Compare and contrast how treatment would proceed for a woman suffering from depression, anxiety and feelings of inadequacy if she undertook cognitive behavioural therapy or psychodynamic psychotherapy.
Cognitive Behavioural Therapy
Cognitive behavioural and psychodynamic approaches to therapy seem to offer contrasting modes of treatment for psychological difficulties, largely due to the fact that they originate from very different theoretical and philosophical frameworks. It seems likely, therefore, that treatment for a woman experiencing depression, anxiety and feelings of inadequacy will proceed along very different lines according to each approach. There do appear to be some features, however, which are common to all effective ‘talking’ therapies, notably rooted in the therapeutic relationship itself and in the qualities and skills of the therapist, whatever their persuasion.
Psychodynamic therapy, as Jacobs (2004) notes, incorporates many different strands, originating from Freudian psychoanalytic theory, and is generally understood to focus upon the unconscious activity of the psyche. The internal aspects, or ‘states’, of the psyche are seen as taking shape during the years of a child’s development and constitute elements of the child’s relationship with significant others, notably mother and father. Consequently, all psychodynamic therapies pay particular attention to “the importance of the child’s early environment as promoting the foundation of later personality strengths or areas of vulnerability” (Jacobs, 2004, p.10). At times of stress we can be driven back to more primitive, or infantile, ways of thinking, feeling and behaving in accordance with our perceptions of those early relationships.
A psychodynamic therapist working with a woman who expresses feelings of depression, anxiety and inadequacy, therefore, will be concerned to attend to various indicators of unconscious psychic activity in the way the woman talks about events and situations, past and present, and her associated feelings. The woman may, for example, speak of disrupted relationships with particular loved family members, through death or separation, or of traumatic or abusive experiences. The therapy is likely to move constantly between past and present, with the client being encouraged to make connections between her perceptions about her past personal history and what she is experiencing, and feeling, in the present. For example, this woman’s present feelings of inadequacy may be interpreted as linked to earlier experiences of never quite being able to live up to her mother’s high expectations of her.
A distinctive feature of psychodynamic therapies is the key hypothetical process of transference. Relationship is central to the therapy in that the client’s personal history is seen as significant for the relationship between client and therapist (Jacobs, 1986; 2004). The client is said to unconsciously ‘transfer’ unacceptable, repressed, elements of her past into her relationship with the therapist. Thus, using our earlier example, the therapist may have noted certain remarks made by the woman suggesting that she may not be able to meet the therapist’s expectations. This would then prompt questions in the therapist’s mind about the woman’s past ‘failures’ to live up to expectations. The task, then, is to identify and work with this transference of feelings of inadequacy, in an attempt to uncover and resolve those earlier conflicted experiences. The client, having gained insight into the origins of her problematic feelings, and brought them to consciousness, is now enabled, through therapy, to resolve those feelings as they impact upon her in the here and now.
The psychodynamic therapist is essentially anonymous in terms of his/her own views, adopting a passive and detached stance. Nelson-Jones (2001), in his review of this approach, comments upon the great power held by therapists of this orientation in relation to their clients since they (the therapists) are the interpreters of the client’s ‘material’ and they get to decide how and when, for example, the client might be resisting, or denying, their underlying difficulties.
Cognitive behavioural therapy (CBT) differs from the psychodynamic approach in a number of ways. Firstly, CBT offers the client a rationale for the approach and techniques used. CB therapists essentially adopt an active, educative, role and encourage clients to actively participate in the therapeutic process. Unlike psychodynamic therapy, CBT tends to focus on a person’s functioning in the present time through an exploration of the interrelationship between thoughts, feelings, beliefs, attitudes, goals and behaviour. Rather than attempting to interpret unconscious psychic phenomena, CBT assumes that a person’s emotional reactions are produced by his or her thoughts and beliefs about a particular event or situation. Our thinking colours our feeling and, in turn, our behaviours and responses.
Myers (2004) describes how, from the CBT perspective, distorted modes of thinking about one’s self and events can predispose a person to depression. Depressed thinking patterns are seen as learnt, and therefore they can be ‘unlearnt’. The therapist’s task is to try to teach people a variety of new, and more constructive, ways to think and behave. Myers summarises the CBT stance, suggesting that “it seeks to make people aware of their irrational negative thinking, to replace it with new ways of thinking, and to practice the more positive approach in everyday settings” (2004, p.517). This therapeutic approach, then, is essentially a collaborative venture in which the client is assisted in building hypotheses about their cognitions, encouraged to review his or her thinking and to evaluate and test out its validity (Dryden, 1996; Nelson-Jones, 2001).
The psychodynamic therapeutic relationship is also seen as a collaborative venture; however, the emphasis is upon exploring hypothetical unconscious psychic conflict rather than cognitions and behaviour. Myers (2004) and others have noted that psychodynamic therapy can be a long-term venture often involving a considerable investment in time and money, whereas goal-oriented therapies, such as CBT, are usually time-limited.
Aaron Beck (1979) a key proponent of the cognitive method, found, through his clinical work, that people with depression tended to express recurrent life history themes of loss, rejection and/or abandonment (cited in Myers, 2004). This often led to negative thinking patterns characterised by unhelpful responses, such as over-generalisation and ‘catastrophising’ in terms of how such clients saw themselves, their situations and their future lives. For our woman presenting with depression, anxiety and feelings of inadequacy, then, a CB therapist would employ gentle and quite specific questioning to help her to discover her irrational beliefs and thoughts. Once the latter have been articulated, the therapist will present her with a rationale for disputing them, and help her to replace them with more reasonable and positive thinking. For example, on attending an interview for a job, she may have said to herself “I won’t get it. Other people are so much better qualified and more confident than me. They’ll think I’m an idiot.” The therapist may challenge the logic and truth of these statements and help the woman to restructure her thinking and self-talk thus “I have had some success at getting a job in the past. I do not know what the other candidates can do – they will not necessarily be any better than me. Even if I don’t get this job, there will be other opportunities”.
Wills and Sanders (1997) describe some of the techniques used in CBT. For example, they cite distraction as very helpful to clients who are depressed and anxious, “encouraging them to stop focusing on how bad they feel and focus, instead on a practical task or activity. It can help clients to stop paying attention to anxiety, which helps the physical symptoms to reduce” (Wills and Sanders (1997, p.103). Problem-solving is also cited as helpful for people with depression because it “encourages the client to work out practical and psychological ways of dealing with problems, using her own skills and resources as well as help from others” (Wills and Sanders, 1997, p.103). The responsibility for setting tasks, goals and session agendas is very much shared between therapist and client and feedback from the client, in terms of their responses to tasks, is an integral part of the therapy. Dryden and Golden (1986) highlight the importance of the therapist as a source of positive reinforcement once the client has begun to think and behave differently. Thus, in our example, the woman will have begun to restructure her thinking in terms of her competence, and to bring her perceptions about others vis-à-vis herself more in line with reality. Her new ways of thinking will give rise to different, more positive behaviours which, in turn, should allow her symptoms to diminish.
It seems clear that in both CBT and psychodynamic therapy, the therapeutic relationship can be seen effectively, as a journey of guided discovery – one which necessitates a working alliance between therapist and client, and characterised by a non-judgemental acceptance of, and compassionate respect for, the client on the part of the therapist. However, the two approaches seem to differ markedly in the way they see the nature of the task and, consequently, the methods and techniques they adopt. The CB therapist seeks to work actively and systematically with the client to discover and change potentially erroneous cognitions, and associated behaviours. The psychodynamic therapist, on the other hand, is concerned primarily with how unconscious phenomena derived from the client’s early experiences are impacting upon her present difficulties. As the therapy unfolds, this therapist will rely on insight as the key to change for the client, rather than concrete, specific cognitive and behavioural tasks designed to change self-defeating belief-systems and associated responses.
Myers (2004) comments that all therapy seems to offer people a plausible explanation of their difficulties and alternative ways of seeing themselves and experiencing their worlds. Good therapists, whatever their persuasion, seem to share much in common, notably sensitivity, compassion and empathy. Myers cites a number of researchers who have studied the common elements in a variety of therapies. Wampole (2001), for example, cited the following three benefits as particularly significant: “hope for demoralized people; a new perspective on oneself and the world; and an empathic, trusting, caring relationship” (Myers, 2004, p. 526).
Studies of therapy treatment for depression, conducted by Blatt et al (1996), showed that close therapeutic bonds along with qualities of empathy and caring yielded the most effective therapists, regardless of therapeutic orientation (cited in Myers, 2004, p.527). In the late 1990s, Goldfried and colleagues conducted an analysis of recorded therapy sessions from some 36 therapists, some practising CBT and others using a psychodynamic approach. Reviewing this research, Myers (2004) stresses the similarity that was found amongst the therapists in terms of the nature and quality of significant parts of the sessions. He notes “at key moments, the empathic therapists of both persuasions would help clients evaluate themselves, link one aspect of their lives with another, and gain insight into their interactions with others” (Myers, 2004, p. 527).
In conclusion then, we have seen how therapy for the woman suffering from depression, anxiety and feelings of inadequacy is likely to proceed along very different lines according to her choice to undertake CBT or psychodynamic therapy. CBT is likely to involve her in a more active and task-oriented therapeutic experience which will focus upon her thinking processes, belief-systems and associated behaviours. Psychodynamic therapy, on the other hand, will demand that she look to her early emotional experiences with significant others and, with help, gain insights into how these are perpetuating her current problems. Despite the apparent disparity between the two orientations in terms of their theoretical and methodological approach, and the actual form that the therapy takes, it seems clear that there is a certain commonality in both camps when it comes to analysing the qualities involved in an effective therapeutic relationship. It seems, then, that the qualities of the therapist are likely to be of more significance to a successful outcome for this woman than the therapeutic approach adopted.
Dryden, W (1996). Introduction to Counselling and Psychotherapy, London: Sage.
Dryden, W & Golden, W (1986) Cognitive-Behavioural Approaches to Psychotherapy, London: Harper and Row.
Jacobs, M (1986). The Presenting Past, Buckingham, England: Open University Press.
Jacobs, M (2004). Psychodynamic Counselling In Action (3rd Edition), London: Sage.
Myers, D.G (2004). Exploring Psychology (6th Edition), New York: Worth Publishers.
Nelson-Jones, R (2001) Theory and Practice of Counselling and Psychotherapy, London: Continuum.
Wills, F & Sanders, D (1997) Cognitive Therapy: Transforming the Image, London: Sage.
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