Approaches to therapy: Psychoanalytic therapy and CBT

All therapists and patients are unique. Therefore, no two experiences in therapy are exactly the same. However, despite the infinite variety, we can talk a bit about the overarching paradigms of the different approaches. This page is a brief overview to give some introductory thoughts about it. The links in the text are to deeper resources, if you happen to be feeling ambitious!

Sometimes therapists will identify their approach as “psychoanalytic” or “CBT”. In the real world, sometimes the lines are blurred a bit and they look similar to one another. However, they are based on different paradigms of mental health and therapy.

What is Psychoanalytic Psychotherapy?

  • Psychoanalytic psychotherapy is similar to psychoanalysis, but there are distinct differences. Psychoanalytic therapy is not as frequent or intense as psychoanalysis, which can be four or more times per week. All psychoanalytic theories are descendants from Sigmund Freud.
  • There have grown to be many different kinds of psychoanalysis and, consequently, different theories of psychoanalytic psychotherapy. (See S. Mitchell, Freud and Beyond: A History of Modern Psychoanalytic Thought.)
  • Psychoanalytic approaches are about the present, not about just revisiting past memories. The point is to understand why the NOW tends to have its particular quality so that NEW experiences have the chance to exist. (Here is a book exclusively about Time, Self, and Psychoanalysis.)
  • The goal is to be more you in the context of the world. There is usually a goal not to judge experience as “good” or “bad.” Nothing can be value-free or completely neutral, but becoming a subject (someone who is able to be on the path of awareness and agency) seems like a pretty noble aspiration.
  • Not all of who we are is obvious. There are aspects of each of us that continuously and actively influence thoughts, feelings and behavior that we can’t directly access. Freud called this the “unconscious.”

What are some common criticisms of Psychoanalytic Therapy?

  • It costs a lot. Response: It can be expensive, but there are many who have benefitted from it see it as an investment in life rather than a cost. Your benefits depend on what you put into it (just as it is with life as a whole).
  • It can take a long time. Response: If you’ve lived your entire life a certain way, it makes sense that deep change won’t be instantaneous or easy.
  • There are no clear goals. Response: Often therapy does start with stated goals, but an open approach is taken because sometimes the evident problem is not the entire issue and other things can rise in importance.
  • The therapist will convince me to blame my mother or some childhood trauma. Response: Your relationship with your parents is important and occasionally also there are unremembered events. However, such caricatures of therapy are too simple and miss the point. Understanding how experiences have impacted and continue to affect us is not relinquishing responsibility to bear the weight of our own life.
  • Psychoanalytic therapy is cold and impersonal. Response: Could be true, but that’s not due to the theory but rather the personality of the therapist. Patients more often comment to me that they are surprised how engaged and active I am.
  • It is not empirically supported. Response: Comparatively, it has less research because the approaches do not lend themselves as well to measurement as other approaches (see below), but there is ample research that demonstrates it effectiveness. For example, see Sedler, J., 2010, The Effectiveness of Psychodynamic Psychotherapy, American Psychologist, February-March, pp. 98-109.

What is Cognitive Behavioral Therapy (CBT)?

  • Cognitive behavioral therapies approaches life struggles from a slightly different starting point than psychoanalytic therapies. These approaches see thoughts (cognitions), and actions as stemming from flawed strategies of thinking and maladaptive learned behaviors. CBT involves various ways of providing alternative strategies for interpreting our own feelings, understanding and evaluating the world, and new behaviors are put into practice.
  • Just as there are a variety of Psychoanalytic theories, there are a variety of CBT schools. Some focus on having more rational or accurate thoughts, others on changing behavior patterns to produce different consequences, but all tend to be focused on getting rid of the symptom (e.g. depressed feelings, anxiety or fears).
  • Often this kind of therapy will prescribe exercises and homework assignments to be completed between sessions.
  • The course of treatment tends to be briefer because it is problem-focused.

What are some common criticisms of CBT?

  • The empirical support is skewed because of the nature of the treatment. It is like teaching for a test by giving students the right answer. Teaching someone they feel bad because they’re doing something wrong, and then telling them the right way, will likely mean they will claim to have learned their lesson (or else be a failure). Response: Well, it still has an effect, regardless of how it does it. (Here is a good paper on publication bias, although slightly different than my point above, it illustrates how outcome research is not always perfect: The Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias).
  • It doesn’t go very deep. Response: True, it is not intended to go as deep as psychoanalytic approaches, but perhaps that’s better for certain situations. After all, not everyone wants to plumb the depths of their existence. It can also be a stepping-stone to deeper work.
  • It’s all technique and there’s no relationship with the therapist. Response: It is true that the content is important in CBT, but one of the most robust research findings about what works in therapy is that the relationship is important. So although the relationship might not be the focus of the conversation in therapy, it is still central to what is therapeutic. (see Dunan, B.L., Miller, S.D., Wampold, B.E., Hubble, M.A., The Heart and Soul of Change: Delivering What Works in Therapy, 2nd Ed.)

Which is better?

Which is better depends on you and what you want. Trusting and feeling compatible with (a “good fit”) your therapist are more important factors than the theory, since all approaches to therapy can be demonstrated as "effective."

Each of us is faced with the challenge of choosing what we want out of life and what we want to put into it. Investing in therapy can help in that endeavor. I hope that you will discover what you might really be searching for, because who knows? You just might be surprised!

I am more of a psychoanalytic psychotherapist, but I try to be flexible within the context of listening to many levels of experience and existence.