Psychodynamic Psychotherapies Notes

Core Principles Across Psychoanalytic Traditions

  • Learning objectives overview (LO1–LO6):
    • Explain basic principles that cut across psychoanalytic perspectives and how they emerge within each tradition.
    • Contextualize public reception and historical forces shaping psychoanalytic practices; compare with other psychotherapies.
    • Trace development from classical Freudian psychoanalysis to contemporary traditions.
    • Describe the therapeutic alliance in modern psychoanalytic and psychodynamic psychotherapy, including transference, countertransference, fantasy.
    • Describe the typical process of contemporary psychoanalytic psychotherapy: features, stages, mechanisms, interventions.
    • Review the Ruth case study and identify how psychoanalytic principles manifest in therapy.
  • Psychoanalysis is a distinctive form of psychotherapy, a model of functioning, development, and psychopathology; not synonymous with Freudian theory alone.
  • Freud’s collaborators and later theorists shaped diverse traditions with shared core assumptions but different emphases.
  • Common cross-cutting principles (the seven core ones):
    • 1) Unconscious motivation: actions, wishes, fantasies may reside outside awareness.
    • 2) Facilitate awareness of unconscious motivations to increase choice.
    • 3) Explore avoidance of painful feelings, fantasies, thoughts.
    • 4) Ambivalence about change; explore this ambivalence.
    • 5) Therapeutic relationship as arena for self-defeating processes (conscious and unconscious).
    • 6) Therapeutic relationship as vehicle of change.
    • 7) Understanding how past/present constructions perpetuate patterns.
  • Chapter aims: introduce psychoanalytic theory as a framework, highlight controversies, dialectics across schools.

Basic Concepts

  • The Unconscious
    • Freud’s insight: “we are not masters of our own houses.” Actions often motivated by unconscious processes.
    • Unconscious functioning may involve the ego, id, or other psychic agencies; some theorists reject a strict agency model and view experiences as compromises between wishes and fears.
    • Alternatives: dissociation or failure of attention/narrative construction as ways unconscious content remains out of awareness.
  • Fantasy
    • Fantasies influence psychic functioning and relationships; range from daydreams to deeply unconscious fantasies that provoke defenses.
    • Functions of fantasy include self-esteem regulation, safety, affect regulation, and mastery of trauma.
    • Exploring and interpreting fantasies is central to psychoanalytic work because fantasies motivate behavior and lie largely outside focal awareness.
  • Primary vs Secondary Processes
    • Primary process: primitive, unconscious, time-invariant (no clear past/present/future distinctions); imagery and symbolic expression; present in infants and often in dreams.
    • Secondary process: conscious, logical, sequential, basis of rational thought.
  • Defenses
    • Intrapsychic processes that push thoughts/feelings out of awareness to avoid emotional pain.
    • Classic defenses: intellectualization, projection, reaction formation; splitting (Kleinian).
    • Splitting (Klein): divide objects (e.g., mother) into all-good and all-bad representations to tolerate ambivalence; integration of good and bad is a developmental achievement; persistent splitting disrupts relationships.
  • Transference
    • Patients relate to the therapist as if they were significant figures from early life (parents); initially seen as resistance, later as a core analytic tool.
    • Evolution: from seeing transference as resistance to viewing it as an avenue to understand past relationships and current functioning.
  • One- vs Two-Person Psychologies
    • From a “blank screen” on which clients project to a two-person psychology where therapist and client mutually influence each other (conscious and unconscious).
    • Implications for technique: therapist awareness of personal contributions, countertransference, and the therapist’s own process as part of the therapy.
    • Working through resistance includes considering therapist contributions (e.g., in the emergence of resistance).

Historical and Cultural Context (LO2)

  • Psychoanalysis as worldview
    • Early influence on Western culture; extended beyond therapy into social theory and critique.
  • Causes of decline in public prominence
    • Psychiatry’s biological tilt; rise of cognitive-behavioral approaches and evidence-based treatments.
    • Public reaction to perceived arrogance, insularity, elitism; resistance to criticisms and empirical research.
    • Cultural biases in the U.S.: intolerance of ambiguity, speed-oriented, “quick fix” mentality; overreliance on medication (e.g., antidepressive use).
  • Cultural and geopolitical factors
    • European origins: many analysts from liberal, progressive backgrounds; engagement with social justice.
    • American transformation: from traditional ego psychology to pluralism; reform movements in the 1960s and beyond.
  • Contemporary movement toward psychoanalytic pluralism
    • Emergence of relational, self-psychology, intersubjective, and attachment-inspired streams.
    • Ongoing debates about the degree to which psychoanalysis should remain a single orthodox system or a family of related approaches.
  • Language of public perception
    • Public caricatures can obscure reforms and changes within contemporary psychoanalysis.

History of Psychoanalytic Thought and Development (LO3)

  • Precursors and early development
    • Charcot: hypnosis and hysteria; splitting of consciousness; influence on Freud.
    • Breuer and Freud: Anna O. and the “talking cure”; discovery that hysterical symptoms can be relieved through talking about trauma and recovered memories; hypnosis vs free association.
    • Studies in Hysteria (1893–1895): collaborative work; emphasis on psychogenic origins of symptoms.
  • Beginnings and methodological shifts
    • Free association: “say everything that comes to mind”; move away from hypnosis toward a non-censured stream of thought.
    • Goals: establish psychoanalysis as a rigorous science and a method for truth-telling about inner life.
    • Drive theory and psychosexual development: libido as psychic energy; pleasure principle driving development and action; shift from seduction theory to an emphasis on fantasy and instinctual drives.
    • Freud’s psychosexual stages and the centrality of sexuality in development; later trend toward emotion and affect-based motivation.
  • Theories of motivation
    • Early drive theory vs contemporary affect/emotion-based theories; evolving view of motivation and emotional life.
  • Jung, Bleuler, and the Zurich Psychoanalytic Society
    • Jung’s early collaboration with Freud, then split due to theoretical disagreements about sexuality's primacy, the nature of the unconscious, and spiritual dimensions.
    • Bleuler’s influence; word-association methods; emotional complexes as unconscious processes.
    • By 1912, Freud–Jung split; Jung develops analytical psychology; tensions over leadership and legacy.
  • Structural theory and ego psychology
    • 1923: The Ego and the Id introduces tripartite agency: id, ego, superego.
    • Id: instinctual, present from birth; ego: reality-oriented; superego: internalized social norms; ego mediates id and superego.
    • Aim of analysis: alleviate harsh superego pressures; develop healthier self-regulation.
  • Object relations and British developments
    • Melanie Klein and the British Kleinians: early mother-infant relationships; development of internal objects and projective identification; aggressive fantasies shaping psychic life.
    • Middle Group (British Independents): Fairbairn, Balint, Winnicott, Bowlby; emphasis on spontaneity, therapist flexibility, supportive environment.
    • Winnicott’s ideas about spontaneity, creativity, authenticity; Bowlby’s attachment theory; internal working models.
    • British developments influenced American psychoanalysis; relocation of emphasis from pure drive theory to relational and internal object concepts.
  • Current status and pluralism in North America
    • American ego psychology evolved into modern conflict theory: emphasis on ongoing unconscious conflicts and defenses; less emphasis on grand theory of the psyche, more on technique and process.
    • Relational/Interpersonal movement: Greenberg, Mitchell, Aron, Bromberg, Ghent, Harris, Benjamin, Dimen, Stern, Altman; shift toward recognizing mutual influence and the therapist’s fallibility; the therapeutic relationship as a central change mechanism.
    • Relational theory critiques classical theory’s blank-screen stance; emphasis on authenticity, mutual influence, and the therapeutic alliance as core.
  • Relational, Kleinian, and Lacanian traditions in Europe and Latin America
    • Kleinian and post-Kleinian ideas (e.g., Bion’s containment) gain traction; Lacanian and post-Lacanian theories critique ego-centered models and stress language, lack of a stable ego, and the misrecognition of the self.
    • Lacan emphasizes that identity is formed through the desire of the Other and language-mediated representation; the self is formed through lack and symbolization.
  • Personality theories within psychoanalysis
    • No single personality theory; multiple perspectives across schools.
    • Conflict theory: intrapsychic conflict as a core driver of personality styles; examples of defenses (displacement, projection, avoidance).
    • Object relations: internal objects shape perception of others and relationships; attachment theory as an important development (Bowlby); internal working models vs internal object relations.
    • Klein, Fairbairn: early internal worlds of object relations; Fairbairn emphasizes internal relationships and the self’s relation to internal objects; the “addicted” patterns to self-defining relational templates.
    • Developmental arrest models (Winnicott, Kohut): failures in the empathic environment leading to arrested development; the therapist’s empathetic stance as a catalyst for repair.
  • Implications for clinical practice
    • No single truth; pluralistic and flexible approaches favored; respect for diverse theories and techniques; ongoing negotiation with patients about meaning, relation, and agency.

Personality Theories in Psychoanalysis (Overview of Major Paths)

  • Conflict Theory (psychoanalytic):
    • Personality styles reflect compromises between wishes and defenses; examples include obsessional, hysterical, and phobic types with characteristic defenses and patterns.
    • Common defenses include displacement, projection, and avoidance; underlying conflicts around sexuality, dependency, and autonomy.
  • Object Relations Theory and Attachment
    • Internal representations of relationships shape ongoing behavior and perception of others.
    • Bowlby’s attachment theory: attachment system, internal working models; dissociation of experiences tied to threat to attachment.
    • Klein: internal fantasies about love and aggression; projective identification as a mechanism by which internal feelings are experienced as coming from the other.
    • Fairbairn: internal objects formed when caregivers are unavailable; the self structures itself in relation to these internalized objects.
    • Winnicott: true self, false self, and the importance of a holding environment; developmental arrest and opportunities for repair.
    • Kohut: self psychology; empathic stance of the therapist as a vehicle for repair of ruptures in the relationship; development of a cohesive sense of self.
  • Integration and clinical payoff
    • Object relations and attachment concepts help explain transference and resistance in terms of early relational patterns.
    • Developmental arrest models emphasize the potential for relational repair in therapy.

Mechanisms of Psychotherapy (Process of Change) (LO5)

  • Making the unconscious conscious
    • Central Freudian idea: increase awareness of unconscious wishes and defenses to expand agency; avoid over-determination by passive self-deception.
  • Emotional insight and interpretation
    • Emotional insight combines cognitive understanding with affective realization; interpretations are most useful when integrated with the therapeutic alliance and client readiness.
    • Transference interpretations can help client experience the here-and-now dynamic rather than merely intellectualizing.
  • Creating meaning and historical reconstruction
    • Clients construct narratives about their lives; therapy helps co-construct a narrative that weaves childhood experiences with current functioning.
    • Meaning-making reduces self-blame and fosters adaptive coping strategies.
  • Increasing and appreciating agency with limits
    • Clinicians help clients recognize how symptoms and patterns are shaped by internal and relational factors while acknowledging life constraints.
    • The myth that one can have it all is tempered by awareness of limits; autonomy and interdependence are balanced.
  • Containment and regulation of affect
    • Containment (Bion) involves therapist holding and processing client emotions; therapist also manages their own emotions to regulate the therapeutic field.
    • Containment helps to regulate affect and enable regulation in clients who dissociate or experience overwhelming affect.
  • Rupture and repair
    • Alliance ruptures are inevitable; repair processes (e.g., transparency, empathy) contribute to relational growth and implicit learning about relationships.
    • The concept extends from Ferenczi’s ideas about retraumatization and repair.
  • Intersubjectivity and the analytic dyad
    • The meeting of two minds produces an analytic dyad; meaning arises through dialogue and negotiation between client and therapist.
    • Transference is reframed as a bid to define reality; the therapist’s response is part of the evolving intersubjective field.
  • Enactment
    • Client and therapist enact complementary relational scenarios; working through enactments fosters new relational schemas and change.
    • Traditional stance favored neutrality; contemporary stance emphasizes participation to understand implicit processes.
  • Practical clinical mechanisms
    • Empathy as a primary intervention; self-other understanding; empathic conjectures.
    • The right mix of empathy, interpretation, guidance, and collaborative problem solving depending on client needs.

The Therapeutic Alliance (LO4)

  • Alliance versus transference
    • Alliance: collaborative bond based on agreement about tasks and goals and the quality of the relationship.
    • Transference: distortions in the perception of the therapist based on past relationships.
  • Components of the alliance (Edward Bordin)
    • Tasks: activities the client must engage in (e.g., dream exploration, transference work).
    • Goals: broader outcomes (e.g., reduced symptoms, personality change).
    • Bond: trust and understanding between client and therapist.
  • Transference and countertransference
    • Transference captures the client’s expectations and relational patterns projected onto the therapist.
    • Countertransference: therapist’s reactions rooted in their own unresolved conflicts; redefined from resistance to a potential information source if handled carefully.
    • Broadening the view of countertransference helps its therapeutic value while guarding against bias.
  • Intersubjective negotiation and enactments
    • The alliance emerges from ongoing negotiation of meaning and relational posture.
    • Enactments and ruptures become opportunities for mutual understanding and growth.
  • Practical stance on empathy and interpretation
    • Empathy as the core intervention; interpretations as potentially threatening, requiring sensitivity and alliance strength.
    • The quality, timing, depth, and empathic tone of interpretations determine usefulness.

Process of Psychotherapy (LO5) and Interventions

  • Empathy as core intervention
    • Empathy fosters alliance and change; therapists communicate understanding of clients’ experiences.
  • Interpretations and their quality
    • Timely, appropriately deep, and empathic interpretations can facilitate insight.
    • The same interpretation can feel different depending on the relational context and therapist’s stance.
  • Clarification, support, and advice
    • Support and reassurance can be appropriate and necessary in many contexts.
    • Advice can reduce power imbalances when clients seek it; withholding opinions can be problematic if it denies client autonomy.
  • Termination (end-of-treatment phase)
    • Collaborative termination with a contract for final sessions can consolidate gains.
    • Poor termination can undermine progress; sensitive exploration of reasons for ending and future implications is important.
    • The termination phase involves reviewing changes, consolidating gains, and exploring feelings about the ending.

Case Ruth: A Contemporary Short-Term Psychoanalytic Case Example (LO6)

  • Background
    • Ruth: 52-year-old, divorced for 16 years; pursued short-term relationships; feared lifelong loneliness; asked for 30 sessions within a brief psychotherapy program.
  • Early enactment and therapist response
    • Therapist experienced disengagement and emotional distance; Ruth’s long-story presentation with obsessional detail aligned with a disengaged therapeutic stance.
    • Therapist attempted to communicate his disengagement to illuminate potential links between Ruth’s presentation and intrapsychic processes; dialogue emerged.
  • Emergence of abandonment fears and relational pattern
    • Ruth disclosed underlying fear of abandonment; she used controlled presentation to defend against vulnerability.
    • Ruth acknowledged a semiconscious perception of therapist disengagement and escalation of her “deadening” monologue as defense.
  • Turning points and progression
    • Session 21: Ruth expressed need for more emotional engagement; therapist’s empathetic response allowed Ruth to express hurt and longing.
    • Subsequent sessions: Ruth faced sadness, despair, and dependency; she began expressing needs and vulnerability directly.
    • A shift toward more authentic engagement and mutual vulnerability emerged; Ruth’s fear of abandonment started to loosen.
  • Specific sequence of sessions
    • Session 23: Ruth voiced ongoing fear of abandonment; therapist acknowledged finite number of sessions and explored implications.
    • Ruth cried; an affective exchange occurred; Ruth articulated need for being cared for; therapist communicated genuine empathy.
    • Emergence of trust and acknowledgment of therapist’s changing engagement levels.
  • Later sessions and consolidation
    • Ruth’s increasing capacity to trust and articulate needs; she confronted inequity and persistence of relational losses.
    • By late sessions (e.g., 28+), Ruth reported better trust in herself and in the therapeutic relationship; she began to recognize patterns in romantic relationships and anticipated changes in life.
  • Termination and aftermath
    • Final sessions focused on closing the treatment; Ruth acknowledged sadness about ending and hope for future change.
    • The therapist reflected on the enactment, the shift in engagement, and Ruth’s capacity to tolerate dependency and loss.

Evidence and Multicultural Context (Evidence, Applications, and Multicultural Considerations)

  • Evidence base for psychoanalytic and psychodynamic therapies
    • Short-Term Dynamic Psychotherapies (STDP): meta-analytic evidence shows substantial effect sizes on general symptoms; meta-analysis with 23 randomized trials (n ≈ 1,431) reported overall effect size 0.97; effect sizes increased at long-term follow-up to 1.51 after nine months or longer.
    • Long-term psychodynamic therapy: 23 studies (1960–2008; n ≈ 1,053) found long-term treatments more effective than short-term counterparts for personality disorders, chronic mental disorders, multiple disorders, and complex depression/anxiety; large and stable effect sizes; improvements persisted and grew at follow-up.
    • Steinert et al. (2017) meta-analysis: psychodynamic and cognitive-behavioral treatments show equivalent overall effectiveness.
    • Naturalistic studies: often necessary due to practical constraints of RCTs; Leichsenring and colleagues (2005) reported on 36 clients with chronic psychiatric problems; average duration 37.4 months; average 253 sessions; substantial effect sizes across symptom and functioning domains.
    • Sweden naturalistic outcome study (Sandell et al., 2000–2002): psychoanalysis vs psychoanalytic therapy; mean duration: 51 months (psychoanalysis) vs 40 months (therapy); mean weekly frequencies: 3.5 vs 1.4; three major conclusions: (1) at 3-year follow-up, psychoanalysis yielded better outcomes on multiple dimensions; (2) more experienced analysts had better outcomes; (3) frequency and duration interacted to improve outcomes.
  • Practical and methodological considerations
    • The evidence base includes both conventional RCTs and naturalistic studies; a pluralistic approach to evidence is warranted due to external validity considerations.
    • The broader literature supports efficacy for a range of disorders (depression, anxiety, personality disorders) and highlights continued benefit after termination.
  • Multicultural and sociocultural considerations
    • Psychoanalysis originated in Western, educated, middle-class contexts; treating diverse populations required adaptations to fit cultural and socioeconomic realities.
    • Unconscious biases, prejudices, and social determinants shape transference, countertransference, and therapeutic interactions.
    • Therapists may encounter cultural differences, class disparities, and systemic barriers; a flexible, relational, and culturally responsive approach is essential.
    • The field emphasizes understanding how race, class, gender, and culture influence symptom formation, presentation, and treatment engagement.
  • Applications and practical scope
    • Psychoanalysis is not a one-size-fits-all treatment; its concepts can be integrated with other approaches in hospitals, clinics, and private settings (individual, group, family).
    • The shift toward pluralism allows psychoanalytic ideas to inform a broad range of therapeutic contexts while maintaining core principles of insight, relationship, and meaning.

Case Readings and Illustrative Examples

  • Sophie (Mitchell, 1993): relational psychoanalytic principles; ongoing negotiation of patient-analyst subjectivities; emphasis on the co-constructed meaning of experience.
  • Alec (Bromberg, 2000): transference–countertransference enactment; authentic contact; exploring mutual affective experiences.
  • Simone (Safran, 2012; in Wedding & Corsini, 2013): transference–countertransference exploration with a woman with bulimia and emptiness; treatment highlights the relational dynamics and changing internal representations.

Summary and Takeaways

  • Psychoanalysis has evolved from Freudian theory to a pluralistic landscape, incorporating object relations, relational, self-psychology, attachment, and Lacanian/Kleinian strands.
  • Core principles across traditions include unconscious motivation, the importance of the therapeutic relationship, exploration of defenses and fantasies, and strategies for facilitating change through empathic engagement and interpretive work.
  • The therapeutic alliance (bond, tasks, goals) is central to successful outcomes; transference and countertransference are key mechanisms that can be harnessed for therapeutic gain.
  • Contemporary practice emphasizes a two-person psychology, enactments, and intersubjective negotiation; therapists must attend to their own contributions and to the client’s relational world.
  • Evidence supports the efficacy of short-term dynamic therapies and long-term psychodynamic treatments for a range of disorders, with ongoing debates about the most appropriate designs and outcome measures; naturalistic studies reveal meaningful long-term benefits and post-treatment gains.
  • Multicultural relevance requires culturally responsive approaches that account for unconscious biases, power dynamics, and social determinants, with an emphasis on meaning, relational experience, and agency within constraints.
  • The Ruth case illustrates how contemporary psychoanalytic therapy can surface and transform enactments, emotional engagement, abandonment fears, and relational patterns through therapist empathy, careful interpretation, and collaborative meaning-making.

Key Terms and Concepts (Glossary-style Briefs)

  • Unconscious Motivation: 1 of core psychoanalytic assumptions; etiologies of behavior outside conscious awareness.
  • Fantasy: play a central role in motivation, self-regulation, and trauma mastery.
  • Primary Process vs Secondary Process: unconscious vs conscious, intuitive vs rational modes of functioning.
  • Defenses: intrapsychic strategies to avoid pain; splitting is a Kleinian defense.
  • Transference: past relational templates projected onto the therapist.
  • Countertransference: therapist’s emotional responses to the client, valuable when used reflectively.
  • Enactment: patient and therapist unconsciously co-create relational scenarios.
  • Containment: therapist’s affect regulation to manage client distress.
  • Intersubjectivity: mutual construction of meaning in the therapeutic dyad.
  • Alliance (Bond/Tasks/Goals): key structural relationship comprising collaboration and trust.
  • Short-Term Dynamic Psychotherapy (STDP): evidence-supported, time-limited psychodynamic approaches.
  • Long-Term Psychodynamic Therapy: more intensive, durable improvements in complex disorders.
  • Internal Working Models: Bowlby’s attachment-informed representations guiding relationships.
  • Internal Object Relations: Klein, Fairbairn; internal representations shaping perceptions of others.
  • Contingent ethical implications: the need to balance insight with client autonomy and societal considerations.