TIFT #136: Mixing CBT and PDT For Better Therapy

Tradition says you shouldn’t do it, but mixing cognitive-behavioral therapy and psychodynamic therapy can improve results for both. Here is why and how to do it. The problem is that taboos from long ago continue to cast very long shadows. To be specific, CBT still suffers from a taboo against looking into the past, while PDT tends, to this day, to shun an active role for the therapist including “gratification” of wishes as well as promoting or recommending changes in behavior.

CBT’s Taboo

John Watson, the founder of behavioral psychology (as well as scientific advertising), rejected introspection as a source of information because it was subjective and not measurable. That taboo continues to day in the behavioral literature in the sense that, except in an initial assessment or formulation, personal accounts of the origins or functionality of mental contents are generally avoided as part of the therapy. The CBT world does view automatic thoughts as important in the causation of pathology, and sees them as arising from irrational beliefs derived from early experiences (Șoflău & David, 2017), but still shies away from detailed exploration. Current behavioral literature (Easden & Kazantzis, 2018) supports the view that individual case formulation can be used for assessment, but has not been shown to be of much use in sessions.

My view, explained below, is that, while they are only indirectly accessible, the exploration of specific nonconscious schemas is critically important in supporting the kinds of transformational change most of us seek in psychotherapy.

PDT’s Taboo

The psychodynamic tradition has its own taboo. Trainees, who are particularly susceptible to internalizing the values of their trade, are taught not to “gratify” client wishes or tell their clients what to do. The origin of these powerful, and often repeated prohibitions goes back to Freud’s early view that the transference was fragile and easily distorted by real interactions with the analyst. Furthermore, gratification, was seen as promoting re-enactment of pathology as opposed to bringing it to consciousness for therapeutic benefit. Within the psychodynamic world, the real relationship or “alliance,” is viewed today as inevitable and valuable, but the fear of gratification still leads to an uneasiness with emotional engagement. While Glen Gabbard’s 2022 article, “The Decline and Fall of Neutrality…” recognizes that the field has moved on, the old taboo still has power, especially in the field of psychoanalysis, which continues to be viewed as a gold standard of psychodynamic thinking.

As I have noted before, the old views are of Victorian origin, much like the austere policies of pre-war orphanages, since discredited by Bowlby’s work on attachment. In those days, shaming and deprivation were seen as ways to motivate people. Since the 60s, we see hope and encouragement as better ways to help people change. Again, my own view is that it is high time to re-evaluate and start fresh with a more human, as well as scientifically informed approach to the therapeutic relationship.

A Taboo-free view

Compatible with both CBT and PDT, a more modern framework can describe human irrationality and the problem patterns that are the focus of psychotherapy in terms that are compatible with traditional theories but approach the problem on a different level as described elsewhere by the author  (Smith, 2025). Experiences, especially early in life, when perceived as being of existential importance, generate survival oriented responses that become frozen in time and can be maladaptive. These are manifested as automatic behaviors as well as conscious thoughts, feelings and impulses to act and to avoid action. The information processing that produces these responses, based on current inputs and past experience, takes place in nonconscious subcortical schemas. While CBT is uncomfortable with the idea of schemas being “unconscious,” the field does recognize that they are deeply held and not as easily accessed as conscious thoughts.

Joining research on how the brain’s information processing is based on predictive coding and work on the learned fear paradigm makes possible a new and much more specific view of the nature of schemas and how their functioning can be changed in psychotherapy. The schemas that influence consciousness and behavior can be thought of as nodes of fuzzy, if-then logic that determines how the individual responses to current sets of sensory inputs are shaped by past experiences. Just two mechanisms have been shown to be capable of changing the functioning of these schemas. Research on the change mechanism of extinction shows that it involves a temporary neurological inhibition of responses. In contrast to the temporariness of extinction, work with the mechanism of memory reconsolidation demonstrates that transformational change involves a rewriting of the logic within the schema. This takes place when two conditions are fulfilled, first that the old pattern is put in an active state, and second the delivery of new, disconfirming information delivered to structures in subcortical brain, where schemas mainly reside.

The Critical Role of Entrenchment

Based on clinical observation and study entrenchment, the tendency toward involuntary resistance to change, can be viewed as serving the evolutionary function of protecting survival-oriented response patterns, frozen at the time they were first “invented.” This is especially true of those established under conditions of existential threat. Those that derive from early life experiences tend to be the source of attachment styles and character pathology, while later ones function as safeguards of emotional development and social survival. Considering that species survival for humans is determined by social cohesion, these response patterns are what human life depends on. That is, in my view, why they are guarded by highly energetic but similar patterns enforcing entrenchment by resisting change.

The key insight is that the role of “common factors” and the positive therapeutic alliance are essential in order to build the trust and sense of safety that are the main vehicles by which therapy encourages clients to overcome entrenchment and adopt new, healthier patterns of response. In addition, in cases of adverse prior relationships, where negative expectations are projected onto the therapist, a positive alliance can provide the experiential information needed to disconfirm and re-write maladaptive schemas.

The Role of Individual Exploration and Insight

The CBT literature (with the exception of work on trauma) tends to remain under the influence of the old taboo in that it tends to cling to skepticism about in-session exploration of past experiences. In contrast, the view proposed here is that such intimate and personal exploration fulfills a number of critical requirements for transformative change. In pathology, the past is reflected in the present. Emotionally engaged explorations of problem patterns either manifested in the present or as they were shaped by the past are centrally important in a number of objectives of critical importance to the success of therapy, especially when the goal is transformative change. Such exploration:

• Supports building trust in the therapeutic relationship by giving a sense of being seen and understood.
• Brings maladaptive patterns to consciousness, widely recognized as helpful for change.
• Combats the shame that often stands in the way of acknowledging pathology, an often-needed step in the direction of change.
• Helps generate motivation for change.
• Fulfills both extinction and memory reconsolidation’s key requirement of neural activation of the old, maladaptive pattern.
• Simultaneously fulfills the second requirement of both extinction and memory reconsolidation, the delivery of disconfirming information to cortical and subcortical structures respectively.

For all these reasons, I am arguing that modern thinking about psychotherapy should encourage exploration of individual experiences, past and present, with all their richness and specificity. We will do better to let go entirely of the worry that the scientific validity of our work will somehow be tarnished by attention to the unique individual. In this case, the only caveat is needing to recognize that conclusions about causation and the function of specific responses represent hypotheses, always subject to later revision further refinement.

Active engagement on the part of the therapist

The situation of the psychotherapy trainee is a perfect place for internalization of values and the potential for shame they bring. At that point in our lives, we are highly motivated but anxious about belonging to our group. That’s when we are primed to take in the kinds of taboos that take root and have lasting effects. An elderly colleague, as I have described before, retired and transferred some of his patients. In a subsequent phone call, he admitted, with trepidation, that some patients might describe ways he went out of his way to be helpful to them. He imagined that I would be shocked. Instead, I recognized an analytic therapist who had largely overcome his taboo, but still felt a twinge of shame about treating his patients well. We’ll see below, that being active and engaged can lead to missteps and even harm, but the need to monitor for potential problems exists anyway and should be part of any therapy. Specific potential dangers are listed below.

The role of voluntary behavior change

Maladaptive patterns of behavior are recognized in all forms of psychotherapy. In CBT, practicing healthier behaviors is strongly supported, even prescribed as homework. In PDT, it is largely left to the client, where change is either something that simply “happens,” or is the result of the client’s own decisions making. This is where the taboo in PDT against behavioral suggestions requires a more nuanced treatment. My position is that there are dangers, but they are manageable and far outweighed by the advantages of an emotionally engaged relationship, where voluntary behavior change is welcomed and thoughtfully discussed.

Maladaptive behaviors, as Wilhelm Reich observed long ago, often serve the function of “character armor,” embodying attitudes and ways of relating with a protective function. When these are left in place, they keep unhealthy meanings hidden from consciousness and from change. “That’s just how I am.” However, the consequences can be highly significant and destructive. The proof of the emotions they hide is that trying to change such habitual patterns typically leads immediately to strong emotions. Even when pointed out or brought to awareness, unless they become the focus of treatment, these patterns are likely to continue unchanged. They are among the most potent and entrenched manifestations of pathology, at least the kinds that are the targets of psychotherapy.

This is where the taboos of PDT tend to bias towards leaving maladaptive behavior patterns unchallenged and untouched. Consider patterns like body posture, preferences in dress, and the infinite variety of “personal preferences” that so often represent unhealthy compromises. I’m not saying we should systematically attack such patterns or insist on treating them when the patient is not in agreement, but being aware of their meaning and importance should be a goal of any psychotherapy. Furthermore, returning to the requirements for memory reconsolidation, one of the two main requirements is disconfirming information, often in the form of new experiences arising from the adoption of new ways of responding. Those need to be learned before they are available as alternatives.

Thus, I believe the important advantages of PDT’s emphasis on exploration of the uniqueness of the individual need to be balanced with a more active relationship and willingness to engage in discussion of behavior patterns as well as thoughts, feelings, and impulses.

Let’s consider the rarely discussed issue of arrested development. When life challenges lead to maladaptive responses that become entrenched and frozen in time, related areas of development tend to remain stuck. Development stops for those threads of maturation. Ultimately the goal of psychotherapy is to leave the trauma in the past and support the resumption of development. How development works is very simple. It moves forward through action and experience. As individuals try out previously blocked avenues of behavior, they gain experience and learning. That is the essence of what development brings over the lifespan. In my view, somewhere close to half of the effort of psychotherapy is in supporting growth and development through exploration of new behaviors.

The Potential Dangers of Promoting Behavior Change

As indicated earlier, there are dangers that can come with an active stance and with the use of the alliance to promote behavior change. These dangers are inherent in any therapy and need to be managed. Being cognizant of the dangers is far more valuable than using blanket prohibitions to try to avoid trouble. Overall, the advantages of being actively engaged greatly outweigh the problems as long as we are sensitive and vigilant. Here are some considerations.

• Infantilization: Clients, like children, are moving targets. What is helpful at one point may be infantilizing later on. As parents know, infantilization only happens when we give “help” that isn’t needed. As growth takes place, what was once beyond the individual’s capability becomes acquired knowledge. At that point, help is not needed, and offering it is a vote of no confidence in the person’s ability. Accepting unneeded help can become a maladaptive response, part of resistance to further growth and a way of protesting the over-helpful other.
• Distortion of the transference: In my experience, the phenomenon of transference is remarkably robust and powerful. The original fear that transference would disappear is simply unfounded.
• Re-enactment: Behaviors on the part of the therapist, including responding to client wishes, can “step into” a pre-existing relationship paradigm, where they can have complex consequences. Sensitivity to those should be part of the training and experience of every therapist. Left unexamined, re-enactments do tend to reinforce maladaptive patterns rather than supporting change.
• Erosion of trust: Insensitivity and mistuned suggestions can damage trust in the relationship. Again as in parenting, it is not possible to be perfectly attuned all the time. It is our willingness to acknowledge our role and repair ruptures that, in the end, strengthens the relationship.
• Betrayal of trust: I’m using a strong word for failure to respect community standards and expectations as well as the therapist’s implied or explicit promises. Sensitivity to the client’s legitimate expectations is vitally important and failure in this area can have a severe consequences or even damage the relationship beyond repair.

All of these potential problems represent opportunities that can lead to growth, or that can be squandered if missed. It is better to cultivate sensitivity and manage them, than to resort to black-and-white rules to try to eliminate their effects.

Better Psychotherapy

In conclusion, the ultimate aim of talk therapy is to help clients rewrite their schemas so as to trade maladaptive patterns for more satisfactory ones. In supporting that aim, we therapists will do better to leave behind the traditional taboos of the early 20th Century and make use of what we know now, that an emotionally engaged therapeutic alliance and a sensitivity to the specifics of individual experience can be expected to enhance any therapy.

References

Easden, M., & Kazantzis, N. (2018). Case conceptualization research in cognitive behavior therapy: A state of the science review.. Journal of clinical psychology, 74 3, 356-384 . https://doi.org/10.1002/jclp.22516.

Gabbard G. O. (2022). The Decline and Fall of Neutrality in Psychoanalytic Discourse. Journal of the American Psychoanalytic Association, 70(2), 309–315. https://doi.org/10.1177/00030651221094623

Smith, J. (2025). Psychotherapy integration from the bottom up: A unifying, science-based view of psychotherapy’s infrastructure.Journal of Psychotherapy Integration, 35(4), 256–271. https://doi.org/10.1037/int0000371

Șoflău, R., & David, D. (2017). A Meta-Analytical Approach of the Relationships Between the Irrationality of Beliefs and the Functionality of Automatic Thoughts. Cognitive Therapy and Research, 41, 178-192. https://doi.org/

Jeffery Smith MD