Marv Hurvich and I recently spent two days as invited participants at a conference with Aaron (Tim) Beck and CBT researchers/clinicians from the states, the UK and the Netherlands (thank you to Dr. Yulia Landa for inviting us to participate in this very interesting event). I would like to share my observations derived from this conference on the contrast between CBT and psychoanalytic approaches. This CBT group has been meeting annually for about 10 years to discuss CBT and psychosis under Aaron (Tim) Beck's able leadership. They include borderline and bipolar disorder in their research and discussions. I am also aware of some good work they have done with severe OCD, depressed and panic patients -- demonstrating equal efficacy to SSRI's (in some cases of OCD and psychosis using neuroimaging to confirm change at the neural level).
The CBT clinicians do a great deal of research. There was more discussion on the research and not as much on what actually transpired between the patient and therapist. Clinical interventions were referred to as the usual CBT techniques. The group was incredibly organized and devoted to evidence-based treatment (there was no discussion of practice-based evidence). Presenters were given roughly about 10 minutes (or less in some cases) to present their findings (all with PowerPoint slides). This caused them to have to do streamlined soundbites-thereby giving no room for in-depth discussion of clinical process. Such an approach, would not be desirable or even possible with psychoanalytic presentations, in which the clinical complexities are given a chance to emerge and be worked with. However, I think we are beginning to see changes in this in CBT research, with researchers calling for longer periods of treatment and drawing attention to developmental experience (e.g., Max Birchwood).
There were some CBT theorists/researchers/clinicians, e.g., Max Birchwood, whose work overlapped with psychoanalytic models. Some presenters, like Phillipa Garety and Richard Bentall, have developed sophisticated models of paranoia and delusions, incorporating traditional psychoanalytic contributions.
Unfortunately, there was no attention paid to the emotional responses of the clinicians to patients, nor focus on transferential issues. However, there was a strong emphasis placed on childhood traumas. Some CBT persons were attempting to explore the meanings involved in symptomatology, e.g., Max Birchwood's team focused on the nature of the relationship between the patient and their voices (in hallucinatory individuals) and related this to actual developmental experiences which are dissociated.
Although Aaron Beck started as a psychoanalyst, he and most of the group rarely make reference to psychoanalytic contributions. My impression was that, as in the media, psychoanalysis (classical as well as contemporary) is poorly understood. I spoke with Drs.Beck and Landa about furthering a dialogue between psychoanalysts, CBT clinician-researchers and neuroscientists (at the recent Biology of Mind conference we did at New York University, a dialogue was formally initiated between clinical neuroscientists and psychoanalysts on such topics as anxiety/panic, empathy/mirror neurons, psychosis, etc.). They seemed quite interested in seeing this happen. I was placed on their CBT listserve, which they just started in order to share research, clinical work, etc., as a psychoanalyst who will share my impressions of their research and clinical work.
Since CBT is being increasingly adopted by many hospitals, outpatient clinics and governmental agencies (the NICE guidelines in the UK mandate psychological services, i.e., CBT, for challenging and refractory or medication resistant/refusing patients, including psychotic patients), and the research has demonstrated efficacy, even with clinically complicated patients, I think it would be good if we in ISPS-US made some inroads into furthering dialogues with these groups, since, we have much to offer, as well as to gain from such contact. I was very impressed by some of the innovative CBT group work done by Dr. Landa with individuals who are paranoid, delusional and hallucinatory. She and Dr. David Silbersweig (director of the neuroimaging lab at Cornell-NY Hospital) presented some intriguing neuroimaging data demonstrating the therapeutic effects of CBT in neurofunctioning. In psychoanalytic history, there have been many psychoanalysts who incorporated cognitive processes into their work, e.g., Arieti, Bieber, etc., and I suspect many analysts use variations of cognitive therapies in their daily work without identifying it as such.
In regard to a dialogue with clinical neuroscientist, as pointed out by Harvard social psychiatrist, Leon Eisenberg, we need to steer between the brainless psychiatry of the past and the mindless psychiatry of the present. Although, I certainly do not think one needs an in-depth knowledge of neurobiology to practice clinical psychoanalysis, it may help our work to be aware of the neurobiological effects of early relational/social experience, e.g., the effects of traumas, separations, humiliation and social defeat, isolation, e.g., in their effects on stress reactivity, access to traumatic memories, relationship to transferential/countertransferential enactments, etc.
I believe that we in ISPS-US, as well as in ISPS international, have much to gain should we foster greater levels of dialogue between psychoanalysis, CBT, psychiatric rehab/psychosocial approaches, and neuroscience. Within this dialogue, there should be made a valued place for patients themselves-for we have much to learn from each other.
Brian Koehler PhD
New York University
mailto:brian_koehler@psychoanalysis.net
