What are the differences between psychoanalysis,

psychodynamic therapy, and cognitive-behavioral therapy

(CBT)?
by Joe Cohen

Introduction
Psychoanalysis, psychodynamic therapy, and cognitive-behavioral therapy are all forms of talk therapy. In
the broadest terms, talk therapy is a psychological procedure by which a skilled practitioner uses
language and active listening skills to assist patients with their difficulties in living.

How language and listening affects us

Before addressing the differences in psychoanalysis, psychodynamic therapy, and cognitive-behavioral
therapy (CBT), we should consider just how important language is to humans. It sets us apart from all the
other animals on the planet.
Ever since we developed brains large enough to generate and learn language, we have experienced its
helpful as well as its hurtful effects. We symbolize our love with wedding vows; we symbolize our hatred
with epithets or declarations of war. We use language to communicate our thoughts and feelings to others
in conjunction with non-verbal signals; others can then use language and non-verbal signals to convey
the extent to which they have understood or misunderstood what we tried to communicate to them. We
need only think of how mothers and fathers try to grasp and interpret their infants' cries as requests for
food, a clean diaper, or a cuddle to appreciate that, from the start of our physical and psychological
development, we have a need for another person to understand and react to our mental state. A cry from
an infant can be thought of as a precursor to the three-year-old child's demand for a cookie just before
bedtime, or the 30-year-old adult's demand to have his ideas valued in the workplace.
The act of talking to a receptive and active listener can be helpful as we have all observed from
conversations with our open-minded friends and relatives. But talking to a listener hasn't always been
conceived of as a kind of medical or psychological treatment. That didn't happen until the early 20thcentury when Sigmund Freud created psychoanalysis. Nonetheless, human societies recognized a need
for an in-depth listener outside of the family. As an example, one can think of the Catholic confessional as
a type of talk therapy. There are of course many important differences between confessing and therapy,
especially that the therapist, unlike the priest, does not grant absolution or pass condemnation. A
therapist is not a representative for anything except therapeutic ideals: a therapist listens in a nonthreatening, non-judgmental, objective and value-free manner. His goal is to listen closely to his patient's
wishes and help increase the overall expansiveness with which his patient lives life.

How it began: Psychoanalysis gave birth to talk therapy

Talk therapy was formally invented by Sigmund Freud at the turn of the 20th century when he created
psychoanalysis, a psychological treatment and psychological framework that explains normal and
pathological thoughts, feelings, and behaviors. Psychoanalysis sought to treat and heal patients the

Victorians labeled as hysterics and obsessives -- perhaps in our modern times, we might just use the
words "neurotic", "depressed", "anxious", "attachment disordered" or "somatizing" to describe these types
of patients. Freud stumbled upon two crucially important aspects of human mentation.
1. One is the concept of psychic determinism. This means that all thoughts, feelings, and actions
arise from previous thoughts, feelings, and actions we've had and that have been recorded at
various topographic "layers" in our memory. An example of psychic determinism: a woman
inadvertently burns bread she's preparing for her family's dinner. Earlier in the day, she may have
had the brief but disturbing thought that she resented how lazy her husband is, how much
domestic work was expected of her despite the fact that they both work full-time jobs. It could be
said that her burning of the bread was psychically determined and symbolically represented her
anger and resentment towards her husband for hiding his laziness and ineptitude behind
stereotypical gender roles . Psychic determinism is responsible for many such Freudian slips.
2. The second and perhaps greater discovery made by Sigmund Freud was the existence of the
unconscious. This is the part of our mind that assists us in making dreams at nighttime, largely
determines our emotional states in relationships (especially with bosses, parents, lovers, and
children!), and can harbor ideas unknown to us that still have an impact on our mood. Because
conscious thought is such a powerful lived experience, it's hard for us to come to terms with how
little we know about ourselves and how much of our thought is buried beneath that lived
conscious experience. We think consciousness is 99% of our thought, but it is just the tip of a
very large iceberg, most of which is composed of the unconscious mind. An example of how the
unconscious can affect us is: a woman presents for treatment because she is unreasonably
jealous of her boyfriend. Whenever he spends time with his female friends, she becomes
obsessed with thoughts of how he is cheating on her with women she thinks are more desirable
than she is. After talking to the therapist, the woman begins to understand that she has some
sexual desires for women that she was unconscious of. Because these sexual wishes were
unacceptable to her, she used the defense mechanism of projection to deny them and attributed
them instead to her boyfriend (he becomes the desiring one, not her!). Rather than
acknowledging her same sex desire, she represses these wishes and developed a symptom of
pathological jealousy for her boyfriend. Once these repressed thoughts and feelings became less
threatening to her (the process is known as the unconscious becoming conscious), her symptom
of pathological jealousy vanished and her relationship with her boyfriend improved. She also
became more comfortable with the plasticity of her sexuality and fantasy life.

Psychodynamic therapy is an adaptation of psychoanalysis

For many years, psychoanalysis was the only talk therapy, but there were complaints that psychoanalysis
required too much time and was too expensive. Efforts were made to shoehorn psychoanalysis into a
more efficient and less costly therapy, which resulted in psychodynamic therapy. Psychodynamic therapy,
like psychoanalysis, relies on the basic concepts of psychic determinism and the unconscious. Session
frequency is capped at just one or two times per week unlike psychoanalysis. Psychoanalysis is still
practiced today, though it is less common for people outside of the mental health profession to
experience its salutary effects.

Research limitations of psychoanalysis & psychodynamic therapy

Psychoanalysis and psychodynamic therapy have been criticized by the medical research community
because they are not adaptable to an experimental research design that is the "gold standard" for

Western science. There are many papers written about this subject so I won't spend much time on the
issue here. Instead, I will try to make my point through an example and be as brief as possible.

Randomized, double-blind, placebo-controlled research design

When researchers want to test the efficacy of a treatment (let's say a pill for weight loss), the
experimental design they use is called a randomized, double-blind placebo-controlled experiment.
Randomized meaning that experimental subjects are randomly assigned into one of two groups, the
group that gets the weight loss pill and the group that gets the placebo. Double-blind meaning that neither
the subject nor the researcher knows whether the subject is receiving the actual weight loss pill or the
placebo. Control meaning that research subjects are similar enough to one another that the control group
(which receives the placebo) and the experimental group (which receives the actual weight loss pill) are,
in aggregate, identical populations of subjects.
The reasons that this type of experimental design is the "gold standard" of medical research is that it
minimizes any extraneous or confounding variables that could result in researchers over- or underestimating the actual effect the weight loss pill has on subjects. For example, as the researcher, you
would want to be sure that all your research subjects are eating the same number of calories and exerting
the same amount of energy over the period of your study so you are measuring the effect of the placebo
or weight loss pill, rather than studying the confounding effects of dieting and exercise. Furthermore, if a
different group of researchers re-created the experiment with the weight loss pill with subjects who were
similar to the original researcher's subjects, all other things being equal, it would be expected that the
original researcher's results would be repeatable. This is known as external validity and is the measure of
the degree to which an experiment's data can be re-created by other researchers using the same tools
and methods as the original researchers used, but with different subjects.
The problem with psychoanalytic treatment and psychodynamic therapy (and with all talk therapies for
that matter) is that there are many intervening and confounding variables that result in it being more
difficult to say with certainty whether a treatment was effective, why it was effective, and whether it is
repeatable with different subjects and therapists. The equivalent to the weight loss pill in talk therapy
could be an intervention by the therapist or the therapeutic relationship itself. Whereas a pill has no
subjectivity, no past of its own, none of its own feelings or quirks to pollute the results of the double-blind
trial, the therapist does. This is a threat to external validity because the therapeutic intervention in talk
therapy relies not just on what is said but also who is saying it. What if another therapist isn't as skillful as
the one in the experiment? The researchers in the weight loss example above have had their subjectivity,
which could unduly influence the data, controlled for by the stringent experimental design, the random
and double-blind assignment of subjects to control and experimental groups.
It has been very difficult to use randomized, double-blind, placebo-controlled experimental designs for talk
therapy research. For example, let's say you are researching whether talk therapy can help with
workplace distress and the therapist says to the research subject something like, "What comes to mind
about the words you used to describe your boss ('angry', 'controlling', 'vindictive')?" Suddenly, what is
therapeutic relies on an idiosyncratic human response that may open up a patient's experience to further
self-reflection. This is the threat to external validity. If we were the therapist, each of us might respond
differently depending on our unique personality, our past experiences with workplace distress, and our
theoretical orientations (for example, a humanistic therapist might respond to the patient by saying, "If I
were in your shoes, I would be angry as well.")

There are other issues with conducting research on psychotherapy outcomes. For example, there is the
issue of how to measure whether the verbal intervention has had an effect on a subject's mood, or
whether a life change (for example, let's say a subject wins the lottery or less dramatically, gets a new
and more lucrative job) has resulted in an increase in mood. This concept refers to internal validity, the
measure of how accurately an experiment actually measures what it intends to measure.
Finally, and perhaps most salient for psychoanalytic and psychodynamic therapists, there is the reliability
of a patient's self-reported mood. Reliability refers to the confidence one can have about the instrument
one is using to measure something. For example, when you measure water temperature, you can feel
confident that your thermometer is a reliable instrument. However, when you measure mood in
psychotherapy research, it is almost always based on either the subject's self-report or the therapist's
assessment of the subject's mood, both of which are questionably reliable instruments. We humans have
a particular talent for lying to ourselves and denying our feelings. Our conscious feeling states have a
tendency to obscure how we really feel. In an interview in Contemporary Psychoanalysis (2011) the
esteemed Lacanian analyst Bruce Fink said of psychotherapy research:
"I would suggest that psychoanalysis --genuine psychoanalysis--could survive only by refusing to
engage in such research. There is a movement afoot in the American psychoanalytic community to
attempt to reduce psychoanalytic practice to something that can be quantified so as to try to satisfy
the American demand for outcome studies....A certain number of analysts are preparing outcome
studies for psychoanalysis and psychodynamic therapy in Germany, the U.S., and elsewhere.
They implicitly assume that (1) the infinitely complex psychoanalytic process can be reduced to a
set of variables that can be easily explicated and quantified, and (2) that people consciously
know whether they have been helped or haven't been helped by a certain process. The
unconscious is immediately ruled out in the very construction of such studies because in most
outcome studies I've heard of, you give a survey to people or interview people about what they
believe has happened in their therapy. Freud indicates that a big transformation often takes place
over the course of the first few weeks for months after patients end psychoanalytic treatment...so
when should you administer outcome surveys or conduct interviews? If you do so at some
predetermined period while treatment is ongoing, you may end up catching people in the midst of a
negative transference [this means when the patient experiences the therapist as unhelpful or
menacing], leading them to give very negative responses, and yet that rough patch may have been
a very necessary step along the way to a successful outcome. There's no particular time of the
unconscious..." -- Bruce Fink

About Cognitive-behavioral therapy (CBT)

Despite the difficulty of adapting talk therapy to randomized, double-blind, placebo-controlled research
design, cognitive-behavioral therapy lends itself more to this design because it is more structured than
psychoanalysis and psychodynamic treatment and purportedly minimizes the threats to internal and
external validity by relying less on the therapist's unique personality and interventions and more on the
therapist's adherence to a treatment manual. Cognitive-behavioral therapy posits that changes in a
patient's conscious thinking can reduce or eliminate his negative feelings and behaviors. Patients tell the
therapist what their problems are and a problem list is made. To use an earlier example, the woman with
pathological jealousy might tell the CBT therapist her problem ("I'm afraid that my boyfriend is cheating on
me when he hangs out with his female friends, who I worry are sexier than I am.") and the therapist would
list that problem on a treatment plan as the troubling cognition/thought. Then, the therapist would
determine what feelings arise when the patient has this thought (for example, jealousy, depression,

anger, anxiety, remorse) and what behaviors the patient tends to engage in when she has the thought (for
example, drinking alcohol heavily, rummaging through her boyfriend's belongings looking for evidence of
his infidelity, etc.). The therapist would then try to reduce the symptom's destructiveness by identifying
other thoughts and behaviors the patient could engage in when she has the feelings of jealousy,
depression, anger, and anxiety. For example, the therapist suggests she could replace the pathological
thought with calming cognitions like ("My boyfriend loves me and has assured me he wouldn't cheat on
me."). Also, the therapist may assign the patient homework to brainstorm three alternate behaviors when
she is feelings jealous that may alleviate her negative feelings. The patient might return the following
week with this list and then start engaging in these new behaviors when she feels jealous: taking a walk,
calling a friend, or listening to relaxing music. The patient then rates on a scale of 0-10 how helpful it was
to engage in these therapeutic behaviors when distressing feelings arose in conjunction with her
problematic cognition, "I'm afraid that my boyfriend is cheating on me when he hangs out with his female
friends, who I worry are sexier than I am."

Limitations of cognitive-behavioral therapy

The crux of the patient's problems, in some therapists' opinion including mine, would not have been
addressed by cognitive-behavioral therapy because the patient's unconscious attraction to other women
has not been identified and analyzed. She would still unconsciously feel unreasonably guilty for her
normal sexual desires and seek to punish herself by engaging in risky, destructive behaviors. As long as
those ideas remains unconscious and unanalyzed, the patient will not be able to will away her
pathological jealousy with different thoughts. The same feelings and behaviors will still haunt the patient's
life or new symptoms will appear in the pathological jealousy's place. In fact, some psychodynamic
therapist and psychoanalysts would go so far as to say that if the patient were to improve in CBT, it's
partially out of a need to please the CBT therapist in the same way she sought to please her pushy,
narcissistic parents from childhood! As far-fetched as this might sound, patients are routinely focussed on
pleasing their therapists and waste no time in figuring out what makes their therapists happy, even if that
means that they are not making any therapeutic improvement themselves, still afraid of expressing their
true feelings (for example, their resentment at being asked to complete homework for their therapist).
There are dozens of other types of talk therapies, but most are built from core principles derived from
either or both cognitive-behavioral and psychodynamic therapies.