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Tools, Not Schools, of Therapy
Part 6: The Psychodynamic Model

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Copyright © 2008 by David D. Burns, M.D. Any reproduction, electronic or otherwise, is strictly prohibited without expression written permission of the author.

By David Burns, M.D.

In this edition of the newsletter, I’ll focus on the Psychodynamic Model.
Although Cognitive Behavioral Therapy (CBT) originally broke away from the psychoanalytic and psychodynamic schools of therapy, there are actually some neat psychodynamic components embedded within CBT. However, I would definitely not promote myself as a psychodynamic therapist, and I’m not convinced that psychoanalytic or psychodynamic therapists would resonate with what I’m about to share with you. But I think there is some potential overlap and room for dialogue. Feel free to send me an email with your own thoughts about this, or any, of the blurbs I’ve been writing for this newsletter: david@feelinggood.com. If you have questions, that would work, too. Perhaps I could answer a few of them in future editions of this newsletter.
CBT therapists have always focused on pinpointing and modifying the Self-Defeating Beliefs (SDBs) and schemas that can trigger depression, anxiety, or interpersonal problems. Most therapists are familiar with these SDBs, such as Perfectionism and Perceived Perfectionism, along with the Achievement, Love, and Approval Addictions, as well as a host of others. Some SDBs are highly associated with depression, such as the Achievement and Love Addictions. Others are highly associated with the anxiety disorders, such as Perceived Perfectionism, the Spotlight and Brushfire Fallacies, Magical Thinking, and the “Niceness Cluster”—Submissiveness, Conflict Phobia, Anger Phobia, and Emotophobia. And some beliefs trigger anger and conflict in relationships.
I use several techniques to systematically identify the SDBs that are causing problems for my patients, including the Individual Downward Arrow, the Interpersonal Downward Arrow, and the What-If Technique, as well as the Hidden Emotion Technique, discussed previously. Although all of these point to the deeper structures in the patient’s psyche, the Interpersonal Downward Arrow is the most psychodynamic, or psychoanalytic, of them. I developed this technique in the late 1970s when I began working with individuals with troubled relationships. When you use this technique, you are literally doing psychoanalysis at warp speed, especially when you focus on your relationship with your patient.
When you use the Interpersonal Downward Arrow, you always start with a negative thought on the patient's Daily Mood Log. It will be a thought about a some person the patient isn’t getting along with. Then you ask these types of questions: "If this were true, what would it tell you about—

• "The kind of person she or he is? What’s his or her role in this relationship?"

• "The kind of person you are? What’s your role in this relationship

• "The kind of relationship you have with this person? What is the rule that connects these two roles?"

Although you'll usually use this technique to help patients understand their conflicts with other people, you can also use it to explore their negative feelings about you. In this case, you're analyzing the patient's "transference" reactions from a cognitive perspective, as illustrated by my work with a young chemist named Rodney who suffered from extremely severe depression, shyness, and panic attacks. He was referred to me by a colleague who’d used aggressive pharmacologic approaches without any luck. Whenever he referred a patient to me, I knew I had a pretty challenging case on my hands. Rodney was no exception.

Rodney had completed a post-doctoral fellowship in chemistry at UCLA and worked in a research laboratory in Berkeley, California. He’d suffered from mood and anxiety problems all his life, and lived with his mother, who also had severe emotional difficulties.
Although he was attractive and successful, Rodney had a phobia about eating in public and was crippled by shyness. Whenever he was around young women he was attracted to, he felt nauseated and had the overwhelming urge to vomit on them. Needless to say, this put a bit of a crimp in his social life, and I’m pretty sure he’d never gone out on a date.

At the initial evaluation, Rodney's depression and anxiety scores were off the charts. However, he was very motivated and faithfully did all his written therapy homework with the Daily Mood Log. Over time, his depression and anxiety slowly improved, and I was able to taper entirely him off the large doses of antidepressant medications he was taking when he was referred to me.

Still, I couldn't get him over the hump completely, and he was unwilling to confront his fears. He carefully avoided women and always ate lunch alone in his lab. This was awkward because two attractive women from his lab would often drop by and invite him to join them for lunch. He'd thank them, but sheepishly make an excuse about a crucial experiment that he simply had to continue working on.

Despite my best efforts, Rodney always gave me low scores on the Therapeutic Empathy scale. His scores indicated that he didn't think I was warm or supportive, and that I didn't really understand how he felt inside. Whenever I encouraged him to tell me more about these feelings, he resisted. He'd insist that the therapy was helping him and change the subject.

I had a hunch that it might be important for him to tell me how he really felt, but he absolutely wouldn't open up. One day, I asked him what he was so afraid of. What did he think would happen if he criticized me?

After a moment he said, "You might get upset if I criticized you."
I told Rodney to write this down in the Negative Thoughts column of a Daily Mood Log, and to put a downward arrow under it. I said, "Let's assume that was true. Imagine that I've encouraged you to open up and criticize me, and you finally go ahead and do it. Then I get upset. What would that mean to you? Why would it be upsetting to you?" These are the questions you’d ask if you were using the Individual Downward Arrow Technique.

Rodney said, "Then you'd get mad and wouldn't want to work with me any more." I told him to write that down directly underneath the arrow, and to put another arrow underneath it.

I said, "Rodney, let's assume that happened. You criticize me, just as I've asked you to do, and I get mad and decide that I don't want to work with you any more. What would that tell you about the kind of person I was?" This is the type of question you ask when you’re using the Interpersonal Downward Arrow Technique.
He paused and then replied, "I guess that would mean that you were very fragile and narcissistic."

I told him to write that down directly under the arrow, and to put another downward arrow under it. Then I said, "Let's assume that I was very fragile and narcissistic. What would that tell you about the kind of relationship you had with me?"

Rodney replied, "That would mean I'd have to be really careful all the time–like walking on eggshells." I told him to write that down directly under the arrow, and to put another downward arrow underneath it. This time I said, "And how would you feel about working with someone like that? First, Dr. Burns pushes you to tell him how you really feel, but when you do, he gets mad and rejects you. How would you feel about Dr. Burns?"

He said, "I guess I'd feel pretty angry. I wouldn't like him much at all."

I said, "Rodney, it sounds like you do have some negative feelings about me, but you've been reluctant to express them because of these fears. Does that ring true?" He nodded, but didn't say a word.

We're trying to understand three things about the way Rodney views his relationship with me, and conceivably with people in general:

1.     How does he view me? In his mind, what role am I in?
2.     How does Rodney view himself? What's his role in the relationship?
3.     What's Rodney's understanding of how two people in a close relationship interact with each other? In his mind’s eye, what’s the rule that connects the role he plays with the role the other person plays? Or to put it differently, what is his view of the nature of an intimate relationship?

Review Rodney's negative thoughts on page 5 and see if you can pinpoint his assumptions about me? What kind of person does he think I am? What's my role in the relationship? Put your ideas here:

What are Rodney's assumptions about himself? What kind of person does he think he is? What's his role in the relationship? Put your ideas here:

What are his assumptions about close relationships? Put your ideas here:

When you've written down your ideas, I'll share my thinking with you.

Answer
Here's what Rodney came up with:

• The people I care about are powerful, self-centred and dangerous.

• I must always please them and be on my guard.

• If I express my needs or feelings, I'll be punished and rejected

It's no wonder that Rodney avoids intimate relationships. It's interesting that he sees me as both powerful and weak at the same time. On the one hand, I'm dangerous, and if he isn't careful, or if he offends me in any way, he thinks I'll crush him, like a bug. But at the same time, he sees me as very weak and fragile, because he believes I can't tolerate criticism.

He seems to view himself with the same type of ambivalence. On the one hand, he sees himself in a weak, submissive role. He thinks he always has to please the other person in order to avoid being hurt or rejected. But he also sees himself as powerful and dangerous, because he thinks that any expression of his feelings would be devastating to others. As a result, he keeps his relationships superficial because he thinks that intimacy is extremely dangerous.

I told Rodney that I liked his analysis, and that it was suddenly clear why he'd been so reluctant to open up and tell me how he felt. I reminded him that we'd been working together for several months, and that I was proud of all he'd accomplished. At the same time, he was still struggling with feelings of anxiety and depression, and he was still holding back in the therapy. He also hadn't confronted his fears of dating and getting close to other people yet.
I said that the next step might feel a lot like jumping off the high dive at the pool for the first time, and that there was no way I could make his fear go away. But if I could persuade him to jump, he'd quickly land in the water, and realize that he'd conquered his fear. I told him that I wanted him to take the plunge today. Right now, in fact.

He looked puzzled and asked what I was talking about, and what he was supposed to do. I said:

"Rodney, I think you know what I'm talking about. Every week, you mark me down on the Therapeutic Empathy scale. But when I ask you about it, you clam up and refuse to tell me how you feel inside. It's suddenly clear why you've been doing this. You're afraid that I'll get upset and reject you. But that's what I'm asking you to do right now. I want you to tell me how you really feel."

Rodney swallowed hard and said:
"Dr. Burns, this is hard to say, because you're by far the best shrink I've ever had. I feel like I'm finally making some progress, and the techniques you've taught me are invaluable. But if you want to know the truth, I don't actually like you very much. I don't like coming in for sessions, and I don't like being around you. When our sessions are over, it's always a huge relief, and then I dread having to come back again the next week. I hate to hurt your feelings, because you've done so much for me, but that's how I feel."

I said:
"Rodney, to tell you the truth, I haven't enjoyed our sessions as much as I'd like, either, because it never seems like we're really connecting. But now I feel like you're being honest and real, and I feel a lot closer to you. I hope you'll continue to be open, the way you were just now. Tell me more about how you’ve been feeling. I’m wondering if you’ve been feeling lonely, or anxious, or even a bit resentful. Does any of that ring true? This is important."

Rodney's jaw dropped open as if he couldn't believe his ears, and he began to pour his heart out. It was the best session we'd had. At the end, he gave me perfect scores on the Therapeutic Empathy and Helpfulness scales.

When he handed me his depression and anxiety tests the following week, I could see that his scores had improved dramatically. In fact, it appeared that all his symptoms had vanished entirely. He explained that our last session had been extremely helpful, and that the next day at noon, the two young ladies stopped by at his lab and invited him to lunch again. Only this time, he had the thought, "I’m standing on the high diving board again. How along am I going to stand here? Maybe it’s time to jump." So he told them he’d love to join them.

He was surprised to find that he didn't get nauseated at all, but got into an animated discussion with them during lunch. One of them asked him if he enjoyed movies. He said he loved movies and was a movie buff. Then she asked him if he ever went out on dates. He said, "Well, not real often, but it might be lots of fun."

She said, "How about tonight?"

Rodney replied, "I'd love to!"

They went to a movie and had a ball. When he dropped her off, she asked if he wanted to come in and have a drink. He said that sounded like a good idea, too. They ended up making love—the first time for this young virgin, and it blew his mind. Then she asked if he might want to stay the night. He said that sounded good, too! They made love on and off all night long. He said he was crazy about her, and told me that they'd gone out every single night since then. He said he was feeling on top of the world and wondered if he was ready to terminate therapy.

The odd thing was that he attributed his success to the fact that he was wearing Birkenstock sandals. He made me promise to tell all my colleagues that they should tell all their lonely, shy patients to wear Birkenstock sandals, and they'd get laid right away. So I'm passing the information along to you.

I felt that expressing his feelings to me and discussing his feelings about our relationship was a crucial component of his recovery. He'd believed that his own feelings of anger and sexuality were too powerful and dangerous for other people to handle. When he finally confronted the monster he feared—his own emotions—he discovered that the monster had no teeth, and there was really nothing to fear.

You could view the Interpersonal Downward Arrow as a bridge between CBT and the psychodynamic / psychoanalytic therapies, but it doesn’t take years of analysis to identify the core conflicts that trigger the patient's problems. Instead, you simply ask the Downward Arrow questions, and all the information comes spilling out of the patient's head, almost like magic. Of course, the insight alone won't be enough. Patients will still have to take action and confront their fears if they want to change their lives.

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