TIFT #127: CBT and PDT Share the Same Infrastructure

These two psychotherapy orientations, Psychodynamic Therapy (PDT) and Cognitive-behavioral Therapy (CBT) appear radically different, but the differences are more superficial and less fundamental. Readers of this blog will recognize three clinical requirements that universally explain what all therapies need to accomplish. Let's review:

New Learning: As described by Pavlov and well known to all of us, conscious awareness and experiential practice lead gradually to adding new behavior patterns to our repertoire of available responses.

Activating the old schema: The problems psychotherapy is designed to change are “Entrenched Maladaptive Patterns,” EMPs. There are only two known mechanisms for modifying existing EMPs, extinction and memory reconsolidation. In both cases the first requirement is neural activation of the old schema, which is located sub-cortically in a “survival circuit” (See LeDoux and Hayes).

Disconfirmation: The second requirement for modification of EMPs is delivery of disconfirming information. In the case of extinction, delivery is to the cortex, where temporary inhibition of the problem response is initiated. For memory reconsolidation, the new, disconfirming information must ultimately be delivered in nonverbal form to the subcortical survival circuit where the problem schema is located. This must happen at approximately the same time as the activation of the old schema. Focusing on memory reconsolidation for its ability to produce enduring change, this combination of two requirements leads to volatility in the procedural memory that is at the core of the problem schema. The memory is then re-consolidated in a new configuration based on the new information.

How are PDT and CBT different?

 We’ll return to the three requirements, but first, let’s look at some of the ways PDT and CBT are different.

Voluntary behavior change: This happens in both but in PDT the therapist avoids suggesting changes and waits for the patient to realize that behavior change is needed. In CBT, voluntary behavior change is often suggested as a requirement for change to happen.

Automatic Thoughts/Free Associations: These are important in both therapies. Behaviorists say that these arise from memory, but are generally reluctant to identify the source or speculate on the purpose of such thoughts. PDT therapists work actively to understand the unconscious sources of spontaneous thoughts and the purposes they may serve. They rely on the lack of conscious control of such thoughts to determine authenticity, and feel free to formulate their purpose. They start with working hypotheses then test and refine them as the therapy unfolds.

Delivering disconfirming information: CBT therapists perform “cognitive restructuring” and consider it fundamental to change processes. Change in conscious ideation has been questioned as the actual mechanism of change (xxx), but is nonetheless foundational to the technique. PDT therapists rely on “interpretations” to deliver unfamiliar information to clients and look for "resonance" and change as confirmations of accuracy. When PDT was invented, no one knew how unconscious content and processes might be modified. As a result, PDT therapists suggest multiple pathways for the effects of interpretations. Overlapping to an extent with CBT theory, explanations have included the idea that conscious awareness trickles down and restructures unconscious processes. Another explanation is experiential, for example the Corrective Emotional Experience, in which interpersonal expectations are contradicted by experience and this causes change. A third explanation is that being understood seems to have a positive effect, making the client feel safe and connected, leading to greater flexibility of response.

Style: CBT therapists favor scales and protocols, which have the effect of providing reassurance and structure for clients who are comfortable in that kind of setting. The therapies are also generally shorter, but relapse is considered common and new episodes of therapy are expected as part of the treatment. PDT therapists mostly maintain a more open ended stance in relation to the material considered and the length of treatment. They rarely use rating scales. This is comfortable for some clients and not others. The expectation is that problems are mostly resolved definitively and re-treatment is considered to indicate a less-than-complete cure.

Goal of treatment: CBT aims to reduce distressing symptoms. PDT aims to “resolve unconscious conflicts,” which are not recognized in CBT theory. These consist of presumably conflicting unconscious goals and needs that are located unconsciously, but where free associations provide indirect evidence. When these are resolved, for example by grieving losses and accepting adult reality, symptoms are relieved and a sense of resolution is transmitted to consciousness. PDT envisions also a process of “working through” in which resolution of underlying conflicts leads to further changes in behavior.

Homework: CBT often uses homework to help with cognitive restructuring. PDT generally avoids it, assuming that unconscious processes continue between sessions without direction from the therapist.

Why they seem so different

What I will suggest here is that both orientations did their best to make sense of how they worked at the time they were invented. Behaviorists avoided speculating about things that could not be measured objectively, so they excluded subjective content. They are still reluctant to talk about unconscious processes, though one of their greatest theoreticians, Steven Hayes, dares to identify LeDoux’s survival circuits as sources of pathology amenable to psychotherapy (Hayes 2018). Behaviorism was founded on Pavlov’s descriptions of learning, based on lower mammal conditioning. This has since been questioned as the science of biological information processing has advanced. In particular, the mechanism of memory reconsolidation is fundamentally different from Pavlovian learning in that it takes place over a very short time with minimal repetition.

Like their CBT colleagues, PDT therapists and thinkers did not, until recently, have access to neurophysiological explanations of change processes. Until Eric Kandel received the Nobel Prize for describing how information is encoded in neural networks, no one knew even how information is stored, let alone processed in the human brain. Only in the year 2000 did neuroscientists like Karim Nader begin to describe how extinction and memory reconsolidation work and how they are mutually exclusive.

Therefore, we need to be understanding that the theories behind the two very different therapeutic orientations left their founders and followers with no choice but to do the best they could to explain what was going on. In both cases, they left the actual mechanisms of change somewhat vague. That’s how it’s possible to resolve the differences by filling in the infrastructure they both have in common.

When we use modern science to look at change processes and mechanisms, areas of science that were not possible before the year 2000, it becomes possible at last to see how such very different approaches can actually accomplish the same results. And by the way, realizing how both orientations do the same few things, it finally makes sense that no one therapy has been shown clearly to be more effective than the others. 

How do both orientations fulfill the three requirements for change?

Let’s return now to the three clinical requirements that allow therapy to work, and I’ll add a fourth requirement at the end.

Using the mechanism of new learning

Both orientations, CBT and PDT, lead clients to learn and practice new patterns of response. While one prescribes changes in behavior and the other avoids making suggestions, in both, clients realize that they need to adopt new ways of responding to the same inputs. Whether it’s part of working through, or a primary expectation in the therapy doesn’t matter. What counts is that the client will have to make changes in behavior, which will lead to new experiences.

Voluntary behavior change not only brings new patterns to the client’s repertoire, but it has an additional and critically important consequence. It activates emotion. My favorite example is the TV show, “What Not to Wear.” There participants were required to wear clothing chosen by experts, rather than what they were accustomed to. What made the show interesting was the intense emotional response participants had to such a superficial change. Minor changes in behavior had powerful emotional effects on a very deep level. They were sending disconfirming information deep into subcortical structures to invalidate old patterns having to do with identity and self-esteem.

In a similar way, changes in behavior are powerfully important ways the conscious mind can communicate experientially with the unconscious subcortical world of survival circuits and schemas. 

Activating the old schema

 The next clinical requirement for change is activation of the old schema. We just saw how voluntary change leads to intense affects. Affect is the clinician’s indicator that non-conscious schemas are in an neurally active state and generating responses. Why is that? It’s because activation of schemas leads to launching a response. The earliest and most direct pathway for expression of the response is the brain’s control over the body, including tears, movement, spontaneous vocalizations, etc. Those are what we recognize as affects, indicators of emotion. Thus, affects, the physical aspects of emotion, are, for the most part, authentic indicators that those subcortical schemas have been activated.

There are many ways to activate old schemas. Meeting more than once a week over a period of time leads naturally to activating old schemas and the affects that form part of the responses schemas are designed to produce. These response are ultimately related to survival. Similarly, in an intense therapeutic relationship, clients begin to experience transference, which is the expression of old schemas. This expression, too, is heralded by affect. The structure of PDT is made to encourage the activation of transference, meaning outward manifestations of inner activation of non-conscious schemas having to do with relationship. CBT tends to discourage this transference and is intended to be of short duration so this doesn’t happen, but both exploration of core beliefs and voluntary behavior change do activate old schemas and result in the same kinds of affective response.

Experiential therapies including exposure therapy have other ways to activate old responses. They use external cues to activate old schemas. It might be sensory experiences, two-chair exercise, or role playing that bring the old situations “into the room.” These triggers lead the client to re-experience (i.e. re-activate) the old pattern.

Both orientations use verbal exploration to great advantage. PDT asks for free association as a way of bringing material up from non-conscious places. CBT does the same by encouraging identification of cognitive distortions. In both cases, talking about human irrationality tends to bring old truths to consciousness, accompanied by affect, which is, once again, our indicator of activation of the old schema. Thus, both orientations and sets of techniques are rich in ways to activate old schemas as indicated by in-session affects.

Delivering disconfirming information

 Both orientations put a great deal of emphasis on the therapist communicating a larger perspective, a new point of view that encourages acceptance of adult reality and contradicts childlike learnings derived from early development to cope with the serious problems of life. CBT uses cognitive restructuring and PDT uses interpretation, but they both accomplish the same function, providing disconfirming information. While less overtly recognized, voluntary behavior change in both orientations is a powerful source of corrective experiences.

It’s critical to realize that in many cases, especially in trauma, the disconfirming information is embodied in the context. It is the therapist’s calm and warmth that disconfirm the traumatized client’s sense of danger. It is the comfortable office and the therapist’s modeling of mindfulness that show a different way to experience memories associated with pain and fear.

While we are on the subject, the inner mind, that collection of subcortical structures dedicated to our survival does not process language. The data it works with is non-verbal. It is non-verbal, contextual, connotative, and metaphorical. That’s why therapeutic communication needs to speak those languages if it is to be delivered. Pure intellect doesn’t reach those structures. The channel between consciousness and the inner mind needs to be open. The presence of affect tells us it is, and that’s why PDT pays attention to timing interpretations when affect is present. In contrast, CBT counts on the new ideas penetrating at some time before the next session. 

A fourth requirement: common factors

 The "E" in EMPs (subunits of pathology treatable in psychotherapy) stands for “Entrenched,” meaning that they are not easy to change. There is naturally resistance to change. Why? It’s because the survival oriented subcortical mind is jealous of solutions it has found to serious, even existential threats. It perceives therapy’s goals of change to be threats. “Are you saying you want to take away a protection that has kept me alive for all these years?” That leads the survival oriented mind to generate "resistance EMPs" specifically designed to block the change process of therapy.

How is the therapy to prevail? We all know that when children try new things they are often afraid. Think of going to school for the first time. What gets them past their understandable fears? It’s the presence of a “big person,” who is reassuring, safe and comfortable. That’s what the “common factors” do. They are nearly all about making the alliance safe enough to help a frightened inner self take a big risk in responding differently to the same inputs as before. That’s why common factors are important. By the way, one common factor is not about the relationship. It is the presence of affect in the session. From the earlier discussion we already know that in-session-affect means both that the old schema has been activated and that a communication channel has been opened to those subcortical structures where enduring change needs to take place. 

Conclusion

So it is, that both the CBT and the PDT orientations have found their way to doing what all therapies must do if they are to produce change. And that’s why they have about the same effectiveness. They really amount to different ways of doing the same three things. 

Reference:

Hayes, S., & Hofmann, S. (2018). Survival circuits and therapy: from automaticity to the conscious experience of fear and anxiety. Current Opinion in Behavioral Sciences, 24, 21-25.

Jeffery Smith MD

Photo Credit: Timon Studler, Unsplash