Psychodynamic Therapy / Psychoanalytic Psychotherapy

What it is

A family of therapies descended from psychoanalysis and unified by the understanding that unconscious processes, early relational patterns, and the therapeutic relationship itself are the primary domains of clinical work. Modern psychodynamic therapy is substantially different from classical psychoanalysis: it is typically face-to-face rather than couch-based, shorter in term (though still often long), more collaborative and less hierarchical, and more explicitly focused on the here-and-now therapeutic relationship as a window into the relational past. The various psychodynamic traditions, including object relations (Winnicott, Klein, Fairbairn), self psychology (Kohut), relational psychoanalysis (Mitchell, Aron), and mentalization-based therapy (Fonagy, Bateman), all share the premise that what happens between people in close relationships, including the therapeutic relationship, is where the most important psychological work occurs.

How it works

Psychodynamic therapy works through multiple interconnected mechanisms: increased self-awareness of unconscious and procedural patterns that drive behavior outside conscious awareness; exploration of early relational experiences and their effects on current relationships and self-experience; transference analysis (noticing when the client is relating to the therapist as a past figure and using that pattern as a window into relational history); and the experience of a new kind of relationship within the therapeutic frame, one that is boundaried, consistent, and able to contain difficult emotional material without retaliating or withdrawing. Peter Fonagy's concept of mentalization, the capacity to understand one's own and others' behavior in terms of underlying mental states, is both an outcome of secure attachment and a mechanism of change in psychodynamic work: as the therapeutic relationship provides a secure base, mentalizing capacity increases, which in turn makes relationships less reactive and more genuinely understood.

Research base

A landmark 2010 meta-analysis by Jonathan Shedler at the University of Colorado, published in the American Psychologist, found that psychodynamic therapy produced effect sizes in the moderate-to-large range, comparable to those reported for CBT, with evidence of superiority at long-term follow-up. Shedler's analysis challenged the prevailing assumption that CBT's evidence base was uniquely superior. Research by Falk Leichsenring and colleagues at the University of Giessen has further demonstrated long-term psychodynamic effectiveness in complex presentations including personality disorders and chronic depression, where shorter-term approaches frequently show limited durability. Peter Fonagy's Mentalization-Based Treatment (MBT) research (University College London) has produced strong RCT evidence for a specific psychodynamically-informed approach to BPD.

Works best for

• /Personality patterns and character-level psychological organization
• /Relational difficulties that repeat with different partners over decades
• /Chronic depression with a long developmental history
• /Existential questions about identity, meaning, and purpose
• /Understanding the deeper structural reasons behind symptoms
• /Presentations that have not responded to skills-based or shorter-term approaches

Limitations and considerations

Psychodynamic therapy is typically long-term and therefore costly in both time and money, making it less accessible than briefer approaches. The evidence base, while growing, has historically lagged behind CBT due to the difficulty of manualization and the heterogeneity of psychodynamic approaches, which makes standard RCT methodology harder to apply. Some clients, particularly those seeking skills or relief from acute symptoms, may find the exploratory stance frustrating when what is needed first is stabilization or skill-building. The quality of psychodynamic work is highly dependent on the therapist's training depth and their own capacity to work with unconscious process.

In this framework

Psychodynamic therapy provides the depth work, the exploration of how the past lives in the present through unconscious relational patterns, that is assumed in this framework but not always explicitly mapped. It is particularly relevant for the attachment-identity loop: understanding how early internalized object relationships (Winnicott's use of object being technical, meaning important people rather than things) are reproduced in current relating. The concept of internalized objects corresponds to what this framework calls the internal working model: the body's procedural prediction of how relationships work. Psychodynamic work, at its best, makes the implicit explicit and creates the conditions for new relational experience within the therapeutic frame.

This connects to

A Woman's Guide to Reclaiming Her Worth

Other modalities

• Somatic Experiencing (SE) →Developed by Peter Levine in the 1970s-1990s
• Eye Movement Desensitization and Reprocessing (EMDR) →Developed by Francine Shapiro in 1987-1989
• Internal Family Systems (IFS) →Developed by Richard Schwartz beginning in the 1980s

The Elysian Press

Weekly essays on healing, attachment, and the nervous system.