Is There a Place for Cognitive-Behavioral Therapy in Psychoanalytic Therapy?

Susen Kay, Psy.D.

Recently my institute has generated an online discussion thread expressing great concern about the increasing emphasis on cognitive-behavioral therapy throughout the medical and psychological communities. Not much, if anything, is written in the psychoanalytic literature about the use of these techniques, although I believe that the general tone, when there is discussion, is one of disparagement and disdain. I wish to offer an alternative opinion: that these techniques can be integrated and, further, might be helpful when coupled with a psychoanalytic approach.

I want to thank the editors of this newsletter for encouraging discussion and controversy and I want to encourage you the readers, to respond with your thoughts.

The following case example is intended to show how cognitive-behavioral techniques helped the patient to develop a beginning awareness of his personal subjectivity, while the concurrent psychoanalytic process, expanded and deepened that awareness.

Hank, an average-looking 30 year old male patient, came to me because he was having panic attacks. How did he know he was having panic attacks? His heart would start racing, he would feel light-headed and it would be difficult for him to breath. Notice that these are all physical symptoms (he had no awareness of any anxiety, except that in the midst of the attack, he did admit that he was afraid for his health and his life). Questions about his internal states usually resulted in a one-word answer, "fine." If pressed he would respond with a list of tasks or activities, but never any "feeling" words.

Coming as no surprise, Hank researched his symptoms on the web. He concluded he had panic attacks and the best advice on the web was to get medication and then cognitive behavioral therapy. He went to his internist to get medication and he came to me because I was listed on a website as specializing in anxiety disorders. I started working with Hank once a week while we moved him to a psychiatrist to get his medication adjusted.

A very telling example of Hank's life concerned how he made his career decision. When he was to graduate from high school, his parents told him he had to go to college and decide on a career. His older sister was dating someone who was a program developer in the computer industry and he decided that it seemed like a good choice so that's what he did. Questions about how he felt at the time elicited nothing. Of course, it is very meaningful to me that his parents didn't prepare him for college, leaving him alone to decide what to do.

Frankly, I have never worked so hard with any patient. I would ask him how he was feeling and it quickly became clear he had no concept of feelings. He would answer with his usual "fine," even when I could sense small differences in his states; sometimes happy, sometimes stressed. Pursuing it further would result in an evaluation of the number of panic attacks he'd had that week and their intensity.

We could diagnose Hank as "alexithymic" and we could postulate that during childhood his emotions were not validated, mirrored or acknowledged, so therefore he has no awareness, knowledge or words for them.

I started reflecting back to him what I guessed was his internal state; happy at the purchase of a new truck, frustration at the process of debugging a computer program, helplessness and anger at the occurrence of a panic attack, hopefulness as he tried a new medication. My statements and guesses about his internal state would often be met with another monosyllabic response, usually in agreement. If I didn't ask for a response, he would just stare back at me blankly. Occasionally he would initiate a response with a sentence or two, an association, and I would inwardly rejoice and demonstrate interest.

Hank's psychiatrist gave him a cognitive-behavioral manual along with worksheets to fill out at each panic attack (there were several attacks every week). As his work became more stressful because of deadlines, I continued to try to develop his awareness of these stresses. Having programmed computers myself, I was able to walk through the process with him and identify various instances of frustrations and anger to help him identify these feelings. It was slow and hard work.

I asked him to bring in his cognitive-behavioral manual and forms. We went over his answers. I noticed that all his panic symptoms were still expressed somatically and he was not aware of any anxiety leading up to the panic attacks. I pointed out patterns, asked about his internal state before the attacks, what was it like to fill out the forms, etc. Often, I brought the discussion back to my guess of his feeling state, which might elicit a blank stare or sometimes an affirmative nod. I would ask about the deadlines at work, the increased workload, and his reactions. When I inquired, he would usually agree that, yes, he did feel frustrated, angry, or whatever. I asked him whether our discussions were helpful to him and he answered "yes," although he couldn't say how or why.

I dreaded his sessions, sought consultation, worked to develop his curiosity about what, exactly, was happening to him, and kept trying to find something of this process that would interest him, simultaneously, wondering what inhibited him from being curious and interested. He noticed that although the medication had decreased his symptoms, he still experienced symptoms. I identified his discouragement. In his usual manner, he flatly agreed and waited for me to say the next thing. I expressed his thought and hope that the medication would solve his panic problems and again repeated that maybe more was going on, that his emotions were involved as well.

Over the course of months of this type of work, Hank slowly became aware of some slight feelings of anxiety. Based on the forms he filled out, we concluded that Hank had the panic attacks when he managed to ignore these anxious feelings. He thought he was distracting himself, but together we decided that he was cutting himself off from his feelings and that panic would result. This was progress I thought. He was tentatively admitting that how he managed his feelings might be affecting his panic attacks.

As his work deadlines passed, Hank still continued to have several panicky periods a week. He learned to manage these through deep breathing and keep them from escalating into full panic attacks. He became resigned to them and drew some measure of confidence that he could control the panic. Hank kept coming and I attributed this to his slightly obsessive tendencies at managing his anxiety. The website had said to get therapy and he was getting it! At 5 months of treatment he asked to come every other week and I readily agreed, inwardly both relieved and guilty.

After two more months, I went to greet him in the waiting room as usual. He had his cognitive-behavioral manual with him and he smiled at me and bounded into the room! He was excited! He said that he just read a chapter that expressed what he and I had been talking about for all these months. The chapter he read was about making assumptions and jumping to conclusions. He talked hurriedly and excitedly, telling me his discoveries. He had noticed that when he went into a store, he avoided the salesman. Why should he avoid the salesman, he questioned. As I picked up his question and inquired more, he explored. He realized that he was "uncomfortable" talking to the salesman if he wasn't intending to buy something, instead, only wanting to get information. This was a new dimension of his concept of his world; it wasn't just the flat perspective of "doing whatever he did" but that he had a deeper dimension of feeling and awareness of connections between his thoughts, feelings, and his reactions.

And then he had another thought. He noticed that when he drove, he was anxious about getting off at his exit, changing lanes several miles beforehand, afraid that others would not let him move over. He noticed that he made this "assumption" and also realized that there was no practical basis for it. Why would he have this fear, he asked me? I was so excited for him! He had become aware that his subjective world affected his choices and actions. This was big news!!! Noticing that he was engaging in these behaviors was the result of both the psychodynamic and the cognitive-behavioral work, but asking the "why", I believe, was the result of our psychoanalytic work.

The cognitive-behavioral techniques were a tangible, concrete methodology and gave him something to do when he had attacks. The specific questions helped Hank to direct his attention to his subjective state and to identify what he was specifically thinking at the time of the attack and just prior to the attack. They helped him identify patterns, even if they were only concrete physical patterns. My psychoanalytic approach was to explicate the specific feelings associated with his thoughts and validate their significance. I was doing my best to identify and mirror his subjective world within an implicit attitude of curiosity and exploration. His breakthrough occurred in the contexts of both the cognitive-behavioral assignments and the psychoanalytic treatment.

Hank no longer uses the cognitive-behavioral manual, coming to a point that he said was repetitive and not helpful anymore. I believe that the manual, forms and techniques were helpful in several ways when joined with my psychoanalytic approach.

First, Hank was relieved of the specific fear that his panic attack was solely a physical problem, although this took some cognitive work. For example, while he was in the process of an attack, "feeling" his heart race, he needed to remind himself that it was not like his racing heart when he jogged. In explicitly explaining the process of the attacks, Hank moved from the fear that he had something physically wrong with him to an acceptance that they were part of a larger complex process involving his thoughts, feelings, and body sensations that carried important meanings for him in specific relational contexts, even if he couldn't understand his emotions in context for a long time.

Second, the cognitive-behavioral questions focused him on his subjective state, asking pointed questions about his thoughts. Implicitly they held, as I did, that there was something other than a physical cause. I worked with Hank to identify his feeling states associated with his thoughts. Hank noticed that filling out the forms seemed to relieve some of the panic. I explained that answering the questions on the CBT forms helped him reflect back on the panic process, stopping his panicky thoughts. I was to use this example of reflecting on his actions and thoughts many times and slowly he was able to see himself and his actions from a different perspective.

When he was able to make the leap to recognize that his behavior was "not rational," but was connected to his assumptions, convictions, and feelings he experienced in different self states within a variety of relational contexts, he was able to bring these experiences and awarenesses to me. My reaction served as another, new validating experience for him that supported his own self-regulation. He needed to have a validating "other", a mirroring "other" that would accept and help him name and understand his states and their contexts.

In conclusion I believe that the cognitive-behavioral approach reassured him he was "doing something" while beginning to point him internally towards his own subjectivity. The analytic approach focused implicitly and explicitly on a deeper subjectivity that, after many months of exploring many different situations and many specific examples, he was finally able to experience.

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