A Possible Bridge Between CBT and PDT

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Going far back in the history of psychotherapy, there has been a major divide between behaviorism and its descendants, e.g., cognitive behavioral therapy (CBT), and those psychotherapeutic schools derived from the work of Sigmund Freud such as psychodynamic therapy (PDT). The psychotherapy integration movement and trends within both traditions have brought the two sides closer together, but the divide has continued to undermine respect for psychotherapeutic treatment as well as bringing confusion to patients, students, researchers, and practitioners. Some of the divisiveness may have to do with outside factors such as guild politics and vested interests, but a sustaining factor for this divide is an old but strongly rooted view that PDT seeks to explore causes while the goal of CBT is to change outward manifestations.

The thesis of this post is that this focus on divergent goals or destinations is actually misleading. What we should be looking at are the details of the journey. Recent advances in biological science have elucidated just two neurophysiological mechanisms that can account for the modification of those entrenched maladaptive patterns (EMPs) that are the primary targets of psychotherapy. As this new science has converged with existing clinical knowledge and experience, a fresh look at what happens in the course of therapy reveals that the actions and interactions embodied in either form of psychotherapy lead naturally to fulfillment of three conditions found to be required for both of the known change mechanisms to do their work.

The Learned Fear Paradigm and Mechanisms of Change

The view expressed here has become possible only in the light of recent work on the learned fear paradigm. To date, through extensive studies across multiple species, two, and only two, mechanisms have been shown to allow modification of existing response patterns. They are extinction and memory reconsolidation. Furthermore, these findings have been extended to the triggering of drug craving and other research paradigms as well. While still questioned by some, these two change processes hold significant promise for explaining the minute-to-minute action of diverse psychotherapies (Lee, 2017).

Extinction happens when the conditioned stimulus (CS) is recalled repeatedly, but without the unconditioned stimulus (US). Under these conditions, cortical learning results in inhibitory impulses going to the basolateral amygdala (BLA), where the response (but not the appraisal of threat), is blocked. This effect is temporary. Over time the triggering of the fear response by the CS will reappear.

Memory Reconsolidation happens when the CS is recalled with some intensity in connection with an unexpected result such as absence of the US or even an opposite result (counterconditioning). This reactivation of memory in the context of an unexpected result initiates a period of memory volatility from 10 minutes after the recall to about five hours after, during which the memory becomes volatile and can be updated according to the surprising new information. In this way, what was previously identified as threatening can be experienced as benign. Furthermore, the effect is permanent, requiring no effort or retraining to be maintained.

If these mechanisms do indeed generalize to the bulk of maladaptive responses or EMPs, it appears that for existing maladaptive patterns to be modified, whether by extinction or by memory reconsolidation, the same three elements must be present. Whatever the conscious goal, it is the interaction between therapist and patient that leads to these conditions being fulfilled. In simplified form, the three requirements are:

1. Experiencing the threat (in the broadest sense, fully conscious or not)
2. Bringing the associated affect “into the room.”
3. Understanding/experiencing the “antidote,” a perspective that contradicts the threat.

Note that “threat” can range from imminent bodily harm down to the level of discomfort and is often not conscious. “Affect” (conscious feeling plus visceral changes) is the clinical sign that the deep emotion needed to trigger a maladaptive response is active. The “antidote” can be cognitive, i.e. realizing that a basic assumption about life is not true, or experiential, i.e., an expected response from another simply does not happen or a dreaded and avoided experience turns out to be tolerable.

How the Therapeutic Journey Fulfills the Three Conditions

Classic CBT, following the “ABC” model, covers the cognitive aspects of the three requirements but does not consider the affective part. An Activating event or circumstance is interpreted according to a Belief, (resulting in the perception of a threat), which leads to a response that has Consequences. The therapist presents an antidote that is presumed to change the belief. What is not classically described is the affective component. As Robert Leahy writes (2003), resistance to change is a universal factor in CBT. In the process of CBT therapy, the therapist’s urging to change the belief or to change behaviors that support the belief is what leads to affect, spoken or unspoken. The presence of this affect, along with the cognitive elements, is the clinical indicator that relevant neural circuits are activated and ready for change to take place.

Interestingly, in the case of trauma, the CBT tradition has thoroughly embraced the need for activation of affect. In exposure therapy, the therapist’s primary activity is to use sensory reminders to bring affect into the room so that the perceived threat can be contradicted by the implied safety of the therapeutic situation.

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Within the broad and diverse psychodynamic tradition, focusing on goals has led to misleading arguments about whether to seek insight or empathic connection. The three requirements for extinction and for memory reconsolidation clarify the answer. Insight brings the antidote into juxtaposition with the maladaptive perception of threat, while simultaneous affect is the indicator that deep emotion is in an activated state. Insight alone is not the agent of change, nor is affect. The presence of both along with the antidote is what signals the confluence of conditions required for change to take place. Verbal exploration, seemingly aimed at insight, is actually one of the most effective ways to bring affect “into the room.” Similarly, the development of transference leads to affect-laden, maladaptive expectations coming into contact with surprising and contradictory experience, in what Alexander and French termed the “corrective emotional experience.”

In both traditions, the ostensible (and incompatible) goals of changing outward manifestations versus exploring causes can, in the details of practice, be seen to lead to the same thing: achieving simultaneously the three requirements for extinction and/or memory reconsolidation. This observation can be extended to many therapies, where traditionally formulated goals may or may not reflect the three requirements for change but the unfolding of the therapeutic journey does.

—Jeffery Smith, M.D.

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