Psychotherapy today is guided by a number of different schools of thought, each with its own theory. In actuality, each “theory” is a large collection of ideas tied together by a few common threads or themes. Those practitioners who are interested in reality and effective treatment, rather than in merely pushing the one school they are familiar with to benefit their own practice, know quite well that some aspects of their school of thought are quite accurate, while other parts are completely wrong.

When I posted a mild criticism of one aspect of Cognitive Behavioral Therapy (CBT), some commenters and one blogger who wrote a rebuttal acted like I was questioning the word of God. That attitude is a true sign of disingenuous argumentation. Many CBT proponents also argue as if everything they do has been scientifically proven, which is obvious baloney.

CBT is currently the predominant psychotherapy treatment paradigm taught to clinicians-in-training in psychology graduate schools. However, when I first received psychotherapy training in the mid 1970’s, by far the predominant school of psychotherapy was psychoanalysis. Just like the CBT industry does now, analysts exaggerated the validity of the scientific evidence for psychoanalytic theory, and made grossly inflated claims about the effectiveness of psychoanalytic treatment. Its theory was applied to everything, even to schizophrenia, although by then it was pretty clear to most of us that they were completely wrong about that condition. I’m surprised analysts did not try to treat ingrown toenails with psychoanalysis.

Analysts also protected their turf back in the day, and very arrogantly. As a trainee, if you criticized any aspect of analytic theory, you were told in no uncertain terms that you needed to go into psychoanalysis yourself, so you could find out why you were “resistant” to analytic theory. In other words, the only reason you were questioning the theory was because you were neurotic!  

This recommendation involved the use of not one, but three logical fallacies, all wrapped up in a single statement. It was a non sequitur, since someone might be questioning the theory for any number of other reasons besides their own psychological issues. It was an ad hominem attack, since it was going after the questioner and not the question. And of course it was begging the question.  The accusation of being neurotic might be true if analytic theory is true, but that is the very issue in doubt and under debate.

Another example of disingenuous argumentation occurs when people in the field try to argue against all the ideas of a particular school, even though many are obviously quite valid, by throwing up a few incidences of when the school had something clearly wrong. They will of course pick the most egregious examples they can find. To criticize psychoanalysis, they might bring up such analytic ideas such as "penis envy," or the wild overemphasis on the Oedipus Complex, even though the majority of analysts no longer buy into them. 

A side note on Freud’s discredited psychology of women. I have no doubt that the upper class females he treated in his Victorian society were indeed envious of males, but that’s because women back then were treated like second-class citizens. Women were envious of male prerogatives.  I also have no doubt that his female patients frequently alluded to missing penises in their dreams and associations. However, what with the whore-madonna complex being rife in his society, his conclusions about those allusions were only half right. He was right about the missing penis, but was wrong about in which direction these women secretly wanted the penis to be pointed.

This post, however, is about a different failing of the analytic theory. But first, I would like to point out what core ideas of theirs were correct. Just as with many aspects of CBT (CBT'ers please take note that I am saying that), many aspects of psychoanalytic theory retain much explanatory power. They are so widely accepted that they have even become part of the cultural conventional wisdom in industrialized countries.

Who doesn’t believe that people sometimes take their anger out about something on someone or something else?  Mad at your boss, come home and kick the dog? That’s the defense mechanism of displacement. Yeah, like that never happens.

Intrapsychic conflict creating emotional and interpersonal problems because people want something really bad but feel guilty about it? Check. Conversations have unspoken subtexts?  Check. Acting towards authority figures in a certain way because they remind you of your father? That’s transference. Check. CBT folks may prefer to call the phenomenon schemas instead, but it's still transference. 

People wanting to avoid unpleasant subjects and in response changing the subject or explaining away inconvenient facts? That's resistance. Check. Forgetting about unpleasant memories? Well, whether that’s unconscious or subconscious may be debatable, but the fact that repression exists? The whole Catholic Church child molestation scandal started with a case of "recovered" memory. Check.

The analysts are even right about personality problems stemming from childhood experiences within the family. The attachment literature is extremely powerful, and we all know that one of the biggest risks for just about every psychiatric condition in the DSM is a history of childhood abuse and/or neglect.

Ah, but there is where the psychoanalysts started to go wrong. They seemed to assume that childhood experiences completely determine  the psychological problems a patient has and that subsequent experiences are somehow inconsequential. Orthodox analysts believe that your personality is fixed by the time you are five years old. Some go back even further than that.

Of course, if subsequent experiences could not affect personality, it would do a person no good at all to go into psychoanalysis, because the experience of psychotherapy would have absolutely no effect—according to the orthodox analysts’ own assumptions about personality formation.

The thing is, family experiences that start to create problems for children do not magically disappear when a child reaches a certain age. In fact, they often go on and on and on - in sometimes somewhat different forms - until the parents die. And the human brain is structured to be highly responsive to what parents do, even in adults. 

When I first started getting interested in family systems ideas and started asking my adult patients about their current interactions with their parents and other members of their families of origin, it soon became clear that some of the interactions followed certain patterns than recurred again and again, and that these patterns served as triggers and reinforcers, as a behaviorist therapist might say, for the very feelings and behaviors that the patients were coming to therapy to try to change. 

These were patients in individual psychotherapy, so I was not a first hand witness to these interactions, although later I found ways to see them in person. And my psychoanalytic and behaviorist psychotherapy supervisors had not discussed what to do about them.

It seemed to me that if my patients were just more assertive with their families, they might be able to change these problematic family interactions. The behaviorists had taught me about something called assertiveness training, so I tried that. The first time I tried it, I tried to teach a Chicana woman to stand up to her father. She wanted none of that. Wouldn’t even really discuss it. So, I thought, maybe it’s some sort of cultural force that I was up against in that particular case.

So how about with a patient from a somewhat more egalitarian culture? I taught an Anglo woman with traits of borderline personality disorder (BPD) to be assertive with her family. Her parents seemed to be subtly sabotaging her efforts to establish independence from them. When she was doing well, they ignored her. Or more like gave her the silent treatment and a cold shoulder. When she was in financial trouble, however, they were always right there to help out - although strangely they gave money to her teenage son rather than to her!

Every week in therapy she would dutifully practice assertiveness techniques, and would leave the session confident that she could address the issues with her family. The very next week, however, she would come back with her tail between her legs. Her best efforts seemed to have been totally defeated, and she became even more unhappy than she had been, and even less self-confident.

I discovered that as a therapist I was absolutely no match for this woman’s parents in affecting her behavior, for either good or for ill. And it was not just her. I found out—again and again—that parents were way more potent influences on the patient than I as a therapist could ever be.

 If a patient’s family of origin is not too dysfunctional, getting the patient to make changes without worrying about family reactions can certainly be effective. If the family basically accepts the change, everything is cool.

But in significantly dysfunctional families? Not so much. The family therapists were right. The entire family will confront the patient in a variety of ways that all boil down to the message, “You are wrong, change back.” Many times I have even seen relatives such as aunts and uncles who previously had had little involvement with the patient come out of the woodwork screaming, “How can you do this to your mother?!?”  

Sometimes the situation would escalate to incredible extremes, with parents figuratively sticking their heads in the oven threatening suicide in response to the patient’s meager attempts at self actualization, or doing what they want and not what the parents seem to want. 

“But,” I hear you protest, “a lot of patients with personality disorders are highly oppositional to their parents, seemingly doing the exact opposite of what the parents say that they want. So that theory can not be right!"

My answer to that: these people are oppositional to their parents because that’s what they think the parents need from them. The parents seem to need them to be black sheep. For a further discussion of this point, I refer you to my post about the role of the spoiler.

New developments in neuroscience are consistent with the proposition that parents can have strong effects on their children even as adults, even if they do not want to. Studies have shown that the perception of faces activates specific cells in the amygdala, which is the part of the brain responsible for fear reactions. Different cells there respond to different facial features, and certain cells respond only to one parent or the other. The amygdala is also strategically located for generating a rapid and specific autonomic nervous system and endocrine pattern in response to complex social signals. In general, the attachment system seems to be one of the most important regulators of overall arousal.

Attachment research indicates that the brain regions that compose the limbic system use input from the emotional states of attachment figures to regulate both internal and external responses. Individuals exhibiting so-called disorganized attachment have been found to have parents who display both frightened and frightening responses. 

In a sense, rage and panic are both communicated to and conditioned within the offspring of such parents. According to attachment researcher Mary Main, if parenting generates multiple, contradictory models of attachment, this creates a sense of insecurity in the offspring.

Complex limbic system reactions to the social environment have been found to be specific to important individuals within the family. Problematic reactions such as rage attacks can be seen to occur with one parent but not the other! If interactions with primary attachment figures are highly stressful over prolonged periods, this can have a profound effect on the development of a child’s brain that last a long, long time.

Early learning may be particularly difficult to inhibit. In general, it is much harder to unlearn fear than to learn it in the first place—a fact highly consistent with the experience of psychotherapists trying to extinguish chronic anxiety, particularly chronic interpersonal anxiety. 

Extinction of fear responses has also been found to be context specific. If a fear response is extinguished in one context, it may come right back if an animal is moved to a somewhat different environment. If the new environment is similar to another one such as the early family environment, fearful patterns of behavior learned early in life but inappropriate for the new environment may therefore be seen.

So, early influences are very powerful, but that does not mean that later experiences are inconsequential. When individuals grow up, their parents usually continue to act in ways that recapitulate social interactional sequences from the patient's early life experience. This parental behavior automatically both cues and reinforces old but engrained role relationship schemata (mental models of how to respond to different social cues).  

In turn, these reinforced schemata become more likely to be activated in the patient's current social interactions. This leads to reenactment and recapitulation of these patterns in other relationships. This is the basis of what Freud referred to as the repetition compulsion.

As I have described, parental behavior seems to be an extremely potent environmental trigger for previously learned social behavior. This most likely stems from the survival value of coherent group structure in evolution. As psychoanalysts have hypothesized, children internalize the values and role behaviors of their social system, and conformity to the group has continued to have survival value throughout the life cycle.  

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