Very unfortunate to see both psychoanalytic and CBT approaches being caricatured in this thread presumably by people who are not so familiar with one or the other.
Lets consider some of the stereotypes/myths described above in turn:
1. It is easy to learn CBT and anyone can do it.
This is partially true but a vast oversimplification. In the UK, they have "low intensity CBT therapists" now for many years who have little training and can effectively provided basic interventions for uncomplicated depression and anxiety. But how many patients (particularly seen by psychiatrists) have uncomplicated mood or anxiety disorders? It is well recognized that it takes a higher level of skill, training, and professional education to work effectively with patients with PTSD, other trauma related disorders, eating disorders, OCD, somatoform disorders, addictive disorders, psychosis and bipolar disorders. So yes, it has been demonstrated that not much training is required to deal with basic uncomplicated depression, panic disorder, and social anxiety disorder, there are many patients who need more skilled therapists.
We also know therapist effects are very relevant to effectiveness outcomes. For example in the TADS study for adolescent depression there were significant center effects for CBT with patients doing much worse at certain institutions than others even in the context of an RCT.
2. CBT is paint by numbers manualized therapy, while psychoanalytic therapies are not.
There are actually several psychoanalytically based interventions which are manualized including Dynamic Interpersonal Therapy, Panic-Focused Psychotherapy, and Luborsky's supportive psychotherapy based on the core conflictual relationship model (CCRM). Additionally, not all CBT interventions are heavily manualized. In fact the initial manual for cognitive therapy for depression by Beck et al (which was the first such) provided a lot of flexibility and was not very rigid in its application. Manuals were necessary to operationalize treatment to ensure fidelity and uniformity in clinical trials, but in practice experienced therapists will use manuals as a starting point and deviate as necessary.
3. CBT is boring.
This is partially true. Some patients can benefit from very simple behavioral interventions that do not take much skill or have much depth to them. However, patients with more complex presentations do have more depth and CBT provides a framework for understanding and formulating patients problems and working through them. Identifying problematic patterns of thinking, dysfunctional beliefs, and core beliefs can be very illuminated and "insight oriented" for patients. Similarly, identifying clinically relevants behaviors (CRBs) in session and working through such behaviors in sessions as they come up in the therapist-patient relationship is not dissimilar from mutative interpretations made in the transference affect. Good CBT therapists do not forget the role of emotion, and for more complex patients understanding the role of develop is very important in developing good formulations/conceptualizations to guide treatment.
There are a wide range of techniques and theories beyond classic CBT including using mindfulness, DBT techniques, ACT, compassion focused therapy, functional analytic psychotherapy, relational frame theory, and hypnosis. You can also bring in imagery, metaphors, and play with language in CBT based interventions. Put simply, when working with more complex patients, only boring uninspired therapists will find CBT boring or limited in its offerings.
4. Psychoanalytic approaches require years and multiple sessions per week unlike CBT.
While psychoanalysis is typically defined as 3-5 sessions per week and is of several years duration, many psychodynamic or psychoanalytic approaches can be weekly or twice weekly in duration. While many patients are treated over years, even Freud treated some patients in a single session. Intensive Short Term Dynamic Psychotherapy and Dynamic Interpersonal Psychotherapy are two such approaches and there are many other patients who benefit from short term dynamic oriented psychotherapy. Patients with more simple problems or a narrow goal or focus can be treated with a small number of sessions whereas where the focus becomes underlying personality structure, treatment will be of longer duration. Put simply, the more lofty or unfocused the goal of therapy is, the longer its duration regardless of modality.
Conversely, CBT approaches can be provided multiple times per week (for example cognitive processing therapy can be done daily and some people offer CBT intensives where they see patients for daily treatment). In addition, CBT for problems such as personality disorders is typically provided over years.
5. CBT is for patients with psychopathology whereas psychoanalytic approaches are meant for growth.
This is totally untrue. People can see either approach regardless of whether they have a psychopathological diagnosis or not and CBT techniques can be very helpful for personal improvement (e.g. developing negotiating skills, organizational skills, improving relationships, improving work habits, understanding thinking traps and core beliefs). Conversely, most people seeking psychoanalytic approaches have serious psychiatric disorders these days.
David Barlow had proposed that we distinguish between psychological treatments and psychotherapy. He regarded psychological treatments as psychological interventions targeting psychopathology or specific diagnoses, whereas psychotherapy was more focused on personal growth and problems of living. Nowhere did he suggest that one specific modality was better for for each despite his behaviorist inclinations.
6. Only patients with problems in living or simple neuroses undergo psychoanalysis.
While this may have been true in the mid-20th century, this has not been true for over 50 years. While the above might apply to those who are in psychoanalytic training doing their training analysis, the overwhelming majority of patients seeking psychoanalysis in the US today do so as a treatment of last resort. They tend to be patients with serious personality disorder, complex trauma history, borderline personality organization, narcissistic pathology, refractory depression, eating disorders, and severe relational disturbances. In the present era, few individuals have the money, time, or inclination to engage in psychoanalysis for their own personal curiosity or lofty goals of self understanding and improvement.
7. CBT and psychoanalytic approaches are diametrically opposed.
While there are some significant differences between the therapist stance, the structure of sessions, the focus, and the way cases are conceptualized, there are many similarities, and many patients benefit from approaches integrating the two (which commonly occurs in clinical practice). There are also several psychotherapies developed that do combine the approaches including cognitive analytic therapy (CAT), schema focused therapy, and functional analytic psychotherapy. acceptance and commitment therapy (ACT), while regarded as being as based on CBT is also recognized as not being wedded to CBT and is recognized as being easily integrated into a psychoanalytic framework.
8. Psychoanalytic approaches are not evidenced-based whereas CBT is evidence-based.
One of the reasons why CBT approaches were very successful was that Beck was persuaded by John Rush, who was his resident at the time to study cognitive therapy "like a drug" so he endeavored to use controlled studies and rating scales and manualize and operationalize the therapy. Of course, in the real world there is quite a lot of variation from this (for good and for ill) which means that the applicability of this evidence base to clinical practice becomes somewhat more limited. Psychoanalytic approaches started off published based on case histories, and while Freud himself was concerned they "lacked the serious stamp of science" it took many years to subvert the thinking that psychoanalytic approaches were some how impervious to being studied in a similar way to other clinical interventions with controlled trials. There are of course substantial limitations to such an approach, but it is not impossible.
In addition, while it is true that the evidence base for psychoanalysis itself is quite limited (see: de Maat S, de Jonghe F, de Kraker R, Leichsenring F, Abbass A, Luyten P, Barber JP, Rien Van, Dekker J. The current state of the empirical evidence for psychoanalysis: a meta-analytic approach. Harv Rev Psychiatry. 2013 May-Jun;21(3):107-37), there is considerable evidence for psychoanalytic psychotherapy and psychoanalytic-informed approaches which include mentalization based treatment, transference focused psychotherapy, dynamic interpersonal therapy, and panic-focused psychotherapy.
See:
Steinert C, Munder T, Rabung S, Hoyer J, Leichsenring F. Psychodynamic Therapy: As Efficacious as Other Empirically Supported Treatments? A Meta-Analysis Testing Equivalence of Outcomes. Am J Psychiatry. 2017 Oct 1;174(10):943-953
Milrod B, Leon AC, Busch F, Rudden M, Schwalberg M, Clarkin J, Aronson A, Singer M, Turchin W, Klass ET, Graf E, Teres JJ, Shear MK. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. Am J Psychiatry. 2007 Feb;164(2):265-72
Gerber AJ, Kocsis JH, Milrod BL, Roose SP, Barber JP, Thase ME, Perkins P, Leon AC. A quality-based review of randomized controlled trials of psychodynamic psychotherapy. Am J Psychiatry. 2011 Jan;168(1):19-28.
McCarthy KS, Chambless DL, Solomonov N, Milrod B, Barber JP. Twelve-Month Outcomes Following Successful Panic-Focused Psychodynamic Psychotherapy, Cognitive-Behavioral Therapy, or Applied Relaxation Training for Panic Disorder. J Clin Psychiatry. 2018 Sep 11;79(5):17m11807
Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA. 2008 Oct 1;300(13):1551-65.
Fonagy P, Lemma A, Target M, O'Keeffe S, Constantinou MP, Ventura Wurman T, Luyten P, Allison E, Roth A, Cape J, Pilling S. Dynamic interpersonal therapy for moderate to severe depression: a pilot randomized controlled and feasibility trial. Psychol Med. 2020 Apr;50(6):1010-1019
Bateman A, Constantinou MP, Fonagy P, Holzer S. Eight-year prospective follow-up of mentalization-based treatment versus structured clinical management for people with borderline personality disorder. Personal Disord. 2021 Jul;12(4):291-299.
Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009 Dec;166(12):1355-64.
Rost F, Luyten P, Fearon P, Fonagy P. Personality and outcome in individuals with treatment-resistant depression-Exploring differential treatment effects in the Tavistock Adult Depression Study (TADS). J Consult Clin Psychol. 2019 May;87(5):433-445.
Fonagy P, Rost F, Carlyle JA, McPherson S, Thomas R, Pasco Fearon RM, Goldberg D, Taylor D. Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS). World Psychiatry. 2015 Oct;14(3):312-21.
Doering S, Hörz S, Rentrop M, Fischer-Kern M, Schuster P, Benecke C, Buchheim A, Martius P, Buchheim P. Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. Br J Psychiatry. 2010 May;196(5):389-95.
