Psychoanalysis Is a Type of Exposure Therapy

Sometimes I like to think about the ways that manualized therapies, such as CBT, and psychoanalysis are more similar than different. For instance, I would argue that traditional CBT is a manualized form of dynamic supportive therapy, the goals of which are to strengthen existing defenses (or “coping mechanisms”), rather than to dismantle the current set of defenses to allow for a maturation of the personality. But perhaps exposure therapy and psychoanalysis have the most in common.

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In exposure therapy, a patient has a discrete issue with, for instance, a phobia or a particular set of obsessions and compulsions; the patient and therapist develop a staged approach to exposing the patient to the feared object/thought/situation. In psychoanalysis, the analyst and patient also work to expose the patient, in a graded manner, to a feared stimulus. In this case the feared stimulus is relationships.

Think of how a therapist and patient might tackle a spider phobia: by having the patient first imagine a spider, then look at a photo of spiders, then look at a real spider, then hold a spider. Over time, the patient develops new ideas about spiders as a direct result of exposing themselves to the feared stimulus over time and noticing explicitly with the therapist that the anxious fantasies (narrative ideas) the patient has about spiders have not come to pass. This allows the patient to reframe their fear of spiders in a new way and incorporate a more benign version of arachnids into their personal narrative of the world.

Analogously, in psychoanalysis the analyst and the patient first start by talking about the patient’s problems with current and past relationships. Over time, the discussion develops into talking about the relationship with the analyst, feeling deeply for and about the analyst, and eventually incorporating new ideas about relationships generally from the specific experience of the analytic dyad. The anxious fantasies about what is frightening about relationships is explored directly in the analysis, both about the patient’s oldest intimacies (parents, siblings), current relationships, and most important, the relationship happening between patient and analyst.

Because relationships are central to the experience of being human (much more central than, say, spiders) it is perhaps not surprising that it takes a lot of relearning over a long period of time for the exposure to a new kind of relationship to start loosening old ideas, fears, and fantasies about how to exist in relation to others. It takes a lot of trust, patience, and love from both patient and analyst for a patient to start to imagine that others can be a source of joy, comfort, care, pleasure, excitement, tolerance, and more.

Our spider-phobic patient might come to find spiders tolerable, though they may not choose to adopt a tarantula as a pet. Our relationship-phobic patient must continue to exist in the world as one node in a web of relationships, and those connections to others are much harder to avoid than spiders.

It takes a lot of bravery to engage in any kind of exposure therapy, and we should commend our patients for doing so. For those who need exposure to intimacy and connection, the bravery they show over a much longer period of time is truly inspiring.