Psychodynamic versus Behavioral Psychotherapy

Indications for Psychotherapy

Cognitive Behavioral Therapy

: Dialectical Behavioral Therapy



- treatment of pychological distress through verbal and behavioral techniques;
 - known as "the talking cure";
 - many different schools of psychotherapy, sometimes at war with each other;
 - listening, empathy, interpretation, and action may all be involved.
 - to discuss "psychotherapy" as an entity is about as difficult as discussing "medication"; there are perhaps as many types of psychotherapy as there are classes of medications, each of which may be indicated for a different population group..

        At the core of any psychotherapy is an EMPATHIC RELATIONSHIP, the THERAPEUTIC ALLIANCE.  This is a unique type of relationship in which the therapist maintains a certain neutrality and objectivity while helping the patient explore and perhaps gain mastery or understanding over a problem or set of problems.

        At the risk of oversimplification, psychotherapy can be divided into two broad schools:


    - Relies on NATURALISTIC mode of inquiry (see below).
    - Observer is CRITICAL to the process and is entirely dependent on the ability of the observer to describe, articulate, and generalize from a particular case or set of cases.
    - Skeptical of MEDICAL MODEL.  Most psychodynamic theorists eschew the idea of illness and health, per se, but instead believe that all of us fall somewhere on a spectrum (in other words, all of us are a little bit depressed, a little anxious, even a little psychotic and it is only the degree to which we are these things that defines whether we are patients or providers (or both)).
    - "Symptom" is only a hint of the real problem, of which the patient (and therapist) is initially unaware.  Like the tip of the iceberg, the patient's presenting complaint (anxiety, depression, unhappiness) is simply the visible portion of a hidden, underlying conflict or problem that the therapist and patient can only discover with time.
    - "Blank screen" often used by therapist - minimal intervention.  The therapist may say very little, but instead listen, occasionally reformulating or interpreting what is reported by the patient.  The underlying belief is that the patient, through a process of free association, will stumble upon what is important given enough time.
    - Process more important than content.   The symbolic meaning to a behavior or pattern of behavior is often viewed as more significant than the behavior itself.  For example, if a patient is repeatedly late to appointments, each time giving a different excuse, following the discussion of a particularly painful event in the patient's life, the therapist might explore with the patient whether the tardiness represents unconscious anxiety and acting out toward the therapist.
    - Symptom reduction seen as superficial, not a goal in itself.  Since symptoms are seen as the manifestation of a deeper underlying problem, unless that problem itself is addressed, psychodynamic therapists feel that symptom reduction will not be helpful or may even get in the way of probing the underlying problem, much as giving a febrile patient aspirin may lower the body temperature but do nothing to fight the underlying infection, and may even mask a worsening of the illness.
    - All behavior seen as symbolic:  "nothing happens by accident."  Refer again to the example of being late.  Freud posited that there is no such thing as an innocent slip of the tongue, but that these represent unconscious thoughts, impulses, and feelings bubbling to the surface.


    - Relies on EMPIRICAL mode of inquiry.
    - Tends to be more QUANTITATIVE than QUALITATIVE.
    - Endorses the MEDICAL MODEL.
    - Symptom reduction seen as an end in itself, the goal of therapy.  Insight or understanding is seen as either secondary or irrelevant.
    - Behavior taken at face value; speculation about underlying meanings or unconscious motives is discouraged.
    - Focuses on things that can be measured and observed (behaviors, reported mood) and avoids theoretical abstractions and speculations (e.g., avoids speculative but colorful descriptions  such as "The patient's libidinal urges seem in conflict with her punitive superego, most likely a product of a harsh, controlling mother whose own libidinal urges were similarly prevented from discharge perhaps by strong repression and reaction formation." instead sticking to what can be observed:  "The patient reports feeling very guilty about masturbation and becomes anxious and constricted in affect when discussing this.  She thinks this may have something to do with her mother, whom the patient describes as a `strict, religious woman.'").

Types of Psychotherapy:

    Most therapy can be grouped into three broad categories:



 - based on the work of Freud and later theorists;
 - objective is to make the unconscious conscious via free association;
 - "blank screen" often used by the analyst, who says very little, often remains out of sight of the patient (who is supine), and thereby encourages a transference.
 - one must receive before giving; analysts must undergo analysis themselves.
 - 3-5 sessions per week over a period of 3-5 years; cost is roughly $20,000-$30,000 per year.

Insight-Oriented Psychotherapy

 - any type of therapy that attempts to give patients a better understanding of themselves and their inner conflicts and drives;
 - referred to as "introspective psychotherapy" in Stoudemire's text;
 - anxiety may increase or worsen early in the therapy;
 - usually weekly over a period of years.

Supportive Psychotherapy:

 - objective:  immediate symptom relief or crisis management without necessarily probing deeper, underlying causes of symptoms;
 - means:  problem-solving, social skills training, supportive group therapy.
 - financial burden is minimal.
 - weekly-monthly over months or until problem is solved.

Indications for Psychotherapy:

     This is actually a very controversial area and is based on the theoretical background of the therapist, the financial assets of the patient, and the philosophy (and financial resources) of the third party payer.  Several principles are in conflict:

     AUTONOMY v. JUSTICE:  The principle of autonomy holds that as much as possible, a patient should be allowed to have as much input into and control over decisions regarding treatment.  According to this principle, a patient who requests psychotherapy should be able to receive it.  However, the principle of justice dictates that one should attempt to allocate limited financial and medical resources (including the therapist's time) to the most patients, hopefully triaging to those who are most in need.  These two conflict, especially if there is more demand for a therapist's time than there is a supply of therapist hours.  In the world of managed care, this has become particularly thorny, since many managed care plans limit reimbursement for therapy.

     SPECTRUM v. MEDICAL MODEL:  In the spectrum model, we're all a little neurotic or whatever, so could theoretically all benefit from therapy, some more than others.  In the medical model, however, one likes to first make a diagnosis (answering the question, is this patient sick?) and the clinician and patient may disagree over this.  For example, if a patient with a cold demands that you give him antibiotics, you as a clinician must first make an assessment to see if the patient has a condition for which antibiotic treatment would be appropriate, such as a bacterial sinusitis.  If not, you cannot ethically prescribe the medication.  If one uses the medical model to view psychotherapy as one of many possible interventions, then the clinician is obligated to diagnose appropriately and match the patient to treatment.

     THIRD PARTY REIMBURSEMENT?  This is a very thorny issue.  In the past, psychotherapy was often reimbursed at a 50% rate, no questions asked, for at least a certain number of sessions per year.  Today, managed care companies have become much more intrusive, requiring extensive documentation about indications for therapy, goals of therapy, and expected outcome and length of therapy.  When granted, reimbursement is often very limited and finite.  There are now three potential decision-makers:  the patient; the clinician; and the third party payer.  Of course, for affluent patients or those with access to a therapist in the public sector, the decision to treat is independent of the decision to reimburse, but for many patients, failure to reimburse, at least partially, means the patient could not afford therapy.

Does Psychotherapy Work?

        The answer to this question depends on how it is posed and what you measure:

 - Spectrum Model:  This model avoids terms such as "normal" or "illness," instead viewing all of us as lying somewhere on a spectrum between different extremes (e.g., anxious, depressed, angry, extroverted, neurotic).  This model also assumes that one can understand the extremes of mental phenomena (such as psychosis) by improving self-awareness.  Many adherents of the spectrum model use terms such as client and provider instead of patient and doctor or therapist.
    According to adherents of this model, subjective reporting by patients of relief or increased understanding is enough to prove the efficacy of an intervention.  If a patient states he is improved, then the therapy is a success.  There might be little or no attempt to account for possible sources of bias, such as survivorship (those who continued therapy might be self-selected, higher functioning patients better able to tolerate the process, for example), spontaneous remission, or comparison with other interventions (there are often no control groups).
 - Medical model:  This model focuses on categorizing illnesses, defining them by clusters of signs and symptoms, and makes a demarcation between healthy and pathological.  It tends to emphasize diagnosis, treatment, outcome, and uses the same terminology when viewing mental phenomena as it uses when approaching physical illness.  Adherents of this model would argue that a schizophrenic is markedly different from a non-schizophrenic, for example, that some chemical, biological, or other abnormality distinguishes his brain from those who do not suffer from the illness.  Medical model proponents tend to use terms such as patient and therapist.
    To prove efficacy, they believe symptom relief must usually be operationalized in some way (clinician evaluation with a quantitative scoring system, patient self-report using a standardized instrument) and "success" or "failure" must be predefined categorically (e.g., a 50% reduction in depressive symptoms from baseline).  Adherents of the medical model may subject psychotherapy to the same scrutiny given a new medication:  is the therapy as effective as some other intervention or none at all (control group).  Does it alter the natural course of the disease?

 Naturalistic v. Empirical Approach

    Some understanding of these two different ways of approaching and studying reality is necessary to understanding some of the tensions in the field of psychotherapy, as well as some of the difficulty inherent in getting adherents of one mode or the other to communicate with each other in a meaningful way.

Naturalistic Mode of Inquiry:

 - Qualitative
 - Cases emphasized over studies
 - Observer is critical:  cogency of ideas, how eloquently they are expressed, how they relate to consensus views in the field/discipline determines "truth"
 - Spectrum model favored
 - no formal effort to control for bias (control groups, replication, blinding, etc.)

Empirical Approach:

 - Quantitative:  attempts to operationalize, categorize, dichotomize variables, e.g., "depression" "response"
 - population-based, usually with controls
 - speculation by observer discouraged "show me the data"
 - minimizing bias is a priority
 - derived from MEDICAL MODEL (diagnosis, treatment, response)
 - proof lies in statistical tests of difference between treatment and control group
 - Relatively new approach in psychotherapy; first controlled trial showing efficacy of therapy over placebo was in 1972.

Does psychotherapy work?

Naturalistic response:

 - impossible to answer conclusively but many patients report subjective relief;
 - benefits may be intangible and difficult to measure, e.g., improved self-awareness, improved insight into repeating patterns of behavior

Empirical Response:

Many trials have demonstrated efficacy of several types of therapy:
 - CBT in depression and anxiety
 - exposure therapy in phobias
 - interpersonal therapy in depression
Important negative results:
 - Boston Collaborative Study:  failure of psychoanalysis in treatment of schizophrenia

Cognitive-Behavioral Therapy (CBT):

    Cognitive-behavioral therapy is perhaps the first psychotherapy that was successfully shown to be at least as effective as medication (imipramine) (and more effective than placebo) in treating moderate depression.  It has since been shown to be effective in treating a wide array of mood disorders, including anxiety and depression, and has been used successfully in other mental disorders.
    The basis of cognitive-behavioral therapy is that at the assumption that at the heart of any mood disorder is a distortion in cognition (referred to as an automatic negative thought) such as "I'm a failure; nothing I try works out." which leads to a distortion in affect (mood).  The idea, simplistic as it sounds, has been shown to be effective:  disrupt the negative distortions with realistic interpretations ("Although I have failed at some things, I have also had successes, and on balance have had more successes than failures.") based on an empirical weighting of the evidence for and against the negative thought.  As you can imagine, the realistic interpretation has a less negative or painful affect associated with it and over time, the cycle of distortion in cognition and mood can be prevented.
    Note that CBT is not simply "positive thinking" a la Stewart Smiley ("I'm good enough, I'm smart enough, and gosh darn it, people like me.")  Instead, the emphasis is on REALISM - seeing the world as it really is.  CBT posits that depressed patients have distortions of their view of themselves ("I'm no good."), their relationships ("Everyone hates me."), and the future ("There's no hope things will ever get better.").    Each of these thoughts is a distortion, but each has an element of truth.  (We all have faults, there are probably some people who hate us, and there is a chance things may at times be worse in the future than they are today.)  However, in depressed states, the person is unable to balance this negative view against positive conflicting evidence.
    Note that CBT's goal is symptom reduction through disruption of distorted cognitions - less distortion of affect.  The chief complaint taken at face value and the therapist and patient form a therapeutic alliance and through a very active collaborative empiricism between therapist and patient, try to reduce depressed or anxious affect.  This will often include homework assignments, keeping a log, and a much more structured type of therapy than is true in many dynamically oriented approaches.  Many patients will resist this type of therapy because it requires a lot of activity on their part and may strike them initially as too simplistic.  Also, the therapy is usually short-term, often only several weeks in length, although it can go longer if necessary.
    According to Aaron Beck and early cognitive-behavioral therapists, the unconscious, underlying "meaning" of symptoms is seen as irrelevant or at best unnecessary for successful outcome.

See also: Dialectical Behavioral Therapy for Borderline Personality Disorder

   ** Make sure that you also understand different behavioral reinforcement schedules. **


 - There are many flavors of psychotherapy; be aware of the tension in the field between dynamically and behaviorally oriented therapists;
 - Keep an open mind; be aware of appropriate matching of patient to type of therapy.
 - All doctor-patient contacts, however cursory, have a psychotherapeutic element.