Tuesday, 20 March 2012

Beck and Psychoanalysis

Aaron T Beck
In the last few years I've come upon a couple of rather lazy papers that try to challenge an opposition between CBT and psychoanalysis by pointing out the Aaron T. Beck - the founder of cognitive therapy - started life as a psychoanalyst. Some even claim that CBT was 'rooted' in psychoanalysis.

The real story is rather different. But what interests me here, mainly, is just how lame Beck's rejection of psychoanalysis looks from today's perspective on what psychoanalysis actually amounts to. The story is told by Paul Salkovskis, arch critic of analysis, in the epilogue to his edited volume Frontiers of Cognitive Therapy. Whilst Beck certainly started life as a psychoanalyst, his theory of the causes of depression grew in direct opposition to his own psychoanalytical convictions. These convictions apparently included the view that depression always or at least typically arose from self-directed hostility. (Even when we consider Freud's Mourning and Melancholia, with its talk of reproaches of the object being directed onto the self once the identification with the ambivalently regarded object has taken place, we can see how simplistic Beck's psychoanalytical (ego psychological) theory really was. To say nothing, that is, when we compare it with more recent psychoanalytic formulations - see, for example, Trevor Lubbe's Object Relations in Depression: A return to theory.) Beck looked at the effects on the self-esteem of depressed people on their doing well in various tasks. Apparently he reasoned that if psychoanalytic theory were correct then depressed people who hated themselves ought to be distressed by doing well, and was then surprised to find that depressed people actually cheered up when they did well!

Paul M Salkovskis
What today appears as the extraordinary naivety of Beck's psychodynamic theorising goes unmentioned by Salkovskis, but this is perhaps not surprising given Salkovskis's own well-known animadversions concerning psychoanalysis. (btw, hear his contribution to this year's Maudsley debate on psychoanalysis here.) Beck writes to Salkovskis: 'I went back to my dream studies and I thought "Maybe there is a simpler explanation [of why people espoused critical views of themselves in their dreams than the idea that they are motivated to by self-hatred] and that is that the person sees himself as a loser in the dream because he ordinarily sees himself as a loser. ... If you take motivation and wish fulfilment out of the dream, this undermines the whole motivational model of psychoanalysis. I started to look at the motivational model all the way through, and its manifestations in behaviors, everyday slips, and so on. It seemed to me that the motivational model did not hold. Once that collapsed and I inserted the cognitive model, I saw no need for the rest of the super-structure of psychoanalytic thinking.' (Frontiers, pp. 535-6)

So, firstly, so much for the idea that CBT is 'rooted' in psychoanalysis. But more interestingly, how extraordinary to think that the content of dreams might not reflect the patient's general self-concept, along with all the patient's conscious and unconscious wishes, fears and drives. That at any rate is the general idea of analytical approaches such as Jungian dream analysis (see Marcus West's Understanding Dreams in Clinical Practice). Another question one might ask is whether or not someone's conception of themselves as a loser - both in their waking life and their dreams - is born of a defensively motivated identification with a childhood aggressor (a bully at school, for example, or a critical aspect of their father). Are we to believe that dreams never contain wish fulfilling elements? Only yesterday I dreamt of going to shut the curtains to get the sun off my face, only for the curtains to keep reopening - and then awoke to find the sun shining hotly on my head. Are we to believe that people who are depressed never suffer from harsh superegos, that they have not felt the need to suppress their id impulses for fear of their social unacceptability - for fear that love would be withdrawn or that they would go painfully unrecognised? Clearly, I believe, Beck would today be the last to deny that motivational dynamics such as these have any part to play in the psychogenesis or maintenance of psychological distress - whatever he might make of the value of psychoanalytic therapeutic technique.

It therefore remains a bit of a puzzle what we are to make of the birth of cognitive therapy out of his rejection of psychoanalytic therapy. I am however reminded of nothing more than the dramatic conversion experiences of rather literalist-minded devotees of a religion or of atheism into their opposite number. They always seem to be the ones with the dramatic backstory of 'I used to believe minus X but now I believe plus X'. We are supposed, it seems, to be more persuaded by the authenticity of their belief by the fact that they once held so closely to what is touted as its opposite. The real rhetorical effect, however, to my mind at least, is always to incline the reader to wonder whether the author had originally accumulated quite all the sensibilities necessary to fully grasp what was meant by X in the first place. If you start by thinking that unconscious self-hatred would invariably cause a sufferer (who is presumably a stranger to ambivalence, and hence a rather unlikely psychoanalytic subject) to be disappointed if they met with success in their life, it is perhaps no surprise that you end up a cognitive therapist...