Comparison Between Psychodynamic Therapy And Cognitive Behaviour Therapy

In this essay, Psychodynamic therapy will be described and its key theories and concepts explained. How these concepts and theories are applied in clinical practice will be evidenced by the use of published case material to explicitly illustrate these points. There will also be a discussion on how a Cognitive Behaviour Therapy practitioner might have approached this particular client differently. Psychodynamic therapy is the oldest of the modern therapies and is also known as insight-oriented therapy. Its primary focus is to reveal the unconscious content and processes of a client’s psyche in order to alleviate any psychic tension that may be manifesting itself outwardly in the form of disadvantageous behaviour or ideations. Therapy’s secondary focus is for the therapist to enable the client to increase their own self- awareness and help them to gain an understanding of how past events and experiences influence their present behaviour and ideations. Key concepts in psychodynamic therapy include the belief that psychopathology develops from early childhood experiences and that these experiences are organized around interpersonal relationships. There is an emphasis on how unconscious conflicts relate to the development of the client and these unconscious conflicts are explored by the use of Free Association. Another major concept within psychodynamic therapy is the use and development of Defense Mechanisms by the client. Therapy will aim to uncover how the client uses these in order to protect themselves from the psychic distress of unconscious conflicts. There is also the belief that these unconscious conflicts will re-emerge as transference and counter- transference within the therapeutic relationship and therapy’s goal is to work through the interpretations of these conflicts. The healing and change process during long-term psychodynamic therapy typically requires at least 2 years of sessions. This seemingly long duration of treatment enables the change of certain undesirable aspects of the client’s identity or personality, or to regain key developmental learning missed while the client was having difficulties at an earlier stage of emotional development, which would not easily be achieved during brief therapy. Lenneberg (1964) put forward a theory that the crucial period of language acquisition ends around the age of 3-5 years and that if no language is learned before that stage of development, then it could never be learned in a fully functional sense. This became known as the ‘Critical Period Hypothesis’. Psychodynamic therapy also recognises critical periods of development in the client, however, the focus is on emotional development and, with work, these periods can be re-visited and any missed learning can be regained through the therapeutic relationship. In its brief form, therapists from the psychodynamic approach believe that some changes can happen through a more speedy process or that an initial short intervention will begin an ongoing process of change that does not need the therapist’s constant involvement. They further believe that this enables the client to examine unresolved conflicts and symptoms that have arisen from past dysfunctional relationships and that are currently manifesting themselves in the need and desire to abuse substances. A central concept in brief therapy is that there should be one major focus for the therapy rather than the more traditional psychoanalytic practice of allowing the client to associate freely and discuss unconnected issues. In brief therapy, the central focus is developed during the initial evaluation process, occurring during the first one or two sessions. This focus must be mutually agreed upon by both the client and the therapist. This central focus prioritises the most important issues thereby creating a structure and in so doing, identifies a goal for the treatment. The therapist’s clear agenda in keeping the session focused on the main issue makes it possible to do all the interpretive work within a relatively short time period, as the therapist is only addressing the prioritised issue. Several different approaches to brief psychodynamic psychotherapy have evolved from psychoanalytic theory and have been clinically applied to a wide range of psychological disorders. In this essay, however, the focus will be on Object Relations theory and how it applies to the treatment of depression and anxiety. The term ‘Object Relations Theory’ was formalised by Ronald Fairbairn, (Fairbairn, 1952) and was actively pioneered throughout the 1940s and 50s by British psychologists Ronald Fairbairn, Melanie Klein, Donald Winnicott, Harry Guntrip, Scott Stuart, among others. Object relations theory is a derivative of psychoanalytic theory that places the emphasis on the client’s interpersonal relationships, primarily within the family and more especially between the client and his or her mother during the client’s childhood. It is a modern modification of psychoanalytic theory that places more emphasis on human relationships as being the primary motivational force in life rather than on Freud’s libido and aggression as motivational forces (Freud, 1961). ‘Relations’ refers to interpersonal relationships and suggests that past relationships affect the client in the present. It is this fundamental human need to initiate and maintain relationships that forms the basis for libidinal and aggressive drives gaining meaning. Object relations theorists are interested in the client’s inner images of his or her self and their interpretations of the inner images of others and how these interpretations manifest themselves within interpersonal situations. Probably the most important of the key concepts of object relations theory is the ‘object’ itself. Freud used ‘object’ to mean anything that an infant will direct his or her drives toward in order to satisfy their hunger. Modern object relations theorists, however, believe that ‘object’ refers to the person that is the object of the client’s feelings or intentions and who is also the target of missing relational needs within the client’s development. Objects can be internal (a memory or fantasy about a person, place, or thing) or they can be external (an actual person, place or thing that a person has invested with emotion). An object can also be a part object such as a hand or breast, or a whole object such as a person who is recognized by the client as having rights, feelings, and needs similar to their own. Object constancy is the term used in object relations theory when the client shows capability in maintaining a relationship of some duration with a specific object, or when they reject substitutes for this particular object. Mahler (1975) describes object constancy as “the capacity to recognize and tolerate loving and hostile feelings toward the same object; the capacity to keep feelings centred on a specific object; and the capacity to value an object for attributes other than its function of satisfying needs.” Another key concept within object relations theory is that of Splitting. This occurs when a client cannot hold two contradictory thoughts or feelings in the conscious mind simultaneously as it causes such a psychic tension, and so they keep the conflicting feelings apart and focus on just one of them. The division can take on any form, from visual appearance to concepts such as good and bad. The good part can then be retained and loved, while the bad part is ridiculed or repressed. “Splitting is a boundary-creating mode of thought and therefore a part of an order generating process.” (Ogden, 1986). Two main researchers in object relations theory are Donald Winnicott and Margaret Mahler. After briefly looking at each in turn, this essay will then illustrate the key points of object relations theory by the use of a published study on the case of Ms A. (Traub & Lane, 2002) who was treated for depression, anxiety, and dependent character traits. Winnicott, a pediatrician, watched many mothers and infants interact. According to Winnicott, it was how this interaction played out over time, that was crucial to infant growth and development and there were three stages of care (Winnicott, 1953). The first is ‘Holding’, which involves actual physical holding of the child, and caring for the child over time as this has both a psychological benefit as well as a physical benefit; the second is that both Mother and child live together; and the final one is that Father, Mother and child, all live together. Although, nowadays, the idea of the original ‘nuclear’ family is somewhat old fashioned given that, according to the National Office of Statistics Census 2001 – Families of England and Wales, single parent families made up 9.6% of households in England and Wales, that is almost one in ten households, and 9 out of ten of these households are headed by the mother. That notwithstanding, according to Winnicott, with ‘good enough’ care the true self can emerge, this is the part of the child that feels real and spontaneous. False self emerges in the absence of ‘good enough’ care. Winnicott also believed that Transitional objects are the child’s first ‘not-me’ possessions, for example, a security blanket or doll. This transitional object allows the child to let go of the mother and develop more independence, become less clingy. The child can take the object anywhere and receive a quick dose of comfort whenever it feels anxious thus lessening the stress of separation. Transitional phenomena are behaviours, such as rocking or developing fantasies, which also serve to lessen the separation stress. Mahler agreed with Winnicott over the importance of holding a child. For Mahler, it was a method of reducing tension in the child and involved the mother creating a space within which the child can be itself and feel protected and secure. Wrong holding can mean refusal to hold the child physically or psychologically when it needs to be held, or by holding it so tightly that the child feels smothered, so that the child does not have a chance to develop as an individual. Mahler believed in the developing child’s ‘psychological birth’, (Mahler et al, 1975). A good mother will encourage this psychological awareness in many ways, such as a mobile over the child’s cot. Soon, the child begins to gain a sense of self, and they start to have a memory. For Mahler separation from the object is an inner mental process wherein one distinguishing oneself from the object. Mahler described four phases of this development process… The first phase is that of Differentiation also known as the ‘hatching’ phase. The child starts to pull away from the mother, but will always check back to her. There is a distinct shift from outwardly-directed to inwardly-directed attention. The second phase is the Practicing period. As the child is now more physically active it begins to explore and become more distant from the mother. However, the child will still look back to see if mother is there, and never stray too far away. A psychologically healthy child may go to another friendly adult, but a child with a neurotic or overprotective mother may be delayed through this phase. There are elements here of Bowlby’s attachment theory (Bowlby, 1969) and Ainsworth’s Strange Situation study (Ainsworth & Bell, 1970) in the similarities of the individual differences in attachment styles of children and how they can manifest in psychopathology in later life. The third phase is Rapprochement. Here the child realizes that his physical mobility demonstrates a psychic separation from his mother. The child may then become hesitant in his explorations and require the mother to be continuously within his sight in order that he may continue exploring, however, the mother can misinterpret this need and become either impatient or unavailable to the child. This can result in feelings of abandonment and a fear of rejection in the child. Resolution of this psychic tension comes about with the development of language and the superego, which can lead to the development of a greater autonomy for the child. The final phase is Object Constancy. In this phase the child understands that the mother is a separate individual. This leads to Internalization, which is when the child forms an internal representation of the mother. This internal image of the mother within the child gives the child an unconscious level of support and comfort without the mother actually having to be physically present. A negative internalization could result in psychopathology in adulthood. In relation to the case of Ms A. and her treatment, the key points of psychodynamic therapy in general can be seen, for example, the belief that psychopathology develops from early childhood experiences and that these experiences are organized around interpersonal relationships is illustrated in Ms A’s depression and anxiety stemming from her childhood experience of being burned in house fire and feeling abandoned and rejected by her mother. With regards to object relations theory, the concept of holding, considered so important to both Winnicott and Mahler is also in evidence as Ms A described her mother as “unstable, unloving and unsupportive” and if Ms A was in any way disobedient, then her mother would “discipline by hand” or “inflict pain or ignore her completely”. This would be considered by both Winnicott and Mahler as ‘wrong holding’ and has resulted in Ms A failing to develop as a psychologically healthy individual. The aspect of ‘good enough care’ espoused by Winnicott where Father, Mother and child all live at home is not present in this particular case as although Mother and child lived together in the family home, Father was rarely present and this seemed to be yet another source of psychic tension for Ms A in creating possible abandonment issues and further tension within the family home which may have aggravated the situation with her mother. Winnicott’s ‘false self’ emerges in Ms A’s description of herself as having to “wear a mask” during any social interaction with others. This developed over time beginning with her mother’s failure to nurture and be a ‘good enough’ mother, hence Ms A’s continuous search for this gap in her emotional development to be bridged for her by other people, namely her husband, and later her fiancé. Mahlers object constancy is a negative internalisation of the mother. Ms A developed the defence mechanism of splitting her mother into two parts in order to protect herself from the psychic tension arising from the ‘not good enough mother’. Ms A identified with the ‘good object’ which was the internalisation of the image of a good mother and repressed her anger and ambivalence towards the ‘bad object’ which was her mother the person. Psychodynamic therapy is not, of course, the only method to treat anxiety or depression, another popular treatment is that of Cognitive Behaviour Therapy (CBT) and, although there are some similarities with psychodynamic therapy, for example, they are both ‘talking therapies’, however, there are some major differences. Within the cognitive model, psychopathology is thought of as simply irrational thoughts, or errors in thinking. It assumes that people’s thoughts direct their emotions and behaviours. Ellis and Beck are 2 main names within the cognitive model. Beck’s (1967) theory of depression states that negative thinking leads to negative mod which leads to depression. With negative thinking there is a ‘cognitive triad’ –

1) The Self – “I am worthless”. 2) The World – “Everything is against me” 3) The Future – “Nothing is ever going to change”

Ellis (1962) proposed Rational Emotive Therapy (REBT) which espouses that thinking and emotion are inter-related. Thinking affects emotions and emotions affect thinking. When we think rationally, we behave rationally. According to Ellis, people who think irrationally use words such as ‘should’; ‘ought’; ‘must’, a lot. The idea of this type of therapy is that the client must prove their thought to be correct, and then replace the irrational thought with a more rational one. So how might a CBT therapist have treated Ms A? CBT differs from psychodynamic therapy in that it addresses current thoughts and feelings rather than analysing the causes of depression. During a session, a CBT therapist would help Ms A. to chop her problems into smaller separate parts. Ms A seems to have intellectualised her depression and therefore would be less likely to be paralysed by her problems, and therefore more able to face up to them and deal with them effectively. Often during depression or other mental health conditions, a person can feel overwhelmed with stress and anxiety, and all of these worries and anxieties may combine into one scenario. The idea in CBT is that by breaking problems down to more simple, clear issues, you can address each problem one-by-one and can also identify any common threads. A CBT therapist might first of all require Ms A to self evaluate. In depression, self-evaluation is generally negative and critical. When something goes wrong, the client may think, “I messed up. I’m no good at anything. It’s my fault things went wrong.” The therapist will then work through these ideations one by one and encourage Ms A. to see more positive aspects in her day to day life. Sometimes a depressed person may accurately identify a skill deficit within themselves. This is usually coupled with negative self-evaluation. Ms A described herself as a ‘yesser’, she felt that she had an inability to say no to people, and therefore, felt that it was her fault that she didn’t get the life she wanted. A CBT therapist would help Ms A to realistically identify her skill deficits, and also help her to develop a step by step plan to improve those skills. As stated earlier, Ellis (1962) first presented the idea that irrational beliefs are at the heart of most psychopathology. CBT therapists would suggest that these ideas are irrational because they are based on false assumptions, such as Ms A feeling that she could not be happy unless everyone else is happy. She sacrificed her own desires for her husband to her detriment. What makes these ideas irrational, is the belief that they are always correct. The result, as for Ms A, is a loss of self-esteem, and depression. CBT therapist would help Ms A to identify these irrational ideas, and enable her to see that the ideas need to be changed to reflect reality. CBT is becoming more and more popular and it has been increasingly applied in different settings, however, there is a problem with cause and effect, in other words, did the irrational thoughts cause the depression or did the depression cause the irrational thoughts? It also ignores the possibility that some so called irrational thoughts might actually be rational and the model has yet to answer the question of where irrational thoughts come from in the first place. In conclusion, all psychological theories provide conceptual frameworks to enable counsellors to think systematically about human development and the practice of counselling. These frameworks enable counsellors to decide how to view, respond to and treat clients’ maladaptive behaviour. Theories are needed to make predictive hypotheses. Every time a counsellor decides on how to treat a particular client they are actually forming a hypothesis. The same is also true for the client when they make predictions on how best to live their lives. The accuracy of these predictions is greatly enhanced if the knowledge of proven counselling theories is available to them. However, Kline (1988) states that a theory is not invalidated just because it cannot be tested scientifically. There are, however, disadvantages to counselling theories…

– Roger’s diagnosis of clients is simply that they are not self actualising and all they need is help in this regard. – Ellis’s view that it is merely the clients irrational beliefs that are the problem neglects other aspects such as accurate perception and the use of coping self-talk. – Behavioural psychology pays little attention to thoughts or feelings. – Freud’s dream analysis to uncover the unconscious mind does not take into account the need to learn effective behaviours to cope with day to day issues. – Counsellors becoming so entrenched in their favourite theory that they let it cloud their assessment and treatment of clients, leading to ‘rigor psychologicus’. – They can be seen as unscientific, for example Freud’s Id, ego and Superego (Freud, 1962) are all merely concepts, they cannot be observed or measured.

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Object relations theory itself comes in for particular criticism in that it does not take into account the social norms and values that can help to create pathology, and its superficiality is highlighted in its interpersonal approach to the dyadic relationship between mother and child, which it seems to imply is partially responsible for any emergence of future psychopathology in the child.



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