So here you are, looking for someone to talk to because, well, doing it all on your own just doesn’t work any more. Or perhaps it has never quite worked, but now you are ready to take that step to see someone who is not a friend, not family. A ‘professional’. A stranger. It can be a little daunting, to put it mildly.
For those seeking psychological health or happiness, or even just a bit of relief, a space to pause and breathe, a chance to get in touch with themselves, there are plenty of options out there. In fact, there are so many options within the field of talking therapies that even the practitioners offering these options struggle to explain the difference between some of them. The end result is that many of those seeking help end up with someone more or less by chance, and it may take months or years of attending sessions for you to discover whether the background, approach and style of this particular professional works for you, or not.
There are some general differences, though, that are useful to be aware of:
Cognitive Behavioural Therapy (CBT)
Within the NHS, a small number of CBT sessions is what you are most likely to be offered, with a chance of another cycle at a later point. For years now, CBT has been promoted aggressively as the cheapest and most effective form of treatment for a number of conditions, such as phobias and depression. Lately, the available evidence has come under a much more critical light. This Guardian article does an excellent job at summing up these developments. More on the effectiveness of CBT versus psychotherapy here.
From a client’s perspective, you can expect sessions that are very structured. CBT is a manualised therapy, a kind of step-by-step programme to follow. You will be given homework and monitor progress on your efforts to change behaviour. For some people this works, at least for a while. For some it is all they want, at least for now. Others perceive it as an insult to their intelligence and the complexity of their minds. The fact that CBT-based forms of therapy are now offered online – i.e. you are talking to a computer programme rather than a real person – says a lot about how the proponents of CBT think about how human beings function. If you do see a therapist in person, the focus will be on your irrational thoughts and behaviour. There will not be a lot of talking about your past, and you will probably get some tools to cope better in difficult situations. There is neither the time nor the space to understand and engage with the root causes of your difficulties. The idea is, basically, that with a little bit of willpower you will be able to change the way you feel and behave, no matter how long you have been feeling and behaving like that, and no matter, why.
It is perhaps no surprise that many people who have tried CBT end up looking for something different, something deeper, something longer lasting and more suited to their individual experience.
Counselling is a broad field. Some counsellors have very little training and almost no experience of counselling themselves, some are great at what they do, and some are actually trained psychotherapists offering “counselling” because some people prefer the idea of seeing a “counsellor” rather than a “psychotherapist” (for much the same reason they prefer thinking of themselves as “clients” rather than “patients“). Counsellors will generally have had a shorter and less intense training than psychotherapists or psychoanalysts. Some rely on one particular model or approach (e.g. person-centred, humanistic, Gestalt etc.) for every client that walks through their door, others work in an integrative way. Many are more “chatty” and involved than psychotherapists would allow themselves to be. Sessions are usually once a week or less frequently.
Psychoanalytic (or psychodynamic) therapy comes out of the psychoanalytic tradition as founded by Sigmund Freud more than a century ago. Freud has had many colleagues and followers, some of whom have questioned, developed and added to his ideas. Soon the field of psychoanalysis fragmented into a number of different schools, including Jungian (following C. G. Jung, called Analytical Psychology), Object Relations or Kleinian (following Melanie Klein, the school dominant in the UK), and Lacanian (following the French psychoanalyst Jacques Lacan). There is an independent tradition, ego psychology, self psychology, attachment theory and so on. They all work from the position that people are not always rational, and that much of what we feel, think and do is driven by unconscious processes. Without becoming aware of them and working through them we cannot change in a fundamental way. Psychoanalytic therapists tend so see patients once or twice a week in either time-limited or open-ended work.
The term “therapy” is an interesting one and worth thinking about for a moment. It implies that something is “wrong” and needs to be put “right”, that a patient who feels bad ought to feel better, happier and so on. The therapist is someone who helps you along this journey. Unlike with manualised therapies there is no step-by-step programme to follow. Sessions are unstructured, i.e. what you talk about is entirely your choice. You will not get homework and there is no expectation on you to do anything in order to be “a good patient”. It is a space to talk. Your therapist helps you understand what is going on in your unconscious and how this impacts on your daily life.
By getting to know yourself better, and by using the relationship with your therapist as a kind of laboratory for relating to other people, you may find that you gradually feel less controlled by your symptoms, that they may even disappear completely, and that you are better able to cope with a whole range of other situations that life throws at you. Psychotherapy takes time (months or even years) because it acknowledges that problems we have developed over a lifetime cannot be solved over night, that change at a fundamental level of our personality cannot be forced or rushed. The pace is different for everyone. You may not want to stop talking in the beginning, or you may find no words at all to describe how you feel for a long time. A psychoanalytic psychotherapist will listen to you, explore your thoughts and feelings with you, sometimes challenge you, but will not tell you what to do.
There is an important difference between psychoanalytic psychotherapists, psychoanalysts and Jungian analysts on the one hand, and counsellors and clincial psychologists on the other. This difference refers to the time the practitioner her- or himself has spent in psychotherapy or analysis. In other words: the amount of work the person you are about to trust with your innermost thoughts has done on themselves, on their own issues and problems. Because we all have some. The last thing you want as a patient is a “professional” who starts reacting to you like a family member, who gets caught up in his own internal world without even realising what is happening. This is more common than you may think, and it does not happen with bad intent. It happens, almost inevitably so, when those trying to help others have not done enough work on themselves to be able to distinguish between what is theirs and what is yours. There are, as always, individual exceptions to this, so it is worth asking the question when you first meet someone you think of working with.
Psychoanalytic therapists and analysts have had to undergo many years of intense personal therapy as part of their training, and the self-awareness gained through this is perhaps their most important professional tool. One could go as far as saying that you are paying a therapist not for her theoretical knowledge, but for her ability to be present – really present – with and for you because she has worked on her own issues elsewhere. The fact that this is by no means common in the mental health field is alarming. This is where harm gets done.
There exists a perception that psychoanalysis is just another name for an orthodox Freudian analysis where the patient lies on a couch behind which sits a stern and bearded analyst who refuses to answer questions, stays mostly silent and, occasionally, offers an “interpretation” of what is (supposedly) really going on. The added benefit is that if you disagree with his words of wisdom, you are being “resistant” to treatment, something to work on in further treatment, of course. Excuse the sarcasm. While there are still some people working this way, this is not what modern psychoanalysis is about.
But what is it about?
Now we are entering political territory. Is there a difference between therapy and analysis?
In practice, many psychoanalysts practice psychoanalytic psychotherapy, and many psychoanalytic psychotherapists practise psychoanalysis. Some people draw the line between the two at the number of sessions a week (e.g. 3+ sessions, ideally using a couch = psychoanalysis, 1 or 2 sessions = psychotherapy). It is true that a higher frequency of sessions usually deepens the work, but there is no guarantee for that. And in turn, deep and meaningful work can be done at one ore two session per week. Making this largely artificial distinction has had political reasons within the profession that have more to do with status, income, and power than with (the slight) differences in training, or, indeed, the actual work with patients.
If one wants to differentiate between psychotherapy and psychoanalysis in a more meaningful way, then there is a different take on this contentious question. It has nothing to do with counting sessions, or the use of a couch, or with sessions being exactly 50 minutes long, and so on. It has something to do with what the analyst thinks she is doing; with her aim, with the position she takes up in the room with you.
If happiness is what you want, then who defines what happiness is? Should life be without negative feelings, or is there a place for them? Is getting rid of depression, for example, the same as “getting better”, in each and every case? There are many depressed creative people who feel extremely ambivalent about getting rid of their dark moods for fear of losing their creativity. Who, then, is the judge on what “getting better” means? And what do we do with the fact that so many of us have such great trouble changing the way we are, even when we, perhaps after years of counselling, know exactly what we would need to do to finally “get better”?
It seems that, after all, the business of being happy and getting better is more complex than it would seem at first sight. Psychoanalysis acknowledges this. It makes space for it, it takes it seriously, it takes you seriously, including your puzzling contradictions and inconsistencies.
While psychotherapy is primarily concerned with making people ‘better’, psychoanalysis is concerned with analysis. With digging deeper, with getting to the bottom of things, with understanding, with new and different emotional experiences, with finding words for feelings and, most importantly, with having a protected space to feel and think. In the process of all of this profound things can happen, and they may well be therapeutic for you. But changing you is not what the analyst sets out to do. The analyst is focussed on helping you getting to know yourself. What you do with that knowledge is up to you. To come back to the depressed artist, psychotherapy may try to get you to the point of ‘no depression’. Psychoanalysis tries to get you to a point where you have obtained the mental freedom to choose what to do with the self-knowledge you have gained, and if this choice means finding a way to coexist with depression in order to be creative, then so be it.
A final word on all of this: categories are categories, and they call for generalisations. The differences between individual practitioners, even when they cary the same ‘job title’, are tremendous. And so are the consequences for the way they work. If you think that these differences matter to you, do not be afraid to ask questions when you are choosing that someone to talk to that you are looking for.