Acquisition of adaptive skills

Clinical Psychology Review, Vol. 19, No. 6, pp. 721–737, 1999 Copyright © 1999 Elsevier Science Ltd Printed in the USA. All rights reserved 0272-7358/99/$–see front matter

PII S0272-7358(98)00081-6

ACQUISITION OF ADAPTIVE SKILLS: PSYCHOTHERAPEUTIC CHANGE IN COGNITIVE AND DYNAMIC THERAPIES Peter C. Badgio, Gregory S. Halperin, and Jacques P. Barber University of Pennsylvania

ABSTRACT. We argue that there are important areas of overlap in the types of patient change processes that occur in cognitive therapy and dynamic therapy. These common processes of patient change have been obscured by differences in language and theoretical constructs between the two traditions. We suggest that the acquisition of adaptive skills describes patient change processes that are common to both therapies. More specifically, we propose that the concept of adaptive skills encompasses both the compensatory skills model of cognitive therapy (Barber & DeRubeis, 1989) and some of the patient changes that occur in dynamic therapies. In clarifying these areas of overlap between cognitive and dynamic therapies encompassed by the adaptive skills acquired in both, the present article highlights the fact that the two therapeutic traditions employ radically different techniques to achieve some of the same outcomes. Recognizing the overlap between change processes in the two types of therapy, and adopting a common language for them, allows for further theoretical and empirical investigation of therapy process and outcome. © 1999 Elsevier Science Ltd

PSYCHOTHERAPY PROCESSES WHICH MAY contribute to favorable outcome have been a major focus of psychotherapy researchers in the past few decades. Thousands of studies on a highly comprehensive list of these factors (i.e., therapist support, reflection/clarification, patient’s affective response, the therapeutic “bond”, etc.) have been performed. These studies have evaluated the contributions of each factor to positive patient change through psychotherapy (see Orlinsky, Grawe, & Parks, 1994, for a review). Many of these discussions of therapeutic process, however, seem either to conflate therapeutic interventions with patient change processes, or focus primarily on therapeutic interventions without consideration of corresponding change processes. The vast therapeutic process literature has yielded information on which ingredients of therapy appear important in helping a patient, but it has not yielded as much Correspondence should be addressed to Jacques P. Barber, Center for Psychotherapy Research, Department of Psychiatry, University of Pennsylvania Medical Center, Room 704, 3600 Market Street, Philadelphia, PA 19104-2648. E-mail: [email protected]

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insight into the underlying mechanisms through which patient change occurs. Perhaps due to a dearth of adequate instruments or methodological sophistication, empirical research addressing the internal states of the patient as the psychotherapy process unfolds is limited. Research on the impact of psychotherapy on patients’ internal states has therefore been left to more theoretical work, which has concentrated on the development of overarching models of patient change through psychotherapy. When discussing how patient change occurs through psychotherapy, it is important to note that opinions are generally developed within the theoretical framework of a particular school of thought (i.e., dynamic, humanistic, cognitive, or behavioral to name just a few). As each of these schools holds its own theories on the etiology of psychopathology and optimal techniques to be used toward its management or eradication (as well as a language to describe these theories and techniques), it is difficult to even conceptualize a model, or a set of models, which would be broad enough to encompass patient change process across different schools of psychotherapy, and still specific enough to explain it adequately. We have chosen to focus on a theoretical model which attempts to explain one aspect of the change process that we believe is common to both cognitive therapy and dynamic therapy. It is our hope that our proposal will help bridge some of the theoretical gaps between these major schools of thought in psychotherapy, and therefore contribute to psychotherapy integration on the theoretical level. We propose that the development of adaptive skills is one process of patient change common to all psychotherapies. Where therapies differ is in the language used to describe these skills and in the techniques and activities of the therapist designed to bring about change in these skills. To illustrate this aspect of therapeutic change, in this article we describe how a model of change in cognitive therapy—the compensatory skills model (Barber & DeRubeis, 1989)—describes change processes that parallel some of the (primarily cognitive) changes that take place in dynamic therapy. We discuss the different language used to describe these common change processes in both therapies and contrast the therapeutic techniques in cognitive therapy and dynamic therapy used to bring about these changes. Viewing change in psychotherapy from the perspective of adaptive skill acquisition brings to bear a developmental perspective. Adaptive skills are, of course, acquired through the course of an individual’s development. Depending on the complex interaction of biological disposition and environmental influences, the particular repertoire of skills acquired by a given individual may be more or less adaptive. Moreover, skills that are adaptive in one context, such as for a child within a given family constellation, may later be maladaptive in a new context. Thus, from this perspective, adaptive skills are part of personality and coping resources. Psychotherapy change processes can in this way be viewed within the larger context of the whole person, rather than simply in terms of particular symptoms.1

1We

prefer the term adaptive skills to describe change processes in cognitive therapy and dynamic therapy over the term compensatory skills, as adaptive skills seem more theoretically neutral. The concept of compensatory skills implies that therapeutic gains are achieved through patients learning to compensate for a pathological process, rather than changing the pathological process itself. The term adaptive skills is broader and can encompass either adaptive compensatory skills or new adaptive modes of patient functioning that replace previously pathological mental processes.

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MODELS OF PATIENT CHANGE IN COGNITIVE BEHAVIORAL THERAPIES The role of compensatory or coping skills in cognitive behavioral psychotherapies has been recognized by many writers in this area. As early as Goldfried (1971), it was argued that systematic desensitization helps clients to do more than simply reduce anxiety levels through conditioning associations between formerly anxiety provoking stimuli and relaxation; it also provides the patient with increased perceived self-control achieved through the patient’s learning relaxation skills. Goldfried (1980) offered the “coping skills” concept, arguing that therapy achieves more than mere symptom removal, and suggested that psychotherapy be seen as patient training in the use of more general coping skills (e.g., problem solving, the use of relaxation for coping with anxiety, the ability to reevaluate situations more realistically, and communication skills). Hollon and Kriss (1984) refer specifically to the acquisition of behavioral or cognitive self-management skills which can be considered to comprise a coping schema (Ingram & Hollon, 1986). Examples of these metacognitive skills include the ability to generate accounts or explanations for events other than automatic depressive thoughts, and the ability to seek and generate evidence germane to the competing accounts. The view that clients acquire self-management skills in psychotherapy has been further developed by Barber and DeRubeis (1989) who argue for the validity of the compensatory skills model of cognitive change in relation to other prevailing models. The compensatory skills model of patient change in cognitive therapy (Barber & DeRubeis, 1989; Hollon, Evans, & DeRubeis, 1988; Persons, 1993) describes the reduction in depressive symptomatology as the result of the patient’s utilization of a set of skills that are learned through therapy. These skills help the patient “compensate” for the negative effects of depressogenic, automatic thoughts as they arise. According to this model, cognitive therapy does not change depressed patients’ tendency to generate negative thoughts in distressing situations. Instead, treatment inculcates a set of (compensatory) skills that helps them deal with these thoughts when they arise. For example, cognitive therapy teaches the patient to identify and challenge their negative, depressogenic thoughts and to generate alternatives. Initially, use of these skills is deliberate and effortful, and encouraged by the therapist. Over time, however, this self-conscious process becomes automatized as with other forms of skill acquisition (Barber & DeRubeis, 1989; Fitts & Posner, 1967; Neisser, 1967). In this way, according to the model, the eventual automatic use of these compensatory skills may reduce the frequency of occurrence of depressogenic thoughts during CT and for a period following termination as new skills are utilized (Persons, 1993). To illustrate the acquisition of such skills in cognitive therapy, consider a patient reporting that she was walking along the street on the way to her session when she saw a friend across the street. Her friend kept walking without acknowledging her. The patient thought “She pretended she didn’t see me because she didn’t want to talk to me; she doesn’t like me; she thinks I’m boring;” and so on. Through cognitive therapy, the patient would come to recognize these ideas as “automatic thoughts” that contribute to her depression. She would learn to take note of, and step back from, such ideas and employ strategies or compensatory skills (e.g., generating alternative explanations, considering the evidence, examining her underlying beliefs that led to such automatic thoughts, etc.) to combat these automatic and negative thoughts. With the therapist’s encouragement and guidance, the patient can come to entertain alternatives such as, “I realize that I was putting the worst spin on the situation. There are

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other explanations like: It was a busy street; she seemed to be in a hurry; she probably didn’t even see me.” After repeatedly exercising these skills with the help of therapy, the patient would slowly come to alter her underlying beliefs, and adaptive skills such as considering alternative explanations would become more automatic. The compensatory skills model is consistent with research findings of lower relapse rates in remitted depressives following CT as opposed to a course of antidepressant medication (Blackburn, Eunson, & Bishop, 1986; Evans, Hollon, DeRubeis, & Piasecki, 1992; Simons, Murphy, Levine, & Wetzel, 1986) while rates of depressive symptomatology between these two treatments at the end of treatment is highly similar (Elkin et al., 1989), as are changes in cognition (e.g., Hamilton & Abramson, 1983; Silverman, Silverman, & Eardley, 1984). Taken together, these findings may indicate that skills are learned in the CT condition which may then be utilized after termination, while no such skills are likely to be learned through pharmacotherapy.

THE ACQUISITION OF ADAPTIVE SKILLS DURING DYNAMIC PSYCHOTHERAPY Generally speaking, therapist interventions in dynamic psychotherapies revolve around a shared main goal—the facilitation of increased patient ability to function more adaptively through increased awareness and understanding of his/her behavior, thought, and emotional patterns. According to dynamic theory, patient difficulties arise as a result of intrapsychic conflicts between wishes or between wishes and fears, along with the maladaptive modes of behavior and thought which the patient utilizes in the attempt to manage these conflicts (i.e., defenses). Increased awareness of these wishes, fears, and defenses in conjunction with their behavioral, cognitive, and emotional manifestations in daily life is termed insight. If this type of understanding is achieved, the patient is in a position to alter these patterns. Such change processes are viewed as curative in dynamic therapy. Several cognitive behavioral theorists have proposed similar patient change processes using various terminology such as coping skills, self-management skills, and compensatory skills. Such theories hold that these skills are learned through psychotherapy, and are then utilized by patients when confronted with psychologically challenging circumstances in an effort to mitigate the negative effect of those situations. The language used in describing skill development is certainly consistent with the theories of cognitive and behavioral psychotherapies from which they arose, where the use of words such as learning and skills in discussion of positive patient change are commonplace. One goal of cognitive therapists is to “teach” their patients such skills. These terms are far less frequently used when describing change through dynamic therapies. While dynamic therapists would not be reluctant to say that their patients “learn” things about the way their minds work through the course of therapy, dynamic therapists may be hard pressed to say that they teach their patients cognitive skills. Teaching, however, is not the only means of fostering skill acquisition. We suggest that some intended results of dynamic therapy may be very similar to the intended results of cognitive therapy, although the techniques used to facilitate it and the language used to describe it may be very different. We propose that the acquisition of adaptive cognitive skills is not limited to describing change through cognitive-behavioral interventions. The adaptive skills model also describes important aspects of patient change through dynamic therapy. Specifically, the development of an “observing ego,” increased capacity to gain psychological distance, and changes in

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adaptiveness of defensive function are some of the desired patient changes occurring in dynamic therapy which can be viewed in terms of the acquisition of adaptive (cognitive) skills—very similar to the changes that take place in cognitive therapy.

DEVELOPMENT OF AN OBSERVING EGO THROUGH COGNITIVE AND DYNAMIC PSYCHOTHERAPIES A common goal of both cognitive and dynamic psychotherapies is increased patient ability to observe and scrutinize his/her own behavior, thoughts, and emotions. We caution against the simplistic dichotomy by which cognitive therapy is viewed as dealing with thoughts and dynamic therapy with interpersonal relationships. In both therapies, patients are encouraged to examine both their intrapsychic experiences and their interpersonal patterns. In cognitive therapy, this process is set in action through active therapist instruction, such as homework assignments to write down automatic thoughts when facing stressful situations. In dynamic therapy, achievement of this goal is facilitated through therapist interpretation, and more passively by encouraging an attitude of curiosity toward one’s stream of consciousness. As the therapist offers interpretations which encourage the patient to consider alternate perspectives on, and new meanings for, his/her thoughts, emotions, and behaviors, the patient’s ability to do so for him/herself increases. This process, termed the development of an “observing ego” by dynamically oriented psychotherapists and theorists “refers to the part of the self that is conscious and rational and can comment on emotional experience and makes an alliance with the practitioner to understand the total self together” (McWilliams, 1994, p. 26). The observing ego is also well illustrated by the patient who reports “hearing” the therapist’s voice when confronted with an anxiety provoking situation in the therapist’s absence. This is also considered a manifestation of “internalization of the therapist” (Geller & Farber, 1993). The development of an observing ego refers specifically to the patient’s developing an ability to observe, monitor, and scrutinize his/her behaviors, thoughts, and emotions. The process of internalizing the therapist refers to the patient’s increasing ability to fulfill functions performed by the therapist during therapy for him/herself, both within and outside of the therapist’s office. These functions typically include listening to and questioning the patient’s perception of events, helping the patient increase his/her awareness of (or insight into) his/her role in maladaptive relationship patterns, and interpreting defenses and transference reactions. Through experience with the therapist’s listening, the patient comes to be better able to listen to him/herself. In cognitive-behavior therapy, the means toward increased patient ability to observe and scrutinize his/her own behavior, thoughts, and emotions are manifest in the therapist in teaching the client to monitor automatic thoughts and to use various cognitive self-management skills (Hollon & Kriss, 1984), coping skills (Goldfried, 1980, 1987) and compensatory skills (Hollon et al., 1988) to revise these negative thoughts (Barber & DeRubeis, 1989). This learning is performed through didactic persuasion and psychoeducational methods. Although the didactic persuasion and psychoeducational techniques utilized by the cognitive therapist differ greatly from the techniques in dynamic therapy, the end result of increased self-observation may be often highly similar. Both sets of interventions lead to increased introspective capacity and greater metacognitive awareness (knowing how one’s own mind works). Although the jargon may differ, the following

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example of emerging self-observational skill, drawn from the cognitive behavioral therapy literature, appears equally illustrative of this process through dynamic or cognitive therapy. Client to therapist: “Now, whenever I become upset over something, I first ask myself if I am responding rationally. I picture myself talking to you and I can almost hear you pointing out the distortions in my reasoning. I soon see how I may still tend to exaggerate and magnify things” (Lazarus, 1996, p. 180). The increased self-observation, facilitated by the patient’s internalization of the therapist’s role, reflected in this example represents the acquisition of an adaptive skill common to cognitive and dynamic therapies. The goals of cognitive and dynamic therapies might well diverge at this point. For many cognitive therapists, the patient’s tendency to “exaggerate and magnify things” would be viewed as the problem causing their distress, to be remedied by compensatory skills such as considering alternatives, examining the evidence, and the like. For most dynamic therapists, the patient’s tendency to exaggerate, rather than being viewed as the problem, sets the stage for discovering the problem. This self-observation of a tendency to exaggerate allows the therapist to then pose the question, “What is it that gets stirred up in you to cause you to get upset and respond in a seemingly exaggerated fashion?” Although differences between cognitive and dynamic therapies may emerge at this point, we wish to emphasize the commonality of increased self-observation as an adaptive skill fostered by both treatment approaches, despite differences in technique used to achieve it and language used to describe it. A concept related to the idea of an observing ego is that of psychological distance. When faced with situations having a particular dynamic meaning, the depressed or anxious patient often becomes swept up in an emotional reaction, experiencing the situation in terms of his/her own internal meanings and associated feeling states. Under the pressure of such emotional stimulation, he/she may lose distance. That is, higher level mental processes involved in objectivity, articulating affects, and distinguishing fantasy-based conclusions from more realistic appraisals all become temporarily suspended under the pressure of emotionality. It is not that the patient necessarily lacks these mental functions (although this may be the case in psychotic or some primitive character disorders), it is that the patient has temporarily lost psychological distance from the situation under the influence of the idiosyncratic, dynamic meaning of the given circumstances. For example, an anxious patient who views every organizational meeting at work as a personal threat to his job security is likely failing to maintain reasonable psychological distance, and thus, overpersonalizing the situation. Of course, we all allow ourselves some temporary loss of psychological distance, such as when we enjoy a horror movie and become scared, or when we identify with a patient in order to gain a better empathic understanding. It is the degree of adaptive control that one has over this psychological distance that is important, and we suggest that this is one mechanism of change in psychotherapy. One result of the patient’s having developed increased functioning of an observing ego is that the patient comes to be better able to achieve some distance from emotionally stimulating situations. He/she learns to step back as it were, gain a more objective (or adaptive) perspective and begin to identify his/her own internal reactions and dynamic meanings that cause the situation to be so emotionally overwhelming. Thus, observing ego refers to a set of mental functions; psychological distance refers to a quality of one’s mental state resulting from the application of those functions. In dynamic therapy, this adaptive skill of increased capacity to achieve psychological distance from troubling events is facilitated, in large part, by insight gained through

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self-observation and interpretations made in therapy. With increased awareness and verbal articulation of his/her own dynamic conflicts, a person comes to recognize what in his/her own internal reaction leads him/her to experience certain kinds of situations as so upsetting. Distinguishing his/her own internal reaction from the situation itself, he or she is then able to regain some distance from the situation and make use of his/her mature cognitive capacities to appraise his/her affective state and draw conclusions from it. In cognitive therapy, increased capacity to gain psychological distance from upsetting situations is also achieved, in this case, largely through the use of metacognitive skills that are directly taught in the form of compensatory skills. Through assigned (obsessional) activities such as keeping a self-monitoring schedule of the events of their day and associated feeling, writing down reactions to upsetting events, and so on, patients increase their adaptive skill of taking some objective, intellectual distance from their feelings and the events which stimulate them. As Barber and DeRubeis (1989) point out, depressed patients treated with cognitive therapy may still generate depressive primary appraisals of distressing events. Through cognitive therapy, the remitted patients have learned to identify, step back from and critique their initial appraisals (automatic thoughts). They may not have achieved insight into why such situations produce the particular internal reactions that they do (as is the goal of dynamic therapy). Nevertheless, they share with the dynamic therapy patient the increased adaptive capacity to step back from emotionally stimulating events, and thereby utilize higher level cognitive skills to modify their reactions.

CHANGES IN EGO DEFENSES AS ADAPTIVE SKILLS As their name implies, ego defenses are utilized when the ego experiences something as potentially harmful, either in terms of a perceived loss or the perceived threat of loss. Possible reasons for the utilization of defenses are countless, but all share the common thread of the subject’s experiencing of some unpleasurable affect, typically anxiety or depressive affect (Brenner, 1982). Defenses are utilized in an effort to eliminate or at least minimize the potential unpleasurable affect. In this way, defenses serve a compensatory function by transforming the content of incoming information to a less threatening state. Essentially, defenses distort incoming information, or the affect associated with that information. According to dynamic theories, defenses are specialized ego mechanisms utilized to deal with unpleasurable affects or with the internal and external conditions that arouse unpleasurable affects. Internal sources of distressing affect can include conflictual desires (wishes) that have become associated with anxiety or depressive affect, or internal prohibitions (guilt). External sources of painful affects can include such things as repetitive relationship patterns (Luborsky, 1984). Defense mechanisms are mental processes used in the attempt to alter these internal and/or external conditions. All dynamic therapies share a familiar conception of the various defenses such as repression, denial, displacement, projection, intellectualization, undoing, and so on. It is beyond the scope of this article to provide an exhaustive list and description of these mechanisms. What we wish to point out here is that the notion of defense mechanisms entails the concept that the patient attempts to deal with some psychological situation by altering or limiting the sources of distress. In this way, a defense mechanism can be viewed as an adaptive skill. Not all defenses are equally adaptive. Some are thought to be more immature and maladaptive (e.g., projection), whereas

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others are seen as more mature and adaptive (e.g., humor; Vaillant, 1971; see also the American Psychiatric Association’s, 1994, Proposed Axis for Further Study Defensive Functioning Scale, DSM-IV; Perry et al., 1998). It is generally agreed that one outcome of dynamic therapy is that patients develop more flexible and mature defenses (Klein, 1976; Vaillant, 1992; Wallerstein, 1988). We suggest that the development of a more flexible and mature defensive repertoire can be viewed as the acquisition of adaptive skills. In this way, such an outcome of dynamic therapy shares common ground with outcomes of cognitive therapy, despite differences in language and technique. The concept of mental processes which distort incoming information has been adopted by cognitive therapy, often without recognizing its origins in dynamic therapies’ conception of defenses. According to cognitive theory, faulty information processing is a major contributor to the genesis and maintenance of depression. Selective abstraction, arbitrary inference, and overgeneralization are examples of processes of information distortion which typify the cognition of depressives (Beck, Rush, Shaw, & Emery, 1979). Although their role as defense mechanisms is not addressed in cognitive theory, their property as distorting mechanisms makes them analogous to the ego defenses of dynamic theory. This analogy has technical implications and illustrates a further similarity between cognitive and dynamic therapies when dealing with these processes. In cognitive therapy, the therapist teaches the patient hypothesis testing methods to evaluate the validity of negative thoughts as they arise and therefore combat their impact. Inherent to this process is the therapist pointing out to the patient how he/she distorts information in a way which yields predominantly negative emotions (i.e., depression). For example, Beck, Freedman, and Associates (1990) recommend that addressing the dichotomous thinking (i.e., the defense of splitting) of patients with borderline personality disorders should be a primary goal in cognitive therapy. As they say, “it is then necessary to help the clients to consider whether thinking in terms of continua could prove more realistic and more adaptive than dichotomous thinking” (p. 199). In dynamic therapy it is theorized that patients’ change in the utilization of defenses is fostered through therapists’ interpretation. Interpretation refers to the therapist’s reference to patient material which is preconscious, or unconscious. Reference to transference manifestations, ego defense patterns, defense mechanisms, unconscious drives and the like would all be considered interpretations. These interventions facilitate insight as they help the patient to increase his/her understanding of his/her affective, cognitive, and behavioral patterns, which includes helping the patient to consider alternative perspectives on his/her emotions, thoughts, and behaviors. Once the patient gains insight, this new understanding must be incorporated into the patient’s existing psychic structure, and applied to the patient’s life outside the session. Therapist interpretation of a patient’s use of an ego defense may help the patient consider an alternate, more adaptive coping strategy, which he/she can then test out the next time he/she is faced with similar real-world stressors. This repeated “testing out” is one aspect of “working through,” and is essentially a learning process which starts with insight and continues as the patient incorporates the implications of insight into his/her life. That is, the patient comes to give up rigid, largely unconscious adherence to a maladaptive defenses, in favor of a more adaptively flexible repertoire of mature defenses. In this way, the dynamic therapist facilitates a stalled learning process without relying on teaching as an explicit therapeutic technique. That is, although the

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cognitive therapist might teach a patient to consider alternative solutions, the dynamic therapist assumes that the adult mind will do this automatically unless it is somehow blocked or inhibited through reliance on a maladaptive (primitive) defense. To illustrate the acquisition of adaptive skills through defense interpretation, consider the following vignette. A patient who frequently “forgets about” important but anxiety provoking issues (repression) is told by the therapist of a proposed fee increase that must be discussed. At the end of the session, the patient says as she leaves that she is sure she will not forget to talk about this issue. Sessions go by and the patient says nothing about the proposed increase. When the therapist points out the omission several sessions later, that patient notes that “You know, I’ve thought about it once or twice, but as soon as I do I get scared and forget about it.” The patient and therapist go on to recognize (interpret) this situation as an example of the patient’s tendency to handle scary situations by putting them out of her mind (i.e., the patient relies on repression as a primary defense). The patient then observes that “When I’d think of the fee increase, I would think how I want to have my cake and eat it too, and that would get me nervous. So, instead of talking to you about it or discussing the money with my husband, I’d handle it my usual way of just closing one eye and pretending it isn’t there. When I think about it rationally, I see that there are other solutions. I know I can make other sacrifices to handle the higher fee and it’s easy to decide to do that when I think about it practically.” Made aware of her repressing the fee issue because of the anxiety it stimulated, the patient quite spontaneously was able to consider other alternatives. Her taking her “practical” approach still left unexplored what she meant about wanting to have her cake and eat it too, and why such desires were so anxiety provoking. Nevertheless, the practical approach represented a more flexible and adaptive defense. Interpreting the repressive defense allowed the patient to become aware of her anxiety around wanting. Her adult mind then quite spontaneously arrived at the process of considering alternatives. She did not have to explicitly be taught to do this once the inhibiting effect of repression was clarified. Obviously, this one instance of self-observation and insight is not sufficient to produce lasting and far reaching change. A repeated observation of this kind, made in a variety of contexts is necessary for meaningful patient change. To be sure, the goal of dynamic therapy would be to go further and help the patient discover what makes wanting something so anxiety provoking for her. That is, the goal would be to discover what motivates her use of repression in such situations. Nevertheless, positive patient change has taken place already in the form of increased awareness of her reliance on maladaptive defenses and the acquisition of a more flexible defensive repertoire. This patient’s reliance on repression previously had been a source of considerable personal and interpersonal difficulties in her life. To reiterate, through psychotherapy patients learn adaptive skills which lead to positive change. In cognitive therapy, compensatory skills are explicitly taught that patients can use to compensate for maladaptive thoughts as they arise. Although generally not as directly explicit, the dynamic therapist’s use of interpretation similarly aims to point out and question maladaptive elements of the patient’s functioning. As the cognitive therapy patient’s faulty information processing methods (selective abstraction, overgeneralization, arbitrary inference, dichotomous thinking, etc.) are a target of therapist challenges, so too are the dynamic patient’s defenses a target area of therapist interpretation. Several theorists in the dynamic and psychoanalytic traditions

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have underscored the central role of defense interpretation in facilitating patient’s acquisition of more adaptive skills as a key process of patient change. A main goal of defense interpretation is patients’ movement on what may be considered a maladaptive-adaptive (or immature-mature) continuum. “Enhancement of the repertoire, maturity, effectiveness, and flexibility of ego defenses” is widely considered to be a goal of all psychodynamically oriented psychotherapies (Baker, 1985, p. 37). More specific to the change process is Vaillant’s (1992) statement that in our efforts to “monitor the healing process . . . a shift in the maturity of defensive style may be our best clue” (p. 38). Gray (1994) describes psychoanalysis as most effectively an analysis of the patient’s ego defenses. He considers analysis and interpretation of the patient’s use of defenses as the primary tool through which positive change (insight) may be achieved. He asserts that the analyst’s interpretive efforts should concentrate on the patient’s activity inside the session as opposed to outside (e.g., concentrating on the patient’s use of defenses as he/she recounts an episode as opposed to the use of defenses described in the episode), which focuses the patient’s attention on observable defensive processes as they are manifest in the analyst’s office. Concentration in this sphere facilitates the analysand’s recognition of the existence of these internal processes independent of external circumstances, and perhaps as a result, encourages his sense of responsibility for them, leading to an increase in perceived control of defensive function. From this, the patient is better able to self-analyze, or in other words, develops a stronger observing ego. Through self-analysis, the development of an observing ego, or however else we wish to term an increase in metacognitive skill utilization, the patient is in a better position to alter patterns of defensive utilization and move toward the use of more adaptive defenses. In this way too, the patient’s utilization of defenses can be seen to be more flexible. The borderline patient’s reliance on splitting in emotionally charged interactions may be quite automatic and inflexible. Similarly, the obsessional patient’s use of intellectualization may be quite rigid. Recognizing these defenses and their (maladaptive) role in their lives, patients come to interrupt their automatic, rigid application, and with some effort, allow themselves a more flexible set of options.

LONG-TERM CHANGE Obviously, one goal of both cognitive therapy and dynamic therapy is to produce long-term change in patients’ psychological functioning. As early as Freud, it became clear that that the mere alleviation of symptoms (Breuer & Freud, 1893–1895/1964) did not produce satisfactory or lasting change. Therapists hope that patients will achieve some basic and lasting change in psychological functioning that will improve their lives beyond the remission of the current episode of psychopathology and will help protect them from future episodes. Indeed, as previously mentioned, there is some evidence from outcome studies that cognitive therapy treated patients have a lower rate of relapse of depression when compare to medication treated patients (DeRubeis & Crits-Christoph, 1998). The compensatory skills model was, in fact, developed in order to explain such long-term benefits of therapy (Barber & DeRubeis, 1989). According to the model, long-term change is the result of patients’ use of the (compensatory) skills learned in cognitive therapy whenever they confront new stressful life events in the future, thus

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protecting themselves from the emergence of depression. It is suggested that over time, use of these skills becomes more automatic. The automatic use of new modes of thinking, if repeatedly applied in the context of patients’ lives, eventually leads to change in underlying schemata. Schema change is, by definition, a long-term alteration in a person’s basic psychological adaptation and mode of functioning (Persons, 1993). The concept of schema change in cognitive therapy shares some similarity with the concept of structural change central to most analytic and dynamic theories of therapeutic process (Klein, 1976; Wallerstein, 1988). Historically, structural change refers to change in the balance of dynamic forces among the id, ego, and superego. With the emergence of new analytic theories such as object relations and self psychology, the concept of structural change has come to encompass a broader range of alterations in the ego. Additionally, increasingly popular interpersonal and intersubjective theories (Greenberg & Mitchell, 1983; Kohut, 1971) place greater emphasis on relationship patterns. Descriptively, however, the concept of structural change in all theories refers to alteration of basic characterological features of a person’s habitual mode of thinking, relating, and interacting with the world. Structural change in dynamic therapy has been viewed as occurring through a variety of means. In part, interpretation of unconscious wishes, fears, and prohibitions allows for their modification and integration with more adult desires and goals. More relevant to the scope of the present article, however, structural change also entails changes in ego functioning and defensive functioning. Indeed, over the course of Freud’s writing, change in the quality of ego functioning became an increasingly central patient change process. Earlier in his writing, when the topographical model was prominent in his theories, the goal of treatment was “making conscious what is unconscious” (Freud, 1916–1917/1964). With the introduction of the structural theory and the tripartite model, however, the goal of treatment came to be viewed in terms of the functioning of the ego, “Where id was, there ego shall be” (Freud, 1933/1964). Freud came to describe psychotherapeutic change quite explicitly in terms of strengthening of the ego. More recent theorists, particularly those working with personality disorders, have also emphasized ego functioning in their investigations of patient change processes in dynamic therapy (e.g., Kernberg, 1975; Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989). Increased capacity for self-observation and reflection, as well as the development of a more mature and flexible repertoire of defensive function constitute structural, long-term changes (improved ego functioning) according to dynamic theories. Thus, the acquisition of adaptive skills, whether automatic compensatory skills achieved through cognitive therapy or more mature defensive functioning achieved through dynamic therapy, may account for some of the long-term benefits of psychotherapy in both traditions.

RESEARCH EVIDENCE FOR THE ACQUISITION OF ADAPTIVE SKILLS IN DYNAMIC THERAPY Although dynamic therapists are largely in agreement that addressing patients’ defenses is an important aspect of therapy, there has been rather little systematic research in the area of patient change in defensive functioning through the course of treatment. Winston, Winston, Wallner Samstag, and Muran (1994) analyzed treatment sessions from brief dynamic therapy and found that the frequency with which therapists addressed patients’ defenses predicted positive outcome. Further, frequency

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of therapists’ addressing immature and intermediate defenses early in treatment was correlated with a decrease in such defenses later in treatment. Change in patients’ defenses, however, was not found to be correlated with other outcome measures, although the study limited itself to brief psychotherapies, and thus patient change in defenses within treatment may not yet have generalized to other areas of patient functioning. In their research on defenses, Perry and his group have listed commonly used defenses in a hierarchical fashion, from most adaptive or mature to least adaptive or immature (Perry, Kardos, & Pagano, 1993). Examples of more adaptive defenses include use of humor, self-observation, self-assertion, altruism, and affiliation, and less adaptive include acting out, hypochondriasis, splitting, projective identification, and rationalization. Empirical evidence for the view that change in defensive structure is an indicator of positive outcome in psychotherapy comes from Perry (1997, personal communication) who found that, when transcripts of psychotherapy sessions with personality disordered patients were scored for type and frequency of expressed use of defenses, patients generally moved over the course of therapy from use of less adaptive to more adaptive defenses on the hierarchy. Furthermore, Hoglend and Perry (1998) found that depressed patients who exhibited less mature defenses improved less than would have been predicted by their level of psychiatric severity at the beginning of treatment, whereas patients who displayed the “high adaptive level defense” self-observation improved more than predicted. Further, it was found that self-observation emerged as a significant skill in combating depression. Additional support for the view that defensive use changes through psychotherapy may be found in a study by Crits-Christoph and Luborsky (1990) addressing changes in the pervasiveness of patients’ expressed wishes, perceived responses from others, and responses of themselves during dynamic therapy. They found that, although their wishes remained fairly stable, patients’ responses from self and responses from others became less negative. The results suggest that “patients learn to recognize and cope with their wish-response patterns” (p. 143), which alludes to acquisition of metacognitive self-observational skill and improved defensive functioning through psychotherapy. These gains then translate into assumed change in defensive processes, as “emotional responses to the others’ actions or expectations have more flexibility or malleability” (p. 142), which itself is indicative of positive change, as patients then received “fewer negative and more positive responses” (p. 142) from self and others.

DISCUSSION AND CONCLUSIONS In this article, we have attempted to point out the similarity between models of patient change in cognitive therapy and some of the patient change processes that take place in dynamic therapy. In both therapies, patient change occurs, in part, through the acquisition of adaptive skills that enhance psychological functioning and help patients in handling dysphoric affects in more functional, less pathogenic ways. It is suggested that the development of the observing ego, increased capacity to gain psychological distance from emotionally stimulating experiences, and the use of a more flexible and mature repertoire of psychological defenses all represent patient change processes, of a largely cognitive nature, that take place in both cognitive therapy and dynamic therapy. We have argued that one can conceptualize a learning process which occurs in both cognitive and dynamic psychotherapy. Specifically, in each therapeutic modality, pa-

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tients learn adaptive psychological skills. The process through which these skills are developed is characterized by the patient’s gradual acquisition and integration of metacognitive abilities (observing ego), their increased capacity to gain perspective on that which distresses them (psychological distance), and patients’ insight into their existing repertoire of compensatory mechanisms (ego defenses). Previously, use of different language and different theoretical constructs has obscured this broad area of common (cognitive) patient change processes in cognitive and dynamic therapy. Identifying common patient change processes in cognitive and dynamic therapy helps point out that widely different therapeutic techniques can lead to similar patient changes, thus opening areas for further empirical and theoretical exploration within each therapeutic tradition. The development of the observing ego in dynamic therapy is facilitated by therapist interpretation and complimented by the patient’s identification with and internalization of the therapist. The observing ego which is, in part, an internalization of the therapist’s listening and interpretive techniques, then adopts the function of the therapist, resulting in the patient’s more objective observation and examination of his own thoughts, feelings, and behavior. We propose that this concept is highly similar to metacognitive skills explicitly taught and learned through cognitive therapy. The capacity to gain psychological distance from distressing experiences, and thus free oneself from the pressure of emotionality which temporarily suspends the use of more mature mental functions, is one result of increased functioning of an observing ego, and is facilitated in dynamic therapy through interpretations. The therapist interprets the unconscious dynamics that lead to emotional reactions to certain types of events. Through identifying the dynamic source of one’s own reaction, one can gain some objective distance from a situation and thereby have more available higher level mental functions for handling the situation. The ability to gain such psychological distance from upsetting circumstances also is an aspect of metacognitive skills taught in cognitive therapy. Change in dynamic therapy is also characterized by patient movement from use of less adaptive ego defenses to more adaptive ones to reduce anxiety and dysphoria. The defenses are the direct target of therapeutic intervention as well as the indirect target of the patient’s own use of increased self-analytical, observatory skills (the observing ego) learned in dynamic psychotherapy. The systematic scrutiny of defensive operations by the patient eventually leads to a more adaptive, flexible defensive repertoire. As a result of using more adaptive defenses, patients will deal more adaptively with their own conflicts, eventually leading to changes in their characteristics way of handling a range of situations. Follow-up data from controlled studies which examine defensive processing during (and after) a course of psychotherapy have leant support to this particular theory of assumed change (Hoglend & Perry, 1998; Winston et al., 1994). Adopting the adaptive skills model of patient change, parallels are easily drawn between the metacognitive compensatory coping skills learned in cognitive therapy and the development of the observing ego in dynamic therapy. Similarly, the eventual goal of increased flexibility and malleability of the patient’s defensive repertoire in dynamic therapy is analogous to “schema change” in cognitive therapy, which is theorized to be an eventual result of the utilization of compensatory skills taught and learned during cognitive therapy. We hope to have pointed out significant areas of overlap in patient change that occurs in both cognitive and dynamic therapy, which until now, have been obscured by

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differences in language and theoretical constructs. In clarifying areas of commonality in patient change that takes place in cognitive and dynamic therapies, we have highlighted some important differences in technique which we believe are theoretically and empirically intriguing. If the acquisition of adaptive, largely cognitive skills does, as we have argued, describe important patient changes that take place in both cognitive and dynamic therapies, then it is quite obvious that therapists from the two traditions utilize very different techniques, grounded in different theoretical constructs, to achieve some of the same changes (albeit using different language to describe these similar outcomes). We have suggested, for example, that cognitive therapists use explicit teaching and didactic persuasion to facilitate patients’ learning adaptive skills, whereas dynamic therapists may use interpretation of defenses to facilitate a stalled learning process that the adult patient’s mind will pursue spontaneously if not inhibited by immature (maladaptive) defenses. Thus, we suggest that there are largely cognitive patient change processes that occur in both forms of treatment, although the interventions that lead to such change may not themselves be cognitive in nature. Given similarities in outcome, one may wonder to what extent therapists from different schools truly differ in practice in the real world. Ongoing work measuring therapists adherence and competence in applying cognitive and dynamic therapy in the context of a research treatment protocol does indeed demonstrate readily identifiable and significant differences in the use of several types of interventions (Barber & CritsChristoph, 1996; Barber, Krakauer, Calvo, Badgio, & Faude, 1997; Luborsky, Woody, McLellan, O’Brien, & Rosenweig, 1982). To be sure, these points of overlap between patient change occurring in cognitive therapy and in dynamic therapy by no means exhaust the full range of therapeutic aims in either approach. Nevertheless, we believe that these areas of overlap are substantial, and indeed, likely account for much of the therapeutic work in the briefer treatment paradigms within each tradition. That is, we suggest that much of the benefit of short-term treatment paradigms occurs through the inculcation of adaptive skills. Therefore, theoretical and empirical questions are raised as to the differences in efficacy of the two treatment approaches with respect to their common goals. Might the two sets of techniques be differentially suited to different types of patients? Research into such a question is facilitated by delineating the areas of overlap in patient change processes among the two approaches and adopting a common language for describing and studying them. A relevant hypothesis is proposed by Beutler and Consoli (1993) which suggests that therapeutic techniques must be matched to “predisposing client variables” in order to best facilitate client benefit from therapy. Empirical support for this type of matching of patient personality characteristics to therapy is given by Barber and Muenz (1996), who found that depressives with elevated levels of avoidant personality responded significant better to cognitive therapy then interpersonal therapy, whereas the reverse held true for depressives with elevated levels of obsessiveness. If different techniques between therapies yield a similar result on the acquisition of adaptive skills, will one method be more effective for patients with a particular disorder and/or personality profile? In other words, how does degree of directiveness in regard to the dimension described (from free association and interpretation on the less directive side of the scale to homework assignments and teaching metacognitive skills on the more directive side) interact with DSM-IV (American Psychiatric Association, 1994) Axes I and II diagnoses? And further, if differences in outcome are found, how does technique differ in regard to this dimension for similar patients in different

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therapies? In fact, Beutler et al. (1991) has shown that highly resistant patients improved more following a nondirective treatment than following a directive treatment (see also Shoham-Salomon, Avner, & Neeman, 1989). Answers to questions such as these will shed much needed light on the needs of individual patient groups and allow clinicians to meet those needs with greater efficacy. In considering the areas of commonality between cognitive and dynamic therapies, one must not rush to overlook the broad differences in patient change processes that may remain. In examining where each approach can borrow from the other, we must also be mindful of the extent to which the two approaches seek different patient change and outcomes and should explore whether such differences necessitate the traditional differences in technique. For examples, what change processes in dynamic therapy might be hampered by a therapist’s active, didactic technique, or, on the other hand, what potential benefits might be lost by a therapist’s reluctance to adopt a directive, didactic stance in some situations? Only by clarifying the common patient change variables and adopting a common language for them can we begin to investigate empirically some of the important differences in the aims and effectiveness of each tradition. Acknowledgments—The order of authorship was determined randomly; all authors contributed equally to this article. Gregory S. Halperin is now at the Department of Psychiatry, Penn State University. This work was supported in part by Grants NIDA DA 08237 and NIMH RO-1 MH 49902 to Jacques P. Barber. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Baker, E. L. (1985). Psychoanalysis and psychoanalytic psychotherapy. In S. J. Lynn & J. P. Garske (Eds.), Contemporary psychotherapies: Models and methods (pp. 19–68). Columbus, OH: Merrill. Barber, J. P., & Crits-Christoph, P. (1996). Development of an adherence/competence scale for dynamic therapy: Preliminary findings. Psychotherapy Research, 6, 79–92. Barber, J. P., & DeRubeis, R. J. (1989). On second thought: Where the action is in cognitive therapy for depression. Cognitive Therapy and Research, 13, 441–457. Barber, J. P., Krakauer, I., Calvo, N., Badgio, P. C., & Faude, J. (1997). Measuring adherence and competence of dynamic therapists in the treatment of cocaine dependence. Journal of Psychotherapy, Practice and Research, 6, 12–14. Barber, J. P., & Muenz, L. R. (1996). The role of avoidance and obsessiveness in matching patients to cognitive and interpersonal psychotherapy: Empirical findings from the Treatment for Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64, 951–958. Beck, A. T., Freedman, A., & Associates. (1990). Cognitive therapy of personality disorders. New York: Guilford. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford. Beutler, L. E., & Consoli, A. J. (1993). Matching the therapist’s interpersonal stance to clients’ characteristics: Contributions from systematic eclectic psychotherapy. Psychotherapy, 30, 417–422. Beutler, L. E., Engle, D., Mohr, D., Daldrup, R. J., Bergan, J., Meredith, K., & Merry, W. (1991). Predictors of differential response to cognitive, experiential, and self-directed psychotherapeutic procedures. Journal of Consulting and Clinical Psychology, 59, 333–340. Blackburn, I. M., Eunson, K. M., & Bishop, S. (1986). A two-year naturalistic follow-up of depressed patients treated with cognitive therapy, pharmacotherapy, and a combination of both. Journal of Affective Disorders, 10, 67–75. Brenner, C. (1982). The mind in conflict. New York: International University Press. Breuer, J., & Freud, S. (1964). Studies on hysteria. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 2, pp. 1–335) London: Hogarth Press. (Original work published 1893–1895)

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