Psychodynamic Therapies: How Did We Get Here & Where Are We Going?

• Psychodynamic Therapy’s Checkered Past
• Psychodynamic Therapy’s Current Status
• Future Directions

I just finished reading Our Time Is Up, a wonderful combination of novel and memoir authored by the talented psychoanalyst and writer, Roberta Satow. Dr. Satow has created the most vivid description I’ve ever read of what real psychotherapy actually feels like — from the very different perspectives of the patient, the therapist, the supervisor, and the trainee. Most books on psychotherapy either miss its elusive magic or overplay its drama — this one has perfect pitch and puts you right there in the room.

Throughout my career, doing psychodynamic psychotherapy was always the part of my week I most enjoyed. Satow’s book both recalled many fond memories and inspired me to pull together what will likely be my final thoughts on what is wonderful about dynamic psychotherapy, and what are its limitations. 

Psychodynamic Therapy’s Checkered Past

I’ll start with the checkered past — especially paying tribute to Sandor Ferenczi, the master clinician who was the underappreciated father of psychodynamic therapies. Next, I’ll evaluate the much reduced, but still crucial, role of dynamic techniques among the current chaotic and bewildering array of therapies. Finally, I’ll try to predict the future — what is the best-case final fate of psychodynamic therapies?

[Full disclosure] I graduated from Columbia University’s Psychoanalytic Center and taught its Freud course for 10 years. But I never was much of a fan of 4/5 times a week, on the couch, traditional, regressive psychoanalysis — regarding it as unnecessary and impractical for almost all patients and wasteful of resources better allocated to once a week, sitting up, long- or short-term dynamic therapies. While best at psychodynamic therapy, I also learned and integrated cognitive, behavioral, interpersonal, and family approaches. I think Freud was greatly overvalued in his own time and is greatly undervalued in ours — and I equally oppose blind Freud worshipers and blind Freud haters.

Freud: Great Model Builder, Lousy Clinician

Having invented psychoanalysis (in collaboration with his mentor, Joseph Breuer, and their shared patient, Berthe Pappenheim), Freud divided it into three separate endeavors: 1) research tool; 2) model of the mind; 3) clinical treatment.

Psychoanalysis as a research tool was at the outset enormously exciting — uncovering basic aspects of human nature that informed not only psychology, but also the study of myth, anthropology, sociology, art, and literature. But most new insights into the unconscious were made early on, and nothing really novel has emerged from the couch since Freud’s death.  

Much more enduring has been the psychoanalytic model of the mind. Here Freud sat on Darwin’s shoulders — applying Darwin’s revolutionary, but generalized, discoveries in evolutionary psychology to the specifics of human behavior and symptom generation.

Freud borrowed from Darwin three crucial insights: 1) human mental functioning is just as derivative from our primate ancestors as is our bodily morphology; 2) much of our behavior derives from inborn motivations that reside outside our conscious awareness; and 3) these have been shaped by natural and sexual selection. 

Freud filled in Darwin’s general outline with exquisitely detailed and specific analyses of the form and content of the unconscious and how one’s past experiences powerfully influence current hehavior. Freud’s model of the mind contained some bad (but then plausible) guesses which are the source of current ridicule — but the main concepts hold up extremely well and remain important in understanding people and treating them.

Freud never claimed to be a great therapist, or even to having much interest in psychoanalysis as a clinical art. He saw himself much more as an adventurer using psychoanalysis as a research tool in the scientific exploration of how the human mind works — awake and in dreams. Descriptions by Freud’s patients describe him as highly intellectual and patriarchic in his approach, using the therapeutic encounter to formulate and test his theories of how the unconscious works.

Ferenczi: Master Clinician

Sandor Ferenczi, Freud’s student & analysand, was the great clinician of early psychoanalysis and by far the most powerful influence in how psychodynamic therapies have since evolved and are practiced today. He was responsible for defining its healing qualities, introducing many major innovations, and adapting esoteric psychoanalytic theory to real world practice.  

Here’s a summary of Ferenczi’s clinical contributions:
 
Therapeutic Alliance: Ferenczi emphasized the importance of negotiating a strong collaborative relationship with the patient, established on more equal terms, characterized by shared goals, and with mutually agreed upon roles and division of labor.

Interpersonal/Relational Therapy: Ferenczi was much more alive than Freud to the power of the healing relationship and the importance of establishing a strong affective bond with the patient. As his student, Sandor Rado, put it, “Insight never cured anything but ignorance.” The relationship is more curative than specific interpretations, however brilliant or accurate they may be.

Empathy: Ferenczi regarded therapist empathy as an essential tool in promoting change. Sharing feelings and feeling understood facilitates change as much as does gaining specific insights.

Here-and-Now: Freud mainly used psychoanalysis as a research tool to determine how past experiences shaped the unconscious and influenced current behavior. Ferenczi did this too, but also brought more focus to the triggers of present problems and how best to solve them.

Therapist Activity: Freud aspired to (but never really achieved) being a passive “blank screen” upon which patients could project their fantasies. Ferenczi was much more active and real in the sessions.

Patient Activity: Patients don’t get better just through free association and the insights gained in the therapy sessions — they must also widen their experiences and get out of repeated behavioral ruts. What happens between sessions is at least as important as what happens within sessions.

Corrective Emotional Experience: This was best stated by Ferenczi’s student, Franz Alexander, who said, “The patient, to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.”

Psychodynamic Therapy: Regressive psychoanalysis was originally a great research tool but has never been a practical treatment — it is way too resource wasteful, suitable only for pretty healthy patients, and risks creating excessive dependence and hiding in the treatment. Ferenczi’s innovations allowed psychodynamic theory and technique to be flexibly applied in less intensive, but very effective, sitting-up psychodynamic therapies occurring usually once a week.

Time-limited Focused Therapy: Ferenczi and Rank realized that long-term therapies were too intense and inefficient to treat the many people who needed help. They developed a remarkably useful brief dynamic therapy (currently much underutilized) that focuses only on understanding and changing the most pressing presenting conflict.

Self- Disclosure: Ferenczi was not shy about revealing information about himself if this would further the relationship or provide a useful model for the patient.

Role of Childhood Traumas: Freud’s first theory of neurosis attributed it exclusively to early childhood sexual traumas. But he abruptly and completely abandoned this causal theory in the early 1890s because such childhood sexual experiences were so commonly reported by his patients. Freud then assumed the reported experiences existed only in fantasy, rather than having actually occurred in reality. Ferenczi had the more balanced view that real childhood traumas do sometimes play a contributory, but not exclusive, role in producing adult symptoms and that they are not exclusively sexual.

Treating More Difficult Patients: Many classic psychoanalysts were often so picky about selecting patients that only the people who didn’t really need treatment would qualify for it. Ferenczi adapted psychodynamic understanding and techniques so that they could be usefully applied to the more severely ill. 

In summary, Ferenczi, not Freud, was the clinical father of psychodynamic psychotherapy and his innovations shaped how it is still practiced today.

Psychodynamic Therapy’s Current Status

My previous essay; Psychotherapy Status Report offered a report card on the current status of psychotherapy. It nicely provided context for the more specific question of where psychodynamic therapies fit in. The short answer is that all psychotherapy practice is fragmented and chaotic — and that psychodynamic training and practice add to the confusion.

There is little integration among the more than 50 different named forms of psychotherapy. These are often seen as competing; most trainees receive instruction in just one narrowly focused method and many practicing clinicians identify with just one form of therapy. “CBT” is the most popular brand name, followed by “psychodynamic,” and “trauma-informed” which is becoming increasingly popular. There is also an age and gender disparity. Older therapists are more likely to identify with psychodynamic; younger with CBT; women with trauma-informed. 

Training in psychodynamic psychotherapy is also chaotic. There are hundreds of different programs varying greatly in theoretical model, prerequisites, intensity, techniques, and accreditation. At one extreme are the traditional psychoanalytic institutes which are more selective, require many years of intense didactic and clinical training, often still use of the couch, and require personal analysis. At the other extreme, there are now psychodynamic training programs that are open to all and, remarkably enough, completely online.  

There is very little research on psychodynamic psychotherapy because it does not conform easily to standardized clinical trial research designs and only a handful of its practitioners are research trained. The few scattered research studies suggest that psychodynamic therapies are equal in efficacy to better studied psychotherapies.

Dynamic therapy is gradually declining in influence. Most psychiatric residency programs now provide little or no training in psychodynamic therapies — even though such training is still often desired and sought after by some residents. Young therapists in other disciplines are less and less likely to be trained in dynamic techniques. And insurance companies are less likely to fund dynamic as opposed to other techniques that are less intense and better studied. The average age of dynamic therapists is rising, and its cultural relevance is diminishing. The future does not seem bright.

Future Directions

Will Psychodynamic Therapy Continue as a Separate Profession?

I hope not. Psychodynamic therapy was always my favorite technique, but only if combined with cognitive behavioral, interpersonal, and family techniques. Similarly, the training programs I created were based on the integration of psychotherapies, not their separation into separate silos.

I have long felt that psychoanalysis is too important to be left to the psychoanalysts. They have maintained an unfortunate rigidity in technique and teaching; have been resistant to innovation; and missed opportunities to expand their purview and influence. Their biggest mistake was rejecting Aaron Beck’s CBT. Beck was a trained analyst who originally conceptualized his innovations as an expansion of psychodynamic techniques, not a replacement. Had the psychoanalysts been wise, they would have embraced CBT as an extension, rather than rejecting it as a competitor. I don’t think that psychodynamic therapies should be taught in institutes that specialize in it. Similarly, I don’t think that “CBT” or “DBT” or any of the other 50 alphabet denoted therapies should be taught or practiced as a separate discipline distinct from other psychotherapies.  

Instead, I think psychotherapy should be considered a unified therapy which includes within it a wide variety of techniques. And training programs should no longer brand themselves narrowly. Narrowly trained therapists become hammers looking for nails, rather than flexibly responding to patient need. Psychodynamic techniques should be highly valued because they are very valuable- but they should be valued as a component of psychotherapy, not as a separate specialty.

Will Psychodynamic Therapists Be Replaced by Computers?

I’ve written an entire blog on the history of computers delivering psychotherapy: their current role and their future potential. Bottom Line — there is nothing humans do that computers won’t eventually do better.

One small consolation is that computers will have more trouble and take longer replacing psychodynamic therapists than almost any other type of professional. More than most human endeavors, uncovering someone’s unconscious motivations and facilitating corrective emotional experiences are intuitive and inferential processes that don’t easily lend themselves to the number-crunching powers of machine learning. But given enough data and enough time, even these most human of skills may be mastered by artificial intelligence.  

Should this pessimistic prediction discourage people from entering the field? I think not at all. First off, psychodynamic psychotherapy is a better hedge against computer replacement than almost any other career choice. But more important, doing psychodynamic psychotherapy is one of the most rewarding ways of spending one's time on earth. You have the immense satisfaction of understanding and helping others, with the valuable added bonus of learning from your patients how to become a better person.

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Which brings us back to where we started. Roberta Satow’s book is a great introduction for new psychotherapists and a great refresher for experienced ones. No manual of psychotherapy, and no textbook, can ever capture the special healing ambiance of the therapist/patient relationship. Only the lived experience of someone who has been a patient, been a therapist, been a supervisor, been a trainee — and can write really well — can bring therapy alive in a way that inspires and educates.

Questions for Thought and Discussion

In what ways do you concur or disagree with the author’s assessment of dynamic psychotherapy?

Would you consider training in psychodynamic therapy?

What kind of client would you refer to an analytic therapist and why?   

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