Psychodynamic vs CBT: Which One Do You Actually Need?

People very often ask us this question before they book. We do both here, and here is a simplified version.

What CBT Is Good At

CBT works especially well for problems with clear edges: panic attacks, phobias, OCD, insomnia. These are conditions where you can identify what is keeping the symptoms going and work on it directly, and where a focused course of treatment produces real change in a reasonable number of sessions.

If you have been having panic attacks and need them to stop, a good CBT clinician is often the fastest way there. The research is vast (Hofmann et al., 2012), and there is no reason a psychoanalytically oriented practice should be prickly about it.

Where Things Go Wrong

The trouble starts when a protocol built for a problem with clear edges gets applied to something that has a pattern, a recurrence whose cause the patient cannot identify but feels is deeper than the symptoms.

With those, a short protocol often produces something that looks like improvement but does not hold. The person may feel better for a while, and turn up a year later with the same thing in different clothes.

What Depth-Oriented Work Does Instead

Depth-oriented approaches like psychoanalysis start from a different question: what is this doing here, and what has it been holding in place? In practice, that means working with what repeats, with the distance between what a person says and what they mean.

This type of approach tends to be slower. There is no set number of sessions, because nobody knows at the beginning what will be at stake. When it works, it produces a change in how a person stands toward their own history and their own wanting. Symptom relief usually comes along with that, but it is not the only focus or the priority.

Psychodynamic vs CBT: It Is Not Really a Contest

The comparative research on depression and anxiety mostly shows both approaches performing similarly (Driessen et al., 2013; Steinert et al., 2017). What matters is what this particular person is carrying, how long it has been there, how much of their life it has arranged around itself, and what they actually want out of treatment. A person with a specific phobia and a person who has never been able to want anything for themselves need different things.

And many times the two are not opposites. Someone may need symptom relief first; once there's ground underneath, the other work becomes possible. We do that sequence often.

How We Decide

When deciding between psychodynamic vs CBT, keep in mind that every inquiry at Real Talk is read by a clinician instead of being routed to whoever has an opening. The match is based on what the clinical picture calls for: sometimes focused, structured work; sometimes long-term, depth-oriented treatment; and occasionally telling someone that what they need isn't what we do and helping them find it somewhere else.

If you would like to explore this further, read about psychoanalysis at Real Talk, or Request a Session.

Real Talk Clinical Psychology is a doctoral-level group practice in Houston, Texas. We accept Aetna, BCBS, Cigna, UHC/Optum, Tricare, Curative, and Oscar. In person in Houston and via telehealth across Texas, in English, Spanish, Portuguese, and Farsi.

References

Driessen, E., Van, H. L., Don, F. J., Peen, J., Kool, S., Westra, D., Hendriksen, M., Schoevers, R. A., Cuijpers, P., Twisk, J. W. R., & Dekker, J. J. M. (2013). The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: A randomized clinical trial. American Journal of Psychiatry, 170(9), 1041–1050. https://doi.org/10.1176/appi.ajp.2013.12070899

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1

Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry, 174(10), 943–953. https://doi.org/10.1176/appi.ajp.2017.17010057