Sometimes I want to think about manual therapy, such as CBT psychoanalysis are more alike. For example, I have argued that traditional CBT is a manual form of dynamic support therapyto goals which involve strengthening existing defenses (or “coping mechanisms”) rather than dismantling the current set of defenses to allow for maturity personality. But perhaps exposure therapy and psychoanalysis have more in common.
In exposure therapy, the patient has a discrete problem, such as a phobia or a specific set of obsessions and compulsions; the patient and therapist develop a stepwise approach to exposing the patient to the feared object/thought/situation. In psychoanalysis, the analyst and patient also work to gradually expose the patient to fearful stimuli. In this case, the motivation for fear is relationships.
Consider how a therapist and patient can deal with a spider phobia: by having the patient first imagine a spider, then look at a picture of a spider, then look at a real spider, then hold the spider. Over time, the patient develops new ideas about spiders as a direct result of exposure to the fear stimulus over time and clearly with the therapist, who worrying fantasies (narrative thoughts) the patient about the spiders did not occur. This allows the patient to recover fear of spiders incorporate a new and unique version of the arachnids into their own narrative of the world.
Similarly, in psychoanalysis the analyst and patient first begin by talking about the patient’s problems with current and past relationships. Over time, the discussion turns to talk about the relationship with the analyst, deep feelings for and about the analyst, and finally incorporates new ideas about the relationship in general from the specific experience of the analytic dyad. Anxiety phantasies that are frightening about relationships are studied directly in the analysis, both about the patient’s closest relatives (parents, siblings), current relationships and, most importantly, the relationship between the patient and the analyst.
Since relationships are so central to the experience of being human (for example, spiders are more important), perhaps it’s no surprise that exposure to a new kind of relationship takes a lot of learning to begin shedding old ideas, fears, and preconceptions about how to exist in relation to others. For the patient to imagine that others can be a source of joy, comfort, care, pleasure, excitement, tolerance, etc., requires a lot of trust, patience and love from both the patient and the analyst.
Our spider phobic sufferer may find that they are tolerant of spiders, although they may not be able to accept a tarantula as a pet. Our relationship phobic patient must exist in the world as a node in a web of relationships, and it is much harder to avoid those connections with others than with spiders.
It takes a lot of courage to engage in any kind of exposure therapy, and we should commend our patients for doing so. For those who need exposure proximity and the consistency, the courage they show over such a long period of time is truly inspiring.
