ut that for the p atient to re- ing with personality-disordered patients. They experience relationship difficulties in relation include careful attention to the relat ionship to the therapist may be useful and ‘grist to the between patient and therapist, which, if it is not mill’. H owever, in co ntrast to th e an alytic addressed, can lead to losing the patient pre- approach, the therapist is supposed swiftly to maturely, or the th erapy getting stu ck. T he challenge these negative transference phenom- patient (we are told for example) will not want ena, in order to re-establish a benign working to mention his o r her trou bling n egative relationship. Beck says one should: ‘be in the thoughts about the therapist, and instead will role of friend and advisor ’, ‘draw on one ’s own go silent, or show in other ways that something life experience and wisdom ’ in order to ‘pro- is being resisted, like pausing, clenching fists, pose solutions ’ and ‘educate the patient regard- stammering, changing the subject. To qu ote ing t he n ature of in timate relationships ’, and Beck: ‘When questioned th e p atient may say , become a ‘role model’ for the patient (p. 66). “It’s not important, it ’s nothing”. The therapist From the psychoanalytic angle, although the should press the patient nonetheless ’ (Beck et psychoanalyst may indeed at times be seen as a al., 1990, p. 65). This is reminiscent of Freud ’s role model by the patient in the transference, 442 JANE MILTON one tries as an analyst to analyse rather than that their brand of treatment is mo re effica - accept this sacrifice of the patient ’s autonomy. cious than the other. There are indications that Analysts might see Beck ’s statement as claim- clinicians of different temperament tend to be ing so me u nwarranted superiority over drawn towa rds th e differen t mo dalities patients in knowing how a life should be lived. (Arthur, 2000), ma king it hard for each to The fo llowing quotation from Beck perhaps appreciate both the value of the other ’s way of illuminates this assumption, by illustrating the working and the limitations of their own. simple ‘deficit’ model assumed in CBT, which One oft-quoted argument for offering CBT requires the therapist to be a sort of teacher of rather t han psych oanalytic treatments to life-skills: ‘This process of re-education is par- patients in the public sector is that there is so ticularly important in treating p atients with much more empirical research evidence for its borderline p ersonality disorder, wh ose own efficacy. It is also asserted as being cheaper, as personality deficits may have prevented them it is brief and needs far less training to apply. from acquiring and consolidating many of the CBT, as a brief, fo cused th erapy, lends itself basic skills of self-control and stable relations well to the popular randomised controlled trial with others ’ (p. 66). (RCT) format, which has been repeatedly and Beck, in this recent work, refers frequently enthusiastically undertaken, albeit often not to disappointment, frustration and other nega- with typ ical outpatient populations (Enright, tive feelings that will be induced in the therapist 1999). O utcome measures are usually in th e by th ese difficu lt patients. He stresses t he form of simple symptom scores, and follow-up importance of su pervision in such cases, a nd periods short. also refers now and again in the book to the Psychoanalysis itself, of co urse, req uires idea of the therapist dealing with his negative four- or five-times-weekly sessions over some feelings and impulses toward s th e patien t by years; on e oft en sees ra dical ch anges in th e keeping a ‘dysfunctional thought record ’ of his patient’s relationships, work capacity and crea- own. Although Beck makes no mention of it, tive fulfilment, over and above ‘symptom there is some indication nowadays that trainee relief ’. Such outcome criteria are difficult and CBT therapists are entering personal psycho- complex to measure, though progress is being therapy more often, albeit on a non-intensive made in this area of ‘objective measurement of basis, as an aid to their work. It seems to me the subjective ’ (Luborsky et al., 1986; Barber & that this has to be a logical progression of these Crits-Cristoph, 1993; H obson & P atrick, new (re)discoveries in CBT. Without personal 1998). P sychoanalytic psychotherapy as it is analysis, fo r exam ple, m ost p eople are ill- typically constrained within the public sector equipped to make sustained clinical use of their uses the same methodology, usually on a once- countertransference rather than enacting it. weekly b asis over on e o r several years, an d expects to foster the same sorts of changes to a lesser d egree. M y view is th at what I was EMPIRICAL RESEARCH COM PARING PSYCH O- describing earlier —the str iving towa rds th e ANALYTIC AND COGNITIVE TH ERAPIES tension of th e an alytic stance —characterises the psychoanalytic approach, whether it is car- Unfortunately, both professional r ivalries ried out once or five times a week, and whether and political pressures mean that something of it is brief or long term. The vital factor to my a ‘horse race’ mentality can enter into the mind is that for a therapist to be able to estab- empirical comparison of outcome in cognitive lish and maintain an analytic stance requires and psychoanalytic treatments. C ompetition training on a very in tensive, experiential and for scarce resources, fo r example in the U K long-term basis. public sector, ca n mean that clinicians u sing When attempts are made to fit psychoana- the different methodologies are eager to prove lytic work into the extremely atypical sixteen- PSYCHOANALYSIS AND COGNITIVE BEHAVIOUR 443 session format suited to CBT, most psychoana- behavioural t herapies (Wiser & G oldfried, lysts would not predict more than symptomatic 1996) looked specifically at the types of inter- change, or a temporary alteration in sur face ventions made in sections of sessions the expe- cognitions, as there is no opportunity for vital rienced therapists themselves deemed change- working th rough. Thus one migh t expect the promoting for their patients. A gain, th ese efficacy of very b rief psychoanalytic psycho- researchers n oted an unexpected tendency in therapy to resemble that of CBT. This is borne the cognitive therapists towards both using and out in the relat ively few circum stances where valuing m ore ‘dynamic’ techniques, a nd sug- good quality comparative trials o f C BT and gest that this is part of the recent shift in CBT brief psychoanalytic psychotherapy have been towards a more interpersonal focus. carried out —there is found to be essentially no When we research outcome in more typical difference in o utcome (C rits-Cristoph, 1992; length psychoanalytic treatments, th e ‘gold Luborsky et al., 1999). standard’ RCT format, which works reasona- One stu dy attempting to link process an d bly well for brief therapy, poses huge logistical outcome in brief cognitive and dynamic thera- problems an d may b e q uite inappropriate pies has suggested, interestingly, that it is the (Galatzer-Levy, 1995; Gunderson & Gabbard, more typically ‘dynamic’ elements of th erapy 1999). We are dealing with a complex interper- that are important (Jo nes & P ulos, 1993). sonal process invo lving multip le variables. These authors expected to find that cognitive Controls m ay beco me impossible to achieve therapy worked via cognitive procedures and and randomisation is a questionable activity in dynamic therapy through dynamic ones. comparative trials where patients show marked Instead they observed that ‘evocation of preferences o r aptitudes fo r different ways of affect’, ‘bringing tro ublesome feelings in to working. The relative dearth of RCT evidence awareness’, and ‘integrating current difficulties for the efficacy of p sychoanalytic work is a with previous life experience, using the thera- function of the huge difficulties involved in pist–patient relationship as a change agent ’ (p. researching typical psychoanalytic treatments 315) all predicted improvement in both thera- in this way , and is o ften falsely equated with pies. This was in contrast to the more typically ‘evidence against ’ (Parry & Richardson, 1996). ‘cognitive’ procedures of ‘control of n egative Having said this, there is a growing body of affect through the use of intellect and rational- empirical research concerning m ore typical ity’ and ‘encouragement, support and reassur- length public sector psychoanalytic psycho- ance from therapists ’, (p. 315) which were not therapy in adults and children (e.g. Moran et predictive of positive outcome. al., 1991; Sandahl et al., 1998; Bateman & Fon- Jones & Pulos su ggest th at all such treat- agy, 1999; Guthrie et al., 1999). Taken together ments work via the provision of a unique, safe with studies of psychoanalysis itself, the hard- context within which relationships with the self est of all to research, evidence begins to emerge and the world can be explored. They are aided that these lengthy, more ambitious treatments by p rivileging emo tional experience over may indeed offer important additional benefit. rationality, and by emphasis on developmental Fonagy et al., (1999) have collected and criti- history. According to this study at least, in so cally reviewed fifty-five studies of psychoana- far as cogn itive therapists t ake a ‘rationalist ’ lytic outcome. These a uthors, alth ough they approach, in which affect is conceptualised and expose many methodological limitations in the treated as the expression of irrational and unre- data, adopt overall what they ter m a ‘cau- alistic beliefs, and in so far as they view their tiously op timistic ’ attitude to psychoanalytic role as one of imparting technical instruction outcome given the evidence available. Key pro- and guidance, the th erapy ap pears to be less visional findings (which are fully referenced in successful. A nother study co mparing p rocess the work itself) include the following: (1) inten- in ‘dynamic-interpersonal ’ and cognitive – sive psychoanalytic treatment is generally more 444 JANE MILTON effective than psychoanalytic psychotherapy, endeavour is recognised, to relieve the misery the d ifference sometimes only b ecoming evi- of psych ic suffering, and also the differen ces, dent years a fter treatment has en ded, th is which will have important im plications for applying particularly to the more severe disor- which patients are treated, in what way, and ders. (2) L onger-term treatment has a better with what aims. It is unfortunate that clinicians outcome, as does completed analysis. (3) There from the two groups are currently often pushed are fin dings that suggest p sychoanalysis a nd by extern al economic pressures to compete psychoanalytic psychotherapy are cost-benefi- with on e an other in t he p ublic sector, which cial a nd perhaps even cost-effective, and that exacerbates the innate rivalries that are bound psychoanalysis can lead to a reduction in other to exist between practitioners of two such very health-care use and expenditure, although one different sorts of treatment. study suggests an increase. (4) Psychoanalytic The select ed empirical eviden ce I h ave treatment appears to improve cap acity to quoted gives some interesting indications as to work, to reduce borderline personality disor- shared therapeutic factors in b rief psychody- der symptomatology, and may be an effective namic and cognitive therapies. In the relatively treatment for severe psychosomatic disorder. few instances in which comparative studies of CBT and very b rief psychodynamic therapy have been carried out, th ere is fo und to be SUM MAR Y AND CONCLUSIONS essentially no difference in o utcome. Th is should be no surprise to a psychoanalyst, as we I have tried to show how I see the CBT para- would not predict deep and lasting change in digm as a useful bu t less co mplex paradigm inner world structures with out considerable than the p sychoanalytic one, limited in it s opportunity for working through. We might, in explanatory power and in terms of the change fact, be rath er su rprised an d impressed th at its therapeutic application can be expected to psychodynamic therapy d oes as well as C BT achieve. Its far less in trusive an d threatening under such circumstances. The claims I made nature will, however, make it more acceptable earlier in the paper about psychoanalysis as a for a number of patients. I have also tried to method facilitating deep and lasting ch ange show how there is a strong attraction towards certainly need substantiating emp irically working in a ‘cognitive’ way, for both psycho- rather than simply asserting, and I think we are analyst and patient, and that the inherent ten- not yet able to do this with confidence and in sion and complexity of th e an alytic stance is detail. However, research evidence of the last constantly on the br ink of decom posing, o r couple of decades is beginning to confirm ana- collapsing, sometimes resulting in a weak ver- lysts’ expectations that intensive and long-term sion of cogn itive therapy taking p lace. H ow- psychoanalytic treatments h ave something ever, if the tension of psychoanalytic work can substantial to offer over and above what brief be b orne by b oth patient and analyst, t he treatments, whichever the modality used, can reward can be experiential, emotional learning provide. by the patient, which is likely to be deeper and more enduring than purely cognitive learning. I have also suggested that, because psycho- TRANSLATIONS OF SUMMAR Y analysts a nd cognitive-behavioural th erapists share the same field of study, they are increas- L’auteur sugg ère que l’enthousiasme contemporain ingly going to discover the same clinical phe- apporté à la thérapie cogn itive-comportementale nomena, a nd indeed are now do ing so, reflète notre désir de soulager rapidement et rationnel- although they m ay th en approach these ph e- lement la souffra nce psych ologique. La comp étition présente dans le monnaiement menace la pr ésence de nomena in fundamentally different ways. It is la psycha nalyse d ans le secteur publique. L ’auteur important, I think, b oth that the sha red comparent les mod èles psychan alytiques et cognitifs- PSYCHOANALYSIS AND COGNITIVE BEHAVIOUR 445 comportementaux et souligne la richesse relative du durch für manche Patienten akzeptabler sind. Ausge- paradigme p sychanalytique. Elle mont re qu e le wählte empirische Prozess- und Outcome- Forschung modèle co gnitif est sens commun , ma is mo ins von kognitiven und psychoanalytischen Behan dlun- complexe et poss ède moins de potentiel explicatif et a gen wird diskutiert. K urztherapien haben ähnliche, moins de pouvoir th érapeutique. Elle montre la fa çon mässig gute Ergebnisse in beiden R ichtungen, wob ei dont la sph ère analytique subit toujours la pression de es einige Eviden z gibt, d ass d ies mehr auf „dynami- ‘s’effondre’ en des modes plus simp les, don t l ’un schen“ als auf „kognitiven“ Behandlungselementen ressemble a u mo de cogn itif. Ceci ap para ît aussi beruht. F ormale Outco me-Studien von t ypischerer inévitablement d és lors que l ’on s’efforce d’ ‘intégrer’ psychoanalytischer Psychotherapie und Psychoanaly- les deux mod èles. Les traitements cognitifs et ‘intégrés se weisen d ahin, da ss diese langen und komplexen ont néanmoins l’avantage d’être moins envahissants et Behandlungen in der u mfassenderen Weise effektiv donc plus acceptables pour certains patients. L ’auteur sind, wie sie das Modell voraussagt. traite du processus emp irique et du r ésultat de la recherche cognitive et des th érapies psychanalytiques. Des thérapies brèves de l’un ou l’autre des mod èles ont La autora sostiene que el entusiasmo actual por la des résultats proches et modestement bons, et il semble terapia cognitivo —conductual refleja nuestro s inten- que cela soit du plus à des éléments dynamiq ues du sos d eseos d e logra r que el alivio del su frimiento traitement que du à des éléments co gnitifs de ce psíquico sea r ápido y basado en la l ógica. Las rivalida- dernier. D es études fo rmelles sur le r ésultat des des económicas ponen en peligro la presencia del psi- psychothérapies psychana lytiques typiques et sur la coanálisis en el sector p úblico. Se contrasta el modelo psychanalyse elle m ême commen cent à montrer qu e psicoanalítico co n el co gnitivo —conductual, su bra- ces traitements longs et complexes sont efficaces dans yándose la mayor riqueza del primero. La autora opi- la manière plus compr éhensive prédite par le mod èle. na que el modelo cognitivo, aunque tiene su l ógica, es menos complejo, tiene menos posibilidades explicati- vas y menores p osibilidades terap éuticas. Estudia Nach Meinung der Autorin reflektiert der heutige cómo la postura psicoanal ítica está siempre bajo pre- Enthusiasmus f ür kognitive Verhaltenstherapie unsere Sehnsucht nach schneller, rationa ler Hilfe f ür seeli- sión y a punto de resq uebrajarse, par a acercarse a sches Leiden. Der Wettstreit um finanzielle Mittel be- modelos más sencillos, uno de los cuales su ele ser el droht die p sychoanalytische Pr äsenz im öffentlichen cognitivo. Seg ún la a utora, esto ocu rre, in evitable- Sektor. Das psychoa nalytische Modell und das M o- mente, cuando se hace un intento por ‘integrar’ ambos dell d er k ognitiven Verh altenstherapie werd en ein - modelos. Lo s t ratamientos co gnitivos e ‘integrados’ ander gegen übergestellt, und der relative R eichtum tienen la ventaja de que son menos intrusivos y, por lo des psychoa nalytischen Parad igmas wird dargelegt. tanto, mejor aceptados por algunos pacientes. Se ana- Nach Meinung der Autorin entspricht das kognitive lizan los m étodos empíricos y los resultados de algu- Modell dem allgemeinen Menschenverstand, ist aber nas investigacion es. Las p sicoterapias breves de weniger komplex und seine potentielle erkl ärende und cualquier tip o pueden ten er un resultado parecido y therapeutische K raft ist geringer. Sie d iskutiert, wie relativamente bueno. Y es evidente que, en tales casos, die a nalytische H altung immer u nter D ruck ist, zu se basan más en elementos din ámicos que en elemen- einfacheren M odalit äten „zusammenzufallen “, von tos cognitivos. Estudios m ás profundos sobre los re- denen eine der kognitiven ähnelt. Dies geschieht nach sultados de las psico terapias p sicoanal íticas más ihrer Meinung unvermeidlicherweise auch, wenn man típicas y del mismo psicoan álisis empiezan a indicar- versucht, die zwei Modelle zu „integrieren “. Kognitive nos q ue esos trata mientos, la rgos y co mplejos, son und „integrierte “ Behandlungen haben and ererseits eficaces en un sentido m ás completo, ya pronosticado den Vorteil, dass sie wen iger tief eindringen und da- por el modelo.

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Jane Milton Copyright © Institute of Psychoanalysis, London, 2001 6 Narcissus Road London NW6 1TH [email protected] (Initial version received 22/5/00) (First revised version received 11/12/00) (Final revised version received 26/3/01)