My experience with psychodynamic therapy vs CBT
When I moved to Maryland in June of 2017 to start a new job at the University of Maryland I needed a new therapist. I was pretty sure that I wanted a male therapist for two reasons I had stuck in my mind. First, I just finished seeing a female therapist and she had mentioned that the transference wasn’t very good. I had looked up “transference”, which is a term from Freudian psychology, but I hadn’t read the Wikipedia article to get a full picture. Instead, I assumed what Freud meant was the degree to which feedback transferred from the therapist to the patient. I was familiar with the concept of implicit bias, so it made sense to me that I might not take an old woman as seriously as an old man. So I felt maybe I could bond closer and more quickly with a male therapist. I had other reasons for preferring a male therapist as well — such as the idea they may be able to better understand issues with porn addition etc.
It turned out there were very few male therapists around where I lived in Silver Spring, Maryland, but I did find one. I have decided to keep him anonymous though since I don’t want to single him out. The point of this post isn’t to hit on one particular therapist, but to explore the differences between psychodynamic therapy and cognitive behavioral therapy. So, won’t go into details about this therapist, but I will say he was an older gentleman with an excellent academic pedigree.
One of the main issues I discussed this therapist was terrible loneliness. This is something I have written about elsewhere, but which hasn’t been published yet (should be forthcoming). I had dealt with loneliness for a few years, but it was at least moderated by the fact that I lived with other people in graduate school. While I was never close with my housemates, at least there were other people around. After moving to Silver Spring and starting to live by myself for the first time, my loneliness reached a whole new level. Prior to moving, loneliness had largely taken the form of a craving for intimacy and occasional pangs of unrequited love. After moving, my loneliness morphed into a general craving for social connection. There were entire days going by where I wasn’t talking to anyone since I worked in an office alone at UMD. I remember waking up in the middle of the night a few times and feeling very anxious and lonely, to the point where I had pain in my chest. There are some exchanges I had with my therapist that have left an effect on me:
Me: “I’ve been waking up every morning and feeling a horrible sensation of loneliness hit me first thing in the morning. I have trouble getting out of bed because I feel so terrible.”
Him: “Well, morning is when couples often do things together.”
This response stuck in my mind and magnified my suffering. Really I had not thinking about life with a SO (at least not consciously). But as a result of the therapist putting the idea into my mind now in addition to feeling lonely every morning I was also ruminating about much better life might be if I had a romantic companion to wake up to every morning. The imagery of how others were spending intimate time with a beautiful companion every morning greatly magnified my suffering and was hard to get out of my head!
One theory I had as to why the loneliness hit me hardest in the morning and seemed to fade in the evening is that it was due to the fact I was taking Lexapro in the morning every morning. Serotonin peaks about 5 hours after taking Lexapro, and then decays with a half life of about a day. It also seems that serotonin levels are lowest in the morning (serotonin production shuts down during REM sleep).
Another thing he said that bothered me was : “You are in a tough position because you realize what you’re missing. There are other guys who are perfectly content being single.” This made me feel worse, since he had just given me another reasons to think that my problems were completely intractable.
The Rorschach test
This therapist was really into the inkblot test, also called the Rorschach test, for which he charged $100. At first I resisted doing it since I knew it was unscientific. After some pestering though he eventually convinced me to do it. He explained that in the 80s a methodology for quantifying the test had been developed. He took copious notes while I explained each slide, marking down different features such as people, animals, motion, and of course genitalia (which the average normal person sees in at least a few of the 10 slides). I found taking the test to be extremely exhausting mentally. At the next session we sat down and went over my results. The results were quite underwhelming- they basically said that I had high anxiety. There had been several slides where I saw running water, and seeing things that are moving is correlated with high anxiety, which makes intuitive sense from an evolutionary perspective. I do feel like I got something out of the test, however, in that it informed me about how I process information. He noted that he had hardly ever seen anyone who went into so much detail about the slides and come up with such elaborate description. My processing style was to focus on minute details and try to make sense of each one.
“Doubling the dose”
In the spring of 2018 I started to become very depressed. Contra dance events, which used to be a life-saving antidote to depression and loneliness no longer brought me any joy. I would dance with beautiful joyful young women (and occasionally men) but the joys of the music, rhythm, group solidarity, and physical contact were all missing. Moreover, the occasional sexual tension I used to experience which enlivened the entire experience was missing. I was very disturbed by the anhedonia I was experiencing and expressed everything as best I could to my therapist. He said that sometimes you need to “double the dose” to twice a week. At first I resisted this because I was already finding the sessions to be a big drain on my time and my wallet (I was paying a $15 copay each time). However, I decided to give it a shot. The result was that I felt worse rather than better. I’m not exactly sure why this was.. but I think it was because of the negative self-talk I was verbalizing and bad memories I was going through during the sessions were leaving me feeling worse. The sessions were also emotionally exhausting, to the point where I remember there were a few times I literally could not work afterwards.
Another thing my therapist taught me was thought stopping, since I was struggling with repetitive thoughts. Some of these had to do with feeling “stuck”, and others had to do with the way particular people in my environment annoyed me. After explaining how I was bothered by constantly reoccurring unproductive negative thoughts he told me to look straight at him. He then said to imagine a large red stop sign. I pictured the stop sign in my head, and while I was holding it in my head he yelled “STOP!!” at near the top of his lungs. He then said to repeat the same thing inside, mentally, when the thoughts occurred — picture the stop sign and yell internally. Another thing he suggested that he said works for some people was to wear a rubber band around my wrist and snap myself with it when the bothersome thoughts arose. I didn’t want to wear a rubber band because I had hear it is a sign of homosexuality, but I was quite enthusiastic about thought stopping. I thought it was brilliant how he startled me with the yell (it was completely unexpected) since it left impression on me which stuck. I began to try to implement thought stopping. However, while perhaps I was able to more quickly recognize and shut down negative or annoying thought patterns, it didn’t decrease their frequency. Later I was told by a CBT therapist that thought stopping doesn’t have much scientific research supporting it. Indeed, if you search for “thought stopping” on Google scholar, most of the scientific papers on it are from the 1970s. So it seems it has fallen out of style. This makes sense — it is hard to stop thoughts, which just arise from our unconsciousness (try not to think about a purple unicorn, for instance). Instead, a better strategy is to explore negative thoughts and the beliefs and experiences that created them. It is also useful to dwell on negative thoughts and explore their logical consequences to see if they match reality. By doing this the thoughts can be disputed and ultimately put to rest.
CBT and lessons learned
During the summer of 2018 I became very depressed so I considered trying to get a different therapist. I knew that the scientific studies (randomized controlled trials) showed CBT to be one of the most effective schools of therapy, but I was under the false impression that there would be a high “switching cost” to switching to a CBT therapist. So, I stayed with my therapist, but told him I wanted to do some CBT techniques (we ended up practicing the ABCDE method, which I have found fairly useful).
However, CBT is different than psychodynamic and other types of therapy because it doesn’t require a long “build up” period. CBT therapists start by giving you things to implement from day one to get you out of the hole you’re in (aerobic exercise, how to recognizing cognitive distortions, sleep hygiene, social activities, diet, etc). Then when you’re out of the hole they may wish to explore the historical sequence that got you to that place and how to avoid it in the future. CBT therapists will ask some basic details about your past, but don’t spend a lot of time going through all the details of the past. CBT therapy is very practical minded and the goal is to get the patient back to normality as quickly as possible and to the point where they no longer need therapy.
Since June 2019 I have been seeing a CBT therapist and am finding it much more useful. Eventually I will write about that.. but for now I figured I’d “push” out this content to “get the ball rolling” with my writing on Medium.