Recently a patient, nearing the end of a lengthy and difficult psychoanalysis, remarked that he was shocked when I advised him to attempt to do some things differently. "Is this after all just behavior modification?" he asked. My response was to point out to him that insight by itself is never enough unless it leads to some change in attitude or action. Insight, one of the stated goals of psychodynamic therapies, involves an understanding of how one's conscious and unconscious attitudes, fears, conflicts, defenses, and ultimately actions, evolved, and how they influence current life. Analysts are quite familiar with the patient who achieves a profound intellectual understanding of his psychodynamics but is unable or unwilling to translate these insights into a different approach to day-to-day living. Sometimes this represents merely the ultimate resistance to change which may or may not be analyzable; on the other hand, it may represent a conscious choice that the change is not worth the price. We may see the latter as a bad choice by our own standards, but since it is not our mission to control our patients we have to let their decisions stand. After all, the goal of any therapy is to not only enable the patient to function more efficiently and effectively, but also to give him greater control over what happens to him in the course of his life.
Many proponents of the psychodynamic point of view and many of those who hold to a behavioristic point of view argue that no rapprochement between the two is possible. Franks, for example, sees the two as quite incompatible.1 Others such as Goldfried see incompatibility at a theoretical level of abstraction, but with the two having many points of similarity in actual clinical practice.2 The Society for the Exploration of Psychotherapy Integration was founded in 1983 by a mixed group of professionals interested in working toward the development of an approach to psychotherapy not necessarily associated with a single theoretical orientation. Most of the membership consists of individuals from diverse professional backgrounds who have recognized that the theoretical orientation in which they were reared is not the answer to all clinical problems. Thus, some psychoanalysts, recognizing that analysis does not solve all clinical problems but who have been unwilling to refer their resistant patients to colleagues with other techniques, began to experiment with some behavioral approaches to their patients. Similarly, some behaviorists concerned about the recurrence of illnesses and the recalcitrance of some of their patients, began to look at motivations in their difficult cases.
Whereas training programs in psychology and psychiatry were usually monolithic in their theoretical approaches in the 1950s and 1960s, the 1980s have seen a number of programs offering to their trainees a broader and more eclectic approach. Chairmen and directors of such programs take the view that not only do patients differ in what methods they will respond to, but therapists also differ in their abilities to use various approaches.
While integration has generally been thought of in terms of varying degrees of unification of behavioral and psychodynamic methods, modern psychiatry has offered still another approach, namely medications. The theoretical roots of psychodynamics go back to the latter part of the 19th century. The origin of behavioral methods dates to the same period and the work of Pavlov, although the application of learning theories and their rapid clinical evolution dates to the 1950s and 1960s. The mid 1950s also marked the introduction into psychiatry of effective drug therapy. Prior to that time, with the exception of some treatments for organically based illnesses, electroconvulsive therapy, sedatives, and hypnotics, treatment was limited to psychotherapy and environmental management. The most recent decade has seen the application of antidepressant drugs for treatment of neurotic depression and phobic disorders - illnesses previously treated largely with psychotherapy. Effective anxiolytics have been available for several decades. Clomipramine has been used extensively outside the United States for treatment of obsessive-compulsive illness. Several new drugs are currently under investigation for treatment of this illness hitherto treated almost entirely by psychotherapeutic methods. Because these medications do not always, or even usually, deal with the multiple manifestations of the above illnesses, they have been combined increasingly with psychotherapies of both types. Thus it is possible to have patients treated concurrently with medication, behavior therapy, and a psychodynamic method, as well as environmental manipulation!
It is axiomatic that theory follows clinical developments. A therapist is dissatisfied or frustrated by lack of progress with a given method, tries something different and is rewarded occasionally by seeing improvement. A theory is then devised to explain what has happened. It is at this latter level of abstraction that Franks sees the irreconcilability of behaviorists and analysts, although he remains committed to a bias against technical eclecticism.1
Diehard proponents of a particular method tend to regard alternative methods as monolithic structures, with the underlying assumption that all members of that school practice identically. Such is hardly the case. Gustafson, in a recent book describing his personal journey through psychodynamic therapies to arrive at a method for brief psychotherapy, lists 17 variants of psychodynamic therapies and has used each of them.3 Similarly, behaviorists run the gamut from strict Skinnerians, through the multimodal therapy of Lazarus,4 to varieties of cognitive therapies evolved from the work of Beck.5 Arkowitz and Messer have reviewed attempts at integration of psychoanalytic therapy and behavioral therapy from a historical perspective.6 They cite early work by French, and by Dollard and Miller, noting that these scholarly works had little impact, perhaps because they were ahead of their time. With the clinical maturation of behavioral techniques in the 1960s, it was inevitable that some efforts at integration would follow. They note that individuals from both camps advocated integration in the 1960s, including Marmor,7 Weitzman,8 and Marks and Gelder.9
Not until the late 1960s and 1970s were there clinical publications of actual cases involving integration of therapies in a variety of ways. In 1977, Wachtel endeavored to integrate behavioral and psychoanalytic approaches at both theoretical and clinical levels.10 Arkowitz and Messer stress that Wachtel based his concepts not only on orthodox Freudian analysis, but on more recently developed interpersonal and object related concepts. They add, "Like Feather and Rhoads, Wachtel concluded that treatment interventions based on these inferences need not be limited to traditional psychoanalytic approaches but could include the behavioral ones as well ... He demonstrated how behavioral interventions might facilitate insight and how, in turn, insight might facilitate behavior change further . . . emphasized insight into current feelings and behaviors, rather than the early historical insight that was characteristic of Freudian psychoanalysis." We and others have emphasized the use of the concepts of transference and resistance in behavior therapy," as well as the use of assigned activities and fantasies, relaxation training and biofeedback, and ego educational techniques in dynamic therapies.
Wachtel sees the essence of psychodynamic therapies as a focus on unconscious processes, conflict, the compromises that conflict, anxiety, and self-deception lead to the uncovering of unsuspected motives, and the effort to make sense of the unities behind the diverse and confusing range of phenomena elicited in the sessions.'2 Dynamic therapies focus on the subjective. He contrasts this to the behavioral approach characterized by a focus on the current environmental context of the patient's behavior, the focus on specific target complaints, a relatively greater emphasis on active intervention, and usually sharing explicitly with the patient the rationale for each procedure. Wachtel summarizes that in most psychodynamic therapies, "the inquiry into the patient's difficulties and the intervention techniques are essentially the same. Understanding is the therapy ... In behavior therapy, the understanding that is attained- by both patient and therapist - is applied." With these striking differences, how is it possible to achieve synthesis and integration?
It seems appropriate to point out that there are differences in the vocabularies of the two points of view. A number of efforts have been made to translate the one into the other. Dollard and Miller made this effort almost four decades ago.15 Lazarus coined the term "technical eclecticism," referring to the use of whatever seems to work in a given case regardless of theoretical system.14 Wachtel, on the other hand, tries to synthesize behavioral techniques into a general psychodynamic point of view.15 Both may be useful approaches to the problem of treatment in a given case. Behavior therapy and psychodynamic therapies may be combined in the following ways:
* Behavior therapy may serve as an introduction to therapy.
* Behavior therapy may be an adjunct to psychodynamic therapy, used in the course of the latter.
* Psychodynamic therapy may be an adjunct to behavior therapy. Either may follow the other sequentially.
* Either may be used in conjunction with medication prescribed to control a particular symptom.
Patients come because of concern about symptoms. Therefore, alleviation of symptoms is the logical approach, and one to which patients can relate. Thus, if a symptom can be relieved by medication or behavior therapy, the working relationship with the therapist is enhanced. Although this may be all that is necessary, in some instances symptoms may be due to conflicts of an intrapsychic nature or environmental pressures. For more lasting relief, these may need to be understood by the patient, and new approaches to the solution of these life problems may need to be evolved. To illustrate this situation, let us take the example of someone suffering from panic disorder. Conventional therapy for this illness involves a variety of medications: tricyclic antidepressants, MAO inhibitors, benzodiazepines, and propranolol. These usually control the random and unpredictable occurrence of the attacks. However, the panics may lead the patient to develop some of the secondary complications of the illness, such as phobias or even agoraphobia. Such phobias yield to a variety of behavioral methods, including in vitro or in vivo desensitization or modeling. However, freed from the disability imposed by panics and phobias, hitherto unsuspected immaturities or conflicts may only now emerge. These may be best treated by a psychotherapeutic approach aimed at a greater awareness of repressed fears, conflicting motives, guilts, and selfdefeating defenses.
Behavior therapy may serve as an adjunct to dynamic therapies by dealing with specific aspects of the patient's difficulties. In the course of psychodynamic therapy, the patient may learn control over disabling anxiety through relaxation techniques, possibly combined with biofeedback. In one such instance, a patient in psychoanalysis whose anxiety utterly preoccupied him was referred for relaxation training and biofeedback. This therapy enabled him to better control the anxiety, and enabled the analysis to move forward as more relevant content emerged. Similarly, the use of ego-educative techniques such as assertive training may help the patient in therapy to apply what he has cognitively learned.
Psychodynamic therapy may be adjunctive to behavior therapy by facilitating the process when it is slowed by resistances or by negative transferences. A dynamic interpretation can help the patient understand the nature and origin of these impediments to progress. I reported the case of a patient suffering from severe obsessive-compulsive disorder manifested by prolonged showers and multiple handwashings who was assigned behavioral tasks to help control his symptoms.'6 The patient consistently "forgot" to time the duration of his showers, he consistently lost count of the number of handwashings, so that it was difficult to establish a baseline. Part of this resistance derived from his ambivalent relationship with his parents. Another part arose from the current ward situation where his primary nurse was a young, pretty, and very religious nurse. He asked to be reassigned to another older, more motherly nurse. Discussion led to the disclosure of a Madonna-prostitute fantasy, which determined the wretched consequences of his relationships with women. This disclosure led to improved cooperation with the behavioral program, and to a start on a new way of looking at women.
Either therapy may be used sequentially after the other. Thus, in one of my cases, a young man with a crippling inhibition of urination was initially treated by in vivo desensitization by having him use restrooms in the hospital, distant from the ward and seldom used, with gradual habituation to restrooms where he would be more apt to encounter others.13 A fortuitous event in group therapy led to the use of a flooding technique wherein he was encouraged to fantasize urinating on people with whom he was angry. The breakthrough led to an almost immediate mastery of his symptom, and opened up to both patient and therapist the long repressed problem of his inability to cope with angry feelings. Based on this insight, a period of assertive training was instituted. Psychodynamic insight was the basis for choice of a behavioral technique. This was followed by psychodynamic therapy aimed at exploring the origins of his inhibition of aggressiveness and assertiveness that had paralyzed nearly all types of social intercourse. A further illustration of this principle is the use of Maletzky's technique of covert desensitization for management of exhibitionism.17 It has been well documented for many years that psychodynamic therapy for exhibitionism usually does not control the illness. Behavioral methods have had considerably greater success. In many instances, however, the psychodynamics that lie behind the symptom and lead to recurrences may need to be understood in an effort to ensure against recurrence.
To return to the illustration of panic disorder, after the initial symptom has been controJled, the patient often manifests a variety of other problems of a conflictual nature. Particularly, when the panic disorder has been present for a number of years, the individual has withdrawn and personality growth and development have suffered because of social isolation. Such arrests of development may best be dealt with in group therapy aimed at enhancement of social development, or in individual therapy with the goal of aiding the individual to develop a better understanding of social and personal interactions.
To summarize, there are a number of superficial similarities between behavioral and psychodynamic methods. These involve aspects such as modeling and identification with the therapist, cognitive learning, and corrective experiences, as well as the analysis of antecedents and consequences. There are the basic differences noted above in that the one focuses more on subjective elements, the other on more objective ones; there is a relative difference in the activity level of the therapists. The two therapy methods may be used as indicated in some of the above instances, sequentially or concurrently in a given case. They may also be used in a synthesized fashion, such as a behavioral/educative method to remedy ego defects in the course of psychodynamic therapy, or dynamic insights and interpretations used to determine the type of behavior therapy used or to remove blocks to its progress. Additionally, either may be combined with appropriate medication. This is especially true in cases of depression, where the symptom is severe enough to sap energy and motivation. No one form of psychiatric treatment is 100% successful. Therefore, it seems logical to attempt various combinations of therapies deemed most likely to be effective in a given situation. This is particularly true today as insurance companies, government agencies, and utilization reviews press us for briefer and more effective forms of treatment.
1. Franks CM: On conceptual and technical integrity in psychoanalysis and behavior therapy. Two fundamentally incompatible systems, in Arkowitz H. Messer SB (eds): Psychoanalytic Therapy and Behavior Therapy. Is Integration Possible? New York, Plenum Press, 1984, pp 223-247.
2. Goldfried MR: Toward the delineation of therapeutic change. Am Psychol 1980; 35:991-999.
3. GustafsonJP: The Complex Secret of Brief Psychotherapy. New York, WW Norton, 1986.
4. Lazarus AA: The Practice of Multimodal Therapy. New York. McGraw-Hill, 1981.
5. Beck AT, Rush AJ, Shaw BF. et al: Cognitive Therapy of Depression. New York, Guilford, 1979.
6. Arkowitz H, Messer SB: Historical perspective on the integration of psychoanalytic therapy and behavioral therapy, in Arkowitz H, Messer SB (eds): Psychoanalytic Therapy and Behavior Therapy. Is Integration Possible? New York, Plenum, 1984, pp 1-30.
7. Marmor I: Psychoanalytic therapy and theories of learning, in Masserman I (ed) : Science and Psychoanalysis. New York, Grune & Stratton, 1964, vol 17.
8. Weitzman R: Behavior therapy and psychotherapy. Psychol Rev 1967; 74:300-317.
9. Marks G?, Gelder MG: Common ground between behavior and psychodynamic methods. Br / Med Psychol 1966; 39:11-23.
10. Wachtel PL: Psychoanalysis and Behavior Therapy. New York, Basic Books, 1977.
11. Rhoads |M, Feather BW: Transference and resistance observed in behavior therapy. Br J Med Psychol 1972; 45:99-103.
12. Wachtel FL: On theory, practice, and the nature Of integration, in Arkowitz H, Messer SB (eds): Psychoanalytic Therapy and Behavior Therapy. Is Integration Possible? New York, Plenum, 1984, pp 31-52.
13. Dollard J , Miller NE : Personality and Psychotherapy. New York, McGraw-Hill, 1950.
14. Lazarus AA: In support of technical eclecticism. Psychol Rep 1976; 21: 415-416.
15. Rhoads JM: Relationships between psychodynamic and behavior therapists, in Arkowitz H, Messer SB (eds): Psychoanalytic Therapy and Behavior Therapy. Is Integration Possible? New York, Plenum. 1984, pp 195-211.
16. Rhoads IM: The integration of behavior therapy and psychoanalytic theory. J Psychiatric Treatment and Evaluation 1981; 3:1-6.
17. Maletzky BM: "Assisted" covert desensitization in the treatment of exhibitionism. J Consult Clin Psychol 1974; 42:34-40.