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Psychodynamic psychotherapy is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension. In this way, it is similar to psychoanalysis. It also relies on the interpersonal relationship between client and therapist more than other forms of depth psychology. In terms of approach, this form of therapy uses psychoanalysis adapted to a less intensive style of working, usually at a frequency of once or twice per week. Principal theorists drawn upon are Freud, Klein and theorists of the object relations movement, e.g. Winnicott, Guntrip, and Bion. Some psychodynamic therapists also draw on Jung or Lacan. It is a focus that has been used in individual psychotherapy, group psychotherapy, family therapy, and to understand and work with institutional and organizational contexts.
The principles of psychodynamics were introduced in the 1874 publication Lectures on Physiology by German scientist Ernst Wilhelm von Brücke. Von Brücke, taking a cue from thermodynamics, suggested all living organisms are energy systems, governed by the principle of energy conservation. During the same year, von Brücke was supervisor to first-year medical student Sigmund Freud at the University of Vienna. Freud later adopted this new construct of “dynamic” physiology to aid in his own conceptualization of the human psyche. Later, both the concept and application of psychodynamics was further developed by the likes of Carl Jung, Alfred Adler, Otto Rank, and Melanie Klein.
Most psychodynamic approaches are centered on the concept that some maladaptive functioning is in play, and that this maladaption is, at least in part, unconscious. The presumed maladaption develops early in life and eventually causes difficulties in day-to-day life. Psychodynamic therapies focus on revealing and resolving these unconscious conflicts that are driving their symptoms. Major techniques used by psychodynamic therapists include free association, recognizing resistance and transference, working through painful memories and difficult issues, and building a strong therapeutic alliance. As in some psychoanalytic approaches, the therapeutic relationship is seen as a key means to understanding and working through the relational difficulties which the client has suffered in life.
Core principles and characteristics
Although psychodynamic psychotherapy can take many forms, commonalities include:
- An emphasis on the centrality of intrapsychic and unconscious conflicts, and their relation to development.
- Seeing defenses as developing in internal psychic structures in order to avoid unpleasant consequences of conflict.
- A belief that psychopathology develops especially from early childhood experiences.
- A view that internal representations of experiences are organized around interpersonal relations.
- A conviction that life issues and dynamics will re-emerge in the context of the client-therapist relationship as transference and counter-transference.
- Use of free association as a major method for exploration of internal conflicts and problems.
- Focusing on interpretations of transference, defense mechanisms, and current symptoms and the working through of these present problems.
- Trust in insight as critically important for success in therapy.
Meta-analyses in 2012 and 2013 come to the conclusion that there is support or evidence for the efficacy of psychoanalytic therapy, thus further research is needed. Other meta-analyses published in the recent years showed psychoanalysis and psychodynamic therapy to be effective, with outcomes comparable or greater than other kinds of psychotherapy or antidepressant drugs, but these arguments have also been subjected to various criticisms.
A system review of Long Term Psychodynamic Psychotherapy in 2009 found an overall effect size of .33. Others have found effect sizes of .44-.68. Meta-analyses of Short Term Psychodynamic Psychotherapy (STPP) have found effect sizes ranging from .34-.71 compared to no treatment and was found to be slightly better than other therapies in follow up. Other reviews have found an effect size of .78-.91 for somatic disorders compared to no treatment and .69 for treating depression. A 2012 meta-analysis by the Harvard Review of Psychiatry of Intensive Short-Term Dynamic Psychotherapy (I-STPP) found effect sizes ranging from .84 for interpersonal problems to 1.51 for depression. Overall I-STPP had an effect size of 1.18 compared to no treatment.
In 2011, the American Psychological Association made 103 comparisons between psychodynamic treatment and a non-dynamic competitor and found that 6 were superior, 5 were inferior, 28 had no difference and 63 were adequate. The study found that this could be used as a basis "to make psychodynamic psychotherapy an "empirically validated" treatment."
A 2011 meta study showing that long-term psychodynamic psychotherapy was superior to less intensive forms of psychotherapy in complex mental disorders, has been challenged on methodology in the British Journal of Psychiatry, stating "we would greatly appreciate caution against a conclusion that the overall effectiveness of LTPP for treating complex mental disorders should now be considered as definitely proven." Positive research on efficacy would be very helpful to increase health systems provision of psychodynamic research.
Because of the subjectivity of each client’s potential psychological ailments, there is rarely a clear-cut treatment approach. Most often, therapists vary general approaches in order to best fit a client’s specific needs. If a therapist does not understand the psychological ailments of his/her client extremely well, then it is unlikely that they are able to decide upon a treatment structure that will help the client. Therefore, the client-therapist relationship must be extremely strong. Therapists like their clients to be as open and honest as possible with them. Clients must trust their therapist if this is to happen. Because the effectiveness of treatment relies so heavily on the client giving information to his/her therapist, the client-therapist relationship is more vital to psychodynamic therapy than almost every other type of medical practice.
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