Psychodynamic Psychotherapy Today

Psychodynamic psychotherapy today involves a spectrum of treatments. Some are specifically tailored to disorders—for example, transference-focused psychotherapy and mentalization-based therapy for borderline personality disorder. Others are more general and deliberately not focused on symptom removal.

All psychodynamic therapies are based on a thoroughgoing understanding of human subjectivity and how it interacts with the individual’s relationship with both the external and internal environment. It occurs on a continuum from expressive or interpretive interventions, on the one hand, to supportive and empathic interventions, on the other, and incorporates unconscious conflict, internal representations of relationships, and idiosyncratic and complicated meanings that are attached to experience. Central to dynamic psychotherapy is a search for the truth about the self that leads to a greater sense of authenticity.

While controlled studies of dynamic psychotherapy were once scarce, that situation has changed. Two highly influential randomized, controlled trials have been published in the last few years that compared the outpatient treatment of major depression with psychodynamic therapy and with cognitive-behavioral therapy. Both studies reported that no statistically significant treatment differences were found for any of the outcome measures between cognitive-behavioral therapy and psychodynamic therapy. These two studies together have done much to influence the acceptance of psychodynamic therapy as an empirically validated treatment.

In the July 2015 Lancet Psychiatry, Falk Leichsenring, D.Sc., and his team discussed 64 randomized, controlled trials that demonstrated convincing evidence of the efficacy of psychodynamic therapy in common mental health disorders. They concluded that there is substantial evidence for the efficacy of psychodynamic therapy in depression, anxiety disorders, somatoform disorders, eating disorders, substance-related disorders, and personality disorders. The effects of the psychodynamic therapy were found to be stable or increased in follow-up assessments.

Some forms of psychodynamic psychotherapy eschew a symptom focus. A fundamental principle of psychodynamic thinking is that we are consciously confused and unconsciously controlled. We don’t really know ourselves. Because of a variety of conflicts, prohibitions, anxieties, and defenses, we tend to hide out from ourselves, and the task of the psychodynamic therapist is to join the patient in a search for the patient’s true self.

One of the most distinctive features of psychodynamic psychotherapy is that the therapist addresses the person with the illness, not simply the problematic symptoms. Patients who come to psychotherapy, like everyone else, have built up a lifetime of defenses so that self-deception is a ubiquitous factor in psychodynamic psychotherapy. We would like to be known and validated and recognized, but we are riddled with shameful fantasies, fears, and wishes, and we worry that others will think badly of us if we reveal the hidden aspects of ourselves. Hence psychodynamic psychotherapists are determined to help patients get in touch with who they are and what they want to do with their lives.

One of the most distinctive features of psychodynamic psychotherapy is that the patient comes for help but unconsciously resists the insights provided by the therapist. The defenses in the patient’s inner world become resistances when the patient enters into the interpersonal relationship that psychotherapy provides. Hence the patient may dismiss what the therapist says, come late for sessions, “forget” the day and time of the session, and draw a blank when asked to speak about what is distressing. The dynamic therapist helps the patient look at the defenses marshalled against the therapist and the underlying fears of being shamed, exposed, misunderstood, controlled, and coerced.

In an era of “quick fixes” and instant gratification on the Internet, psychodynamic psychotherapy fills a need for connection, understanding, empathy, and authenticity. The psychotherapist listens, acknowledges the presence of ambivalence, and helps the patient sort out the sources of distress. The days of strict abstinence and neutrality are long gone. The dynamic therapist knows that psychotherapy is a two-person field and studies the interaction between the two parties with the idea that he or she may influence what is happening in the patient. Above all, the therapy is a collaboration between patient and therapist for answers that seem elusive. ■