Today, psychodynamic psychotherapy tends to get dismissed or outright rejected. It’s seen as ineffective, unscientific and archaic. It’s associated with Freud and some of his “outlandish” theories — many of which have become caricatures. If you’ve ever learned about psychoanalysis or psychodynamic psychotherapy in college or even grad school, it’s likely your professors got it wrong.
Psychodynamic psychotherapy arose out of psychoanalysis, but it’s since evolved. A lot. As psychologist Jonathan Shedler, Ph.D, writes in this fantastic, myth-busting piece: “The development of psychoanalytic thought did not end with Freud any more than the development of physics ended with Newton, or the development of the behavioral tradition in psychology ended with Watson.”
Psychodynamic psychotherapy is depicted as inferior to other interventions, namely cognitive-behavioral therapy (CBT). But this couldn’t be further from the truth. For starters, the question shouldn’t be which treatment is superior. What really matters is that clients have options.
“Different kinds of people will respond differently to different types of treatment,” said Barbara L. Milrod, M.D., a professor of psychiatry at Weill Cornell Medical College who conducts research on the efficacy of psychodynamic psychotherapy for anxiety disorders.
She stressed the importance of giving patients alternatives. For instance, she’s worked with many people who didn’t improve with CBT. One client tried a wide range of CBT treatments for 13 years and still couldn’t cross the street without getting incredibly anxious. They worked together for 4 months, and his anxiety almost completely abated. “This [therapy] saved this guy’s life.” It’s vital for people to know that there are other effective alternatives. And if one treatment isn’t working, they should be able to move on to another.
Psychodynamic psychotherapy also is (incorrectly) viewed as “a fatuous exercise in narcissistic self-examination,” said Teri Quatman, Ph.D, who’s studied, practiced and taught psychodynamic psychotherapy for 30 years. She’s also the author of Essential Psychodynamic Psychotherapy: An Acquired Art. In actuality, it’s about getting seriously honest with ourselves and confronting our internal emotional truth, which is always “an act of courage.” For instance, people who’ve experienced different traumas may—understandably—wish to never think about them again. But those traumas will affect everything—from the partners they pick to the experiences they pay attention to (or ignore) in their own kids.
Today, psychodynamic psychotherapy has become “a countercultural voice and influence,” Quatman said. “Our workaholic, manic, frenetic pace as a culture makes us not think about emotional development in ourselves or in our children.” We may distract ourselves with gadgets, quick fixes and endless to-do lists, and find ourselves too busy to pause and dig deeper.
What is Psychodynamic Psychotherapy?
Psychodynamic psychotherapy is based “on the idea that unconscious thoughts, feelings and behaviors affect our conscious life,” said Deborah L. Cabaniss, M.D., clinical professor of psychiatry at the Columbia University College of Physicians and Surgeons and the director of psychotherapy training in the Department of Psychiatry at Columbia. Identifying these hidden elements—bringing them to light—gives us important insights, which help us in making thoughtful, intentional decisions.
She shared this example: You’re anxious about accepting a new job. You’re not sure where this anxiety is coming from, but you assume it’s there for good reason. Which means you might decline the offer. However, when you take a closer look, you realize that you’re actually anxious about doing better than your siblings. Knowing this can help you make a better decision about your career.
Psychodynamic psychotherapy also is rooted in a developmental view: “Our early experiences affect the way we think about ourselves, relate to others and adapt to stress later in our lives,” Cabaniss said.
Unlike CBT, psychodynamic psychotherapy is flexible and excludes homework. It’s patient-driven, meaning that the therapist doesn’t come to session with an agenda. Patients usually pick the topics to discuss, Cabaniss said. This is important because nothing is random. Our thoughts, feelings, actions, dreams and experiences are connected. They’re all clues into our concerns, into our unconscious. Exploring these clues is paramount and can even be life-saving.
For instance, in his paper, Shedler writes about a patient, Steve, who was recovering from a heart attack. Steve’s memory was just fine, but he kept “forgetting” to take his medication. Even after Steve’s doctor talked to him about the medication’s importance, he still kept forgetting and had no idea why. When they started discussing this in therapy, Steve’s thoughts went to his younger brother. Turns out, his brother was always taking pills because he was sick. He wasn’t good in school or sports and was a disappointment to his parents. Steve (unconsciously) feared that taking medication would also make him sickly, weak and unloved. After exploring these fears, he stopped forgetting his medication.
Treatment in psychodynamic psychotherapy may be long term. For instance, Quatman has worked with clients for 5 to 8 years. Treatment also may be short term. Psychodynamic psychotherapy for panic disorder is a 24-session intervention, which lasts for 12 weeks.
The duration of therapy really depends on the scope of your goals. Quatman works with clients to create fundamental internal changes, which take time. Here’s one example: A female client sought help for her short temper. She’d blow up and become physically violent with her sons and had a hard time understanding her and other’s emotions. She’d regularly misread her environment and relationships both at home and at work. She was cold and mechanical. After seeing Quatman for 7 years, she developed a capacity for intimate relationships she never thought possible. She even talked openly with her adult sons about how it felt to have had her as their mother. She had become a very different woman from the one who regularly misunderstood and berated them.
Psychodynamic therapists focus on the relationship between client and clinician—called “transference”—because this reveals how clients interact with others outside the office. A simplistic example is a client who fears conflict and rarely expresses frustration with her family doesn’t speak up when her therapist angers her.
How Effective is it?
Psychodynamic psychotherapy has been criticized for not having as much scientific support as shorter-term treatments, such as CBT. It’s true that fewer studies have tested the efficacy of psychodynamic psychotherapy. For one, “Longer-term therapies require longer-term studies, and thus are in many ways less appealing to researchers,” Quatman said.
Also, psychoanalysis has less of a research history, said Milrod, co-author of The Manual of Panic Focused Psychodynamic Psychotherapy—Extended Range. In the 1960s, during the “heyday of psychoanalysis, psychoanalytic institutes were unwelcoming to psychologists.” Consequently, psychologists formed their own training programs, many of which emphasized CBT. Many are connected to graduate programs, which conduct research. In general, “there are very limited research dollars available to study psychotherapy.” And credible research is expensive. Which means that researchers, of all psychosocial treatments, are dependent on a budget that is regularly shrinking.
However, when psychodynamic psychotherapy is rigorously studied, it’s not only shown to be effective, but to maintain gains over the long haul—better than other therapies. Milrod and colleagues have found that psychodynamic psychotherapy is an effective treatment for individuals with panic disorder (see here and here). Shedler’s excellent article in the American Psychologist summarizes the scientific evidence for a full range of conditions.
“We’re pretty good at shading the truth to ourselves. We do it every day, and we become less of what we could be,” Quatman said. Psychodynamic psychotherapy helps us discover and face the truth within ourselves. It helps us lead a life with more meaning and less suffering.
Woman reflecting photo available from Shutterstock