George Rudy/Shutterstock
Source: George Rudy/Shutterstock

by Lee Jaffe, Ph.D.

When faced with an array of psychotherapies, it is difficult to know what’s right for you. Psychoanalysis? Psychodynamic PsychotherapyCognitive-Behavioral Therapy (CBT)? Dialectical Behavior Therapy (DBT)? Gestalt Therapy

They are all so very different, right?

In fact, all of these therapies are “talk therapy” and in many ways are more similar than not.  And what’s more, they all originated in the work of Sigmund Freud. That’s right! Freud invented “talk therapy”, and even behavioral therapies such as CBT and DBT are “talk therapies” based on Freud’s original model.

In my book “How Talking Cures” I illustrate the six most important elements of all talking cures. Like ingredients that vary in different recipes, their proportions will depend on the type of psychotherapy:

  1. Direct support
  2. Introjection
  3. Catharsis
  4. Insight
  5. Identification
  6. Working Through

Direct support is giving advice to a patient. For example, George was repeatedly in debt owing to his susceptibility to credit card offers. He came to treatment anxious and depressed about his unmanageable debt. In evaluating his difficulties, it became apparent that he could not understand the realities of the credit card offers. With referral to a debt management professional and ongoing support for the management of his finances, George gained financial stability. 

Introjection occurs when the patient begins to internalize the voice of the therapist. Patients will report that when trying to cope with difficult situations they “hear” the words of the therapist helping them cope more effectively. For example, Alice has a habit of disagreeing with others. Without realizing it she is prone to saying “yes…but” rather than affirming. As this pattern was addressed in therapy, she came to hear the therapist’s voice pointing this out, and increasingly was able to stop herself and instead be more affirming of others. The result was a significant improvement in her relationships.

Catharsis is the when someone who has been unable to express emotion, cries, shouts, or in other ways “lets it out." Mary lost her baby last year to sudden infant death syndrome and refuses to change anything in the baby’s room.She cannot even consider accepting the idea of having another child. Through talk therapy she was helped toward expressing the painful emotions and grief. Now she is considering having another child and moving on with her life.

Insight is the ability to understand a feeling and where it came from. This helps the patient to manage the feeling. Barbara came to see me because she was worried that she was not a good mother when in fact she was quite capable. Through insight, she came to understand that her painful worries are the result of unconscious guilt about being a bad daughter, caused by refusing to have anything to do with her ailing mother.

Identification takes place when patients assimilate an aspect of the therapist’s personality. For example, John, who was unable to assert himself at work, developed the capacity to be more assertive when the therapist is able to confront him with a problem. He was failing to thrive in a business where he was not receiving raises or recognition for his significant contributions. John “identified” with the therapist’s objections to how he was being treated, and as a result became more assertive at work and was reasonably rewarded. Identification is similar to introjection, but different in the sense that John did not “hear” his therapist’s voice, but rather incorporated an aspect of the therapist’s personality into his own personality.

Working through means applying the achievements from therapy outside the sessions. It is required by all talking cures to bring about lasting change. Bobby, for example, is in treatment for a school phobia. He fears he will be separated from his parents and unable to return home. While some insight about his unrealistic fears is important, in order for his treatment to be successful, Bobby also has to go back to school.  Thus, he needs to work through the conflicts in his life, not just in the therapist’s office.

I would love to say I came up with these ideas myself but they actually come directly from the writings of Sigmund Freud. For example, in 1892 Freud created a form of Cognitive Behavioral Therapy. While he did not refer to “negative thoughts” his term was “antithetical ideas.” However, it is essentially the same idea. A year later, he developed a form of treatment very similar to Exposure Therapy. He used suggestion and later hypnosis to produce a release of emotions that relived symptoms, but found the cure was often temporary. In 1900 he developed insight-oriented treatment, in 1926 he recognized the importance of working through, and then in 1938 he wrote about the importance of identification.

Although many of the approaches to psychotherapy described above did not exist in Freud’s day, he developed an early form of each type of them. So when you think about CBT and DBT v. Psychoanalytic Psychotherapy, remember they are all talk therapies, created by Sigmund Freud.

About the Author: Dr. Lee Jaffe is an adult, adolescent and child psychoanalyst in private practice in San Diego, California, and an adult Supervising and Training Psychoanalyst at the San Diego Psychoanalytic Center (SDPC). He is on the faculty of the Department of Psychiatry at the University of California. In 2014 he published How Talking Cures – Revealing Freud’s Contributions to All Psychotherapies. He is President-elect of the American Psychoanalytic Association and Chair of the North American Psychoanalytic Confederation.  

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