An Eclectic Approach to Psychotherapy

Effective therapy requires a thoughtful application of many different but interrelated psychological theories and styles of therapy. The theories and styles I use primarily in my practice are psychodynamic therapy, Erikson’s stages of psychosocial development theory, and cognitive behavioral therapy. Each of these has a unique set of strengths which target different aspects and stages of therapeutic emotional healing and, when used together, provide a comprehensive framework for treating emotional trauma. This is the eclectic approach.

Psychodynamic therapy presumes the concept of the subconscious mind, an entity which stores impressions, memories, and subdued emotions which were unacknowledged upon their inception and so never fully understood or processed through. These dormant mental objects lay deep in the mind, affecting thought, emotion, behavior, and perception to such an extent that they shape our very reality. It is the purpose of psychodynamic therapy to bring these cumbersome mental objects into conscious awareness so that they may be understood, experienced, processed, and let go.

It is difficult to imagine the idea of subconscious thoughts and feelings existing without external, environmental stimuli to implant them. This is where the psychosocial stages of development and psychodynamic therapy intersect. According to Erikson’s psychosocial stages of development theory, childhood and adulthood can be partitioned into distinct stages of psychological development, each stage presenting a unique set of challenges stemming from the conflict between one’s physical and social environment and inherent predilections and limitations. Whether one fails or succeeds in overcoming these challenges determines the development of a particular characteristic which can be either harmful or beneficial, depending on which of these outcomes was attained. This outcome can be simply characterized as the presence or absence of a particular virtue. For instance, in the psychosocial stage of infancy, the infant’s inherent need for maternal affection and environmental security may conflict with the mother’s availability and emotional stability, creating a conflict which will ultimately determine the infant’s development of a sense of trust. Here, trust is the virtue to be attained through overcoming the presented challenge, whereas mistrust — or absence of trust — is the consequence of failure to meet this challenge.

Psychodynamic therapy, then, is a method for identifying the accumulated harmful characteristics (or lack of virtue) — and all of their associated harmful perceptions, thoughts, feelings, and behaviors — and linking them with their source: the ultimate failure to prevail over the challenges met with in any given developmental stage. Once this connection is made, understanding the relationship between the present absence of a given virtue (e.g. trust) and it’s harmful manifestations becomes possible, and once this understanding is achieved, this malignant lack of virtue may be corrected. In short, the application of psychodynamic therapy allows an individual who suffers a lack of necessary virtue to relive this virtue’s associated developmental stage, and so have a second chance at successfully attaining it, thus eliminating the psychological ailments to which it’s absence has given rise.

Psychodynamic therapy and Erikson’s stages of psychosocial development are thus complementary disciplines: though it is possible to consider them in isolation, it is far more fruitful to combine them into a single framework, drawing upon the general properties of each developmental stage to determine exactly which elements of the subconscious are causing which behaviors, and how to specify their historical root.

Cognitive behavioral therapy (CBT) is fundamentally different from psychodynamic therapy in its total rejection of the notion of subconscious mind. It focuses, not on subconscious mental processes and their manifestations as perception, feeling, thought, and behavior, but rather on specific problems associated with a particular mental state. While psychodynamic therapy is a theoretical approach to therapy, being focused on ideas, conceptions, and subjective narrative rather than direct observation, cognitive behavioral therapy deals instead with phenomena which can be directly seen and manipulated. As an example, consider the causal relationship between a doctor striking a child’s knee with a reflex hammer and the child’s lower leg jerking upwards — a relationship also known among psychologists as stimulus-response. CBT essentially aims to eradicate an unfavorable psycho-motor condition — such as anxiety attacks or a physical tic or twitch — by reconditioning the affected agent, presenting new stimulus-response relationships and instilling them through repetition. A patient suffering social anxiety, for instance, may be reconditioned by being placed in soothing, encouraging social environments repeatedly, consistently, and for a long span of time. Eventually, according to the basic tenets of CBT, the patient will cease to associate social interactions with fear and worry, having reassociated the relevant stimulus (in this case, social interaction) with a response more conducive to mental health (e.g. confidence and calm).

It is interesting to note here that, in the above case, while a cognitive behavioral therapist would simply work to establish a more beneficent stimulus-response relationship, thereby focusing only on observable manifestations of a mental illness (in the above example, anxiety), a psychodynamic therapist would identify the patient’s fear of social relationships and lack of interpersonal trust as consequences of his failure to conquer the challenges of certain of the developmental stages of early childhood, and so work to guide the patient to an acknowledgement and understanding of the connection between these early life failures and the errant cognitive-behavioral patterns which they have supposedly caused.

(Note: I use “supposedly” because all of these frameworks are only theories, inventions of the mind which may or may not correlate to the laws of objective reality. Hence, none of their conclusions may be said to be absolutely true, but only supposedly so.)

If CBT seems harshly scientific and observational compared to psychodynamic therapy, it is because it has its origins in rigid empiricism, a stark contrast to the philosophical introspection of psychodynamic theory. Behaviorism, as CBT’s scientific ancestor has come to be known, posited that behavior is solely a product of reflex (or immediate, automatic response), which itself may be conditioned by previously learned stimulus-response relationships and the circumstances of the current environment. Early behavioral scientists had no interest in determining the existence or effects of unseen cognitive processes, unconcerned with the role they played in the outward, observable behaviors which they made their primary focus. As the science progressed, interest spread beyond mere physical reflex to a deeper understanding of mental activity. Though this new strain of research explored processes previously ignored by behavioral scientists, it still restricted itself to investigations of reflex, this time focusing on how behaviors could be controlled and manipulated by applying carefully chosen stimuli consistently over a period of time. Consider a child who, upon being rewarded after completion of a given task, performs this task predictably upon request. These later investigations, though still grounded firmly in empiricism and concerned only with reflexive behavior, broadened the course of study by considering the intermediary effects of then invisible mental processes.

While the later experiments of behaviorism were a radical innovation compared to the stringent, low-concept observational limitations of early behaviorism, the investigations of a newer science, cognitive psychology, were even more so. Cognitive psychologists, rather than considering unseen mental processes as a mere intermediary in the study of reflexive behavior, chose them as their exclusive object of study. It is this seminal and unprecedentedly innovative science which gave us rigorous definitions of attention, memory, and perception, laying the path for the in-depth scientific study of immediately unobservable mental processes. In a sense, cognitive psychology combined the empirical, scientific methods of behaviorism with the abstract conceptualization of psychodynamic theory, giving birth to a science which used abstract models of cognition which could then be tested using the empirical methods of scientific research.

It was from these two eminent sciences that cognitive behavioral therapy was born, inheriting both their methods, concepts, and names. As a psychotherapeutic method, CBT is focused on symptoms, rather than causes: it emphasizes thought modification as a means to behavioral change. Harmful thought patterns and learned stimulus-response relationships are the primary targets of CBT — thus showing its roots in both cognitive psychology and behaviorism; but the initial causes of these thought patterns and their behavioral expressions go unaddressed. Contrast this with psychodynamic therapy, whose exclusive focus is the underlying causes of malign thoughts, perceptions, and behaviors: those murky memories and subdued emotions lying deep in the subconscious mind.

As a clinical psychologist with an eclectic approach to psychotherapy, I employ both psychodynamic and cognitive behavioral therapeutic methods, drawing on the conceptual framework of Erikson’s psychosocial stages of development theory to determine possible sources of a client’s present problems. Clients often do not realize that their present negative thoughts and behaviors are consequences of past traumas, and simply accept these burdens as inevitable.

When first beginning therapy, I seek to determine a client’s problematic thoughts by asking exploratory questions, guided by a strong intuition for spotting the subtlest emotional expression. If a question elicits a painful or conflicting emotion, I can then identify that question as an emotional trigger, and narrow my exploration by asking followup questions which are more narrowly targeted to the client’s unique personality, problems, and history, which I am able to ascertain with greater scope and precision as the process of therapy moves forth.

Once I have gathered this information, and so having gained a clearer view of the complex of emotional triggers which are more immediately responsible for clients’ problematic cognitive-behavioral patterns, I am able to establish a causal connection between them, demonstrating how strongly unresolved emotional conflict colors thoughts and behaviors of the present. This is a cognitive behavioral approach, as this stage of therapy involves identifying harmful thought and behavioral patterns and working to transform them into patterns which are of greater benefit to the client’s emotional health. This, however, is only the beginning.

Harmful thoughts and behaviors do not exist of themselves; they are consequences of damaging and inaccurate beliefs which we have internalized since childhood. You can see that this statement is taken directly from psychodynamic and Erikson’s stages of psychosocial development theory. CBT is only useful insofar as it reduces to a minimum the harmful thoughts and behaviors which cloud our judgement and keep us from seeing the roots of our current suffering. Beyond this we must, with our newfound clarity and insight, apply Erikson’s stages of psychosocial development theory to determine what exactly these roots are — specifically, which traumatic events in our past have created this accumulation of harmful cognitive-behavioral patterns which we have, through CBT, worked to alleviate and reduce — and psychodynamic therapy to understand that these roots are, rather than isolated events in our past, the very cause of our present suffering. It is the ideas underlying psychodynamic therapy which allow us to grasp the persistent, pervasive, and constantly accruing effects of early childhood trauma — which we identified using the tenets of Erikson’s stages of psychosocial development theory — and gain a conscious awareness of their causative relationship with the insidious cognitive-behavioral patterns we have internalized — from one source or another — since birth.

This understanding, though a crucial step on the path to freedom from emotional burden, is but a requisite for yet another: emotional processing of the traumatic event or events which we have identified as the root of our current suffering. This stage is both the most painful and the most enlightening, and as such is the stage where all guilt, shame, or sorrow associated with the original event— no longer trapped and internalized but set free — falls away. This newfound emotional awareness of what we have already intellectually grasped opens the possibility of a life with greater presence and awareness. No longer will past traumas be confused with present troubles; we will be able to process emotional stress as it arises, rather than allowing it to store and accumulate, clouding our thoughts, behaviors, and perception.

People with emotional trauma often dismiss the severity of their present emotions, not realizing that it is the confusion of these emotions with past trauma — not the present emotions themselves — which is the primary cause of their grief. Once thoughts and emotions arising in the present are untangled from traumas previously incurred, the accumulation of negative emotion ceases, and we can live clearly and peacefully, fully enjoying a present now unperturbed by the once tenacious sorrows of the past.