From Psychoanalysis to CBT: One Psychiatrist’s Journey

By now, most professionals in the mental health field acknowledge that psychotherapy treatments grounded in cognitive behavioral principles are effective for a wide range of common conditions. Their efficacy in anxiety disorders, depression, eating disorders, posttraumatic stress disorder, and borderline personality disorder is well documented, and more recently, CBT treatments have been adapted to address Bipolar Disorder, Schizophrenia, and issues connected to aging. But this wasn’t always the case! My own career has spanned the transition from psychoanalysis and psychodynamic psychotherapy to CBT techniques.

Long before I embarked on medical school and psychiatric training (I knew I wanted to be a psychiatrist as a high school student!) I was enamored of psychoanalytic thought. In college I dove into Freud and the object relations theorists. By medical school I had read the psychoanalytic bible of the 1970’s, Kernberg’s Borderline Conditions and Pathological Narcissism (it still has a prominent place on my shelf). His descriptions of his patients were beautifully drawn but the underlying theory, the so-called meta-psychology, seemed murky. He conceptualized that borderline individuals suffered excessive aggressive impulses that had invaded their superegos. His techniques, an adaptation of psychoanalysis, were based on the notion that analyzing the transference would result in improved function. Treatments were arduous; patients made slow progress. The approaches utilized by therapists in the TV series In Treatment are based on these formulations and techniques. Although Kernberg himself was a deeply caring practitioner, other practitioners utilizing his theories often left patients feeling deprecated by their application of the model. And the therapy did not provide a clear framework to characterize their problems or a roadmap to improve their lives.

Then I spent a semester of medical school on an inpatient service in London specializing in eating disorders (the leader of the unit, Gerald Russell, coined the term “bulimia nervosa”). In that era the British were developing cognitive behavioral techniques to treat anorexia nervosa and bulimia. The approach taught the person to challenge her distorted thoughts about the shape of her body and to employ modifications in eating habits and other behaviors to regain and stabilize weight. In the same time period Isaac Marks, a British psychiatrist, and his colleagues were developing behavioral techniques to address anxiety disorders. Quite an eye opener for me.

As a resident, in addition to extensive training in the emerging biological understanding and treatment of mental disorders, I dutifully learned psychoanalytic theory and technique. But I found the advice from supervisors opaque and difficult to implement. Then, on one rotation I met a psychiatrist who had delved into CBT. He taught me how to use diaries and other self-monitoring techniques, important cornerstones of CBT treatment. This was another revelation, but I soon learned that this was not news in the wider world! While American psychiatrists generally clung to psychoanalytic theory and technique, in the late 1960’s Aaron Beck, himself a psychiatrist trained as a psychoanalyst, boldly conceptualized that depression was triggered by negative thinking about the self, other people, and the future. An array of psychologists including such pioneers as Donald Meichenbaum, David Barlow, and Edna Foa developed and validated CBT treatments of anxiety disorders. These approaches involved challenging fearful, irrational beliefs (the “cognitions”) and entering avoided situations, so-called behavioral “exposure”. These pioneers established that people could successfully change how they thought about themselves and fearful situations. The techniques involved identifying immediate thoughts, so-called “automatic” thoughts, occurring at times of anxiety or low mood, and then delving into the thoughts that underpin these ideas, the “intermediary” and “core beliefs”. Cognitive therapists helped people recognize recurrent patterns of distorted beliefs such as “overgeneralization” (e.g., a singular failure means I will always fail) or “catastrophizing” (e.g., a small problem will invariably snowball into a disaster). Further, the CBT pioneers demonstrated that by repeatedly entering feared situations one could overcome anxiety. More recent developments extended CBT to addressing underlying core beliefs inherent in different personality types as well as challenging distorted thinking in psychotic conditions.

The turning point came after my residence when I was charged with leading an inpatient unit treating women with eating disorders, PTSD, and dissociation. I was lucky to be surrounded by several gifted psychologists who introduced me to Marsha Linehan’s landmark work, Cognitive-Behavioral Therapy for Borderline Personality Disorder. In this work Linehan laid out an innovative approach combining CBT with principles derived from Buddhism, what she called “Dialectical Behavior Therapy” (DBT). Her approach was startling. Here was a clear delineation of the main features of this oft-maligned condition. People struggling with this disorder were no longer to be understood as “angry,” “manipulative splitters” who should be loathed and derided (sadly, a common reaction by many practitioners of the day). Instead, DBT clearly described the struggles these individuals faced in managing unstable emotions, tolerating distress, caring for themselves, and navigating relationships with others. Linehan’s work provided understandable, accessible techniques to address these areas. DBT was not burdened by a meta-psychology that was based on theories that could not be proven. Subsequent research has established some of the genetic and environmental roots of borderline conditions. In the wider areas of depression and anxiety, brain-imaging techniques have revealed measurable changes in brain activity following effective CBT treatment for depression and anxiety. Further, the field is moving toward uncovering the neural circuits that underlie the mechanisms of cognitive and exposure treatments.

Patients welcome the respectful approach of CBT and DBT because it provides much needed understanding of painful symptoms and equips them with effective techniques to cope and change. And both CBT and DBT treatments really work! I was a convert! Since that time, I have been fortunate to receive training in CBT techniques to address depression, anxiety, and PTSD, and have been able to employ these techniques in my own work.

Even more exciting, I have participated in the dissemination of these techniques to others. In the last five years, Westchester Jewish Community Services, through its Educational Institute and participation in national workshops, has brought these techniques to our community mental health and school-based clinics. WJCS therapists provide state-of-the-art CBT treatment for depression and anxiety disorders in children, adults, and the elderly. In addition, WJCS clinicians have developed a network of DBT treatment groups. These groups follow the model laid out by Linehan, providing relief to many individuals struggling with these problems. Over the last five years the WJCS Treatment Center for Trauma and Abuse has implemented “Trauma Focused Cognitive Behavioral Therapy” for treatment of children who are victims of sexual abuse and domestic violence. This highly innovative technique developed by Cohen and Deblinger has provided a road to recovery for children suffering from the effects of trauma. Most recently, WJCS clinicians have been trained in STAIR (Skill Training in Affective Regulation), a treatment developed by Marylene Cloitre that combines elements of DBT and CBT for adults who have been victims of repeated trauma. All of these approaches have brought new life and hope to individuals struggling with painful disorders. I am glad to have made this journey in my own career and proud to participate in an agency that has embraced these techniques and brought them to communities throughout Westchester.

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