Comparison of models of psychotherapy

Depression is one of the most common and widespread psychiatric disorders in the UK. Of over 5000 British residents, approximately 5.9% of males and 4.2% of females suffer from depressive illnesses (Based on DSM-IV criteria) (Ohayon, 1999). Consequently there has been much emphasis on implementing techniques and psychotherapy to solve these issues and find effective treatments for depression. This essay describes and critically evaluates psychodynamic therapy which is one of the most traditional psychotherapeutic methods of dealing with depression; while comparing and contrasting this traditional approach to the much more modern and focused intervention, Cognitive Behavioural Therapy (CBT), developed by Beck (1976). It is the disparity between these two forms of therapy, which will make it interesting to see how they are implemented successfully for the treatment of such a prevalent and deliberating disorder as depression.

The essay will begin by briefly outlining depression as a disorder and discussing the development of psychotherapeutic therapy to treat it. After this the psychodynamic approach will be explored in order to gather an understanding of its views of solving the problem of depression, before moving on to introduce the CBT approach concentrating on how both approached have been applied to depression successfully. After each approach has been outlined the essay will go on to critically evaluate each approach, firstly in terms of its empirical grounding in research before moving on to gather an understanding of its theoretical grounding. Before finally going on to conclude as to what is the best option for dealing with such a common and problematic condition.

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Depression is a condition which is characterized by negative mood as well as physical symptoms. In some cases people are born with a predisposition to depression through neurological disorders. However, for many others, depression is likely to occur as a consequence of changing life circumstances. (reference) For many years clients were treated with medicines such as anti-depressants. However, the stigma and the side effects that are associated with this medication, mean that many patients diagnosed with depression are reluctant to use them. A survey carried out by Priest, Vize, Roberts, Roberts and Tylee (1996) used questionnaires and interviews to discover the lay person’s beliefs and attitudes to pharmaceuticals as treatment of depression. The study found that 78% of the 2003 participants from across the UK, regarded antidepressants as negative and addictive. This demonstrates that there is still significant stigma about the effectiveness of anti depressants. The general public are very sceptical about using medication as a quick fix to their depression, even though research consistently demonstrates that medication has been effective in treating many depressed individuals.

When gathering an understanding of depression Freud (1917) believed that the symptoms of depressed individuals were very similar to those reactions of loss and mourning. As such he proposed that depression originates from a loss in early childhood. Furthermore he postulated that the loss, which is experienced, could be imagined (Lowry, 1984). Freud’s (date?) definition of what constitutes a loss was broad, as it was clear that not all depressed individuals had lost a loved one. Thus Freud (date?) incorporated the idea of a symbolic loss. This could involve the loss of social status, a job or even the loss of some believed affection they once held. It was the reaction to losing the real or imagined object, that Freud believed leads the individuals to become depressed and thus develop feelings of self-hatred (Comer, 1992).

Although, at first sight, it would seem as though experiencing love and attention as a youngster is required in order to prevent depression from presenting itself in later life. Freud also argued that in some instances, too many positive experiences are present, during the first year of life, which consequently sets the individual up for developing depression later on in life (Comer, 1992). Freud believed that an infant will not develop beyond the oral stage, in which they constantly require attention and gratification, if an individual is nurtured too much as an infant. Thus when this attention, love and gratitude begin to disappear as the child grows older; this can lead to feelings of loss and thus depression and unworthiness.

In treating depression, psychodynamic therapy aims to aid clients in exploring and understanding the long-term origins to the current function of their issues and problems. This can include various painful emotions, mental conflicts or problematic connections with key attachment figures. When working with depressed individuals psychodynamic therapists are concerned with exploring any indicators such as loss, fear etc as to the unconscious psychic activity of the client. By the way they talk about key events and situations both in their past and present and the associated feelings they hold with these events. The therapy aims to constantly correspond between past and present experiences in order to make any possible connections between the two scenarios.

As the process of transference is such a distinctive and key component of psychodynamic therapy, the relationship between the depressed individual and the therapy is viewed as essentially important (Jacobs, 1986; 2004). It is through this process that the depressed individual is likely to express their true unconscious thoughts and beliefs, while they play out previously disturbing relationships with the therapist. The depressed individual is likely to make negative, erroneous judgements and beliefs about the therapist as they portray previously difficult relationships onto the therapist. It is through the therapist’s interpretation of this transference that the client can begin to gather a better understanding of their true underlying beliefs and bring these into conscious awareness to be dealt with, and thus prevent them from reoccurring in future relationships.

Find all citations by this author (default).Or filter your current searBeck et al (1979) argued that this approach to dealing with psychological disorder such as depression is far too subjective and thus proposed that an effective alternative to this form of psychotherapy was a structured, practical and problem focused intervention which he named Cognitive Behavioural therapy (CBT). Beck et al (1979) believed that by focusing instead on assessing and modifying how the client has constructed their faulty thoughts and thinking habits, along with encouraging the adoption of more functional behaviours, then CBT would give clients a much more active and effective alternative outlook in overcoming their depression.

In comparison to psychodynamic therapy, the focus of CBT is on the patients present thoughts and behaviours. Therefore CBT postulates that although depression is likely to be related, at least to some degree, to previous life events and difficulties, it is the way that we view these difficulties and the coping strategies that we implement that plays a major role in the nature and degree of subsequent depression (Beck, 1976).

When applying the CBT technique to depression the main premises of the technique remains in what is a present orientated, collaborative and a very problem focused approach. Initially, the nature of depression and its maintaining factors (i.e., thought patterns and behavioural tendencies) are outlined. From the outset the client plays a very active role in identifying these factors and working collaboratively with the therapist to mitigate these in the future.

The course for tackling depression using CBT consists of three phases; the first phase consists of behavioural change in which the client is asked to monitor their behaviours by keeping a log of their activities in order to identify the link between their behaviours and their subsequent mood. The therapist and client can then work together to identify those areas which seem to enhance their mood, and thus set realistic short and long-term goals, which concentrate on eliminating and avoiding negative behavioural outcomes or replacing them with active coping strategies. When these goals have been met successfully patients can receive rewards for achieving them.

Once the client has become a much more active participant in their own environment, the focus of the therapy can focus its attention on cognitive restructuring. This is where the therapist works with the client using socratic questioning to identify their faulty core beliefs and thus to evaluate and refute these in order to mitigate and question their automatic negative thoughts and beliefs in the future. Recording these thoughts allows the therapist to identify any cognitive distortions that are held by the individual and express these to the client as well as new positive outlooks.

Finally it is important that the therapy concentrates on avoiding any relapse for the client. Therefore it is important that this stage aims to change dysfunctional assumptions and schemas. This stage will concentrate on exploring current setbacks before going on to plan how to deal with any future relapses. This is an essential elemen to prevent future relapses and address the reoccurrence of this disorder (Fennell, 1989).

Identifying an effective and long-term treatment of depression is crucial. Segal et al (2002) demonstrate that of those who experience major depression 85% of these will relapse into depression over their lifetime. In high-income countries, about 6% of the adult population will suffer a major depressive disorder over the course of a year. Combining the reoccurrence of this disorder with its prevalence in today’s society, demonstrates how imperative it is to identify effective approaches to helping those suffering with depression.

The effectiveness of the CBT approach in treating depression is verified and demonstrated through its grounding in empirical research. Numerous meta-analysis are cited throughout the literature regarding psychotherapy, which support the value of CBT in treating depression. A wide scale meta-analysis carried out by Gaffan (1995) which analysed 65 studies into the effect of CBT in comparison with other therapies in treating depression, confirmed previous conclusions that the outcome of CBT in treating depression was superior to that of other forms of psychotherapy and to that of pharmacotherapy. Further support for the effectiveness of CBT comes from a smaller scale meta-analysis by DeRubeis, and colleagues (1999), which examined four individual studies to compare the outcome of medication and CBT therapy in treating depression. The analysis concluded that CBT is equally as effective as medication in treating depression. However by examining the procedure used by DeRubeis, et al (1999) in more detail, it is clear that the methodology is flawed. Of the four studies used in this meta-analysis three used the drug imipramine and one nortriptyline to represent anti-depressants. Nevertheless, these two drugs were generalised to represent all antidepressant medications. Such problems in methodology, question whether CBT is as effective as antidepressants in treating depression or whether it is in fact only limited to the anti depressant, imiparimine.

Using meta-analysis to collaborate and distinguish the efficacy of therapy is a widely accepted method of synthesising independent studies. Nonetheless this analysis is evidence that although it is important to distinguish that they are not without their limitations. It is also imperative, to disentangle and recognise that the assumptions and conclusions drawn from these wide scale meta-analysis are occasionally incorrect and misinterpreted.

These meta-analysis which have been mentioned are criticised by Lynch Laws and Mackena (2009) for ignoring important variables such as gender differences, age, as well as methodological inconsistencies between and within the studies incorporated, as they are hidden in the mix of numerous independent studies. Lynch Laws and Mackena (2009) argue that there are too many sources of bias in such wide scale meta-analysis. Those investigating CBT and depression have based their conclusions on those studies which have been carried out against treatment as usual or a waiting list control which are not randomised, furthermore they consistently fail to use clear diagnostic criteria to assess depression and consistently ignore the moderating effect of blindness altogether. Shapiro et al (1994) suggest that the common theoretical background of CBT and the Becks Depression Inventory (BDI) which is commonly used to test depression outcomes, may to some degree introduce bias for the efficacy comparisons between those therapies such as psychodynamic. All these sources of bias, which are often overlooked in these studies evidently, question whether the majority of meta-analysis studies can actually be considered as so rigorous in literature reviews.

Although these wide scale meta-analysis are highly criticised, the effectiveness of CBT in treating depression can not be ignored. There have been countless studies that demonstrate the effectiveness of this treatment of depression. Recent independent research by Schindler (2010) implemented a questionnaire to distinguish the prevalence of symptoms before and after treatment. Results illustrated a significant alleviation of depressive symptoms and psychological manifestations during the course of CBT, with 61% of all participating clients achieving better than 50% improvement of their symptoms. Although it is easy to criticise empirical studies such as these as implementing restrictive quantitative analysis such as questionnaires, it is nonetheless important to recognise the empirical validity of this approach.

One key area where CBT stands out in demonstrating its effectiveness is through relapse prevention, especially as it focuses on modifying behaviours and maintaining these modifications after treatment has been terminated. Gloaguen, Cottraux , Cucherat & Blackburn (1998) carried out a meta-analysis that collated findings from eight independent studies. They found that 60% of patients treated with anti-depressants would go on to relapse after discontinuing medication compared to only a 29.5% relapse rate for those treated through CBT. Nevertheless there are restrictions to how this study can be generalised as the studies included were small scale with only 241 patients in total from all eight studies. Furthermore the duration of CBT therapy and anti depressant treatment was not specified; meaning that further more comprehensive research would be needed to be able to conclude that CBT does in fact decrease the risk of relapse from depression

Spinelli (1994) offers an explanation for the vast amount of empirical support for CBT in treating depression. He suggests that it is the focus that is placed on the depressed individuals current thoughts and feelings that helps to explain why so much research shows CBT as an effective form of treatment. He explains that by avoiding placing emphasise on hypothetical constructs such as the unconscious, which is a key component in psychodynamic therapy, CBT allows clients to feel much more engaged both emotionally and intellectually in treating their own depression. As the approach is so participatory in nature, this consequently leads to positive feelings of empowerment for the client. This is supported by Sheldon (1995) who by gathering client’s responses to CBT therapy aimed to discover the reason why this approach seems to be so effective in treating depression. He found that clients consistently described the approach as a useful and a user-friendly intervention.

A different perspective on this was offered by Newell & Dryden (1991) who argue that although the objective and structured nature of CBT in treating depression can be viewed as an attribute of its therapeutic model, in some instances, it can also be detrimental to it. Gilbert (2007) postulates that the CBT approach is a far to formulaic and ritualised approach to treat such an individualised disorder as depression, which is unique both in terms of nature and causes for each depressed individual. Dryden & Mytton (1999) elucidate that treating these patients in such a formalised way can make them feel inadequate and therefore resist the treatment, if therapists do not listen to their own feelings. Thus it is clear to see that in order for CBT to be an effective and worthwhile option the therapist needs to a strike a balance between these two features. The therapist must carefully assess the client’s motivations and how to best approach him or her as an individual, while remaining structured in its approach in order to give the client a realistic and powerful voice in treating their own depression.

In addition, Spinelli (1992) questions the degree to which the therapist can be entirely objective in distinguishing faulty cognitions. Alloy et al (cit ted by 1990) provide evidence that the perception and appraisal of the world and the self can actually be more accurate in depressed individuals than non-depressed individuals. Thus Spinelli (1994) questions the degree of objectivity that the therapist actually holds in making their own judgements when identifying faulty/dysfunctional beliefs or thoughts of the depressed.

It is inevitable that the strong empirical evidence that supports CBT as an effective treatment for depression means that the approach has emerged, in both research literature and the media, as one of the most effective forms of psychotherapy. Abraham et al (1991) criticised this research as being very fitting and self serving in pitching psychotherapeutic techniques against those of pharmaceutical, postulating that CBT must be used autonomously as the best form of therapy, and thus ignoring the presence of deliberating physical and biological symptoms such as sleep disturbance, aches and pains, in depressed individuals. Considerable evidence such as that posed by Calarco and Krone (1991) demonstrates that depression is clearly a psychological and biological disorder and thus incorporating the use of drugs and psychological interventions such as CBT is vital to effectively treating and overcoming such a deliberating illness as depression as there certainly is not one quick fix option for all.

Throughout the literature CBT is positioned as the most empirically valid way to treat disorders such as depression. Despite the significant lack of empirical support for psychodynamic therapy compared to CBT, numerous studies such as Hersen, Bellack, Himmelhoch, and Thase (1984) position psychodynamic therapy as equal to CBT and other psychotherapeutic interventions in treating depression. By analysing 120 women diagnosed with major depression they aimed to investigate the difference between those patients treated via psychodynamic therapy, social skills training and the anti depressant amitriplyine. Analysis showed that there was no difference between these therapies in overcoming depression. Thus questioning whether the lack of empirical support for psychodynamic therapy does in fact mean it is not as useful as CBT in treating depression, or whether it is just the case that CBT is easier for researchers to test empirically and thus more research is readily available to be published.

This premise was supported further by Shapiro et al (1994) who carried out a comparison study between the efficacy of CBT and psychodynamic therapy in treating depression by using 117 clients. They proposed that both therapies were equally effective and equally efficient in improving client’s mood, social adjustment and self-esteem in both eight & 16-week therapies in treating depression. However a key problem with such research is the subjective nature of psychodynamic therapy means that each individual case may have implemented different strategies and techniques to treat their patient and thus without a consistent theoretical grounding it is difficult to test and compare this therapy.

Furthermore, the key premise that loss predisposes an individual to depression in later life has been researched by Maier and Lachman (2000), who implemented questionnaires and telephone interviews to survey 2998 adults aged between 30 and 60. They found that symptoms of depression were more common in those who had lost a parent in childhood through divorce or death. Evidently the methodology used can be scrutinised, social desirability as well as diagnoses was not reliable and therefore biases are very likely. Childhood experiences are not always recollected as an accurate representation.

Although there is research to suggest that a psychodynamic approach to depression is as effective as CBT in overcoming depression. The key criticism, that too much emphasise is given to unconscious processes and subjective past experiences remains. Nurture in childhood is seen as key to the development of depression in later in life, this consequently leads psychologists to ask fundamental questions such as how nurture can be measured in order too prevent depression in later in life. Such hypothetical constructs predispose psychodynamic therapy too criticism from Newell & Dryden (1991) who declare that the efficacy of psychodynamic therapies can not be scientifically proven and thus testing the effectiveness of psychodynamic therapy in treating depression, is difficult and inconsequential (Newell & Dryden, 1991).

The nature of depression lends itself to a psychodynamic viewpoint, in that solving and overcoming the core essential problems leading to depressed feelings is fundamental if depressed individuals are not to relapse again in the future. Providing a empathetic therapeutic relationship in which the client feels safe in revealing their thoughts and feelings is seen as central to psychodynamic therapy, The presence of such a strong therapeutic relationship in itself can leave depressed individuals feeling less burdened, even without any interpretations from the therapist themselves. This idea is supported by Blatt et al (1995) who shows that it is the empathetic and caring therapeutic relationship which is most effective in overcoming depression. If this is the case then psychodynamic therapy holds as a very effective way of treating depression.

On the other hand it has been suggested that this approach puts too much emphasis on the therapists skills, which can lead to individuals becoming overly reliant on the therapist and not an active participant in improving and changing their current feelings. argues that for depressed individuals who are characterised by feelings of worthlessness this may not improve their mind set in order to achieve long-term beneficial change. Because of this, psychodynamic therapy has been characterised as a therapy for those individuals with mild psychological problems who are motivated to spend a substantial amount of time attempting to uncover their unconscious feelings. Fonagy (2010) adds that the very nature of this psychodynamic approach to therapy makes it a notoriously slow moving and long term approach to solving disorders such as depression which can last as long as months or years. This causes problems as depressed individuals often become frustrated as they do not feel that their condition is improving for some length of time, especially in the cases of the suicidal depressed patients where a symptom-focused orientation may be much more beneficial. Ultimately this leads many to give up on this or any form of psychotherapy altogether (Comer, 1992).

While it is clear that the psychodynamic and CBT traditions represent diametrically contrasting models of overcoming depression, the support for the idea that there is no significant difference between such distinctive therapeutic interventions suggests that emphasis should instead be placed on the therapeutic relationship. In both CBT and psychodynamic therapy the therapist and client are seen as working in alliance with each other to treat the clients depression. Blatt et al (1996) as cited by Myers demonstrated that it is the bond between therapist and client that yielded the most effective developments in the clients regardless of which therapeutic intervention was implemented. If this is the case, introducing a much more eclectic approach may be beneficial to treating disorders in the future.

In conclusion, it is clear to see that the way in which depression is treated through psychotherapy will proceed along very different paths depending on the client’s choice of psychodynamic or CBT therapy. CBT will involve a much more interactive action based therapy in which beliefs thoughts and actions can be assessed. Whereas psychodynamic will aim to solve problematic childhood experiences with significant others while examining how these are affecting current problems. Despite the disparity between these two therapies in their theoretical background and the form in which therapy follows. There are also some clear similarities in understanding the importance of the therapeutic relationship, in . The Evidence indicates that CBT is the most effective therapy to proceed along to overcome depression however for many, overcoming depression in the long term requires a exploration of the true reasoning and meaning behind their behaviours before overcoming their depression can even be seriously considered, for these people psychodynamic therapy will be helpful in promoting their inner resources to allow them to lead more fulfilling lives. Overall it is clear the the therapeutic intervention adopted will depend on the individuals values and beliefs regarding their own depression


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