Dr. Richards' timely article candidly shares his variegated reflections and thoughtful concerns surrounding the artistic and therapeutic human endeavor of psychoanalysis, which has remained under substantial, and often scathing, critical scrutiny (see Crews, 2017; Paris, 2019; and Skinner, 1956). I sincerely empathize with his professional angst and existential dismay, which blend into a poignant kaleidoscope of weighty questions and future uncertainties. That being said, if I claimed full identification with his sentiments, I would be misrepresenting my response, which is admittedly hindered by my own academic conditioning (or “upbringing,” for a linguistic aesthetic tailored to this journal) within the cognitive behavioral paradigm.
At present, cognitive behavioral therapy (CBT, itself a summary term for a specific assemblage of psychosocial interventions; see Hazlett-Stevens & Craske, 2002) is arguably, at least in name,1 the most widely accepted and firmly established applied clinical psychological framework in contemporary mental healthcare (Gaudiano, 2008; Norcross, Karpiak, & Santoro, 2005). Over the course of my professional development, I was told by certain clinical supervisors, occasionally in language bordering on the sanctimonious, that I was “one of the lucky ones” to have been raised in this rigorous tradition. I was led to believe that my CBT training has inoculated (indoctrinated?) me against the cardinal sins and innumerable risible faux pas of our more primitively misguided psychoanalytic past. I was taught, in so many words, that the field of clinical psychology is now enjoying a new dawn of scientific enlightenment, which will heretofore prevail with its incontestable scripture of RCTs, dismantling designs, and meta-analyses handed down by unassailable professorial pontiffs in lofty ivory towers. In summary, hallelujah, for I must be among the saved!
Such academic parenting was problematic in the sense of narrowing my conceptual visual field, most especially during my formative clinical
training years. But it was also a blessing in the sense of teaching me a highly useful set of interventions that can, and do, work much of the time when people struggling with mental illness consistently and independently practice those tools in their daily lives beyond the confines of the contemporary therapist's 50-minute hour. The CBT techniques I learned and continue to practice have been shown to assist with the alleviation of human suffering beyond the anecdotal.2 Specifically, CBT interventions are among the most heavily systematically researched (David, Cristea, & Hofmann, 2018) with repeatedly demonstrated efficacy (Hofmann et al., 2012) and effectiveness (e.g., Kodal et al., 2018; Lincoln et al., 2012). That being said, CBT is certainly not without its fair share of larger-scale shortcomings (e.g., dwindling effect sizes; see Johnsen & Friborg, 2015) and unpleasant negative side effects (Barlow, 2010; Schermuly-Haupt, Linden, & Rush, 2018).
Because Dr. Richards' article helped broaden my gaze beyond my own theoretical blinders, I hope to help return the favor, if only partially, by asking him to look beneath the linguistic vestments covering modern incarnations of psychotherapeutic theories and strategies. Is it possible that there may be more than meets the superficial eye? Although labels and manifest content have mutated across theoretical revisions, is it possible that some latent content lies dormant within the core professional beliefs and practices of modern-day CBT acolytes? Might contemplative Socratic aesthetics be at work coloring and shaping previous conceptual frameworks as opposed to innovating them from scratch?
From forced and free association to functional analysis. Functional analysis in CBT, which is frequently the initial therapeutic activity in tandem with goal formulation, involves a rigorous and reflective, yet in some ways uncensored (e.g., when documenting “automatic thoughts”), self-examination and person-centered psychological data collection process. Might this be viewed as a more Socratic reemergence of a hybrid of forced and free associative techniques?
From repression to avoidance, and other defense mechanisms. Can faint echoes of the psychoanalytic concept of repression be heard in the CBT clinician's incessantly repeated “emotional avoidance” mantra? And can elements of sublimation be found in CBT concepts like healthier forms of behavioral activation?
From unconscious conflicts to core beliefs and schemas. Is there any depth psychology lurking in the practice of the downward arrow technique of CBT, which purportedly cracks into one's innermost, and most often dysfunctional, “core beliefs” about the self, world, and future?
I will leave it to the reader to decide whether the abovementioned linkages seem credible or are better viewed as a product of my own conceptual overreach, perhaps reflective of my own wish fulfillment of an interdisciplinary rapprochement. If the former, perhaps Dr. Richards' concerns might find a modicum of relief in the prospect of conceptual theoretical reincarnation, albeit a fragmented one, and certainly not without its share of newly marked territories by dueling academic egos.
A sampling of self-reflective questions that come to mind after reading Dr. Richards' article include the following: Is Dr. Richards, in some respects, grieving a dying aesthetic, some of whose components are diffusely remanifesting elsewhere in subtle ways? To what extent do we habitually fall prey to perceiving our preferred theoretical orientation as a “monolith” (as Dr. Richards correctly points out psychoanalysis is not), thereby erroneously conceptualizing it as a unitary, unwavering Platonic essence3 inhabiting the clinical landscape? And if so, how might this facilitate projecting aspersions, praises, or even fear of crisis and loss onto emotionally-laden abstractions?
In a similar manner that André Green (1975) observed a complex series of historical shifts within the structure and scope of psychoanalytic theory and practice (e.g., from unconscious conflict to ego psychology, to object relations, and so forth), are we now witnessing a broader such shift across broader classes of psychotherapeutic symbolizations? And if so, are we lamenting the fading of more emotionally (and/or egoically) resonant, introjected clinical “objects” with a deep sense of personal loss and nostalgia? As practitioners from various traditions and backgrounds, will we be able to adopt Winnicott's nonintrusive strategy of tolerating the ambiguities, uncertainties, and discomforts of such ongoing changes across the theoretical and therapeutic landscape more broadly, as well as those manifesting more locally in the metaphorical “transitional space” of bidirectional communication between analyst and CBT clinician (as well as between practitioner and patient; see Green, 1975)?
In what ways do we inadvertently slip into a limbic us-versus-them mindset (typical of football teams and modern political parties) with reference to our favored therapeutic modalities such that any candid external scrutiny of a cherished assertion gets impulsively reframed as an ad hominem ego affront (de Dreu & van Knippenberg, 2005)? What are the long-term professional and interpersonal repercussions of such behaviors? To what extent can we embrace the “pleasures of pluralism” (Gould, 1997) of different approaches while tempering our appetite for variety and aesthetic richness with a healthy degree of humble deference to robust, consistently replicated research findings, even when such findings are inconveniently ego-rattling and feel anathema to our early academic conditioning? Are all components comprising favored theoretical and methodological frameworks in which we were intellectually raised and groomed equally indispensable and irreplaceable, especially given the byzantine economic realities of contemporary managed care? Or is there room for reasonable modification, and even pragmatic parsimony, where clinically sensible?
Perhaps a balanced approach lies in a cautious navigation between the Scylla of lockstep ideological introjection and the equally occupationally and cognitively hazardous Charybdis of freewheeling, “anything goes” psychotherapeutic relativism and constructivism. And perhaps along such a cognitively and emotionally balanced middle way also lies a responsibility to face difficult and nuanced questions about which intervention components work best for which psychological struggles, under which conditions, and for whom (Roth & Fonagy, 2005) as best as we are able to discern (fallible as such investigative endeavors will continue to be!), even if such components may not speak to us in as moving a manner as previous frameworks. What is most aesthetically pleasing may not always turn out to be the most practical and effective over time, although we may certainly craft new and stimulating aesthetics around (and find glimmers of previous aesthetics within) what holds therapeutic promise.
Joseph F. Meyer, Ph.D.
VA Boston Healthcare System
Harvard Medical School
I say “at least in name” here in full recognition that some clinicians may claim to practice CBT, but when pressed for details about what they actually do over the course of their services, may disclose practicing something a bit different (e.g., creative medleys of research-supported strategies spanning not only CBT but also acceptance and commitment, dialectical behavioral, interpersonal, and various other alphabet soup therapies, and in some ethically cringeworthy cases, casual conversation for hire masquerading as “psychotherapy”).
It should be acknowledged that the same is true for psychodynamic therapy (see, for example, Shedler, 2010).
Statistical and psychometric applications in psychology are rife with such modern-day Platonic essences, although rarely recognized or discussed as such, in the form of “true scores” in classical test theory and “latent variables” in factor analysis (see Borsboom and Zachar for rigorous scholarly engagements with similar metaphysically thorny issues; see also Dennett for a philosophical deconstruction of essentialist presuppositions).