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

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 swift, rational help for psychological suffering. Competition 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 potential explanatory and therapeutic power. She discusses how the analytic stance is always under pressure to ‘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 dis- cussed. 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, as providing an alternative to tioners are beginning to rediscover the same psychoanalytically orientated therapy that is phenomena that psychoanalysts earlier faced, more rational, quick and efficient, and 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 psychoanalysis, and their expectations. These rediscovered phe- may prove relatively short-lived. However, psy- nomena concern unconscious processes, the choanalysts need to take careful heed of this complexity of the internal world and the intrin- phenomenon, and be prepared to engage in sic difficulties of psychic change. The main 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 than psychoanalytic treatments to continues to become more ‘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, including substantial 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 course in the UK 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 stance of the therapist in CBT is a efficacy of CBT is also questionable empiri- socially acceptable one, which makes immedi- cally, and I will look briefly at the outcome ate intuitive sense. The psychoanalytic stance is research field in this connection. much harder to swallow, and is maintained 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 analyst is pushed constantly 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 discomfort and tension of the his self-analysis. A similar context for Beck ’s striving for analytic neutrality and abstinence, ideas is less well-known and is worth outlining. more disturbance becomes available in the Aaron T. Beck began as a psychoanalyst, grad- room, within the therapeutic relationship itself, uating from the Philadelphia Psychoanalytic to be worked with and potentially trans- Institute in 1956. He became disillusioned and formed. CBT is far less disturbing and intru- impatient with the psychoanalytic 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 not, protecting privacy and 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 situation 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, founded first a ‘cognitive theory ’ of than analytic. Once cognitive or behavioural depression, then derived a brief therapeutic parameters are introduced by the therapist, 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 psychoanalysis involved a card-sorting test. The fact that at one place and time. depressed subjects did not react negatively to Beck’s biographer (Weishaar, 1993) notes success in the task showed, Beck thought, that that Beck is open about having developed his they did not have a need to suffer, and thus theory and technique not just through his clin- went towards disproving the psychoanalytic ical work, but, like Freud, through introspec- theory that depression was due to ‘inverted tion and analysis of his own neurotic problems. hostility’. Many psychoanalysts might ques- Born in 1921, the youngest of a sibship of five, tion this as a research paradigm for psychoan- Beck was according to family mythology the 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 sometimes are between 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 matriarchal figure, overshadowing the 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. He was influenced by Kelly ’s the young Aaron found troubling. She is (1955) personal construct theory and 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 independently developing Rational- phobia’ during his medical training, treating Emotive therapy, which shares some but not all his fears of heights, tunnels, public speaking of its features with cognitive therapy (Ellis, and ‘abandonment ’ with similar sorts of 1980). Beck, together 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 therapy (CBT), an 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. Greenberg suggests that being his CT. ‘Behavioural ’ acknowledges the contribu- own authority and being in control of himself tion of learning theory and classical behaviour were of overriding importance to Beck, and therapy.

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