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Psychodynamic Psychotherapy

Psychodynamic Psychotherapy is a large branch of psychotherapy that derives from psychoanalysis, which was introduced in the early 1900's by Sigmund Freud. There are various different schools of psychoanalysis, but they all share in common the view that unconscious drives and motivations determine people's behaviors, and that early life experiences set the tone for the kinds of patterns that we later develop in relationships and in interpersonal interactions.

Psychoanalysis

Psychoanalysis is a very intensive form of therapy where clients (ie. patients) will meet with their therapist, or analyst, for close to an hour 3 or 4 times a week over a period of years. In the classical forms of psychoanalysis, the client will lay on a couch facing away from the analyst, and will engage in free-association where they simply speak about whatever ideas are going through their minds. The role of the analyst is to discern the unconscious themes that underlie the client's dialogue and free-associations and interpret the ways in which the client relates to the analyst. The goal of this therapy is to have the client gain insight into their unconscious motives and fantasies and also to use the emotionally intense relationship that develops between the client and analyst as a way to explore and develop new ways of relating to others.

Although psychoanalysis continues to be practiced, the considerable cost involved in terms of time and money has made it very difficult to conduct proper studies to determine to what extent this form of therapy is effective, and for which conditions it is best suited. Most government and private medical insurance programs are thus unlikely to cover the costs of such an intensive form of therapy. As a result, it remains unavailable to most individuals.

Instead, Psychodynamic Psychotherapy, as described below, is the form of this therapy that is more commonly practiced and more widely available to individuals with mental health conditions.

Principles of Psychodynamic Psychotherapy

The main way in which Psychodynamic Psychotherapy differs from psychoanalysis is that it is a less intensive form of therapy. Sessions are usually held on a weekly basis, the client and therapist will sit face-to-face (rather then the client laying on a couch), and instead of free-associating the client will engage in a more direct conversation with the therapist.

Time frame of the therapy

In some cases the therapy will be open-ended, which means that there will be no set limit to the number of sessions that are offered, and the therapy will continue until the client and/or therapist decide that the work is complete. In cases where the therapy is being paid for by a third party, such as an insurance company or a government health program, it is more likely that a fixed number of sessions will be offered; this is known as time-limited therapy.

In general, 10 sessions is probably the shortest amount of time in which any benefits from the therapy can be expected. This may suffice for cases where the mental health problem is relatively uncomplicated, where it arose within a short period of time, and where the client is otherwise functioning well in life with healthy and supportive relationships and a stable work or school situation. In other cases, longer durations of therapy are often required.

Short-term Psychodynamic Psychotherapy is usually considered as being less than 40 sessions, whereas long-term therapy is normally 50 sessions or more [ref, ref].

Symbolic significance of symptoms

A basic premise of Psychodynamic Psychotherapy is that the symptoms that a client will report as their initial reason for starting therapy will be symbolic manifestations of the person's underlying unconscious conflicts and issues. As such, the therapist may decide not to focus the discussions directly on the client's stated symptoms, but rather to explore other areas of the person's life and history so as to get a sense of the whole person and the meaning and significance of their symptoms.

Insight-oriented

One of the main goals of Psychodynamic Psychotherapy is to have the client reach an awareness of the meaning and significance of their symptoms and of the underlying reasons for their (problematic) patterns of behaving and relating to others. This process is called "gaining insight." This is not achieved simply by having the therapist explain to the client what these underlying factors may be, because such a dry and intellectual approach would likely be met with skepticism and resistance on the part of the client. Instead, insight tends to be gained by clients making their own connections and discoveries over the course of the therapy. And one element that seems to be particularly important for making these advances is the therapeutic relationship that develops between the client and therapist.

Transference, boundaries, and the therapeutic relationship

In Psychodynamic Psychotherapy, much emphasis is placed on the importance of the emotionally powerful therapeutic relationship that develops between the client and therapist. This is seen as an essential component of the therapy and one of the main factors that help clients change and progress.

The therapeutic relationship is different from the kind of relationships that people will have with friends and loved ones. The main difference is that the therapeutic relationship is asymmetrical or unequal, in the sense that while the client tries to be completely open and to reveal their most intimate and personal details, thoughts and feelings, the therapist will usually say very little about themselves and will tend not to disclose much in the way of personal information to the client.

Part of the reason why the therapist does this is so that a clear frame and set of boundaries of the therapy can be maintained and the line is not crossed where the client and therapist come to feel more like friends or even intimate partners. This would ruin the therapeutic process, and would also put clients in a difficult position where they would come to expect special favors or attention from the therapist, or where they would feel obligated to tend to the therapist's personal needs and feelings.

Remaining as neutral as possible is also a way for the therapist to allow for the client to experience transference feelings towards the therapist. Transference is an unconscious process where a person begins to relate to someone in the way that they related to an earlier important figure in their lives, such as a parent, and to see this someone as imbued with qualities that are similar to the past figure. For example, over the course of therapy a client may begin to relate to the therapist as they had related to a parent, and to see in the therapist many traits of their parent. To the extent that the therapist can remain neutral and keep their life details unknown to the client, the therapist can become an effective projection screen for the client's transferences.

This transference experience allows both the client and therapist to experience in real-time the client's typical patterns and dynamics of relating to others that the client learned early in life, and which tend to repeat, often for the worse, with most of the people in the client's current life. For example, if the client is someone who has trouble entering intimate relationships because her or she has difficulty trusting others, then chances are that they will feel the same way towards the therapist. The important difference is that in the therapeutic relationship these very feelings can be identified, discussed and explored as they occur. This can be a very powerful experience that allows the client to gain a new awareness, or insight, into their patterns of feelings and behaving. This, in turn, will allow them to change and to find new and more healthy ways of relating to others.

Uses of Psychodynamic Psychotherapy

Short-term Psychodynamic Psychotherapy (40 sessions or less) has been shown to be effective for treating Major Depression, Postpartum Depression, Panic Disorder, PTSD, Social Phobia, Generalized Anxiety Disorder, Eating Disorders, Addictions, and Somatoform Disorders [ref, ref, ref].

When these same psychiatric conditions are chronic (ie. lasting for more than a year), or occur in combination with other psychiatric disorders, then long-term Psychodynamic Psychotherapy (50 sessions or more) has been shown to be effective [ref]. This long-term therapy has also been used successfully for treating Personality Disorders of various kinds [ref].