"Underlying Issues"

When people seek therapy to address a problem behavior, whatever that behavior may be (e.g., addictions, eating disorders, impulsive or compulsive behavior), they also usually bring up the issue of "underlying issues" early in treatment.

Some want to focus on behavior change, and bring up "underlying issues" only to request that they not become the focus of treatment, either because "there aren't any," or they're irrelevant to the problem at hand. They are highly skeptical of the stereotype of therapy delving into one's childhood, and assume that changing behavior will be sufficient. Others take the opposite stance, expressing frustration with a focus on behavior change, and asserting that the problem is not the behavior itself, but the "underlying issues" that have caused it. They assume that behavior change will happen automatically if underlying issues are resolved, but intentional behavior change will be transient if these issues are not addressed.

While such requests immediate arouse my curiosity/suspicion about what the person may be avoiding or defending against, or what past experiences are informing their request, I also understand the dilemma. After all, therapeutic approaches have been similarly divided on the most appropriate and efficacious focus for treatment. Psychodynamic and analytical approaches take the latter stance, that behaviors are simply markers of underlying issues, which should be the focus of treatment, with the assumption that resolving underlying issues will also resolve any problematic behaviors. Consequently, interventions focus on uncovering whatever the "underlying issues" may be (for example, via free association, transference/countertransference, etc), and resolving them through analysis, interpretation, and the resulting development of "insight." 

Behaviorism developed in reaction to psychoanalysis, almost as an antithesis. It is no surprise, therefore, that its descendants (e.g., Cognitive Behavioral Therapy) have a reputation for "no-nonsense," short-term interventions targeting behavior change, either by focusing on the behavior itself, or the thought process in which it is embedded. The assumption is that changing behavior, either on its own, or by changing thinking, is sufficient to achieve symptom relief (and avoids the lengthy and therefore costly therapy required to resolve those pesky "underlying issues").

However, most therapists I know (including myself) subscribe to a both/and, rather than either/or, approach - in other words, many of us espouse an approach that integrates the faster symptom-relief of approaches such as CBT, with the longer-term but longer-lasting resolution that comes from addressing "underlying issues." We've probably adopted this stance because we've seen incomplete or transient improvement as a result of a behavioral focus, but also witnessed clients' frustration or discouragement at the slow rate of behavior change when the focus is exclusively on underlying issues.

Because I subscribed to this kind of integrate stance, I was intrigued by the following defense of CBT as a potential access point to "underlying issues."

CBT's focus on symptoms is not meant to be a superficial intervention that has no implications for what lies beneath. Instead, by beginning with the symptoms that are present and accessible, the therapy process has access to what is fundamental and significant in determining the emotional and psychological health of the individual and thereby has the potential to facilitate meaningful and profound change. If CBT were merely a superficial intervention, it would be like weeding a garden by snipping off the top leaves. Instead, CBT interventions begin with the top leaves and follow the organic connections until the roots of the problem have been identified and weeded out. (Pike, Devlin & Loeb, 2004)

What do you think about this question of behavior change vs. underlying issues? How do different approaches you've learned navigate the question? What does it really take to "facilitate meaningful and profound change?"