Psychoanalysis and CBT

The most vociferous criticism of cognitive behavioural therapy (CBT) in the British media has emerged from psychoanalysts and those sympathetic to psychoanalysis - and none has been more vocal than Darian Leader, a psychoanalyst and literary critic (the two tend to go together these days), who recently came out with a book called The New Black: Mourning, Melancholia and Depression, which he has been promoting by writing scathing articles about CBT.

This month, Leader was at it again, in a feature in the Guardian's G2, which labelled CBT a 'quick fix' for the soul, and asserted that it could never have the depth, honesty and psychological insight which psychoanalysis possesses.

Let's go through Leader's charges one by one, and see how they relate to psychoanalysis. As Jung wrote: "Our unwillingness to see our own faults and our projection of them onto others is the source of most quarrels...Projections change the world into the replica of one's own unknown face."

1) CBT is simplistic

Psychoanalysis asserts that all neuroses are the product of infantile sexual desires. It asserts that our infantile sexual desires are repressed by mysterious automatic and genetic biological mechanisms of repression, which render these infantile sexual desires completely inaccessible to the conscious mind. This despite the fact that taboos vary greatly from one culture to another, which suggests that at least some of our mechanisms of repression are culturally constructed and not biological.

Psychoanalysis asserts that chief among these unconscious infantile desires is the desire to sleep with one or other of our parents. This desire is, supposedly, completely inaccessible to our conscious mind, despite the existence of a whole genre of pornography show-casing MILFs (mothers I'd like to f*ck), not to mention the widespread proliferation of incest-themed porn. The popularity of this sort of porn would suggest that, actually, the desire to sleep with older mother-figures is not repressed from the conscious mind at all, but merely repressed from public view - which is a very different thing.

Still, Freud clung resolutely to the view that our neuroses came entirely from infantile sexual desires repressed in the unconscious, that were inaccessible to our conscious minds. This is the central orthodoxy of psychoanalysis.

The only person able to access these infantile sexual desires in our unconscious is the psychoanalyst, who delves into our unconscious through hypnosis, dream-interpretation, free association and other techniques.

However, the psychoanalyst will know before the patient even lies down on the couch what he or she will find in their particular unconscious: repressed sexual desires from infancy, directed against one or other of the parents. This was the case for all neuroses, and must be shown to be true, over and over. All empirical phenomena must fit the theory, rather than vice versa.

Thus all dream phenomena are interpreted as supporting Freudian orthodoxy. Going upstairs in a dream is a symbol of copulation. Women's hats can, in Freud's words, "very often be interpreted with certainty as a genital organ (usually a man's)", as can overcoats and ties, tools, weapons, all forms of luggage, some forms of relative (particularly sons, daughters and sisters), and eyes, noses, ears and mouths. Likewise clocks and watches. Tables and cupboards refer to female genitalia because of their lack of curves. Naturally more obvious phenomena, such as umbrellas, cigars, artichokes and snakes, refer to male genitalia.

Phobias and anxiety disorders are the product of repressed and unconscious sexual desires. Agoraphobia in women, for example, was the repressed desire to be a prostitute, because prostitutes lean out of windows and beckon to passers-by.

All art and literature can also be reduced to symbols of the same highly limited set of infantile sexual complexes - in particular the Oedipus complex. In fact, all of human culture comes down to the Oedipus Complex, and our inability to face the fact we want to sleep with our mother.

Freud's obsession with sex and incest as the cause of most human behaviour often led him to characterize physical symptoms, such as epilepsy or appendicitis, as hysterical symptoms of sexual repression, despite the fact his patients would occasionally die shortly after his treatment of what were, in retrospect, clearly physical illnesses.

For example, his colleague Wilhelm Fliess believed there was a mystic connection between the nose and the genitalia, and that nervous disorders caused by masturbation could be corrected with operations on the nose. He attempted one such operation, by putting a metal tube into the nose of one young lady, who he and Freud diagnosed as suffering from masturbation-related neurasthenia. The operation was not a success, and the patient haemmouraged, and almost bled to death. Freud concluded that this too was a hysterical symptom of the girl's repressed sexual desire for himself - she "bled for love" of him.

Far from being profound or multi-faceted, psychoanalysis is in fact incredibly, wearyingly, simplistic.

2) CBT is authoritarian 'brain-washing'

Freud wrote in 'The Psychotherapy of Hysteria' that "it is of use if we can guess the ways in which things are connected up and tell the patient before we have uncovered it". Since the truth will always out, there is no danger of false trails. "We need not be afraid, therefore, of telling the patient what we think his next connection of thought is going to be. It will do no harm."

In other words, because the empirical facts had to be made to fit the ideological theory, it was often necessary to suggest the 'right', that is, the psychoanalytic, interpretation to patients.

In the early stages of psychoanalysis, when Freud believed all neuroses came from the patient's sexual abuse as a child, that meant forcing the patient to accept that they had been sexually abused by one or both parents, even if they denied any such memory. "The principal point", he wrote, "is that I should guess the secret [of sexual abuse] and tell it to the patient straight out."

In one famous case, Freud treated an 18-year-old girl, 'Dora', who was suffering from catarrgh, stomach troubles and a dragging right-foot. These could have been caused by the appendicitis which Dora suffered from as a child, which in its pelvic form can lead to dragging feet. It could also have been a nervous reaction to the fact her father was trying to set her up with a much older man, with whose wife Dora's father was having an affair.

However, Freud dismissed the possible environmental or physical causes of the girl's distress, claiming both the present symptoms and the supposed appendicitis were both hysterical symptoms of the real cause - Dora was a bed-wetter and a masturbator. Her nervous cough, he insisted, was a symptom of a repressed desire for fellatio.

Janet Malcolm writes: [during the Dora case], Freud often conducted himself more like a police inspector interrogating a suspect than like a doctor helping a patient. 'Aha!' Freud would say to Dora, an attractive and intelligent 18-year-old girl suffering from a nervous cough, migraine, and a kind of general youthful malaise. 'Aha! I know about you. I know your dirty little secrets. Admit that you were secretly attracted to Herr K. Admit that you masturbated when you were five. Look at what you're doing now as you lie there playing with your reticule - opening it, putting a finger into it, shutting it again!'

Either the patient signed up to a confessional which supported Freud's psychoanalytic ideology, or, if they declined to pay any more to listen to this guff, then they were 'in denial'.

The same went for followers of Freud. Either they signed up to the one true ideology of psychoanalysis, or if they criticized it then they were demonized as deviants, perverts and maniacs. Adler, for example, was characterized by Freud as "an abnormal individual, driven mad by ambition...his influence on others depending on his strong terrorism and Sadismus".

Jung likewise, when he broke with Freud's theories, was denounced as being "crazy" and "out of his wits", and even of suffering from "anal erotism". As Jung noted, "Anything which might make them think is written off as a complex...This protective function of [psychoanalysis] badly needs unmasking."

3) CBT is consumerist and market-driven

Psychoanalysis holds that the only way for a person with mental health problems to return to health is to undergo months or, more likely, years of one-on-one psychoanalysis at the hands of a psychoanalyst. Self-analysis is impossible - Freud alone was capable of this superhuman feat. Only those trained in Freud's theories and given his blessing were, supposedly, capable of understanding the unconscious' riddles (which always referred to infantile sexuality). The patient was therefore totally dependent on the psychoanalyst to guide them back to something resembling health.

As some of Freud's followers observed, this created a big temptation for the analyst to continue analysis for as long as possible, in order to get as much money as possible. Sandor Ferenczi, one of Freud's earliest and closest followers, wrote of the danger of psychoanalysts having "no concern for how long the analysis lasts, in fact the tendency to prolong it for purely financial reasons; in this way, if the analyst wishes, the patient is made into a lifelong taxpayer."

The danger is particularly acute because the patient is in such an unprivileged position versus the therapist - only the therapist understands the patient's unconscious, only the therapist knows how much progress the patient is making, or how long the 'cure' may take.

We note, in passing, one particularly outrageous incident in the 1920s, when an American psychoanalyst, one Horace Frink, was having an affair with a patient of his, the bank heiress Angelika Bijur. Rather than telling him to break off the affair, as ethics would suggest, Freud told Frink he was a borderline homosexual and should divorce his wife and marry Bijur immediately.

As Frederick Crews wrote in the New York Review of Books: "Freud's transparent aim was to get his own hands on some of the heiress Bijur's money. As he brazenly if perhaps semifacetiously wrote to Frink in steering him toward divorce and remarriage to Bijur, 'Your complaint that you cannot grasp your homosexuality implies that you are not yet aware of your phantasy of making me a rich man. If matters turn out all right let us change this imaginary gift into a real contribution to the Psychoanalytic Funds.'"

CBT, by contrast, is far more DIY. Indeed, it allows what psychoanalysis never allowed - that people could recover from emotional disorders through their own effort, without ever seeing a therapist. They could learn the basic techniques of CBT via tape courses, podcasts, the internet, books, or self-run support groups. This is how I overcame social anxiety - through a tape course which I downloaded for free through the net, and through a support group which I attended, which was also free.

So, in a way, psychoanalysis and CBT are both market-driven, but they are driven by different models of the market. In one, you have to buy your self-respect back from the monolithic corporation of psychoanalysis. In the other, the market is disintermediated (ie the middle man is rendered unnecessary) and, in an ebay or Napster version of the market, people access for free the information they need to make themselves better. It is DIY therapy.

4) CBT peddles rose-tinted, vacuous positivity

Freud wrote of depression in Mourning and Melancholia:

"The patient represents his ego to us as worthless, incapable of any achievement and morally despicable; he reproaches himself, villifies himself and expects to be cast out and punished...It would be equally fruitless from a scientific and therapeutic point of view to contradict a patient who brings these charges against his ego. He must surely be right in some way...Indeed, we must at once confirm some of his statements without reservation. He really is as lacking in interest and as incapable of love as he says...It is merely that he has a keener eye for the truth than other people who are not melancholic."

Freud's disciple, Darian Leader, has just such a rosy view of human nature, declaring that "the very core of the self" was "self-sabotage, masochism, and despair".

As many critics have noted, the view of human nature which Freud was putting forward was little different from that put forward by Saint Augustine in the fifth century - we are born tainted with original sin, with the win of our violent and perverse infantile sexual desires. There is no escaping from them, we can only confess them to our psycho-analyst-confessor, and try to suppress them with our reason and morality. It is a deeply Judeo-Christian vision of humanity, and a deeply pessimistic vision, a Medieval vision.

By contrast, CBT emerges from a Hellenistic vision of humanity. The main influence for Albert Ellis' ideas was Stoic philosophy. Tim Beck likewise tells me that the inspiration for the 'Socratic technique' that is at the heart of CBT is from Greek philosophy.

He told me: "I came across the notion of Socratic Dialogue when I read about it in my college philosophy course – I believe it was in Plato’s Republic. I also was influenced by the Stoic philosophers who stated that it was a meaning of events rather than the events themselves that affected people. When this was articulated by Ellis, everything clicked into place."

Socrates, and the Stoics, Platonists and Aristotelians after him, put forward a radical view of mankind, that humans were blessed with divine reason, and that this made them capable of self-knowledge. They could - possibly with the help of a philosopher-mentor, but also on their own - analyze their thoughts and beliefs, challenge them, test their consistency and strength, and if they proved to be irrational or illogical, then replace them with wiser or more rational beliefs.

The Greeks believed there was nothing inherently 'sinful' about the self. It could certainly be stupid, irrational and self-destructive. Indeed, the Stoics believed that, in the words of Albert Ellis, '99% of the world are out of their fucking minds". But the potential for emancipation through reason and self-knowledge is almost always there.

I sign up to this vision of humanity. I am aware, from my own life, how difficult it is to change our mental habits, how much struggle and suffering is involved, how great are the barriers to self-knowledge. But I have also had direct experience that the mind does respond to rational self-inquiry, that some progress in self-knowledge is possible, that we can free ourselves from some of the torture chambers we have invented for ourselves.

This isn't a vacuous or facetious view of existence. It's the basis of western civilization, and a much sounder basis than the 15 or so very dodgy case studies on which Freud constructed his great edifice of pessimism and gloom.