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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 36 to 60 of 93. Go back in thread:
Posted by Dinah on December 27, 2003, at 21:47:52
In reply to Re: CBT or psychodynamic?...how do you know, posted by Speaker on December 27, 2003, at 16:33:55
I didn't have the knowledge to ask when I started with my therapist. But if I (gasp!) had to start over, I would ask straight out about their orientation, their familiarity with dealing with my problem, and how long their therapy usually lasted. Along with a host of other annoying questions.
But I'm not sure how clear an answer you'll get. I think my therapist would say something about providing a corrective emotional experience. Which is more or less what I described. He would provide a different response than I was used to getting, do it consistently, and thus change my expectations of the world around me. The main one being that he is there week after week, relatively consistent. And he'd also probably use some attachment terms, providing a secure base or something. But he'd probably say it so obscurely that I wouldn't have the slightest idea what he was talking about. And if I had asked him in the intial interview he would have had something completely different to say, because he didn't yet know me and my needs.
But that doesn't mean that you shouldn't ask. :)
Posted by LostGirl on December 27, 2003, at 22:22:52
In reply to Therapist Orientation? CBT or psychodynamic?, posted by mattdds on December 26, 2003, at 1:52:24
Psychodynamic, once a week.
Wouldn't even know where to find a behavioral one. I feel behavioral isn't deep enough, although you can't get very deep with once a week in any kind of therapy. But I am still wounded from a bad ending in rather deep psychodynamic therapy. I never want that kind of attachment again (whether or not we call it transference).
Posted by gardenergirl on December 28, 2003, at 0:01:55
In reply to Re: Therapist Orientation? CBT or psychodynamic? » gardenergirl, posted by mattdds on December 26, 2003, at 17:59:34
This is a great thread! To answer your questions and perhaps respond to later posts at the same time...
>
> I just had a question about that statement. I was unclear about a couple of things. How does being "introspective" relate to the type of therapy that will work? Also...introspective as opposed to what?By introspective, I meant that I tend to turn inward in understanding myself and my world. I use this in opposition to extroversion, which to me means turning to the external world--other's reactions to you and/or your reactions, your own experience of your actions and their effects, etc. It's somewhat hard to describe at this time of night. I don't mean that introspective is deeper or superior to extroversion. Rather I view them as two processing styles which exist on a continuum.
> Also, what do you mean by "feeling-oriented"?
By feeling-oriented, I refer to my own tendency to emphasize and experience my feelings more so than my thoughts. If something does not engage me emotionally, it does not seem to stimulate me as much as when affect is involved. I believe this is why I felt so dissatisfied with my brief experience with CBT--I kept wondering "Is this all there is?"
In my training, I am often torn between working with the affect and feelings presented in exploring past experiences as they relate to the current Self or focusing on irrational beliefs and maladaptive behaviors. My supervisor and I would focus on very different things when reviewing my sessions in supervision. In searching for a model which incorporates both the experiencing and exploration of affect and the associated cognitive aspects, I found the Process-experiential approach.
This approach emphasizes that we are all composed of cognitive-affective schemes or combinations of thoughts and feelings related to our past experiences. These are constantly being revamped and reconstructed as we encounter experiences which may conflict with our schemes or may validate them. What I like best about this type of therapy is that it focuses on the experiencing and exploration of emotion, but also adds the cognitive aspect of it. Because we all attempt to make sense out of our feelings and experiences. This involves using cognition to label and associate the feeling with the concurrent event. We did this in the past, and we continue to do this. What may have made sense in the past, such as the child of an alcoholic learning to suppress negative feelings in order to avoid setting off the intoxicated parent and risking a beating, is maladaptive in the present when faced with justifiable anger say towards the drycleaner who ruined your skirt. If the adult with the maladaptive scheme represses the anger instead of assertively communicating with the drycleaner, they are less likely to get their needs met. This can then lead to feelings of hopelessness or resentment, depending on the current construction of the scheme. It seems like in this approach you are processing on a more effective level versus focusing on one or the other, cogntitions or emotions.
> In short, what I used to call introspection, I now call rumination.I would agree with your calling it rumination. In viewing introspection/extroversion on a continuum, I tend to think that if one focuses most on just one end of the spectrum, i.e. ruminating in order to avoid action or acting in order to avoid thinking, then it may be likely to cause problems. But then my current path for my own life is to become more balanced in all aspects and to focus on being in the moment more. To that end, yoga and meditation have helped me to focus on my current experiences. This is leading me to ruminate less (I did/do that too!) and to value each moment more. But that is what's working for me.
As has been said by many--we are all different, and thus it's good that there are many approaches to the same goals.
Thanks for starting this thread and for stimulating my thinking about why I am doing what I am doing.
Happy new year to all!
g
Posted by DaisyM on December 28, 2003, at 0:07:30
In reply to Re: Therapist Orientation? CBT or psychodynamic?, posted by LostGirl on December 27, 2003, at 22:22:52
Just finished "Pregnant Man" which is about hypnotherapy. It seems that this is often combined with both CBT and Psychodynamic techniques. I have no experience with it but in reading it seems that the emotions (attached to memories) come first, then coping techniques. But, a base of safety is established initially. (Ok, is this the cart or the horse?)
I can see how Psychodynamic techniques would work in a group, but how about CBT? I think it might feel confrontational. Again, not my experience, just curious.
FYI, my son reports from his classes at UC Berkeley that the trend in psychology being emphasized there has shifted back to Psychodynamics, especially Kohut/self theory and away from the behaviorists.
Posted by DaisyM on December 28, 2003, at 0:16:55
In reply to Re: You know what might be interesting? » DaisyM, posted by Dinah on December 27, 2003, at 11:26:05
Thanks. I hope that my post wasn't too pathetic. I was trying to make a point. I try not to whine, I know so many people who are dealing with worse.
I'm must say though, therapy itself is so "hard" that I can't imagine doing it without the ongoing support of a good therapist. I guess if you didn't have it, you either wouldn't stick with it or you wouldn't classify it as hard.
Sometimes I wonder if I had chosen a more CBT oriented Therapist if it would indeed have gone this deep... It is interesting that the Therapist who essentially dragged me into therapy classifies himself as CBT yet he sent me to someone who definately is Psychodynamic.
Posted by Dinah on December 28, 2003, at 8:36:38
In reply to Re: You know what might be interesting? » Dinah, posted by DaisyM on December 28, 2003, at 0:16:55
Not at all, Daisy. I pointed your post out to Matt as probably a better example than mine were, since mine were more artificial.
(But just for the record, I've never much liked the feeling that one must justify one's pain. Your pain is your pain. Please don't minimize your own pain, Daisy.)
Posted by Dinah on December 28, 2003, at 8:38:43
In reply to Re: You know what might be interesting? » Dinah, posted by DaisyM on December 28, 2003, at 0:16:55
Whoops. If it helps you to feel that way, then please ignore my above post. I should recognize that others find it a helpful coping mechanism. I always feel angry at adding feeling guilty on top of whatever other feeling I have. But I shouldn't assume that others feel as I do.
I apologize. It's too early in the morning. :(
Posted by gardenergirl on December 28, 2003, at 9:21:06
In reply to What about Hypnotherapy? And groups? , posted by DaisyM on December 28, 2003, at 0:07:30
Daisy,
Most of the faculty in my program tend to classify the program as very CBT-based, but we also get some good exposure to Kohut's theory. It really resonated with me. There are also a good number of us who are turning out to be psychodynamic or humanistic/existential despite the emphasis on CBT. That seems to further validate the idea that people tend to migrate towards the approach that speaks to them the most.Enjoying this discussion...
g
Posted by mair on December 28, 2003, at 10:40:44
In reply to Re: Therapist Orientation? CBT or psychodynamic?, posted by gardenergirl on December 28, 2003, at 0:01:55
I was referred to my current therapist for CBT. At that time I didn't know enough to understand the difference or to ask about differences for that matter. Initially it helped quite a bit, particularly with anxiety. I learned how to work through a "what's the worst thing that can happen" scenario which is a technique I still employ. However, it didn't help a bit with the fact that I had developed this very subjective self-hatred and it didn't help me curb persistent suicidal ideation. After awhile, my therapist switched to a more psychodynamic approach. After a few months of telling me that she didn't care about my past, it seems that we evolved into talking about nothing else. When we've talked about her shift in approache, she has told me that she didn't think CBT was particularly effective for me because I just "didn't buy it." (her words not mine). I've also discovered however that while she started out as a behaviorist in her own training, she has alot of doubts about the general effectiveness of behavioral approaches and I think does alot of psychodynamic therapy in which she incorporates some CBT stuff when needed. Therefore I think she might be more prone than more dedicated behaviorists to abandon CBT as the sole approach.
As with Dinah's therapist, mine aims to give me corrective emotional experiences which hopefully will alter my self-view. I understand what she's doing in theory, but with me it's such a long drawn out process and it's frequently very difficult for me to imagine a successful ending to this therapy.
Mair
Posted by Dinah on December 28, 2003, at 10:42:16
In reply to Re: What about Hypnotherapy? And groups? , posted by gardenergirl on December 28, 2003, at 9:21:06
I am thoroughly enjoying your posts. They bring a practical viewpoint to this theoretical discussion. I liked your description of process-experiential approach, and although my therapist doesn't use that term, he does a lot of what you describe. Especially in terms of my favorite and overused coping mechanism, dissociation.
"This approach emphasizes that we are all composed of cognitive-affective schemes or combinations of thoughts and feelings related to our past experiences. These are constantly being revamped and reconstructed as we encounter experiences which may conflict with our schemes or may validate them. What I like best about this type of therapy is that it focuses on the experiencing and exploration of emotion, but also adds the cognitive aspect of it. Because we all attempt to make sense out of our feelings and experiences. This involves using cognition to label and associate the feeling with the concurrent event. We did this in the past, and we continue to do this. What may have made sense in the past, such as the child of an alcoholic learning to suppress negative feelings in order to avoid setting off the intoxicated parent and risking a beating, is maladaptive in the present when faced with justifiable anger say towards the drycleaner who ruined your skirt. If the adult with the maladaptive scheme represses the anger instead of assertively communicating with the drycleaner, they are less likely to get their needs met. This can then lead to feelings of hopelessness or resentment, depending on the current construction of the scheme. It seems like in this approach you are processing on a more effective level versus focusing on one or the other, cogntitions or emotions."
I like that in a couple of ways. First it brings some validation to the ways that we are currently doing things by explaining them in terms of how they were adaptive in previous circumstances in our lives. It also seems to emphasize learning through experience? That appeals to me because unless something reaches both my brain and my gut it's unlikely to work.
I too enjoy the ideas behind self psychology and even more, object relations. And of course attachment theory. Since attachment theory works directly on my area of weakness - a desire for safety above *anything* else, it speaks to me far more than Freud's talk of agressive and sexual drives. But I must confess that I do better reading the translations to semi-layman (and more practical) terms than the originals so I might be missing the subtle nuances.
What do you think of my basic theory that most therapy orientations bring you to the same point, albeit through different learning mechanisms? If that is true, it would seem to suggest that an eclectic approach geared toward the client might be the best solution. Either that or an awful lot of referrals. I'm glad that your training program introduces you to more than one approach.
On the other hand, haven't I read outcome studies that therapists with strong theoretical positions tend to have the best outcomes? Of course, I'm a bit dubious about outcome studies...
Posted by Dinah on December 28, 2003, at 10:54:44
In reply to Re: Therapist Orientation? CBT or psychodynamic?, posted by mair on December 28, 2003, at 10:40:44
We both had similar experiences then in terms of how we came to therapy. I don't think my therapist would have ever espected to still have me coming (much less at twice a week) nine years later.
I admit the subjective self hatred is a hard thing to conquer. My therapist and I have been talking about that lately. Because even though my self esteem is pretty good and based on a realistic appraisal of my strengths and weaknesses, I have pockets of self hatred that seem isolated from any appeal to reason whatsoever. I'm not even sure it's amenable to a corrective emotional experience, because it's so isolated.
This might be different from your own experience. Mine is that I generally feel realistically good about myself then totally surprise myself with a statement (or post or action) that reveals self loathing that seems ego-dystonic to me.
My therapist seems more confident than I feel that it can be addressed.
Has anyone had a successful resolution to this problem and can pass on some tips?
Posted by fallsfall on December 28, 2003, at 11:51:43
In reply to Re: Therapist Orientation? CBT or psychodynamic? » mair, posted by Dinah on December 28, 2003, at 10:54:44
Interestingly, my first therapist (a CBT therapist) worked with me effectively on self-hate. This does seem a little counter-intuitive, doesn't it? I know very little about how this came about because I believe that I dissociated from entire sessions for weeks while we worked on this.
It resolved when I was able to write a pair of poems that described the evil that lived in me, and how I could exit a cave filled with dangers into the outside world.
My journalling from the time contains very few clues - I have to believe that my unconscious was doing all of the work.
So, how did my CBT therapist, who was unable to help me go "deeper" later in our therapy, accomplish this? I don't know.
I probably still have some selfhate, but nothing like I used to have.
I'm happy to have muddied the waters for you.
Posted by antigua on December 28, 2003, at 14:39:20
In reply to What about Hypnotherapy? And groups? , posted by DaisyM on December 28, 2003, at 0:07:30
Daisy,
I've used psychodynamic for 12 years w/my individual therapist and this past year went through a CBT group program. It was disastrous for me, although it did help me resolve the main problem I went for. I could accept CBT to recognize the triggers that caused me emotional turmoil and to logically change my reactions to them, but the rest of it was awful as I was told over and over again I had to change my basic beliefs--mostly basic beliefs in myself that I had worked for 10+ years to develop into a healthy (o.k., just healthier) self-image. The group thought I was in denial, but I knew I wasn't, and I firmly believed that if I had to give up the good stuff I'd learned I would have nothing to hold on to. The experience was so bad that I became suicidal, and that's when I quit.So, for me, psychodynamic is the core of my therapy, but I do see benefits to CBT when used correctly.
antigua
Posted by gardenergirl on December 28, 2003, at 16:14:54
In reply to Re: What about Hypnotherapy? And groups? » gardenergirl, posted by Dinah on December 28, 2003, at 10:42:16
Dinah,
Thanks for the positive reinforcement!> That appeals to me because unless something reaches both my brain and my gut it's unlikely to work.
I feel exactly the same way! CBT alone just doesn't seem to reach my gut. And just sitting with my therapist (or sitting with a client) experiencing emotions without engaging the cognitive system also doesn't seem to really effect change. I really think it takes both.
>I doubt you are really missing subtle nuances. You may be just reacting to the flaws in Freud's theories. I think that practicing from a strict Freudian approach in this day and age, when we know his own biases and know more about psychology would not truly be effective. Many psychoanalysts have expanded on Freud and modified psychoanalysis to better fit clients today and to utilize the knowlege we have gained over the years.
>
> What do you think of my basic theory that most therapy orientations bring you to the same point, albeit through different learning mechanisms? If that is true, it would seem to suggest that an eclectic approach geared toward the client might be the best solution.That's essentially my theory as well, although it drives my supervisor crazy. She talks about cognitive restructuring, and I talk about insight and reconstructing cognitive-affective schemes. I believe we are essentially talking about the same thing. We use the metaphor of backdooring or frontdooring in therapy to represent our different approaches to the same goals.
I also tend to agree with a more eclectic approach. I certainly would not attempt to explore affect and past trauma for someone with a simple phobia. CBT has been proven to work best in those cases. Now if something came up within the context of therapy which added complexity to the case, then I may be more likely to delve deeper or modify my approach...assuming the client wishes to work on that as well.
There is something we learned in school about eclectisism. It is appropriate for therapists to be eclectic in their approach as long as they understand the reasons behind using multiple approaches and interventions. The kind of eclecticism which is not effective is when the therapist is just using a technique because it exists. You need to be doing it for a theoretical reason, not just because you know the technique. That may explain some research which suggests that an eclectic approach can be less effective. The best eclectic approaches are those which integrate different aspects of theories into a more cohesive model. Process-experiential is an example in that it draws from humanistic, Gestalt, and CBT to form a new whole theory.
Posted by gardenergirl on December 28, 2003, at 16:21:39
In reply to Re: Therapist Orientation? CBT or psychodynamic? » mair, posted by Dinah on December 28, 2003, at 10:54:44
>I have pockets of self hatred that seem isolated from any appeal to reason whatsoever. I'm not even sure it's amenable to a corrective emotional experience, because it's so isolated.
I have worked on similar issues with the therapist using something called the two-chair technique. It allows different aspects of your Self, which may be in isolation from each other, to have a dialogue. You'd be surprised what comes out!
Good luck in working on this. In your head I am sure you know that we are all lovable. Now it needs to reach your gut in those isolated areas.
g
Posted by tabitha on December 28, 2003, at 16:36:38
In reply to Re: self hate » Dinah, posted by gardenergirl on December 28, 2003, at 16:21:39
Mine does something similar to the chair work-- sometimes actually involving chairs, sometimes not. She makes me do dialogues between the Critical Parent, Adult, and Child. The point is to get me to empathise with the Child who is being told the hateful message, and to talk back to the big mean Critical Parent as an Adult, in order to refute the unfair criticism and protect the Child. It really does lift my spirits.
Posted by DaisyM on December 28, 2003, at 18:32:58
In reply to Re: You know what might be interesting? » DaisyM, posted by Dinah on December 28, 2003, at 8:38:43
no need to apologize. You sound like my Therapist...:)
Posted by DaisyM on December 28, 2003, at 18:56:18
In reply to Re: self hate, posted by tabitha on December 28, 2003, at 16:36:38
Since termination, voluntary and involuntary, looms large for so many of us in therapy, do you think there is a difference between orientations and how they handle termination?
I'm pretty sure transference is handled differently, but what about "flights into health"?
Do CBT's typically "back out", cutting down on sessions? Or is there a mutual agreement about "cure" or having gone as far as possible.
Posted by DaisyM on December 28, 2003, at 19:00:20
In reply to Self-Hate » Dinah, posted by fallsfall on December 28, 2003, at 11:51:43
Maybe this is a good example of being ready to resolve an issue, and having a caring person to do it with. I still think that like most things in life, trust is 50% of the equation when you are attempting something new.
Posted by DaisyM on December 28, 2003, at 19:02:59
In reply to Re: What about Hypnotherapy? And groups? DaisyM, posted by antigua on December 28, 2003, at 14:39:20
I'm sorry for your experience. I can't see myself EVER in a group but I know people benefit. Support groups maybe, but I'm usually so "in charge" of myself and my emotions, I'd probably smack someone who tried to tell me I was in denial!
Posted by DaisyM on December 28, 2003, at 22:14:58
In reply to Therapist Orientation? CBT or psychodynamic?, posted by mattdds on December 26, 2003, at 1:52:24
I thought the following was interesting from talkingcure.com:
An Introduction . . .
Since the mid-1960's, the number of therapy models has grown from 60 to more than 250. At the same time, virtually all of the research data finds that the various treatment approaches achieve roughly equivalent results. This is true of both the biological and well as the much bally-hoed cognitive and cognitive behavioral revolutions. When all is said and done, virtually all of the data find that the various approaches work about equally well. As leading outcome researcher Michael J. Lambert, Ph.D. summarizes, "Research carried out with the intent of contrast two or more bona fide treatments shows surprisingly small differences between the outcomes for patients who undergo a treatment that is fully intended to be therapeutic" (p. 158, 1994).
Such evidence makes clear that the differences between the various models--much promoted by the developers and marketers of the different approaches--can not account for the effectiveness of treatment. Rather, the mountain of evidence for equivalent outcomes makes it clear that the similarities rather than differences between models account for the effectiveness of psychotherapy. The question, of course, is what similarities approaches share that account for success?
The Facts . . .
Research points to the existence of four factors common to all forms of therapy despite theoretical orientation (dynamic, cognitive, etc.), mode (individual, group, couples, family, etc.), dosage (frequency and number of sessions), or specialty (problem type, professional discipline, etc.). In order of their relative contribution to change, these elements include: (1) extratherapeutic [40%]; (2) relationship [30%]; (3) placebo, hope, and/or expectancy [15%]; and (4) structure, model, and/or technique ([15%] For more info/references: Escape from Babel (Norton, 1997); The Heart & Soul of Change (APA, 1999).
Research on the four common factors makes clear that various therapeutic techniques (e.g., confrontation, the "miracle question," EMDR) are better viewed as different means of empowering one or more of the factors responsible for treatment outcome rather than unique to a specific treatment model. Incidentally, this ămeta-view of therapy models also happens to fit the way experienced clinicians actually practice. Surveys conducted over the last several decades have consistently found, for example, that clinicians tend to identify less with any one approach the longer they have been in the field. Rather, experienced therapists tend to pick and choose from a variety of approaches in an effort to tailor treatment to the makeup and characteristics of the individual client.
Of course, the challenge to practicing clinicians--owing to the many choices available--is which technique(s) or approach(s) to adopt when working with a particular client? In this regard, research conducted by Duncan, Hubble, & Miller (see Psychotherapy With Impossible Cases [Norton, 1977]; Changing the Rules) as well as others (for a thorough review see Chapter 14, The Heart & Soul of Change [APA, 1999]) shows that the clientâs view of the presenting complaint, potential solutions, and ideas about the change process form a theory of change that can be used as the basis for determining, ăwhich approach, by whom, would be the most effective for this person, with that specific problem, under this particular set of circumstances. This same research shows that the probability for success is greater when the treatment offered fits with or is complementary to the client's theory.
Posted by gardenergirl on December 28, 2003, at 22:21:23
In reply to Therapist Orientation? CBT or psychodynamic?, posted by mattdds on December 26, 2003, at 1:52:24
mattdds,
I'm hoping that the turn this thread has taken has not further turned you off from this board. There may be something about those of us who have selected ourselves to participate in this type of support which leans more towards psychodynamic or humanistic approaches. I still think there is a place for discussion and support about CBT. Perhaps you could talk more about your own experience and how it has been helpful?
g
Posted by mattdds on December 29, 2003, at 1:50:23
In reply to Re: Therapist Orientation? CBT or psychodynamic? » mattdds, posted by gardenergirl on December 28, 2003, at 22:21:23
> mattdds,
> I'm hoping that the turn this thread has taken
has not further turned you off from this board.It's very thoughtful of you to be concerned. Thank you!
>>There may be something about those of us who have selected ourselves to participate in this type of support which leans more towards psychodynamic or humanistic approaches. I still think there is a place for discussion and support about CBT.
There may be a place for discussion, but I think it's unlikely to be the type I was looking for. The discussion has been fascinating, but it I always wind up feeling like I can't relate. And with the constraints of this board (and my own tempermental shortcomings), I just can't seem to find a niche here. I know it's nothing personal, it's just that people have different ways of seeing things. Apparently, mine is not compatible with this boards.
Perhaps you could talk more about your own experience and how it has been helpful?
> gI've done that before, but feel preachy, and I've even had people ridicule my progress, saying it's not possible. It's just not worth it to me anymore. However, I thank you for your concern.
regards,
Matt
Posted by Medusa on December 29, 2003, at 6:44:12
In reply to Re: Therapist Orientation? CBT or psychodynamic? » gardenergirl, posted by mattdds on December 29, 2003, at 1:50:23
I have a therapist situation to post, and I'd really, really appreciate your take on it.
Posted by Speaker on December 29, 2003, at 8:57:21
In reply to Re: Therapist Orientation? CBT or psychodynamic? » gardenergirl, posted by mattdds on December 29, 2003, at 1:50:23
Matt,
I hope you hang on for a while for some of us that are new to this board. I too have CBT for several years and it has been a life saver and I have grown a great deal. I now have to change T and am trying to find out what would be best to try this time. However, I have felt CBT is a good fit for me and can't imagine another approach. I have PTSD and have worked through several trauma events...the easier ones - husbands death, killing a child that ran in front of my car and a few others. I am now approaching the most difficult that happened when I was quite young. This has been difficult to even approach and talking has come very slow for me. I guess I am being selfish but your input has been very good and maybe a few of us that are successful with CBT should hang around. I have found everyone to be very supportive here but I have only been posting about six weeks.
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