Re:Psychodynamic critique of CBT (especially transference)

Of course psychodynamic folks will criticize all sorts of things about CT. Sometimes the criticisms are based on true differences between the approaches. For example, psychodynamic therapists generally believe that one should resolve the "root causes" of problems and then the symptoms will go away. Cognitive-behavioral therapists generally argue that: (1) it can take a lot of time and money to resolve the "root causes," (2) resolving the "root causes" often fails to relieve the client's problems, (3) it makes more sense to deal directly with the client's problems and address the "root causes" only when this proves necessary, (4) the available evidence suggests that a symptom-focused approach usually is faster and more effective than treatments that focus on "root causes."

Other criticisms are based on an incomplete understanding of CT. The criticism that CT doesn't address the therapeutic relationship and fails to pay attention to transference is one of the criticisms which is based on a poor understanding of CT. There are a number of texts on CT which explicitly make the point that the client's interpersonal difficulties often are manifested within the therapeutic relationship. In discussing this the authors make several points: (1) when this occurs, the therapist needs to recognize what is happening and address it or else this is likely to interfer with therapy, (2) this presents an opportunity for the therapist to observe the client's interpersonal behavior and to develop a better understanding of the interpersonal problems the client experiences in real life, (3) it also presents an opportunity for the therapist to intervene in the moment (pinpointing automatic thoughts, identifying schemas, helping the client to try out more adapting interpersonal behavior, conducting behavioral experiments, etc.) rather that relying on the client's report of problems encountered outside of the therapy session.

It is true that the concept of transference isn't discussed a lot in CT texts but this isn't because we don't believe in the concept. We don't discuss it a lot because it doesn't happen in CT as much as it does in psychodynamic therapy. Why would that be? Well, why did Freud make a point of sitting out of the client's field of view and saying as little as possible? He was trying to be a "blank screen" so as to maximise transference. In CT the therapist is active and directive, speaks up, and is anything but a blank screen therefore we don't get as much transference and don't spend as much time discussing it. This doesn't mean we ignore it when it happens.

First, how can we understand transference in cognitive-behavioral terms? Why would a client sometimes react to me one the basis of their experiences in significant relationships rather reacting on the basis of their interactions with me? Well, imagine that you go to a party and meet a number of new people. One of the people you meet is a middle-aged, bald guy wearing a leisure suit and white shoes. What is your reaction to him based on? It isn't based on who he is, you don't know him yet. It is based on your preconceptions about middle-aged bald guys wearing out-of-style clothes which were pretty square when they were in style. He could be a perfectly fine guy with lousy taste or he could be on his way to a 70's costume party.

What does this have to do with transference. My point is that when you don't know someone well, your responses will be heavily influenced by your preconceptions. Where do these preconceptions come from? They come from previous experience. What experiences have the greatest impact? The experiences that came first, that went on the longest, and that were emotionally important (such as family of origin experiences). I'd agree with Freud that if I decide to sit back and be a blank screen, the client's responses will be strongly influenced by preconceptions based on the client's previous experience. I'd even agree that by spending some time sitting back and observing the client's behavior I could deduce quite a bit about their experience in their family of origin. Why don't I spend my time doing this in therapy? Because I can spend months analyzing transference to obtain this information or I can get the same information in 15 minutes by asking the client to tell me what their childhood was like and asking them to describe their parents.

When doing CT with straightforward Axis I problems, transference usually isn't much of an issue. it comes up much more when working with clients with personality disorders. Then the preconceptions are more strongly held and are manifested within therapy more frequently. When this happens, it is important for the Cognitive therapist to notice it and deal with it. Why? Well, imagine that I'm calmly reviewing the client's homework when they suddenly react as though I am angry and will punish them. If I don't address their reaction, it will have a big impact on the rest of the session. Does that mean we'll spend the session exploring their experience growing up with a critical, demanding parent? Not necessarily.

The way in which I handle it will depend on what stage we're at in therapy and what our goals are. If we're just getting started in therapy and the client isn't yet comfortable with me, an exploration of the dark side of their relationship with their parent may be too threatening for them. Or if the goals we're working on have nothing to do with dealing with critical, demanding authority figures, then these experiences may not be very relevant and we'll want to focus on something else. In either of these cases, we won't spend our time expolring their experiences with angry parents, I'll find out what their reaction was and clear it up by letting them know that I'm not angry and I'm not going to punish them.

However, if they are reasonably comfortable to me and their reaction is relevant to the goals we are working on (perhaps we're working to reduce their sensitivity to criticism or their fear of offending authority figures), then their reaction provides us with an opportunity to pinpoint automatic thoughts, identify schemas, experiment with more adaptive responses, etc. It's just that we'll address their experiences with angry authority figures in a focused, efficient way rather than spending months on it and, before we're done, I'll make sure that they realize that I'm not angry and won't punish them.

I've addressed these issues in print several places, but I thing that the most detailed discussion of these issues (without explicitly discussing transference) is in: Bedrosian, R. C. & Bozicas, G. D. (1994). Treating Family of Origin Problems: A Cognitive Approach. New York: Guilford.

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