Why psychoanalysis?

(And why not CBT?)

"The truth may be puzzling. It may take some work to grapple with. It may be counter-intuitive. It may contradict deeply held prejudices. It may not be consonant with what we desperately want to be true. But our preferences do not determine what’s true.”
— Carl Sagan

A lurking sense that something is missing knocks quietly at the door of so many therapists longing for a deeper understanding than what they have inherited from their cognitive forefathers 🌚. Still, Freud and Jung get a bad rap in the Golden Age of Cognitive Behavioural Therapy (CBT). Over the course of my training and practice, I have come to find that popular therapies like CBT, which are currently touted as “evidence-based”, in reality, tend to abandon the deeper question of what is really going on with patients, in favour of trying to relieve their suffering and restore their functionality in a succinct way. You might accuse me of having trust issues, but I just don’t buy someone who says they have a simple solution to a complicated problem 😎. And being a person is complicated.

With that in mind, I wanted to share with you some of the big reasons psychoanalytic theory has become the foundation of my practice, and why I want to create this work in service of its celebration and defense.

An explanation for the unexplainable.

People do weird, irrational stuff constantly for reasons they cannot explain. Ergo, in clinical practice, patients do not typically arrive ready with a coherent explanation of their behaviours, feelings and experiences. Often they can’t even really tell us what’s wrong exactly, or the thing they’re saying is the problem isn’t really the problem at all. While short-term, cognitive therapies claim support from a large quantity of scientific research, it also becomes increasingly clear to the early-career clinician attempting to put this research into practice that the patients walking through their doors are not the patients who are carefully filtered into these studies, and the worksheet-touting, agenda-setting, goal-achieving-type therapies they promote are a shortcut to mutual frustration (or worse, and perhaps more prolific, mutual client-therapist people-pleasing).

Within the branches of the tree of psychoanalysis, we find useful, pragmatic, and rich explanations for the kinds of dilemmas and distress that therapists encounter every day in their work with real patients but that don’t fit an obvious mold. Through psychoanalytic theory, we also have space to acknowledge that we as human beings are not the sum of our conscious thoughts and intentions, but are moved by forces within us that cannot be readily known, and that are not directly amenable to being measured with quantitative science. 🧑🏾‍🔬

Rest assured, moving beyond the cognitive revolution doesn’t mean going back in time. In a world of evidence-based practice, science and research matter. In fact, we now know so much about where the unconscious “resides” in our brains. 🧠 Relational neuroscience provides assurance that the influence of early childhood experiences and the neural pathways that get established and repeated are legitimate explanations for the kinds of problems people face when mental or emotional distress shows up.

Everything means something.

Sometimes therapy patients are 20 minutes late, 🕟 or refuse to speak, 🤐 or come all the way into therapy to tell their therapist at length about how the whole thing is a waste of time. 😠 Equally, sometimes a perfectly kind, empathic therapist is so bored in a session they can barely keep their eyes open. It can be easy to attribute these kinds of experiences to glitches, or personal failings. But! The psychoanalytic therapist knows it can also be something unconscious that causes so much of the mischief that we cannot easily explain, in our patients or ourselves; the sabotage, the repetitions in behaviour when we are sure we know better, the times we surprise ourselves, and even the times we sound just like our mother. 😝 Where the CBT therapist might see these issues as barriers to treatment, the analytic therapist is able to use these “annoyances” to understand and sharpen a diagnosis for the patient, rather than needing the patient to conform to their expectations (read, more rules for them to follow).

More broadly, a main difference between psychoanalysis and CBT is that CBT views symptoms as problems and psychoanalysis views symptoms as signs. The theory of the unconscious allows symptoms to become data in service of a greater understanding of the patient. If symptoms are no longer problems to be solved and you also have the techniques to interpret their deeper meaning, you have some important keys to healing and freedom.

Above and below the waterline.

The patient who develops compulsive checking behaviours is actually unhappy in his marriage. The patient with grandiose delusions that he is a member of the royal family is defending against a sense of self so fragile that it would shatter without the protection of an alternative story of greatness. The patient wrestling with lifelong depression has been following a script for how to be a ‘good person’ for her entire life, and has never learned how to follow her real desires.

We know from our own experiences that therapy takes place over several frequencies. The frequency that captures the conscious mind is when the client tells us about themselves - this is where cognitive therapies hang out. However, there are several other more subtle frequencies that can be listened to in order to obtain essential data about the client that they are unlikely to be able to tell us about, but that we need to know in order to help them properly. This is unconscious territory. 🗺️ You can’t tap into the unconscious storehouse by asking your patient directly about it. That’s where the techniques of psychoanalysis - free association, dream interpretation, transference and countertransference - have so much to offer. ⚡ Therapies that don’t acknowledge the unconscious feel like working with the tip of the iceberg - the part that’s seeable above the surface - without acknowledging the bulk of what’s going on below.

If you would like to finally understand what these things really mean and how you can wrap your head and heart around these delicious techniques, I would LOVE for you to subscribe to my Substack. 😊 It’s so exciting to be breaking down these ideas to make them more digestible and usable.

Of course, psychoanalysis is no one thing. Since Freud introduced us to his framework over 100 years ago, many new branches have formed on the tree of psychoanalysis. Broadly though, all types of psychoanalysis offer the therapist the opportunity to become a translator and deep sea diver 🌊, thereby helping patients to bring parts of themselves, memories, and emotions to the surface to settle and become known, so that they might be more of their real selves.