Psychodynamic Therapy: Core Concepts & What to Expect

Main Concepts of Psychodynamic Theory

Present-day psychodynamics is most notably credited to Sigmund Freud who has been known as the grandfather of psychoanalysis. Since Freud, many other theorists and therapists have contributed to psychodynamic theory and application in treatment, including Carl Jung, Alfred Adler, Melanie Klein, Anna Freud, and Otto Rank.

Conscious, Preconscious, & Unconscious

According to Freudian theory, the human mind is essentially divided into the conscious, the preconscious, and the unconscious (sometimes referred to as the subconscious).¹ One analogy of this separation of mental activity is an iceberg:

• The tip of the iceberg represents the conscious part of our minds, which contains everything we are immediately aware of, what we are concentrating on, planning for, and discussing within the private, internal dialogues with ourselves.
• When you look slightly below the tip of the iceberg, you see just enough below the water level—that’s the preconscious. That represents something that is about to surface, just like when we have the name of someone on the tip of our tongues, and eventually becomes conscious.
• The much bigger piece of our minds is that larger part of the iceberg that goes far below our immediate awareness: the unconscious.

Id, Ego, & Superego

Within the unconscious is three interacting forces. They are the id, ego, and superego:

• The id represents all our desires and basic needs.
• The superego represents our sense of moral or social conscience—the do’s and don’ts that we are taught by parents and society at large.
• The ego seeks to mediate between these two forces within us.

The ego may either function well to handle these conflicting forces, or it may break down in the face of harsh realities and become dysfunctional in any number of ways. The more the conflict grows, the greater a sense of anxiety that the ego tries to manage through a variety of possible defenses. Defenses of the ego can basically assist a person in limiting the amount of fear, anxiety, guilt, loss, or shame that a person can manage at any given time. Defenses are not by themselves a bad thing, but they may become more dysfunctional as defenses extend over time and become a way of life that interferes with overall functioning.

But if a person remains in denial without progressing through it, or worse, remains in denial for any number of life situations, this is regarded as dysfunctional. This is especially true if the unconscious conflicts of life—past and present—become repressed; that is, they get pushed down further and further into the depths of the mind and become even more guarded through more complex defensive structures.

Unconscious Drives

In psychodynamic theory, these unconscious processes present in dysfunctional patterns, particularly as the person enters adulthood. These patterns are the result of those unconscious needs, or drives, that compel the person towards certain relatable situations. Unconscious drives include sex, aggression, importance (i.e., having meaning or purpose), and mastery. The drive of mastery is particularly vital in psychodynamic therapy. The action of this drive is known as repetition-compulsion, which means we are all unconsciously driven to what is familiar in order to work out something unresolved from the past.²

The “past” can really mean anything the individual has experienced leading up to the present moment. Childhood experiences can often be the most impactful ones, especially if they are traumatic. Certainly, a person could have traumatic experiences in adult life that can also affect their feelings and behaviors going forward. Examples include how a divorce or death of a loved one, or losses in job status or health, may change a person’s belief of who they are and how cruel life can be.

The Influence of Childhood Experiences

Childhood experiences and traumas big and small play a fundamental role in how the ego consistently operates in adult life, including how traumas and losses are ultimately managed. These early-life influences include how a person was parented, the early perception of their own abilities, social and sexual development, relationships with other adults (e.g., other family members, teachers, coaches, clergy, etc.), peer relationships, and any other significant life events. Not all of a person’s conflicts may come from “bad parenting,” but instead how that individual comes to perceive oneself and others, even if a person’s parents fulfilled their duties adequately.

People often either repeat these perceived roles in adult life, or they may seek to overcompensate in behavior, either to prove others wrong or simply rebel against family and cultural norms. In any sense, the struggle here is to define who they really are separate from these role assignments, what they are genuinely capable of achieving, and which intimate and social relationships can be most fulfilling in their lives.

What Happens During a First Psychodynamic Therapy Session?

Psychodynamic therapy does not usually include advice of what to do in situations, but instead, helps people to better understand themselves, and thus, pursue their life goals from a healthier, more conscientious position. The first session will always involve an evaluation of someone’s symptoms and understanding their background before diving in.

Psychodynamic therapy is usually preceded by a two-factor evaluation:

1. First, psychodynamic therapists may assess for a clinical diagnosis that uses presenting issues and symptoms that may match specific criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
2. The other factor in the evaluation involves developing a dynamic assessment for that person’s life. This part of the evaluation comprises as much information about the person’s life history as possible, including their relationships, accomplishments and failures, personal strengths and deficits, traumas and losses, substance use or addiction patterns, and anything that the therapist and therapy patient deem necessary to proceed with the therapy process.

Once the evaluation is complete, typical therapy sessions can commence. As more information becomes available through therapy, aspects of the assessment can change.

The Role of Diagnosis in Psychodynamic Therapy

Psychodynamic therapy recognizes clinical diagnoses as important, including those of genetic, biological origins, such as schizophrenia and bipolar disorder. These diagnoses help the therapist better understand how particular psychological symptoms affect the individual’s overall sense of self and the world around them. The therapist understands also that factors of both the diagnosed clinical disorder and the person’s dynamic history will influence how therapy goals are defined and reached, and how the person will likely respond to challenges within the therapy process.

However, there are also certain diagnoses or patient complaints that may lead to identifying unconscious conflicts. These can include phobias, somatic (bodily) complaints, and addictive or compulsive behaviors. Additional medical evidence may be needed in some of these circumstances, but the psychodynamic therapist will likely investigate any connection between these problems and underlying unconscious fears that might be producing these symptoms at the conscious level.

The Importance of Therapeutic Alliance

One of the first priorities in psychodynamic therapy is establishing a therapeutic alliance, which may well be the cornerstone of psychodynamic therapy. This is an ongoing process that helps define the professional nature of the relationship between therapist and therapy patient as having important boundaries, but leaves open empathy and positive regard for the patient at all times. Psychodynamic therapists may limit or eliminate any of their own personal self-disclosure (except for sharing professional credentials) to maintain the focus on the patient’s unique needs and pathway to healing and success.

The therapist intends to become involved in care of the patient, but not attached to them, recognizing the need to help the patient overcome their own resistance to revealing difficult issues. The main purpose of the therapeutic alliance is to promote trust on an ongoing basis, so the patient can feel empowered to go deeper into more emotionally painful subjects.

Psychodynamic Therapy Techniques

At the core of psychodynamic therapy is making the unconscious become conscious. This process is encouraged in a client through a variety of tools and techniques that the therapist uses depending on the client’s specific needs.

Common psychodynamic techniques include:

Free Association

Psychodynamic therapy often involves free association. This is when the patient is encouraged to discuss whatever is on their mind, including the events of the week, past conflicts with others, fears and desires, dreams and nightmares, or anything they want to disclose about themselves and their experiences.² Psychodynamic therapy involves listening to the different levels of expressed communication, both from the person’s conscious and from their unconscious that, in a sense, is trying to get out.

Content Vs. Process

Understanding patient communication at various levels is sometimes described as content versus process. The content is what the patient is communicating at the conscious level and is mostly limited to what is understood by the patient. The process of communicating is how the information is presented, which may provide certain clues to the unconscious and represents what the person is trying to communicate outside of immediate awareness. The psychodynamic therapist listens to content, but also observes non-verbal cues, certain errors in speech, how topics can change suddenly, and anything that may contradict or emotionally charge the content that is being expressed. That is an important part of the therapy process.

An example of this is a patient who says early in therapy, “My boss is always looking over my shoulder at work. I’m not the kind of person who needs to be treated like a child.” In turn the therapist may say, “Your relationship with your boss is obviously frustrating for you. I understand it’s important for us to address that problem. But I also believe you’re letting me know something about the way you want to be treated in therapy. I want to make sure you’re always treated with the respect of a capable adult.”

In the first part of the statement, the therapist addresses the conscious content of the patient’s difficulty with the boss. The second part intends to address what is likely a part of the unconscious process—how it is important for the patient to feel the same about the therapist or the therapy process. These references to what the patient is presenting at different communication levels help promote insight and trust in the therapeutic alliance.

Transference

In addition to observing the nuances of communication, psychodynamic therapists understand that patients often unconsciously place feelings, desires, fears, and resentments they may have for real people in their life history onto the therapist. This phenomenon is known as transference because people transfer their feelings from the original person onto the therapist as an object of those feelings. Patients do not always recognize transference when it occurs, but when it does happen, the psychodynamic therapist can make the connection, thus helping the patient locate the actual source of those emotions. They often involve people that represent unresolved conflicts in that person’s life, and even reveal misplaced guilt or shame they experienced in these relationships.

Countertransference

Conversely, therapists may have unconscious feelings toward their patients at any given time in therapy because therapists are human, too. Psychodynamic therapy recognizes this important phenomenon as countertransference. Therapists are trained to understand their own issues to reduce the undue influence of those issues in therapy. As a result, countertransference can be used as a tool for the therapist to better understand the patient’s experience and have a more prepared approach as those issues arise.

Clarification & Interpretation

While the psychodynamic therapist observes and assesses both the content and process of communication from the patient, the therapist responds in either two essential ways: clarification or interpretation. The therapist clarifies through feedback and elucidating questions for both patient and therapist to better understand what is being discussed at the conscious level. Interpretation is the therapist’s direct response to something emerging from the unconscious that reveals repressed emotions and memories that influences conscious life.

Here’s an example of how a psychodynamic therapist may interpret transference in a patient who suffered the trauma of parental abandonment. If previous discussion included that the patient has a history of undermining relationships through anger and emotional withdrawal, the therapist would understand this to manifest in the therapy at some point.

The therapist has worked to clarify the patient’s anger in relationships outside of therapy, but as trust builds through the therapeutic alliance, the patient becomes increasingly afraid of getting emotionally injured by the therapist. In response, the patient starts to transfer anger and emotional withdrawal towards the therapist. When it appears to be the appropriate moment, the therapist can say something like, “I believe you’re worried I will abandon you, just as your father did to you.”

Catharsis

When interpretations are accurate, patients will typically react with a noticeable shift in behavior. These actions can include increased emotional expression (e.g., tears, laughter, anger, blushing, etc.), sudden silence, or the immediate articulation of a recent or distant memory. These behaviors often point to the release of a repressed emotion, known as catharsis.³

In catharsis, the patient may also experience some relief of anxiety, anger, or shame, along with an increase in trust. But the experience may also intensify the challenges of going deeper into the person’s unconscious and essentially further into the conflicts of early life as unresolved issues are exposed. This can become especially difficult when ego defenses are reduced, and the therapy patient is faced with the reality of painful life losses towards grief and acceptance. But the increased level of trust in the therapeutic alliance helps carry the process along with greater confidence.

Working-Through

Ultimately, the psychodynamic process can reveal these unresolved conflicts and provide an emotionally safe place to resolve them, sometimes referred to as working-through. When patients in psychodynamic therapy become acquainted with their compulsions to repeat dysfunctional patterns and early-life roles, they can take control of their own choices and behaviors.

Psychodynamic Therapy for Relationships

Psychodynamic theory can also be applied to therapies that involve more than one participant. In couples therapy with two individuals, conflicts from earlier in their respective life histories are important in understanding how each responds to emotional and communication needs.

Relationships with parents, siblings, and others in childhood, along with how parents had interacted with each other, become points of reference for how people relate to each other in their adult relationships. Because unconscious fears and desires are not limited to childhood issues, prior adult relationships, trauma and loss, and other significant life events can also have a significant influence on present conflicts.

The psychodynamic relationship therapist helps the couple clarify past issues and how they impact the current communication and emotional dysfunctions that impair mutual understanding and conflict resolution. With a deeper awareness of fears, desires, and expectations shared in relationship therapy, a couple can better develop techniques for respectful and effective interactions to meet the needs of the couple’s life together.

Psychodynamic Theory in Family Therapy

Similarly, family therapy seeks to uncover deeper and often unspoken conflicts and issues within the family system. This is often where perceived and assigned roles are explored and challenged to develop healthier and more productive interactions. The overarching goal is to achieve a functional balance in the family system that can tolerate open communication and changes to the family dynamics as the family evolves over time.

Even in dysfunctional family systems, there is a sense of balance among family members, but this type of balance is often precarious and reliant on unspoken fears and needs. These are often referred to as taboos.

An example of this involves a family member, such as the scapegoated child, who acts out in some obviously unhealthy or even dangerous way, while one of the parents harbors a serious substance abuse problem. In psychodynamics, the child may be referred to as the identified patient and would require treatment for any apparent mental health condition. At the same time, the child’s improvement in treatment changes the dynamics of the family, and thus, creates an imbalance in the family system. As a result, more attention is given to notice the parent’s substance problem, which has been previously taboo, but now can be appropriately identified and treated.

 Child & Adolescent Psychodynamic Therapy

The psychodynamic model can be useful for children in helping to identify emotions and experiences that are repressed or unexpressed, while assisting in their personal development. Significant emotional conflicts, such as those resulting from trauma and losses, can impede psychological growth and reduce the child’s ability to form adaptive coping methods and healthy emotional release. Psychodynamic therapy focuses on creating safe places for young people to find healthy emotional expression towards relieving psychological distress, promoting psychological development, and establishing healthy self-esteem.

For Adolescents

For adolescents, psychodynamic therapy emphases the essential need for the young patient to trust the therapist. Although the young person’s ego is not fully formed, many of the same techniques, including interpretation through observing content versus process can be useful in improving trust.

Therapy can assist the patient in the common conflicts of teenage life, including self-image, social and sexual development, and fears involving future life goals. Understanding family dynamics is also an important aspect for adolescent psychodynamic therapy. But adolescents are also influenced by peer relationships and expectations within the group. Therapy helps the young person to sort out these complex relationships towards identifying their own sense of values and self-identity. This development process is known as individuation.

For Young Children

Sometimes young children are not thought of as having a rich mental life, but in fact, they can experience feelings that lead to behaviors revealing deeper, underlying problems.⁴ Psychodynamic therapy for young children often involves different techniques to help promote emotional expression and working-through. Since children have not developed adequate verbal tools, therapists may use play therapy or art therapy, or other kinds of creative expression.

One example involves the therapist encouraging the child to draw pictures of themselves individually or themselves with their families. The therapist observes this process, along with how the picture is organized and how the characters are portrayed in the picture to form a therapeutic discussion with the child, which in turn helps the child develop an emotional connection with whatever conflicts they may be experiencing.

Final Thoughts on Psychodynamic Therapy

There are many specific aspects of psychodynamic theory and its application in therapy that have been developed and refined for more than 100 years. But at its most basic core, the main purpose of psychodynamic therapy is to make the unconscious become conscious for better relationships with self and others.