Psychodynamic psychotherapy or psychoanalytic psychotherapy is a form of psychological therapy.
Its primary focus is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. The terms "psychoanalytic psychotherapy" and "psychodynamic psychoterapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies.
The principles of psychodynamics were introduced in the 1874 publication Lectures on Physiology by German physician and physiologist 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 were further developed by the likes of Carl Jung, Alfred Adler, Otto Rank, and Melanie Klein. Psychodynamic therapy has evolved from psychoanalytic theory, with some later modifications in the therapeutic practice experienced since the mid-20th century.
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: The client is encouraged to communicate their true feelings and thoughts to the therapist. This is done with the client knowing it is a safe space and done without judgment and/ or consequence. These thoughts and/ or responses could possibly be irrelevant, illogical, and embarrassing to the patient. This is to help access unconscious information, memories, or impulses that the patient might otherwise have not been able to bring to the surface. After being brought to the conscious mind they can then be interpreted.
Dream interpretation: (also known as dream analysis) The client keeps a record of their dreams, and communicates or relays them to the therapist, sometimes aided by free association, and then the content is analyzed or interpreted for hidden meanings, underlying motivations, and other portrayals.
Recognizing resistance: This could be in many forms with slight variations depending on the type of resistance. The clients withstanding or withholding information for their better help and interpretation. Often the client could be using this a defense. This could be categorized in three different types of resistance.
The first type of resistance is conscious resistance, where the client is deliberate about not communicating the information needed because of distrust in the system, therapist, shame or rejection of the interpreter.
The second, repression resistance, also referred to as ego resistance, is used by the client to keep unacceptable thoughts, feelings, actions, and/ or impulses in the unconscious. This could be done by the patient blocking thoughts and communications during free associations, not remembering events.
The third, id resistance, is unlike the other two because it arises from the unconscious and is driven by id impulse. It resists change or treatment to further repeat the trauma in different situations, known as repetition compulsion. Additionally, there may be transference of views, feelings, and/or wishes of the patient onto the analyst, often the therapist, that were initially directed towards other impactful individuals in the patient's life. This is often people in early childhood such as parents, siblings, or other important people. By addressing these projected views it is hoped to help the patient reexperience, address, and analyze the effects; and to resolve current distress it could be causing. 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.
Psychodynamic psychotherapy is an evidence-based therapy (Shedler 2010) and its more intensive form, psychoanalysis is also evidence-based. Later meta-analyses 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. For example, meta-analyses in 2012 and 2013 came to the conclusion that there is little support or evidence for the efficacy of psychoanalytic therapy, thus further research is needed.
A systematic review of Long Term Psychodynamic Psychotherapy (LTPP) in 2009 found an overall effect size of 0.33. Others have found effect sizes of 0.44–0.68.
Meta-analyses of Short Term Psychodynamic Psychotherapy (STPP) have found effect sizes ranging from 0.34 to 0.71 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 0.78–0.91 for somatic disorders compared to no treatment and 0.69 for treating depression. A 2012 meta-analysis by the Harvard Review of Psychiatry of Intensive Short-Term Dynamic Psychotherapy (ISTDP) found effect sizes ranging from 0.84 for interpersonal problems to 1.51 for depression. Overall ISTDP had an effect size of 1.18 compared to no treatment.
In 2011, a study published in the American Journal of Psychiatry 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." In 2017, a meta-analysis of randomized controlled trials found psychodynamic therapy to be as efficacious as other therapies, including cognitive behavioral therapy.
Because of the subjectivity of each patient's potential psychological ailments, there is rarely a clear-cut treatment approach. Most often, therapists vary general approaches in order to best fit a patient's specific needs. If a therapist does not understand the psychological ailments of their patient extremely well, then it is unlikely that they are able to decide upon a treatment structure that will help the patient. Therefore, the patient-therapist relationship must be extremely strong.
Therapists encourage their patients to be as open and honest as possible. Patients must trust their therapist if this is to happen. Because the effectiveness of treatment relies so heavily on the patient giving information to their therapist, the patient-therapist relationship is more vital to psychodynamic therapy than almost every other type of medical practice.
^Thombs BD, Jewett LR, Bassel M (2011). "Is there room for criticism of studies of psychodynamic psychotherapy?". The American Psychologist. 66 (2): 148–9, discussion 152–4. doi:10.1037/a0021248. PMID21299263.
^Anestis MD, Anestis JC, Lilienfeld SO (2011). "When it comes to evaluating psychodynamic therapy, the devil is in the details". The American Psychologist. 66 (2): 149–51, discussion 152–4. doi:10.1037/a0021190. PMID21299264.
^Leichsenring F, Abbass A, Luyten P, Hilsenroth M, Rabung S (2013). "The emerging evidence for long-term psychodynamic therapy". Psychodynamic Psychiatry. 41 (3): 361–84. doi:10.1521/pdps.2013.41.3.361. PMID24001160.
^Smit Y, Huibers MJ, Ioannidis JP, van Dyck R, van Tilburg W, Arntz A (March 2012). "The effectiveness of long-term psychoanalytic psychotherapy--a meta-analysis of randomized controlled trials". Clinical Psychology Review. 32 (2): 81–92. doi:10.1016/j.cpr.2011.11.003. PMID22227111.
^Anderson, Edward M.; Lambert, Michael J. (1995). "Short-term dynamically oriented psychotherapy: A review and meta-analysis". Clinical Psychology Review. 15 (6): 503–14. doi:10.1016/0272-7358(95)00027-M.
^Driessen E, Cuijpers P, de Maat SC, Abbass AA, de Jonghe F, Dekker JJ (February 2010). "The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis". Clinical Psychology Review. 30 (1): 25–36. doi:10.1016/j.cpr.2009.08.010. PMID19766369.
^Gerber AJ, Kocsis JH, Milrod BL, et al. (January 2011). "A quality-based review of randomized controlled trials of psychodynamic psychotherapy". The American Journal of Psychiatry. 168 (1): 19–28. doi:10.1176/appi.ajp.2010.08060843. PMID20843868.
^Leichsenring, Falk; Leibing, Eric (2003). "The Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the Treatment of Personality Disorders: A Meta-Analysis". American Journal of Psychiatry. 160 (7): 1223–1232. doi:10.1176/appi.ajp.160.7.1223. PMID12832233.