Addiction A-Z

Psychodynamic therapy

If there’s a type of therapy that truly encompasses the meaning of the phrase “traditional talk therapy,” it’s psychodynamic therapy.  One of the oldest forms of therapy – and one that is still practiced widely today – psychodynamic therapy stems from the work of Sigmund Freud and many other prominent psychoanalysts and psychotherapists.

Psychodynamic therapy is sometimes referred to as “insight-oriented psychotherapy”.  The reason for this is because the primary focus is on helping therapy clients gain deep emotional insight into what drives them at the deepest level.  You see, most people go through life not realizing that much of their behavior and emotional responses are driven by the unconscious – rather than the conscious – mind.  They assume they’re making choices and decisions based on things like logic and reason, when in fact there are much deeper mechanisms in play.

If they’re reasonably psychologically healthy, then this isn’t necessarily a bad thing.  However, if they’re struggling with frequent negative emotions, experiencing ongoing relationship problems, or living with serious psychiatric symptoms or disorders such as major depression, one of several different anxiety disorders, or posttraumatic stress disorder or other manifestations of unresolved trauma, then they have what psychodynamic therapists refer to as “unconscious conflicts”.  And these internal conflicts can create very serious and chronic problems throughout their entire life.

These problems can often be traced back to early childhood experiences and crucial moments when their psychological development got stuck or thwarted.  This is the reason why psychodynamic therapy – unlike many more recent and relatively short-term therapies, such as Cognitive Behavioral Therapy (CBT) or Solution-Focused Brief Therapy, for example – places a strong emphasis on an individual’s past.  Helping clients understand the significant connection between childhood emotional wounds and the difficult issues that led them to therapy is a key factor in the effectiveness of psychodynamic therapy.

Psychodynamic therapy strives to unearth the underlying issues – the unconscious conflicts and emotional blind spots – that cause people to make unhealthy choices and behave in ways that aren’t in their best interest, both of which lead to emotional suffering.  Psychodynamic therapists guide clients through a process of exploration, self-discovery, and self-examination in order to lead happier and more fulfilling lives.  The process includes a strong emphasis on what occurs within the therapeutic relationship itself.

A Brief History of Psychodynamic Therapy

Psychodynamic therapy has its origins in psychoanalytic theory.   Although this therapeutic approach is strongly rooted in classic Freudian psychoanalysis, the work of many different prominent individuals has influenced psychodynamic therapy as we know it today.  They include Carl Jung, Melanie Klein, Alfred Adler, Anna Freud, Erik Erikson, John Bowlby, Heinz Kohut and several others.

Psychodynamic therapy is one of the oldest therapeutic approaches used by psychologists, psychiatrists, and other mental health therapists today.  However, many therapists who use it as their primary approach to treatment incorporate techniques and concepts from other therapeutic approaches, such as cognitive behavioral therapy, as well.

How Psychodynamic Therapy Works / Key Characteristics of Psychodynamic Therapy

In order to have a better understanding of how psychodynamic therapy works – as well as what to expect in therapy sessions – it’s important to look at the key characteristics of this approach.

  • Therapy sessions are unstructured, and clients are encouraged to speak freely about whatever is on their mind, including their fantasies, fears, dreams, and desires.  The therapist’s role is to listen carefully, as this open-ended dialogue provides valuable information about clients.  Recurring themes – particularly those pertaining to how clients perceive themselves, others, and the world – and patterns inevitably appear. Identifying and exploring these themes and patterns helps bring unconscious conflicts into the client’s conscious awareness.
  • Past experiences, particularly those with childhood caregivers and other key figures, are explored and discussed.  This focus on how the past is impacting the present (i.e. contributing to the problems that led the client to therapy) is one of the things that sets psychodynamic therapy apart from CBT and many other therapies that put much more emphasis on the here-and-now.  It’s essential, however, to look at the role of the past to discover and understand the root cause (s) of current problems.  This helps clients finally break free from the recurring impact of negative past experiences.
  • Identifying and discussing clients’ use of defense mechanisms (e.g. avoidance, rationalization, intellectualization, denial, regression, projection, or compartmentalization) is a key focus of psychodynamic therapy.  Clients are often unaware of these protective mechanisms, including the significant role they play in the problems they’re experiencing.  For example, defense mechanisms often cause significant problems in relationships.
  • Psychodynamic therapy places a strong emphasis on clients’ feelings, including how they express their emotions.  Of particular importance are those feelings that clients perceive as unacceptable or taboo (e.g. envy, disgust, or anger), threatening, or especially distressing troubling. Problems occur when people try to repress these emotions rather than owning them and expressing them in a healthy manner.  The therapist helps clients when they have a difficult time identifying or articulating what they’re feeling.  Unlike more cognitively focused therapies such as CBT, in which intellectual insight is emphasized, psychodynamic therapy promotes emotional insight, which occurs at a much deeper level.
  • A strong focus on clients’ relationships is a major aspect of psychodynamic therapy.  Negative or unhealthy relationship patterns (e.g. often dating abusive or controlling men, or being passive-aggressive with one’s spouse) shed light on clients’ unmet emotional needs.  Painful experiences and dysfunctional relationships with early caregivers often have a major impact on adult relationships.  Identifying and exploring this connection helps clients make necessary changes that lead to healthier and more fulfilling relationships
  • Psychodynamic therapy places a heavy emphasis on the therapeutic relationship.  The themes and underlying issues in clients’ relationship history inevitably play out in their relationship with the therapist.  For example, clients who struggle with authority figures may begin to resent the therapist’s perceived role as yet another authority figure, triggering hostility or passive-aggressive behavior. Clients with abandonment issues may become overly dependent on the therapist, or regress if the therapist goes on vacation.  By exploring and discussing what occurs within the therapist-client relationship, clients gain insight into recurring themes in their past and current relationships outside of therapy.
  • An emphasis on exploring avoidant behavior in clients is another key characteristic of psychodynamic therapy.  Clients often become avoidant or resistant when they start to feel threatened or overwhelmed by distressing thoughts and emotions.  This can manifest in a variety of ways, but some of the most common include skipping or canceling sessions, showing up late for therapy, changing the topic, intellectualizing, or being evasive.

Each of these key characteristics of psychodynamic therapy works together to form and drive the process that leads to healing and positive, enduring changes in clients.  It helps promote personal growth and change at a deep emotional level.  This occurs as the various areas of focus, exploration, and discussion help clients gain valuable insight and expand their psychological resources.  The primary goal of psychodynamic therapy extends far beyond merely reducing troubling symptoms; rather, it strives to bring about profound positive changes in the clients’ relationship with themselves as well as others.

Indications for Psychodynamic Therapy

Psychodynamic therapy has been effectively used to treat a vast array of psychiatric disorders and other problems that lead people to seek therapy.  Individuals who may benefit from this insight-driven therapeutic approach include those struggling with:

  • Depression
  • Bipolar disorder (not actively manic or hypomanic)
  • Eating disorders
  • Generalized anxiety disorder
  • Panic disorder
  • Obsessive-compulsive disorder
  • Specific phobias
  • Social anxiety disorder
  • Posttraumatic stress disorder
  • Recovery from substance use disorders
  • Addictive behaviors
  • Certain types of personality disorders
  • Sexual disorders
  • Family conflicts
  • Relationship problems
  • Marital discord
  • Low self-esteem
  • Academic problems
  • Conflicts at work
  • Intimacy issues
  • Self-destructive behavior
  • Trust issues
  • Somatic complaints and somatization disorders
  • Dissociative disorders
  • Grief and loss
  • Unresolved trauma
  • Low motivation

While the above disorders and issues may respond well to a psychodynamic approach, not all individuals are well-suited for this type of therapy.  (See “who is a good candidate” below.)

Contraindications for Psychodynamic Therapy

As with many other types of psychotherapy, there are several contraindications for a psychodynamic treatment approach.  These include individuals who are:

  • Actively abusing alcohol or drugs (therapy can be appropriate once they’ve stopped using and are actively working on recovery)
  • Actively psychotic (once the psychosis is in remission, this therapy may be appropriate)
  • Experiencing an acute manic episode
  • In an acute suicidal crisis (i.e. they are actively suicidal with intent, plan, and means)
  • Actively homicidal
  • Experiencing any other type of acute crisis

With each of the above, once the issue is under control (e.g. the client has stopped using and is working on his or her recovery, the psychosis is in remission, or he or she is no longer actively suicidal), then psychodynamic therapy may be appropriate, depending on other factors.

Ideal Candidates for Psychodynamic Therapy

There are certain types of individuals who usually respond quite well to psychodynamic therapy.  They possess the following traits:

  • They have a strong capacity for insight
  • They have a high capacity for self-observation
  • They want to understand themselves – the “inner workings of their mind” – at a deeper level
  • They can tolerate uncomfortable emotions
  • They’re motivated to make changes to improve their life
  • They’re able to form meaningful and lasting connections with others
  • They’re highly motivated to get better / make positive changes
  • They have a genuine desire for the truth
  • They can allow themselves to feel vulnerable
  • They’re not in an acute crisis
  • They have good impulse control
  • They’re able to be objective
  • They have a strong capacity for introspection
  • They’re empathetic
  • They have good verbal skills
  • They have a sufficient degree of intelligence for this type of therapy
  • Their reality testing is intact

Individuals who are not well-suited to psychodynamic therapy, on the other hand:

  • Are in an acute crisis
  • Have a poor capacity for introspection and self-observation
  • Have poor verbal skills
  • Have low frustration tolerance
  • Are unable to form a therapeutic relationship
  • Have little or no motivation to change
  • Have very limited tolerance for strong emotions
  • Have a poor capacity for insight
  • Are highly impulsive
  • Have significant cognitive deficits (e.g. due to traumatic brain injury or dementia)
  • Have a relatively low IQ
  • Have little to no empathy for others
  • Have poor reality testing

Before starting psychodynamic therapy, it’s essential for therapists to assess the suitability of potential clients for this particular approach.  For those who aren’t well-suited, they can use another approach that’s more appropriate, or, if that’s not an option, refer them to a therapist who offers a type of therapy that’s a good fit.

What to Expect

In psychodynamic therapy, sessions usually last for 50 minutes to an hour and are done on a weekly basis.  In some instances, therapists may recommend twice weekly sessions, but weekly is much more common.  Unlike classic psychoanalysis, in which clients lay on a couch during sessions, this approach is done face to face like most other types of psychotherapy.

Psychodynamic therapy isn’t structured.  There isn’t a strict protocol that dictates the length of therapy or what is to occur on a session by session basis.  Sticking to a limited number of sessions may be discussed at the start of therapy, although an open-ended approach to treatment is more common.

Psychodynamic therapists often listen much more than they talk during sessions.  It’s important to understand that this doesn’t mean they’re not doing anything – in fact, the therapist’s silence can be a very powerful therapeutic tool.  For some clients – particularly those who expect therapists to primarily give advice – the therapist’s lack of advice-giving and frequent silence can be quite frustrating.  It can also be challenging for clients who require constant dialogue in order to feel comfortable.  For these individuals, even short periods of silence feel very awkward and may trigger a fair amount of anxiety.   Understanding and accepting this as part of the therapy process can help lessen both frustration and anxiety.

Psychodynamic therapy is often a relatively long-term type of therapy, often requiring at least 2 years of weekly sessions.  Some individuals may require even longer periods of time to reach a desired level of healing and change.  The reason it’s a long-term approach is because the primary goal is to effect change on a deep level.  The course of treatment is also lengthy because issues rooted in early psychological development often need to be addressed.  It’s one thing to learn how to challenge distorted beliefs or focus on short-term solutions for a specific problems, but quite another to change a deeply ingrained personality trait.

The exception to this is with brief psychodynamic therapy, which involves zeroing in on one particular problem or issue rather than allowing for unstructured dialogue that often covers multiple issues – many of which may seem completely unconnected, at least at first.

In brief psychodynamic therapy, a time limit is imposed at the start of therapy.  Sixteen sessions is typical length with a brief approach.

It should be noted that one of the criticisms of traditional psychodynamic therapy is that the process can be quite lengthy, extending well beyond a year or two.  Unfortunately, many people don’t have the resources to cover long-term therapy.  

Benefits of Psychodynamic Therapy

There are many potential benefits to be obtained from psychodynamic therapy, including:

  • Lasting positive change
  • Significant gains in self-awareness and self-understanding
  • Decreased use of defense mechanisms
  • Improved relationships
  • Healing from past trauma
  • Reduction in troubling symptoms
  • Improved mood
  • Less anxiety
  • Improved decision making
  • Greater life satisfaction
  • Less internal conflict
  • Decrease in emotional reactivity
  • Greater ability to handle stressful situations effectively
  • Greater tolerance for negative emotions
  • Increased self-confidence
  • Improved ability to manage anger
  • A sense of inner peace
  • Improved self-control
  • Greater overall sense of well-being
  • Decreased risk of relapse for those in recovery
  • Greater ability to get needs met in a healthy manner
  • Less self-sabotage

Advantages of Psychodynamic Therapy

There are many advantages to psychodynamic therapy.  Perhaps one of the greatest is that, unlike many popular, shorter-term therapies, it focuses on getting to the underlying cause of psychological problems.  This is what makes it such a powerful approach in terms of bringing about lasting change.

Other advantages include:

  • An emphasis on increasing emotional insight as opposed to mere intellectual insight, as emotional insight is a primary factor in bringing about healing and profound change
  • Because it addresses the root cause of problems, the changes that occur are broader in scope than with many other types of therapy
  • It is effective in the treatment of a wide range of psychiatric disorders
  • Since unconscious conflicts play a major role in relationship conflicts, psychodynamic therapy is very beneficial for anyone who wants to have healthier, more satisfying, and more enduring relationships with others (including family relationships, friendships, and romantic relationships, and also professional relationships)
  • Deeply ingrained maladaptive personality patterns, which are difficult to impact and change with most forms of therapy, often respond well with psychodynamic therapy

Disadvantages of Psychodynamic Therapy

As with other types of psychotherapy, psychodynamic therapy isn’t with its disadvantages.  They include:

  • Although psychodynamic therapy can bring about positive results in a relatively brief timeframe, it is generally a long-term therapy. This sometimes makes it a less desirable form of treatment for individuals who would prefer to not invest many months – or, in many cases – at least a year, two, or even more in therapy.
  • Due to the often longer-term nature of this approach, psychodynamic therapy may not be a good fit for someone who lacks the financial resources to cover lengthy treatment.
  • The lack of structure can be frustrating for some individuals, particularly those who prefer a more “step-by-step”, highly structured form of treatment.
  • Some individuals have a difficult time accepting the premise that unconscious factors play a significant role in the problems they’re experiencing.
  • Psychodynamic therapists are generally less directive when working with clients. This can be frustrating for individuals who prefer a more direct, “active” therapist.  It’s not uncommon for these individuals to drop out of treatment prematurely.
  • Individuals who expect fairly quick or immediate results from therapy often become impatient with a psychodynamic approach. They tend to assume that therapy isn’t working, even though it actually is – just not at a fast enough pace.
  • Some individuals are uncomfortable with the emphasis on the therapeutic relationship itself, which is a key component in psychodynamic therapy.   

Effectiveness of Psychodynamic Therapy

Accurately measuring the effectiveness of any type of therapy isn’t an easy task.  With psychodynamic therapy, measuring effectiveness is complicated by the fact that the approach is unstructured. However, there have been many studies that provide evidence that this approach to therapy is at least as effective as other well-established types of psychotherapy, as well as an effective form of treatment in its own right.

One of the most interesting things that researchers have found is that many of the popular therapies include aspects of psychodynamic therapy, even though that fact is often overlooked.  Research has also shown that a successful outcome is most likely to occur when therapists closely follow the key tenets of this therapeutic approach.

Finding a Psychodynamic Therapist

One of the easiest ways to find a psychodynamic therapist in your area is to search online with phrases like psychodynamic therapy [your city].  Unless you live in a small town or rural area, this type of search should yield several results.  When choosing a therapist, be sure to do your due diligence.  It’s generally best to choose a therapist who has a solid reputation and at least several years of experience using a psychodynamic approach to treatment.

It can feel a bit daunting to pursue a type of therapy that isn’t highly structured or short-term in nature, not to mention one that emphasizes the exploration of deep-seated issues and requires a fair amount of digging into your past.  However, the process can be incredibly worthwhile and bring about lasting changes in your life.

If you’ve already tried other types of therapy, particularly short-term therapies that focus on finding solutions or focus primarily on the present, to no avail or with limited benefit, then psychodynamic therapy is definitely worth considering.   Even if you’ve never been in therapy before, this tried and true therapeutic approach has much to offer.

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