Through an in-depth look at the inner workings of psychoanalysis, and a look into the logic of CBT, we are able to compare the two. While CBT will work for some with its more practical focus, others will benefit more from psychoanalysis’ deep look into the peculiarities of our psyches and the unconscious, writes Denise Cullington.

Based on his observations of himself, his dreams and impulses, and on his work with patients, Freud discovered a part of mind that was not available to logical scrutiny, it was the unconscious.

This includes what is less available because it stems from earliest experience, before there were words in which to ‘think’. But, Freud argued, the unconscious also stems from feelings which are shameful, conflictual – and we expend energy in pushing such disturbing feelings from our minds. We may experience anxieties and bodily symptoms, but we no longer know what it is that disturbs us.

Even when early experience is good enough, we are inevitably faced with conflict. We want to have our mother (or primary carer) all to ourselves. We are jealous when she pays attention elsewhere. We want to be ‘his Majesty the baby’. The one and only. Ways of managing such feelings can be by repressing them and by projecting them, seeing them in another, subtly nudging them and criticising them.

Even when early experience is good enough, we are inevitably faced with conflict.

An example of this is Freud’s Little Hans, a five year old boy who had suddenly acquired a fear of being bitten by a horse, having seen one in the street being beaten and falling down. Freud worked by speaking with the boy’s father. The little boy spoke of wishing to return to the summer, before his little sister had been born and, his father away, he had his mother all to himself. He wanted to be grown up like his father and be the one to give his mother babies, and he also wanted to be loved by his father and given babies by him.

Little Hans’ anxious fears of punishment for such wishes were made worse by the sight of his baby sister unclothed and the evidence that his penis might be lost. (And he had a dream of a plumber taking away the tap in the bath). The fact of the father acknowledging non-judgementally his wish to get him out of the way as well as his little sister, was relieving to Little Hans and his anxieties receded. His father was felt no longer as so dangerously ‘biting’.

Little Hans was a rival with his father – but he also loved him. At the same time he was a rival with his loved mother for the exclusive love of his father. This Oedipal conflict is painfully unwinnable. It is given an extra spin of anxiety with growing awareness of sexual difference, of who has what: if a penis, might his be lost? If not, has hers been lost? Does she have anything else of worth?

Based on external experiences, and also our own impulses and anxieties, we build a model of how we expect the world to be, an internal world.

Melanie Klein, through her work with young children, looked at the pains of this Oedipal dilemma at an earlier age, when object constancy has not yet been achieved and the infant (the one who we once were) feels himself to be in the presence sometimes of a loving and good experience, (as she describes it, a good breast). But in the absence of satisfaction, that experience suddenly is felt to be one of something hateful and bad; that bad breast is attacked in turn (with the baby’s shrill cries, his thrashing limbs and the wordless images in his mind) and is felt to become even more dreadful.

This extreme split, black and white, state of mind can be both exciting and terrifying. Recognising that the source of the relief and the frustration is the same figure, separate from us, our mother, then she has the desired goods, not us. A mother who we love and desperately need and at the same time who we hate and attack, not least when we recognise what is good and envied in her. (This extreme, split state of mind is alarmingly evident online and in much political discourse, ‘us’ v ‘them’.)

Other analysts investigated the help a parent offers a baby in being emotionally attuned to him, and the impact on him when she is less able to do so. Bion, working with psychotic patients, spoke of the state of mind of the infant in his panic and distress when he is not contained by a mother, who cannot recognise her baby’s alarm or feels overwhelmed by it. Then he is left alone to manage his feelings of panic and rage - whether they are felt to be in him or outside in others.

Winnicott, working also as a paediatrician with mothers and babies, spoke too of the mother’s capacity for ‘reverie’, and for her to be able to bear her hateful as well as loving feelings towards her baby, for his demands on her and for becoming separate from her.

Bowlby was one of the first to research the response of 18 month old babies left in a strange situation. The securely attached who could approach and protest to their mother, returning after a short absence, be reassured and play again separate from her, while some babies withdrew and avoided her; others clung and complained but could not leave; and others still were torn between approach and fearful avoidance. A parent, who had not been able to emotionally digest difficulties from their past, were less likely to be able to notice their child’s distress without becoming anxious or angry themselves.

Based on external experiences, and also our own impulses and anxieties, we build a model of how we expect the world to be, an internal world. So Little Hans’ view of his father was affected by his rivalrous and hateful impulses, as well as his love – and when they were brought out into the open, his world and his father suddenly seemed less alarming.

We bring these assumptions, expectations of others and subtle nudgings of them to be a certain way, in all our relationships including to a therapist, in the transference. And a therapist alert to this in his counter-transference, can find this a valuable source of information.

As a patient in treatment, we can want our therapist to endorse our view of the world, not disturb us or point out what might be going on with us that contributes to our difficulties. We may envy their capacity to notice things that we struggle to do. We may want them to be available and resent them taking time away from us, having a life of their own and maybe their pleasures and their relationships separate from us. We may retreat, make complaints, and if the therapist is alert to this negative transference, these hostile feelings alive and in the room, not only towards others ‘out there’, can be experienced and expressed in a powerful way. A therapist who has difficulties allowing himself to be the bad, hated one, can attempt to reassure and placate – leaving a patient fearing that his negative feelings are indeed too destructive and must be got rid of elsewhere.

An example is a patient in analysis, who had been adopted as an eleven month old, having had two foster mothers. I’ll call her Anita. She bitterly complained about her mother, who was useless and abusive – and sided with her father. It turned out that she gained some satisfaction depriving her mother (as she had felt herself deprived) – and when her mother reacted with fury, Anita was delighted. She was good and her adoptive mother the bad, unwanted one.

CBT is logical and rational, rather than directly attending to the emotions and impulses that may lay behind.

In her early analysis Anita felt understood and helped, like she was a good, wanted baby with a careful attending mother. But inevitably there were frustrations: there was evidence of her analyst having a life and relationships elsewhere; taking weekends and holidays. This left Anita feeling deprived – and enraged. She had phantasies of putting burning twigs through her analyst’s letter box, which she spoke of with a mixture of shame and glee. Her analyst being in any way understanding of her feelings was infuriating: Anita stopped paying her analytic bills. When, after several months, her analyst reduced some of her sessions until Anita began paying, she was outraged. This left her in the intolerable position of being in this way like her condemned adoptive mother. She could hold on to her outrage and sense of being justified, or she might begin to bear her need and her envy as a painful part of life – as is so for us all.

There is a notion that psychoanalysis is not scientific. But if scientific method is based on careful observation, hypothesis building, checking the evidence with an absolute preparedness to be disproved – and with further hypothesis generated as a result of the outcomes, then yes, psychoanalysis is scientific. And while early evidence was in single-case studies (and vital for all that), later techniques include meta-analysis of outcome studies, predictive developmental studies, and evidence from neurology, made possible by recent technology.

So, for example, Kahneman (2003) found two different systems of thought processing: one slow and logical (associated with the frontal lobes), the other rapid, and impulsive, associated with the limbic system and the more primitive brain stem. And ditto for memory (Kandel, 2006) and attention (Shevrin et al, 2003).

Analytic studies of the impact on patients with particular areas of brain injury, were consistent with the unconscious and repression (Kaplan-Solms & Solms, 2000).

Turning now to cognitive behaviour therapy (CBT): originally developed by Aaron Beck and Albert Ellis, both of whom had a psychoanalytic training and the experience of being in their own analysis, which would have been helpful in accessing their own difficulties and blind spots. They wanted to make the process more accessible and rapid.

They worked by asking a patient to monitor their internal dialogue, such as ‘if you don’t succeed in this then you are a total failure”; consider the evidence for such a negative view; and find other statements with which to replace them. CBT is logical and rational, rather than directly attending to the emotions and impulses that may lay behind. Therapists also notice where such self-statements originate and can pay attention to the past.

CBT has also developed other techniques such as mindfulness, helping a patient learn to focus awareness and try to calm the buzz of anxiety. Also in their umbrella of tools is EMDR (Eye movement desensitization and reprocessing) in the treatment of trauma.

In terms of what works, studies of CBT and psychoanalytic psychotherapy were both found helpful (and considerably more so than medication). But when CBT worked, a study of process notes found that what helped was not the focus on cognitive distortions, but more analytic ones such as looking at conflict, defences, emotional expression of feelings and exploration of past experiences with early caregivers, which predicted successful outcome, (summarised by Shedler, 2010).

Meta-analysis of outcome studies of psychoanalytically-based psychotherapy show consistently good results, not only in symptom relief but in being able to notice and manage feelings, and in relation to others, which are shown to increase over time (Shedler, 2010). And not only for the worried well, but for those with treatment-resistant depression (Taylor et al, 2012) and with borderline personality disorder (Bell, 2018).

Probably particular individuals are drawn to one training, one way of understanding the world. Just as some patients may prefer the more practical, and find the analytic focus on feelings (such as grief, guilt, and shame) too disturbing, while others can feel that they have been helped to understand themselves more at a deep level. There is no one right way.