A Cognitive Behavioral Critique of Time-Limited Dynamic Psychotherapy

 by

Chris T. Sorrentino, LPC, NCC

             Some of the younger readers haven’t had this experience, but 20 to 30 years ago, theories of personality in general and treatment methods specifically were stovepiped or, as Rudyard Kipling would say “never the twain shall meet” (Kipling, 1889).  According to one of my old textbooks, Personality,  by Jerry M. Burger (Burger, 1990), there was the psychoanalytic camp including the likes of Erikson, Horney, and Fromm, the trait theorists such as Allport, Cattell, and Eysenck, the humanists with Maslow and Rogers taking the lead, the behavioral/social learning group which included Skinner, Bandura, and Rotter, and, finally, the new kids on the block, the cognitive bunch led by Kelly, Mischel, and Ellis (although Beck and Meichenbaum were also quite well known by this time).  The various theories and their clinical applications were extremely diverse and scientists, as well as clinicians, were passionately dedicated to their particular favorite.  Over the past 30 years, I have seen an extraordinary evolution of these theories and their applications.  Today, there is so much overlap and similarity between theories and methods that it’s getting harder and harder to see the difference between them, on paper at least.
            Levenson (2003) discusses, on several occasions, the similarities between Time-Limited Dynamic Psychotherapy (TLDP) and the cognitive-behavioral model.  Levenson states “Not only psychoanalysis but other theories as well are increasingly incorporating interpersonal perspectives, for example, cognitive therapy, behavior therapy, and gestalt therapy (p. 303).  She went on to say that “Modern cognitive theorists voice analogous perspectives when they talk about interpersonal processes that lead to experiential disconfirmation” (p. 307) and “The second goal of providing a new understanding focuses more specifically on cognitive changes than the first goal just discussed, which emphasizes more the affective–behavioral arena” (p. 308).  Originating in the psychodynamic camp, TLDP today looks very little like the psychoanalysis of old, having embraced an eclectic treatment approach that focuses on interpersonal factors and a directive, here and now approach while moving away from insight, interpretation, and a very non-directive approach to uncovering the repressed psychosexual conflicts of long ago.  Hip-hip-hooray!  Unfortunately, once again, there wasn’t a lot of information in the readings related to treatment methods and techniques, so I hope we will be discussing this more in class.

           Aaron Beck’s concept of the “schema” (Beck and Clark, 2010) is not much different then Greenberg’s concept of the “scheme” (Greenberg et al, 2004).  Levenson (2003) also discusses the “interpersonal schema” and “schemata” on several occasions, but never really defines the concept in depth.  In fact, she quotes Goldfried and Newman (1986), who said:

A number of contemporary writers have independently suggested the possibility that a common [integrative] language may ultimately come from the field of experimental cognitive psychology and social cognition....Concepts such as “schema,” “scripts,” and “metacognition” have the potential for covering therapeutic phenomena observed by clinicians of varying orientations (pp. 46–47). (Levenson, 2003, p. 310). 

Based on what I can infer from the context in which the terms were used in Levenson’s article, it sounds like a concept very similar to both Beck’s and Greenberg’s, the only difference being that Beck focused on cognitions, Greenberg on emotions, and Levenson on interpersonal relationships.  I don’t want to spend too much more time on this because I discussed the issue at length in my last paper, but want to add one more point.  The concept of transference is more commonly being utilized by members of the different camps (psychodynamic, cognitive, etc) and the application of transference (and countertransference) in treatment is becoming more and more similar.  As Levenson stated, “transference is not considered a distortion but rather the patient’s plausible perceptions of the therapists behavior and intent” (Levenson, 2003, p. 303) while Beck (1979) made several references to transference and its usefulness in therapy from a cognitive perspective.   Even Linehan (1993) mentioned the similarities between the psychodynamic emphasis on transference and her concept of therapy interfering behaviors as opposed to any aspect of cognitive-behavioral therapy.

               I found it interesting that training effects (Henry, Schacht, Strupp, Butler, and Binder, 1993) could have such a profound impact on outcomes, an assertion supported by Wampold (2001) in his defense of a contextual model and the corresponding limitations of the medical model.   Henry (Henry et al, 1993) found significant effect size differences between the two groups (trained by Trainer A and B) and that Trainer A was more effective than Trainer B for several reasons.  We know that there are “thearpist effects” which influence treatment effectiveness and that some therpists are more competent than others, whether we’re talking about their influence on specific or general factors.  For example, if specific factors are repsonsible for outcome as the medical model proposes, then therapist comptency in that particular treatment modality should have an effect on outcome.  As a result, more seasoned, better trained clinicians will see better results with their clients than less experienced, novice therapists.  At the same time, if general factors are responsible for outcome as the contextual model proposes, therapist competency (in terms of empathy, belief in the modality, ability to convince the client of its effectiveness, etc), in general, should also have an effect on outcome.  Some clinicians, usually (but not necessarily) the more experienced variety, should also have better outcomes with their clients than less experienced (competent) therapists. 

                  Henry (Henry et al, 1993) found exactly that when comparing therapists providing training on how to provide Time-Limited Dynamic Psychotherapy (TLDP) in the study in question using a treatment manual.  It appears that, from the discussion and conclusions in the article, it was the general effects of the individual trainers that were responsible for the differences between groups as the contextual model would predict.  This finding has serious implications on the validity of any study which uses a treatment manual and trains clinicians to treat clients in accordance with the manual.  Not only is there going to be variability in abilities within groups being trained, but there will also be variability between groups depending on the skills and approach of the facilitator.  Wampold (2001) has shown that allegiance has a siginifcant effect on outcome in randomized control trials (RCT) and that, even when utilizing a treatment manual, the allegaince effects are large.  Add to that the impact of trainer attributes, as described by Henry et al (1993), and we have some very serious confounding variables related to RCTs in general and the utilization of treatment manuals (and any associated training) in particular when measuring efficacy.

The article by Shefler, Time Limited Psychotherapy with Adolescents (2000), was quite interesting from a cultural diversity perspective.  I found it interesting that the Israeli adolescent seemed to be struggling with many of the same types of issues as American youth and Shefler’s description of the intervention was probably not much different than an intervention that would be used by a clinician using TLDP here in the United States.  One thing that really turned me off was Shefler’s references to “masochistic tendencies” and “incestuous fantasies” (Shefler, 2000, p. 92):

            Heightened sensitivity to frustration and to a lack of love and support characterizes the narcissistic awakening that typically occurs in adolescence. This awakening can either set the adolescent on track toward healthy development or on the road toward personality disturbance or toward a narcissistic character first manifested in adolescence. Masochistic tendencies toward painful pleasure and passivity characterize adolescent fantasies among both males and females. In addition, preoccupation with issues of bisexuality, anxiety surrounding bodily change, and remnants of incestuous fantasies frequently become intensified.  I understand the relevance of a narcissistic awakening and a preoccupation with sexuality or body image in the budding adolescent, but masochistic tendencies and incestuous fantasies sounds more like the psychoanalysts of old and not the here and now, interpersonal TLDP therapist of today.

            Finally, I didn’t see much relevance in the Strupp article (Strupp, 1990) and don’t think it added much to the readings.  In my opinion, it highlighted his own narcissistic tendencies in that he was clearly off the mark with Helen, but refused to admit it.  Having so much anger toward men in general, he should have referred her to a female therapist in the very beginning and finally admits to it in the discussion section (Strupp, 1990, p. 655):

            Thus, after a few sessions, when the patient's relative unsuitability had become apparent, one might have referred the patient elsewhere, openly admitting one's difficulty in working with her. In so doing, one would not commit the error of blaming the patient for the difficulty but simply indicate that in the therapist' judgment there was no match. He was way off the mark, alienating an already hostile client (and most modern women in general) by insisting that she really wanted to be a man (penis envy).  If TLDP is focused on the here and now, interpersonal aspects of personality and not on the interpretation of and insight into latent psychosexual process characteristic of the old psychoanalytic model, what was Strupp trying to do?  In the end, he refused to admit to his mistakes when working with Helen and even concluded that the therapy was beneficial to the client, clearly displaying his lack of insight and objectivity into his own therapeutic skills as well as his personality.

References

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive Therapy of Depression. New York, NY: The Guilford Press.

Beck, A.T. and Clark, D.A. (2010). Cognitive Therapy of Anxiety Disorders – Science and Practice.  New York, NY: The Guilford Press.

Burger, J.M. (1990). Personality (Second Edition). Belmont, CA: Wadsworth Publishing, Inc.

Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning Emotion-Focused Therapy: The Process-Experiential Approach to Change. Washington, DC: American Psychological Association.

Goldfried, M. R., & Newman, C. (1986). Psychotherapy integration: An historical perspective. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 25–61). New York, NY: Brunner/Mazel.

 Henry, W. P., Schacht, T. E., Strupp,H. H., Butler, S. F., & Binder, J. L. (1993). Effects of training in time-limited dynamic psychotherapy: Mediators of therapists' responses to training. Journal of Consulting and Clinical Psychology, 61(3), 441-447.

Kipling, R. (1889).  The Ballad of East and West.  In Wikpedia online.  Retrieved from 

http://en.wikipedia.org/wiki/The_Ballad_of_East_and_West

Levenson, H. (2003). Time-limited dynamic psychotherapy: An integrationist perspective. Journal of Psychotherapy Integration , 300-333.

Shefler, G. (2000). Time-limited psychotherapy with adolescents. The Journal of Psychotherapy Practice and Research , 88-99.

Strupp, H. H. (1990). The case of Helen R: A therapeutic failure? Psychotherapy , 644-656.

Wampold, B. (2001).  The Great Psychotherapy Debate. Mahwah, NJ: Lawrence Erbaum Associates.

Emotion-Focused Therapy Versus Cognitive Behavioral Therapy...What Next?

Emotion-Focused Therapy Versus Cognitive Behavioral Therapy...What Next?

              Emotions are obviously a key focus when working with clients in a psychotherapeutic alliance no matter which theoretical orientation you might favor.  Emotion-Focused Therapy (EFT) may very well be a useful approach to resolving emotional disturbances, but the readings really did not give me enough information to make an informed decision in that regard.  I will refer to the readings to elaborate on this point, make some general comments regarding “humanistic” psychology, and provide some thoughts on the similarities of different theories as well as the need to develop one overarching meta-theory.

            You will have to excuse me, because I come from a primarily cognitive-behavioral framework and, therefore, have some difficulty grasping some of the “grayness” of humanistic and some of the experiential theories.  Do not get me wrong; even though I am somewhat of a dichotomous thinker, I still believe there are some very valuable concepts to be taken out of the readings and humanistic theories in general.  However, in Elliott, Watson, Goldman, and Greenberg’s text entitled Learning Emotion-Focused Therapy: The Process-Experiential Approach to Change (2004), there is very little mention of therapeutic methods or techniques.  The text explains Process-Experiential Theory in appropriate detail, although I would not necessarily say it was “made simple” as the title of chapter two suggests.  Because I come from a “primarily” cognitive-behavioral perspective, that doesn’t mean that I don’t utilize an eclectic approach and find value in other treatment modalities formulated by such notable and intelligent theorists such as Rogers, Perls, Moreno, or Freud.  On that note, I would have hoped to read more about the contributions of EFT regarding therapeutic techniques, that is all I’m saying.

            In fact, none of the readings, with the exception of Repairing Discordant Student-Teacher Relationships: A Case Study Using Emotion-Focused Therapy (Lander, 2009), focused on therapeutic methods or techniques, which I found quite disappointing.  I hope that these missing components will be elaborated on more in other works.  Lander (2009) did provide an excellent case study that I found quite interesting and possibly useful in working with children.  Since I have very little experience working with small children, the techniques utilized piqued my interest and will inspire me to seek additional information regarding their specific applications. 

            As Wampold (2001) stated so elaborately in his text, I saw the “general effects” in Lander’s (2009) case study as being equally, if not more, responsible for the positive changes (outcome) in the relationship between Guy and Ms. Greenberg.  I believe the individual techniques were an excellent vehicle for building an alliance between teacher and student, and that the collaborative nature of the exercises did more to repair the relationship than any of the exercise’s products.  For the first time, the two individuals were able to see each other as human beings with struggles and emotions not so different from each other.

            Elliott, Watson, Goldman, & Greenberg (2004) mentioned that neo-humanism evolved because the humanistic movement “fell out of favor” (p. 6) in the 1970s and 1980s, but did not elaborate on why that occurred.  I have to assume it is because that is when the behavioral and cognitive revolutions in psychology began to take hold and the humanists really did not fit very well with the medical model.   It would have been nice to hear why the humanists believed this happened, why they felt compelled to create a neo-humanistic model, and what the differences are between the two. 

            I have noticed a lot of discussion of “dialectical” frameworks in the literature over the past several years and it seems to be a concept catching on in many theoretical camps including Linehan’s Dialectical Behavior Therapy (DBT) and EFT.  Is that the big difference between humanistic and neo-humanistic models?  Dialectical constructivism, as described by Elliott, Watson, Goldman, & Greenberg (2004), is not much different from dialectics as described by Linehan (1993).  Both Greenberg and Linehan are talking about the polarity of emotions as well as the dialectical relationship between therapist and client, yet they are coming from humanistic and cognitive-behavioral perspectives respectively.  Is it the dialectical opposition of emotions that separates the humanists of old from the neo-humanists or is there something more radical that I may have missed in the readings?

            I have to say that I take exception to the term “humanistic” psychology in general.  It is not that I do not believe in the principles behind the humanistic perspective, because I see many positive and useful ideas coming out of the writings of “humanists”.  My concern is that if a theory or therapy does not fall within the confines of the humanistic model, does that mean that all other models are inhumane?  What makes the humanistic theories more relevant to humanism than others theories, therefore making it necessary to make this very specific distinction?  Aren’t all theories concerned with helping people solve their problems and lead happier, healthier lives humanistic?  Don’t psychodynamic, behavioral, cognitive, developmental, and humanistic models all treat people with dignity and respect, nurture their clients, and show compassion for fellow human beings?  Of course they do! 

            In reality, the different theories or models of psychopathology and treatment are starting to look more and more similar as time goes on.  I can see many similarities between EFT and CBT for example.  EFT refers to the concept of the “scheme” while CBT uses the term “schema” to capture pretty much the same concept (I believe “schema” came first by the way).  Elliott, Watson, Goldman, and Greenberg (2004, p. 7-8) say they “use the word ‘scheme’ instead of ‘schema’ because ‘schema’ implies a static, linguistically based mental representation, whereas ‘scheme’ refers to a plan of action”.  They go on to say that a scheme is a process, not a thing, including linguistic components but consisting mostly of preverbal elements such as bodily sensations (physiological), images (also cognitions), and smells that are “not directly available to awareness”.  In Beck’s latest book (Beck and Clark, 2010, pp. 44-46), his concept of schemas is not much different from that of Greenberg et al.  Beck describes not only a cognitive-conceptual schema, but behavioral, physiological, motivational, and affective (emotional) schemas as being integral in primary threat mode activation, all of which are “automatic” processes (not directly available to awareness).  Humanists apparently use the “empty chair” technique (referred to, but not elaborated on, on p. 32 of the Greenberg reading), a technique developed by Fritz Perls, but also utilized in cognitive-behavioral therapy as a technique in role playing or behavioral rehearsal.  The readings state that the focus in EFT is on emotions rather than cognitions, but when describing emotions, the authors, Elliott, Watson, Goldman, & Greenberg (2004) and Pascual-Leone & Greenberg (2007), all describe them in terms of thoughts, statements, and cognitions and it is those statements that Pascual-Leone & Greenberg (2007) used to measure “emotion” in the research they describe.  So are emotions and cognitions that different or are they integrated in such a way that they become almost indistinguishable?

            In conclusion, with few exceptions, most science is based on theories that are more or less accepted as facts.  The theory of relativity, for example, doesn’t have four other competing theories explaining how celestial bodies relate to each other in the universe and there aren’t six different theories of evolution (although creationists have an alternative theory of their own), so why does psychology have so many theories of the mind, personality, behavior, emotion, and the treatment of psychopathology?  If we want to be taken seriously as scientists and validate our research on human psychology with credibility, we will eventually need one overarching meta-theory of psychology.  As I stated above, many of the remaining theoretical camps are all starting to sound more and more alike, only using different jargon and semantics to make their approaches sound novel and intelligent.  Rather than fighting each other over who is right, why don’t they all put their heads together and come up with one overarching theory of psychology that we can all accept?  Could that theory change over time?  Possibly.  Nevertheless, who has to say that the theories of relativity and evolution might not change with some unforeseen dramatic discovery in the future?  At least we could be taken seriously as a science and focus our funding and efforts in one direction rather than eight or ten.  If the general effects of therapy are as critical as Wampold (2001) suggested, what would the credibility of one psychological theory add to client expectation, the therapeutic alliance, and positive outcome?  One thing is for sure, allegiance factors, which according to Wampold (2001, p. 206), account for up to ten percent of the variability of outcomes, would be a thing of the past.

References

Beck, A.T and Clark, D.A. (2010). Cognitive Therapy of Anxiety Disorders – Science and Practice.  New York, NY: The Guilford Press.

Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning Emotion-Focused Therapy: The Process-Experiential Approach to Change. Washington, DC: American Psychological Association. 

Lander, I. (2009). Repairing Discordant Student-Teacher Relationships: A Case Study Using
Emotion-Focused Therapy. Children & Schools, 31, 229-238.

Linehan, M.M., (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder New York, N.Y: Guilford Press.

Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional Processing in Experiential Therapy: Why “The Only Way Out Is Through”. Journal of Consulting and Clinical Psychology, 75, 875-887.

Wampold, B. (2001). The Great Psychotherapy Debate. Mahwah, NJ: Lawrence Erbaum Associates.