Cognitive, Psychodynamic, and Humanistic Therapies

Cognitive Therapies

  • Definition and Goals

    • Help clients identify and challenge their negative thoughts and dysfunctional belief systems.

    • A principal goal is to collaborate with clients to define problems and teach them more effective problem-solving techniques for dealing with concrete life problems (Fenn & Byrne, 2013).

  • Duration

    • Generally short-term, typically 1212 to 2020 weeks in duration, with one or two sessions per week (Beck, Rush, Shaw, & Emery, 1979).

  • Three Main Goals in Cognitive Therapy (Beck, 1976)

    1. Assist clients in identifying their irrational and maladaptive thoughts. Clients might be asked to keep a diary of thoughts they have when feeling anxious.

    2. Teach clients to challenge their irrational or maladaptive thoughts and to consider alternative ways of thinking. This may involve evaluating evidence for a belief or considering how others might perceive a difficult situation.

    3. Encourage clients to face their worst fears about a situation and recognize ways they could cope.

Cognitive-Behavioral Therapy (CBT)

  • Often combines cognitive techniques with behavioral techniques.

  • Focus: Problem-oriented and emphasizes the present ("here and now" problems and difficulties), rather than focusing on past causes of distress.

  • Aims to improve a client's current state of mind (Fenn & Byrne, 2013).

  • Therapist's Role: May use behavioral assignments to help clients:

    • Gather evidence concerning their beliefs.

    • Test alternative viewpoints about a situation.

    • Try new methods of coping.

  • Assignments: Presented as ways of testing hypotheses and gathering information useful in therapy, regardless of the outcome. They can also involve practicing new skills (e.g., effective communication) between sessions.

Case Study Example

  • A student was unable to complete her degree due to fear of meeting with a professor about an incomplete grade, convinced the professor would "scream at her."

  • She was unable to call the professor's secretary to arrange a meeting.

  • An in vivo task was agreed upon: she called the professor from her therapist's office.

  • Her thoughts and feelings before, during, and after the call were carefully examined.

  • The professor was happy to hear from her and accepted her final paper, contrary to her belief.

  • Through this experience, she recognized that her beliefs were both maladaptive and erroneous (Adapted from Freeman & Reinecke, 1995, pp. 203−204203-204).

Assessing Cognitive Approaches

  • Evidence of Effectiveness: Studies on mood disorders, anxiety disorders, and increasingly sexual, eating, and substance use disorders, demonstrate the effect of maladaptive cognitions (Joormann & Vanderlind, 2014).

  • Cognitive therapies have proven useful in treating these disorders (Craske, 2017).

  • Greatest Limitation: The difficulty of definitively proving that maladaptive cognitions precede and cause disorders, rather than being symptoms or consequences.

    • Example: Do negative thoughts cause depression, or does depression cause negative thoughts? Answering this question definitively and delineating specific aspects of cognitive therapy that lead to effects is challenging (Lemmens et al., 2017).

Psychodynamic Approaches

  • Core Idea: Suggests that all behaviors, thoughts, and emotions (normal or abnormal) are largely influenced by unconscious processes (McWilliams, 2011).

  • Origins: Began with Sigmund Freud in the late nineteenth century and expanded to include newer theories that accept Freud's basic assumptions but emphasize different processes.

Freud's Psychoanalysis

  • Refers to:

    1. A theory of personality and psychopathology.

    2. A method of investigating the mind.

    3. A form of treatment for psychopathology (McWilliams, 2011).

  • Freud, a Viennese neurologist, became interested in unconscious processes while working with Jean Charcot in Paris.

  • Later worked with physician Josef Breuer, notably on the case of "Anna O."

Case of "Anna O."

  • Anna O. had extensive symptoms of hysteria (physical ailments with no apparent physical cause), including paralysis, deafness, and disorganized speech.

  • Breuer attempted hypnosis, hoping to cure her symptoms by suggestion.

  • Under hypnosis, Anna O. began to talk about painful memories from her past, which appeared linked to her hysterical symptoms.

  • Following the recounting of these memories, many symptoms subsided.

  • Breuer labeled this release of emotions catharsis.

  • Anna O. referred to the entire process as her "talking cure."

  • Breuer and Freud's Hypothesis: Hysteria results from traumatic memories that have been repressed from consciousness because they are too painful.

  • Repression: Defined as the motivated forgetting of a difficult experience (e.g., childhood abuse) or an unacceptable wish (e.g., desire to harm someone).

  • Repression does not dissolve the emotion; instead, this emotion is "dammed up" and emerges as symptoms.

Psychodynamic Theories (Post-Freud)

  • Freud's psychoanalytic theory emphasized the profound influence of early caregiver nurturance on personality development.

  • Many followers modified Freud's original theory, leading to a group of theories collectively known as psychodynamic theories.

  • Ego Psychology (Anna Freud): Extended work on defense mechanisms, emphasizing the ego's importance in regulating defenses for healthy functioning within societal realities (Jacobson, 1964; Mahler, 1968).

  • Object Relations Perspective (Melanie Klein, Margaret Mahler, Otto Kernberg): Integrated Freud's drive theory with the role of early relationships.

    • Early relationships create unconscious mental images, or representations, of ourselves and others.

    • These mental representations are carried into adulthood and affect all subsequent relationships (e.g., early experiences with caregivers shaping expectations for romantic partners).

  • Contemporary Psychoanalysis:

    • Self psychology and relational psychoanalysis.

    • Relational Psychoanalysis: Emphasizes unconscious dimensions of relationships from pregnancy and infancy throughout life. The goal shifts from how the past affects the present to how current unconscious forces influence the relationship between the therapist and client.

      • The present-day therapeutic relationship serves as a model for other client relationships, including problematic ones.

      • The therapist uses this relationship to help clients understand how they relate to others, how problems emerge, and how typical defenses block symptom relief and self-awareness.

  • Carl Jung: A student of Freud who rejected the primary importance of sexuality in development.

    • Argued that spiritual and religious drives are as important as sexual drives.

    • Proposed the concept of the collective unconscious: wisdom accumulated by society over hundreds of years, stored in individuals' memories.

Psychodynamic Therapies

  • Goal: Focus on uncovering and resolving the unconscious processes believed to drive psychological symptoms.

  • Aims to help clients recognize their maladaptive coping strategies and the sources of their unconscious conflicts.

  • The resulting insights are thought to free clients from the grip of the past and empower them to make changes in the present (Safran, 2012).

  • Key Techniques and Concepts:

    • Free Association: Clients are taught to talk about whatever comes to mind, without censoring thoughts. The therapist observes recurring themes, thought transitions, and specific memories.

    • Resistance: Material the client is reluctant to discuss provides important clues to central unconscious conflicts, as the ego works hardest to repress the most threatening issues. Therapist interprets resistance as a sign that an important unconscious issue has been identified.

    • Transference: Occurs when the client reacts to the therapist as if the therapist were an important person from the client's early development (e.g., parent).

      • Example: A client reacting with rage or extreme fear to a therapist being a few minutes late, possibly stemming from feelings of emotional abandonment in childhood (Vyskocilova & Prasko, 2014).

      • This reaction is a clue to unconscious conflicts and needs; the therapist helps the client explore its roots in relationships with significant others.

    • Countertransference: Feelings a therapist may develop for clients during therapy (Jenks & Oka, 2020).

      • Both transference and countertransference are significant sources of insight into the inner worlds of client and therapist and are valuable tools.

      • However, unconscious aspects of countertransference can compromise therapy if the therapist unintentionally uses the client to solve their own problems. Attention to these processes in therapist training and supervision is critical (Vyskocilova & Prasko, 2014).

    • Working Through: Repeatedly processing painful memories and difficult issues to understand them and integrate them into an acceptable self-definition, allowing clients to move forward.

    • Catharsis: The expression of emotions connected to memories and conflicts, considered central to healing. It unleashes bound energy, allowing material to be incorporated into a more adaptive self-view.

    • Therapeutic Relationship: Beyond catharsis, modern analytic therapists emphasize the healing aspects of the therapeutic relationship itself, building trust and mutuality to foster change, rather than only expecting "Ah ha!" moments from interpretations.

Classical Psychoanalysis vs. Modern Psychodynamic Therapy

  • Classical (Freudian) Psychoanalysis:

    • Typically involves 33 or 44 sessions per week over many years.

    • Focuses primarily on interpreting dream content, transferences, resistances, and past experiences (Luborsky & Barrett, 2006).

  • Modern Psychodynamic Therapy:

    • Can also last for years, but can be as short as 1212 weeks (Leichsenring & Steinert, 2018).

    • Also focuses on transferences, resistances, and relationships with early caregivers.

    • However, compared to psychoanalysts, psychodynamic therapists may focus more on current situations in the client's life and prioritize symptom relief over solely deeper self-insight.

Interpersonal Therapy (IPT)

  • Emerged from modern psychodynamic theories, shifting focus from individual unconscious conflicts to the client's patterns of relationships with important people (Klerman, Weissman, Rounsaville, & Chevron, 1984; Weissman, Markowitz, & Klerman, 2017).

  • Differences from other psychodynamic therapies:

    • Therapist is much more structuring and directive.

    • Offers interpretations much earlier.

    • Focuses on how to change current relationships.

  • Designed as a short-term therapy, often lasting about 1212 weeks.

Assessing Psychodynamic Approaches

  • Influence: Dominated psychology for decades and significantly shaped psychology and psychiatry, still referenced in popular culture.

  • Criticisms and Limitations:

    • Lack of scientific data: Widely criticized for the inability to test fundamental assumptions with valid and reliable research methods (Erdelyi, 1992; but see Shedler, 2010; Westen, 1998).

    • Abstract processes: Concepts described (e.g., the Oedipus complex) are abstract and difficult to measure.

    • Unobservable factors: Key influencing factors are unconscious and unobservable, making it easy to provide ad hoc explanations for why predictions might not be borne out.

    • Limited sample: Freud's theories were based on a limited sample of upper-class Austrian women in the early 1900s1900s, limiting generalizability to other populations (Tummala-Narra, et al., 2018).

  • Therapy Affordability: The long-term, intensive nature of classical psychoanalysis makes it unaffordable for many, especially with insurance restrictions.

    • This led modern psychodynamic therapists to develop shorter-term, more structured versions.

  • Effectiveness of Short-Term Psychodynamic Therapies: Studies suggest they can result in significant improvement in symptoms for people with psychological problems (Driessen et al., 2017; Leichsenring & Steinert, 2018).

  • Book's Perspective: This book focuses on theories and therapies with substantial scientific support. Psychodynamic theories and therapies have had less empirical support than many newer approaches, so they are not discussed in detail for most disorders.

Humanistic Approaches

  • Core Assumption: Humans have an innate capacity for goodness and for living a full life (Rogers, 1951).

  • Barrier to Fulfillment: Pressure from society to conform to certain norms, rather than seeking one's most-developed self, interferes with this capacity.

  • Perspective: Humanistic theorists acknowledge that individuals are often unaware of forces shaping their behavior and that the environment plays a large role in happiness/unhappiness.

  • Optimistic View: They are optimistic that once people recognize these forces and gain freedom to direct their own lives, they will naturally make good choices and be happier.

Carl Rogers' Humanistic Theory (1951)

  • The most widely known version of humanistic theory.

  • Belief: Without undue pressure from others, individuals naturally move toward personal growth, self-acceptance, and self-actualization (the fulfillment of their potential for love, creativity, and meaning).

  • Impact of Pressure: Under pressure from society and family, people can develop rigid and distorted perspectives of the self.

  • Internal Conflict: Individuals often experience conflict due to discrepancies between:

    • Their true self (who they are).

    • The ideal self (who they wish to be).

    • The self they feel they ought to be (to please others).

  • This conflict can lead to emotional distress, unhealthy behaviors, and even a loss of touch with reality.

Humanistic Therapy

  • Stated Goal: To help clients discover their greatest potential through self-exploration (Krug, 2016).

  • Therapist's Role: Not an authority figure who provides healing, but rather to create the optimal conditions for the client to heal themselves.

  • Humanistic therapists do not push clients to uncover repressed painful memories or unconscious conflicts.

  • Belief: When clients are supported and empowered to grow, they will eventually face the past when doing so becomes necessary for their further development (Krug, 2016).

Carl Rogers' Client-Centered Therapy (CCT) / Person-Centered Therapy (1951)

  • Key Therapeutic Conditions:

    • Genuineness (Congruence): The therapist communicates authenticity in their role as a helper, acting as a real person rather than an authority figure.

    • Unconditional Positive Regard: The therapist shows complete acceptance and value for the client, giving them a sense that they are inherently valued regardless of their actions or thoughts.

    • Empathic Understanding: The therapist communicates a deep understanding of the client's underlying feelings and their search for self.

  • Main Strategy: Reflection

    • A method of response where the therapist expresses an attempt to understand what the client is experiencing and trying to communicate (Krug, 2016).

    • The therapist doesn't interpret unconscious aspects but tries to communicate understanding and explicitly checks with the client for the accuracy of this understanding.

Shades of Gray Example

  • A student expresses feeling "lost in my career" and states, "Every time I seem to be getting close to doing something really good, like acing a class, I somehow manage to screw it up. I never feel like I am really using my potential. There is a block there" (Bohart, 1995, p. 101101).

  • Humanistic Therapist Response: Would likely use reflection to articulate an understanding of the client's feelings of being lost, self-sabotage, and a sense of unfulfilled potential.

  • Psychodynamic Therapist Response: Might explore potential unconscious motivations for self-sabotage, past experiences, or defense mechanisms contributing to the "block."

Assessing Humanistic Approaches

  • Positive Impact: Struck a positive chord in the 1960s1960s and continues to have many proponents, especially in self-help groups and peer-counseling.

  • Strengths: The optimism and attribution of free will offer a refreshing change from the emphasis on pathology and external forces found in other theories. It shifts focus from "what is wrong with people" to "how people can achieve their greatest potential."

  • Criticisms: Often criticized for being vague and not easily subject to scientific testing.

  • Client-Centered Therapy (CCT) Effectiveness:

    • Used to treat a wide range of problems, including depression, alcoholism, schizophrenia, anxiety disorders, and personality disorders.

    • Some studies show CCT results in better outcomes than comparison therapies, while others do not (Csillik, 2015; Elliott, Greenberg, & Lietaer, 2004).

    • Some therapists believe CCT may be appropriate for people who are moderately distressed but insufficient for those who are seriously distressed.