One of the most encouraged criticisms from psychoanalysis towards Cognitive Behavioral Therapy (TCC) claims that our treatments are superficial. Nothing more wrong than that. In other articles we have already highlighted that the evaluation of the past does not guarantee the resolution of current problems and that, conversely, many present difficulties are resolved without the need to investigate the past. In any case, reviewing events that occurred a long time ago can be useful in some cases, especially chronic or long-term ones. In short, CBT does not a priori disregard the importance of historical episodes, but rather they are examined with a specific operational objective, namely: the identification of variables that allow the modification of the behavior that generates discomfort in the patient today.
In this article we respond to the criticism made, mentioning some of the many interventions that the cognitive behavioral therapist can carry out for the purposes of a detailed evaluation of the patient’s clinical history.
1. CBT and the investigation of the patient’s past
In the criticism of superficiality formulated against CBT, it is usually highlighted that other therapeutic styles, particularly those with a psychoanalytic orientation, resort to supposed past causes of the symptoms while we deal with solving problems “here and now” without mentioning variables. historical. This is definitely a gross mistake.
At CBT we do not blindly discard the historical variables related to the discomfort that afflicts the patient; furthermore, in many cases we carry out a thorough analysis of them, even interviewing significant people who can provide us with data from the past. The difference with respect to psychoanalytic approaches is that the investigation of history is carried out with the aim of improving our understanding of the current situation and, along with this, expanding our ability to intervene effectively. Let’s illustrate it with some examples:
- Some adult patients with Social phobia They fear being rejected and mocked in public. When we investigate this fear more closely, memories of the adolescent stage emerge, traumatic episodes during which the person was the object of ridicule and humiliation by his or her peers or even by school authorities. Some beliefs about how others behave socially have taken root there. Of course, the social practices of adulthood are very different from those of adolescence. Cognitive restructuring in such cases must take into account the historical origins of irrational beliefs and put them in the perspective of social and cultural maturation, providing adequate psychoeducation that the patient can corroborate by his or her own means.
- When a compulsive gambler If you have been cured of your addiction, changes will occur in your deepest thoughts and patterns. The person, for example, will begin to consider that there are more important goals in his life than earning excessive amounts of money, thus valuing other areas of experience. After the behavioral change, the patient usually realizes the dysfunctional beliefs of his past, such as “if I have money I will be accepted by others.”
The aforementioned case of social phobia shows an example where it is necessary to modify current beliefs based on the story and analysis of automatic thoughts associated with past episodes. The compulsive gambler patient represents a characteristic change of schemas rooted in past experiences based on a current behavioral change.
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In CBT we do not blindly discard the historical variables related to the discomfort that afflicts the patient.
Due to the relevance that CBT gives to working on the patient’s history, specific techniques have even been developed. For example, restructuring early memories, proposed by Judith Beck, would be applied in cases such as the aforementioned social phobia. Another prototypical procedure consists of the construction of the subject’s medical history and of the timeline of a specific problem, which aims to evaluate points such as the beginning of the pathology, its course, relapses and remissions. In chronic conditions such as bipolar disorders, schizophrenia eithermajor depressions Such approaches cannot be omitted.
2. CBT and the unique aspects of personality
It is often believed that other therapeutic approaches address the “totality” of the person’s life while in CBT we only deal with “superficial” aspects. We believe that this statement contains at least two criticisms. First, in CBT we deal only with one issue, that which is explicitly expressed by the patient in the first instance as a reason for consultation and that we will remain encapsulated in it without investigating other potentially problematic areas. Second, in CBT we only dedicate ourselves to specific and limited problems, easily definable based on discrete stimuli. Let us discuss these two issues separately.
Truly, the first part of the criticism is answered just by observing everyday clinical practice in CBT. Not only can you, but you must address several problems with the same person. Almost one would say that there is no such thing as a “monosymptomatic” patient, but on the contrary, in all cases, once one issue has been worked on, others immediately arise. Thus, a patient with Obsessive Compulsive Disorder cured of your compulsions, you may need to work on modifying the obsessive style of your thinking. Or perhaps, if you have distorted beliefs about fatal consequences that may occur in the future, we will apply the technique “probability analysis”, which allows changing thought patterns such as “it may happen that in the future it will happen that…”. Such a catastrophic style of thinking could have originated in childhood family models, a fact that will be taken into account during the approach.
¨Almost one would say that there is no such thing as a “monosymptomatic” patient.
The second part of the criticism argues that CBT does not respond well to problems that are presented as diffuse, not very concrete and frequently related to life crises, usually called “existential”. Some examples are reconsiderations that a person formulates about the meaning of your life, your relationship either your sexual orientation. This is, once again, a gross error. CBT works on such problems although in a very different way from other therapies.
As already said, we start from the basic and rational idea that many patients are afflicted by multiple problems and not only by their initial reason for consultation. The criticism leveled by psychoanalysts states that investigating aspects other than the initial and explicit reason for consultation is not easy and that it requires many months (even years) until the patient is prepared to identify and talk about such “deep” topics.
From the scientific perspective in psychotherapy, there is NO evidence of this; On the contrary, the vast majority of patients are from the very beginning open and willing to reveal intimate information, such as details about their sexuality, unresolved inferiority complexes, infidelities, mistakes made long ago, etc. Of course, this is facilitated because a well-trained cognitive behavioral psychologist has communication skills to carry out adequate management of the therapeutic relationship and empathy.
3. Multimodal evaluation of the subject: The 7 levels of behavior analysis
To represent how CBT addresses the diversity of aspects of the human being, it is enough to remember the multimodal evaluation proposed by Arnold Lazarus, called BASIC-ID. The acronym includes the following elements to be considered in a complete treatment: (B) behaviors, (A) affect or emotions, (S) physiological sensations, (I) mental images, (C) cognitions -thoughts and beliefs-, (I) interpersonal relationships and (B) biological bases of behavior. Note the number and complexity of areas that are taken into account in CBT. Likewise, Lazarus emphasizes the detailed construction of the clinical history for which he has designed an instrument called “Multimodal Life History Questionnaire”in which the person is asked to describe family conflicts, relationship characteristics, sexual relationships, among other events from their childhood and adolescence.
Lazarus’ multimodal model reflects the richness of variables analyzed by the cognitive-behavioral therapist
Although CBT is intended to be a focused treatment, this does not prevent the therapist from carrying out a broad screening of potentially problematic areas and, if he finds one that is dysfunctional, from proposing to his patient a further analysis of it for later approach. As an example, if during the construction of the clinical history, the cognitive-behavioral psychologist detects that the patient has doubts about her sexual orientation, she can and should propose to work on this problem.
Lazarus’ multimodal model reflects the richness of variables that the cognitive-behavioral therapist analyzes during the evaluation and conceptualization of the case. This model refutes the idea that CBT is superficial and only takes into account the “immediate and obviously observable.”
4. The cognitive-behavioral therapist is not naive
Sometimes we come across patients who simply lie, hide or distort information. We are fully aware of this and we give it such importance that specific procedures have been designed for such eventualities.
Through specialized psychometric techniques, interviews with third parties, detailed recording of information; Psychologists can identify the contradictions inherent in each case. An attentive therapist will convey such inconsistencies to the patient and will try to investigate the causes of them. They may later be included as part of the therapeutic work agenda.
When faced with a married man who suffers from sexual problems with his wife, the psychologist should investigate whether the patient hides relevant data, either out of shame or fear of being judged negatively by the professional.
The psychologist must investigate whether the patient is hiding relevant data
CBT has specific interview techniques to overcome such barriers. In the present example, the interview with third parties (the patient’s wife) is revealed to be a very valuable procedure. If the patient refuses this, this oppositional behavior is also evaluated and considered by the professional as a possible indicator of concealment.
Needless to say, in addictions, personality disorders, psychopathy and various other disorders in which cognitive mechanisms of…