Cognitive-Behavioral Theory With a Dash of Lacanian Psychoanalysis, Research Paper Example

Abstract

The text presents the author’s personal theoretical model of personality and psychotherapy, as grounded in the theory of Cognitive Behavior Therapy (CBT), alongside the minor influence of Lacanian psychoanalysis. The logic behind this link of theories is primarily based on the intention to avoid any reification of human nature, which is to say, a significant aspect of psychology is the understanding that there subsists no “normal” subject or personality. Furthermore, CBT is selected both because of its reliance on an ever-changing scientific paradigm, which makes it adaptable to the evolution of psychological theory and practice, and its empirically demonstrated efficacy.

Overview  

The selection of a personal theory in psychology is clearly decisive in shaping how the therapist will approach the clinical environment and the relation to the client: in this sense, it can be suggested that theory inevitably overdetermines practice. However, for this same reason, a personal theory must remain adaptable to change, avoiding a “greater meta-narrative”, which already claims beforehand to epistemologically grasp precisely what defines the field of psychology and the subject of the client. In other words, as Cowles notes, “in psychology the sometimes heated discussion of the dangers of the reification of factors, their treatment as psychological entities, as well as arguments over, for example, just how many personality dimensions are necessary and/or sufficient to define variations in human temperament, continue.” (2001, p. 170) Accordingly, instead of proclaiming a theory that would perform such a fallacy of reification in light of the clear ambiguity and ongoing development of psychological concepts, the construction of personal theory must remain cognizant of such heterogeneity within the field, so as to forward the most robust and malleable theory possible. For this reason, it is precisely theories that emphasize the internal dynamism of psychology and the possible revision of prima facie foundational concepts which are of pertinence, to the extent that they do not attempt to hypostatize any essence of the client, nor delimit with a finality what psychology in the last instance entails. With this aim in mind, I would like to stress two theories in particular that I feel capture this idea: Cognitive Behavioral Theory (CBT) and the work of post-Freduian psychoanalysis, particularly that of Lacan. While this may seem like an unlikely marriage of theories, according to the ongoing disputes within the academic literature between the two outlooks, (i.e., Miller, 2007), both share the commitment to a malleable psychological framework. On the one hand, CBT’S reliance on empirical science and research is receptive to change, since scientific knowledge is always evolving. On the other hand, if psychoanalysis in its Lacanian guise opposes CBT to the extent that “the universalization of the discourse of science…forecloses singularity, and thus the dignity of the subject” (Voruz & Wolf, 2007, p. xvi-xvii), it could be argued that science is not a closed discourse, as new scientific discoveries constantly emerge. Rather, both theories oppose reification and allow for such singularity and change within psychology. The Lacanian approach provides us with a strict reminder of precisely what Voruz and Wolf term a singularity – that each client should be treated with a dignity – this is a certain ethical imperative within practice. However, at the same time, the client exists as client following the very real problems with which they are confronted. In this case, calls for singularity and dignity, while providing both an ethical foundation and warning against the reification of science itself, must be supplemented by an empirically valid practice, where practical results are conferred a decisive importance. For this reason, the empirical evidence which points to the successes of the CBT model are of utmost importance (i.e., Butler, Chapman, Forman, & Beck, 2005): the reliance on scientific and empirical data provides a robust foundation for practice.  Hence, in considering this personal theory two factors are of utmost importance: 1) the avoidance of any reification and essentialism of the human subject, human nature, personality, psychology, etc.; 2) the simultaneous acknowledgement of the reality of the psychiatric disorders experienced by the client, which thus calls for an effective practice, one which is most arguably realized by a reliance on empirical data and scientific literature. In this regard, the following overview of my personal theory will be based on views of human nature and personality informed by both Lacanian psychoanalysis and CBT, whereas the therapeutic process shall be informed by CBT alone. This theory implores us to oppose reification, while also demanding real and practical solutions to psychiatric disorders. Moreover, both theories can essentially be viewed as based on an approach to psychology, whereby the latter is construed as a continually dynamic and evolving field.

Basic Overview of Human Nature

Although most explicit in Lacanian psychoanalysis, both the latter and CBT suggest a basic view of human nature in which no essentialization of human nature is advanced. The account of human nature is rather nuanced by a certain epistemological gap or blind spot concerning what is human nature. Whereas voluminous interpretations of Lacan’s  theory exist, in light of the aforementioned imperative to avoid reification, it is worth citing Adrian Johnston’s synopsis of Lacan’s view on human nature: “Nature, (at least human nature) should not be envisioned as an integrated organ wholeness, a co-coordinated sphere of components interrelating according to the laws of an eternally balanced harmony.” (2006, p. 35) Such an account suggests that human nature itself remains somewhat fragmented, ruptured and split – human nature is itself an inconsistency. As Lacan himself notes, in his seminal paper, “The Mirror Stage as Formative of the Function of the I as Revealed in Psychoanalytic Experience,” his theory of psychoanalysis is one “that leads us to oppose any philosophy directly issuing from the Cogito.” (2001, p. 1) This remark can be taken as an imperative to avoid thinking of an isolated and almost solipsistic I as constitutive of the subject of psychiatry – the concept of the subject is not one that is only more complex than the Cogito, but rather, incomplete. As Elliott summarizes Zizek’s interpretation of Lacan there is a “lack, insufficiency, and loss which fundamentally marks the desire of the human subject” (2003, p. 274), to which it could be added that there is a fundamental lack that marks the desire to know the human subject. Our conceptual models of human nature can be continually revised, and we have to understand that the construction of theory is as much constituted by a lack as the subject and phenomena being analyzed.

Theory of Personality

However, the importance of this fundamental lack does not entail that real psychiatric disorders are absent. In this regard, cognitive-behavior therapy provides a pragmatic supplement to the anti-essentialism of Lacanian psychoanalysis. Thus, that “modern behavior therapy is grounded on a scientific view of human behavior”, (Corey, 2009, p. 237) does not indicate the universalization of science, but rather that science itself essentially entails an open discourse, according to which scientific gains and contributions can be added to our continuing understanding of human nature. It is thus prescient to understand the heterogeneous conditions for how personalities develop: following the Lacanian view, we must respect singularities, i.e., there can be no reduction to a pre-given template of how personality emerges (despite, for example, Lacan’s quite detailed account of the Mirror Stage in the aforecited 2001, insofar as Lacan’s theory did change over time); in this regard, my personal interpretation of CBT stresses that, according to the notion of science as open system, and furthermore, CBT’s reliance on system, one must refrain from making transcendental claims about how personality emerges. Rather, the emphasis within CBT on science entails that assumptions about human nature are kept to a minimum, as theoretical and conceptual models may be continually revised, thus avoiding reification.

Causes of Psychopathology

At the same time, such an approach provides a real empirical and practical emphasis on particular cases of psychopathology, which can then be situated in relation, but not reduced to, the scientific literature. In my view, CBT provides a radically open definition of psychopathology, insofar as the latter is understood as a form of maladaptation. As Hoffman notes, the usage of maladaptation deliberately suspends questions of the origin of psychopathology, rather focusing on “psychiatric disorders as real human problems that can be treated with real human solutions.” (2012, p. 8) Such a definition avoids the pitfall of essentialism, by concentrating on specific symptoms and moreover, the fact that they have become problematic, as evidenced in the term maladaptation. As Herbert and Forman write, “like all scientifically-based disciplines, CBT is not static, but continously evolving. Established theories and technologies continuously and inevitably give rise to new developments” (2010, p. 4), such that “CBT has become largely synonymous with empirically supported, evidence-based psychological theories and technologies aimed at improving the human condition.” (2010, p. 4-5) This is indicative of a radical openness in approach, without the pronunciation of any reification – real problems become the entire focus of CBT:

Therapeutic Process

Therapeutic Goals       

Accordingly, such openness does not entail the abandonment of the therapeutic process, but, in contrast, the attempt to continually develop more efficient and successful therapeutic processes. Whereas the Lacanian theory provides a valid imperative in its avoidance of reification, one that is reflected in CBT’s commitment to science, it is the latter which is more conducive to the specific area of therapy, following its acceptance of an ever-changing scientific paradigm, such that my individual therapeutic approach is one entirely defined by the perceived strengths of CBT. Such strengths are lucidly evinced in how CBT approaches therapeutic goals. According to our epistemological lack, “CBT recognizes that treatment is often not curative, but rather is focused on building coping skills.” (Beebee & Risi, p. 376) With such an aim, CBT does not advance an artificial teleology of what constitutes a normalized client, nor is there any desire to advance some reification of normalcy. Rather, there is a specific problem experienced by the client, to which CBT therapy is directed in an attempt to minimize this disorder. The coping as opposed to curative approach thus does not presuppose some ideal psychic state towards which the client should aspire, but rather emphasizes the particular difficulties of individual situations, so as to develop a strategy that may lessen or overcome them.

Accordingly, although CBT acknowledges the heterogeneity of psychiatric disorders and client situations, there is nevertheless an underlying therapeutic approach to improve disorders in light of acknowledged difficulties, concisely defined as follows: “CBT helps clients change the thoughts that they have in particular situations so that they will begin to view the world in a more accurate and adaptive way.” (Ledley, Marx, & Heimberg, 2010, p. 85) Here it is crucial to underscore that the “accuracy” of such a “way” must be supplemented with an acknowledgment that accuracy in this case means the minimization of the client’s own individual problems. Hence, the motivation of clients to change is primarily engendered by a self-acknowledgement of the damaging behavior. The therapeutic process is based on the crucial correlate between the cognitive and the behavioral, in the sense that the former may determine the latter in some manner – the client’s potential change within the therapeutic process follows the minimal imperative of “simply talking about thoughts.” (Ledley, Marx, & Heimberg, p. 85) This basic imperative can be viewed as a certain demystification of the psychiatric disorder at the heart of CBT’s approach to therapeutic change, insofar as the problems of the client are clarified in terms of the minimal pairing of thought and behavior.

Therapeutic Relationship

Thus, despite CBT’s reliance on empirical studies and continuous scientific research in order to better clarify the link between thought and behavior, there is nevertheless a crucial therapeutic relationship at stake in the theory, as the very utilization of the scientific paradigm, primarily guided by the thought-behavior correlate, aims to aid the client. Whereas it has been noted that, “some trainees initially are so focused on the techniques of CBT that they forget the importance of the therapeutic relationship” (Zayfert & Becker, 2007, p. 44), in this regard it is crucial to understand that it is the therapeutic relationship which is the parallel foundation of CBT (along with science), precisely because this relationship is the condition for CBT’s existence. Yet this relationship, as a parallel foundation for CBT, avoids what we have termed reification, which can cause a judgment of the client and thus subvert the trust between client and therapist necessary to the effectiveness of therapy: “embracing the least judgment conceptualization of patient behavior is an important strategy for facilitating the therapeutic relationship and developing a positive view of your patients.” (Zayfert & Becker, 2007, p. 44) Rather, the relation of the patient to scientific evidence, and thus the form of CBT’s precise therapeutic relationship entails that “symptoms and dysfunctional behaviors are conceptualized as evidence that patients have inadequate skills to manage their emotional reactions”, (Zayfert & Becker, 2007, p. 44) such that the empirical data is interpreted in terms of the particular case. The therapeutic relationship essentially denotes the empirical exposure of the symptom to the therapist, followed by the subsequent development of the appropriate CBT technique to address this purely empirical symptom. In this manner, a crucial trust is developed between the client and therapist, as the framework of the relationship is made clear: the client visits the therapist in order to attempt to alleviate or minimize the behavioral problem. For Swett and Kaplan this means that the therapeutic relationship is “a collaborative investigation undertaken by the therapist and the client; it explores thinking patterns and beliefs that an individual holds that may lead to maladaptive behaviors, erroneous beliefs about oneself and others, and debilitating relationships with the world.” (2004, p. 159) In other words, it is, what may be termed, an empirical sharing of the symptom that allows the therapist to offer particular forms of treatment, without the burden of essentialism or judgment, which constitutes the therapeutic relationship within CBT.

Major Therapeutic Techniques

Therapeutic techniques within CBT are relative to the particular case in question, in accordance to both CBT’s openness to conceptual revision and its continual engagement with an ever-changing body of scientific and empirical literature. Accordingly, the radically immanent approach of CBT maintains that “how one thinks largely determines how one feels and behaves”, (Engler, 2009, p. 452) such that techniques are centered on this general principle of encouraging shifts in thinking to engender correlative changes in the patient’s behavior. This essentially foregrounding technique is thus part of what is termed “attribution change techniques” (O’Donohue & Fisher, 2009, p. 38), a “crucial foundation” (O’Donohue & Fisher, p. 38) for the therapeutic process, whereby the “theoretical rationale behind CBT” (O’Donohue & Fisher, 2009, p. 38) is communicated to the client. This permits the patient to understand the correlation between the thoughts, feelings, and behavior, i.e., a conjunction between negative thoughts and specific forms of behavior, furthermore enabling him or her to basically understand the framework in which CBT operates, and moreover, the framework in which their therapeutic relationship is to take place.

Following such a disclosure of the basic spirit of CBT, a common technique is that of “collaborative empiricism”, whereby the relation advances the notion of “the client as a practical scientist who lives by interpreting stimuli, but who has been temporarily inhibited by problems with information gathering and integrating mechanisms.” (Swett & Kaplan, 2004, p. 161) In this scenario, there is a certain radical reversal of power relations, as the client who seeks help collaborates in the investigation of his or her own difficulties – arguably, this creates a distance between the client and the difficulty, to the extent that the client understands he or she is not reducible to the latter. As Ledley, Marx, and Heimberg note, this fundamental CBT technique opposes the “image of therapy” whereby “the “all-knowing” clinician to provide an interpretation of the origins of the client’s difficulties.” (2010, p. 86) Teleologies and essentialisms are broken down in this essentially open investigation of the client’s psychiatric disorder.

Such a technique is supplemented by that of “guided discovery”, primarily based on a form of Socratic questioning, in which different perspectives on how to view the given problem are advanced. Accordingly, the aim is “to gather information and to invite the patient to devise plans to use the information gathered to generate…behavioral experiments.” (Kinsella & Garland, 2008, p. 17) This form of “inductive reasoning” (Kinsella & Garland, 2008, p. 17) particularly concentrates on a “recent problem situation”, in which problematic behavior is registered: the aim at can be construed as radically collaborative, as the client becomes involved in the same function of analysis.

Application and Future Directions

Following the non-essentialist stance of my theoretical position, reflected in the Lacanian (theoretical) and CBT (theoretical and practical) influence, its realization in practice is most conducive to patients experiencing real everyday practical problems. Here, theoretical abstraction is tied to the developing empirical literature, while the crucial link between thought and behavior remains at the forefront. Patients, for example, suffering from post-traumatic stress disorder (PTSD), can clearly view the inter-connection between a given event, their behavior, and their thoughts concerning the event. According to the fundamental correlate of thought and behavior, the CBT approach is thus germane to a wide range of disorders, especially in cases of particular neuroses whereby a particular behavior is linked to a particular thought, such that thought and behavior can be succinctly delimited. Such a wide-ranging application of CBT is supported by empirical evidence. For example, in a review of “meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders” (Butler, Chapman, Forman, & Beck, 2006, p. 17), the authors’ determined “the efficacy of CBT for many disorders.” (Butler, Chapman, Forman, & Beck, 2006, p. 17) More specifically, “CBT was somewhat superior to antidepressants in the treatment of adult depression”, (Butler, Chapman, Forman, & Beck, 2006, p. 17) thus demonstrating the clear empirical efficacy of CBT.

Such empirical data clearly indicates CBT’s validity for a wide variety of disorders. Concomitantly, one of the great advantages of CBT is that it does not make any grand claims about what constitutes psychic disorders, human nature, etc.  Such an advantage is supplemented by Lacanian psychoanalysis’ broader theoretical antagonism towards forms of essentialism and its commitment to the aforementioned “singularity” of the subject. This theoretical approach yields an essentially continuously open system, one that emphasizes real individual problems of clients. Insofar as CBT is a developing theory, its future remains open, such that my own personal utilization of the theory within practice will remain as open as the theory itself. Furthermore, to the extent that CBT relies on empirical data, it is crucial not to separate one’s own clinical practice from the empirical realm itself. That is to say, my own seeing of clients is a part, however minor, of the empirical and scientific data, such that personal clinical practice itself can be used as a foundation upon which to extrapolate techniques and expand the theory itself.

Works Cited

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