What is Psychodynamic Therapy?
Have you ever wondered…
If there are deeper issues going on beneath the surface?
If the answer is yes, then you are in the right place.
In this article, I will describe a type of psychotherapy called psychodynamic psychotherapy, which focuses on understanding the deep emotional and developmental issues underlying psychiatric symptoms.
But wait! Aren’t psychiatric disorders like depression and anxiety caused by chemical imbalances?
Well…yes and no.
The neurological problems found in mental disorders mostly explain why certain feelings become excessively strong to the point where they lead to severe symptoms such as depression and anxiety. However, at least in my opinion, these findings do not necessarily explain why an individual would have those feelings in the first place.
For instance, an individual who has poor self-esteem and views him- or herself negatively may experience even minor slights as proof of these negative self-views.
It’s important to realize that all of experience is filtered through our subjective lenses of how we view ourselves and others.
Psychotherapy works on this level, addressing one’s sense of self, others, and the world in general.
Psychotherapy has been proven effective in many different mental disorders including depression, anxiety, autism spectrum disorder, bipolar disorder, and personality disorders. Therapy that focuses on teaching parents techniques for managing their children’s psychiatric issues have also been shown to be effective with behavioral disorders and anxiety.
It is for these reasons that psychotherapy is not only important, it is crucial.
What are the different types of psychotherapy?
There are many different types of psychotherapy, but the two main types that I have experience with are cognitive behavioral therapy (CBT) and psychodynamic psychotherapy.
These two types of psychotherapy are both effective, but they work in very different ways and have very different goals.
Cognitive behavioral therapy (CBT) is an umbrella term that encompasses many different types of psychotherapy. The two main types of therapy under this umbrella are cognitive therapies, which focus on changing patterns of thinking or accepting upsetting thoughts, and behavioral therapy, which focuses on changing patterns of behavior. Hence the term: cognitive behavioral therapy.
I will discuss CBT in more depth in other articles, but here I will focus on psychodynamic psychotherapy, which is the type of psychotherapy that I provide.
What is psychodynamic therapy?
Psychodynamic therapy is very different than cognitive behavioral therapy. Whereas cognitive behavioral therapy focuses on symptoms and their reduction, psychodynamic psychotherapy attempts to uncover the underlying developmental social–emotional issues that lead to the symptoms.
Psychodynamic psychotherapy is not just a different technique of therapy, it is based on an entirely different view of the mind and why psychiatric symptoms occur.
The topic is complicated, but stick with me because I think it’s such an important perspective.
The central premise of this way of viewing the mind and mental suffering is that symptoms on the surface are often just the tip of the iceberg.
Despite the perception that we are aware of, and in control of, most of our thoughts and feelings, the truth is that much or even most of our experience occurs outside of our awareness.
Sometimes thoughts or feelings are outside our awareness because they are too visceral, basic, and physical to be explained with words. We are used living in a world of symbolic speech and language, but the unconscious mind operates on the level of emotional responses that are not rational. These experiences are sometimes described as “gut feelings.”
The unconscious mind follows an entirely different set of rules than what we are used to. Gone are reason, civility, and prudence. The unconscious does not have to make sense. Two contradictory ideas or feelings can coexist in harmony, there is no linear sense of time, and ideas and feelings are not bound by the constraints of reality or morality.
A good way to get a sense of how the unconscious mind works is to consider a dream.
Think about a dream that had – did it make sense? Chances are that it was totally irrational.
In dreams, one minute you could be in your house, and the next minute you could be on a different continent. One minute you can be happy about what is going on, and the next minute you could be terrified.
Figures in dreams can be compilations of different people, where important family members or others mix features such as hairstyles, faces, or body type. Dreams are actually so bizarre that most people shrug them off as silly or inconsequential.
However, beneath the surface we all have an unconscious internal psychological world that follows these wild, crazy rules.
Two very important aspects of the unconscious mind are feelings and thoughts of love and hatred. These two forces coexist from birth onward, and throughout life one of the greatest challenges that we all face is how to tolerate, integrate, and synthesize our feelings of love and hatred.
It is totally normal for all of us to both love and hate those who are most important to us, such as parents spells it, and children.
Following the rules of the unconscious, there’s no problem with loving and hating one’s parents at the same time.
Above the unconscious mind, things are kept in check by the rational and moral parts of the mind. These mental agencies follow the rules of reality and morality, exist in a linear sense of time, prohibit contradictions, and are sensitively in–tune with reality and society.
The problem with this arrangement is that the demands of the unconscious in terms of love and hatred often come into conflict with one’s sense of morality and reality.
One’s sense of conscience may dictate that feelings of anger, aggression, or hatred of a loved one are morally reprehensible.
One’s sense of reality may dictate that feelings of love and sexuality toward the wrong people, or feelings of aggression, are bound to lead to all kinds of problems. All you have to do is flip through the news-feed on your phone to see countless examples where sexual and aggressive impulses have ruined people’s lives.
This dual reality of human experience leads to a pretty serious problem. What do we do when our unconscious, base experiences and desires conflict with our sense of reality and morality?
What happens is that our realistic and moral agencies employee what are called “defense mechanisms” to protect ourselves, so to speak, from these underlying unconscious experiences and feelings.
A healthy example includes altruism, where somebody takes his or her unconscious feelings and uses them to help others. For instance, somebody with a strong urge to smoke cigarettes could dedicate his or her life to teaching others about the dangers of cigarettes. That’s a healthy way of dealing with the urges.
Another example would be doing the opposite of the underlying feeling. Have you ever met somebody who on the surface seems so polite and almost syrupy sweet, but you had the sense that beneath the surface they were actually incredibly angry? Sometimes these people remind us of the phrase “killing you with kindness.”
This example demonstrates the defense mechanism of reaction formation, which is where somebody turns unconscious feelings into their opposite in order to reassure themselves and others. The syrupy sweet person unknowingly rejects his or her angry feelings and portrays him or herself as the most conscientious and polite person possible. But the angry feelings are still expressed in a disguised way. Hence the idea of “killing you with kindness.”
Another important example is repression, where an individual simply keeps the thoughts or feelings deep down without any conscious awareness or expression at all.
These defense mechanisms are unconscious themselves. They occur automatically without conscious awareness. It’s not that the syrupy sweet person is putting on a show. They also think that they are incredibly kind, courteous, and polite. The underlying anger is automatically and unwittingly kept deep down and then expressed in its opposite.
Defense mechanisms are great, until they’re not.
Defense mechanisms are a healthy, essential way to deal with the central emotional conflicts of life. However, not all defense mechanisms are created equal.
Some defense mechanisms get us into trouble. Being unable to experience or express any angry feelings, as in the example of the syrupy sweet and polite person, can lead to an inability to assert oneself. Others may also find this hollow form of politeness off-putting. If the person is actually controlling others, being passive aggressive, and “killing them with kindness” then that might lead to relationship issues.
In addition, a serious problem occurs when defense mechanisms break down. This happens very often in childhood behavioral disorders. Children may be able to tolerate and defend against underlying anxiety and anger only to a certain point. When that threshold is crossed, feelings come out in temper tantrums, defiance, or even aggression.
Another important aspect of the psychodynamic view is that symptoms are compromises among the warring aspects of the mind. Strong underlying feelings of love and aggression that cannot be kept in check beneath the surface need to be expressed somehow.
What often happens is that the feelings are expressed in a disguised form that satisfies several different demands at once.
Here is a typical example. Rachel, a five-year-old girl, suddenly develops severe difficulty around bedtime. She refuses to go to sleep by herself, and she demands to sleep in her parents bed. She says that she is scared of monsters in her closet, and no amount of reassurance is enough. Eventually, her exhaustive parents give in and allow her to sleep in their bed, where she usually falls asleep right away.
Rachel is not faking, and she’s not consciously aware of any motives other than the desire to escape her fear of monsters.
But where does the fear of monsters come from? And why does it happen only at night time?
Bedtime is a time when children need to separate from their parents, and this separation can lead to all kinds of anxieties. Some children have a hard time keeping their parents in their mind and reassuring themselves that their parents are still around, even if they are in the other room.
Rachel may be worried about losing her parents or losing their love, protection, and affection. Physically seeing her parents reassures her that they are still present and supportive.
In addition, every small child has negative and angry feelings towards his or her parents, and not being able to physically see her parents may prevent her from reassuring herself that she has not somehow harmed them.
Of course, all of these feelings are unconscious, and the defense mechanism that Rachel uses to deal with these feelings is that of projection or externalization, where internal feelings are placed in the outside world. Rather than experience her own aggressive and hateful feelings, Rachel places those feelings in the outside world in the form of a monster.
This defense mechanism works beautifully because Rachel no longer has to experience her own aggressive feelings, but there is a price. Now she lives in a world populated by monsters.
Her fear of monsters and her demand to sleep in her parents’ bed serves as a compromise of the underlying feelings. She gets to reassure herself of her parents’ safety and love, and she gets a sense of security and affection by sleeping in their bed. At the same time, she’s driving her parents crazy, controlling them, and running the show. The controlling and aggravating aspect of the situation allows Rachel to express her angry and aggressive feelings in a disguised form. Quite a clever solution!
How Psychodynamic Therapy Works
Psychodynamic therapy attempts to uncover the underlying issues and to understand the overall picture of how the mind functions. In the case of Rachel and her bedtime issues, the goal would be to understand what the underlying feelings are.
Why does Rachel worry so much about her parents’ love? Does she have issues in her relationship with them? Is there a lot of conflict in the family, screaming, or fighting? Does she have intense sibling rivalry which makes her exquisitely sensitive to whether or not her parents love her?
What is she angry about? Is she angry about the above issues? Is she angry that she does not get enough love from her parents, or that she has to share their affection with her baby sister?
Why did she choose the option of sleeping in her parents’ bed? Is she feeling jealousy about their relationship, and does she feel the need to interrupt their sleeping arrangement?
All of these issues would be explored in psychodynamic psychotherapy, and a detailed view of Rachel‘s mind would come into focus. Since Rachel has no idea why she’s doing what she’s doing, telling her to stop, or even using reward systems like sticker charts may only be partially effective. If those techniques work, that’s great.
However, when issues are very entrenched in a child’s personality structure, it is usually necessary to understand and address the underlying issues.
Whereas medication and cognitive behavioral therapy addresses individual symptoms, psychodynamic psychotherapy addresses the underlying emotional reality that produces the symptoms. It focuses on a much deeper and extensive understanding of who a person is and how he or she functions. The goal is then to intervene in a way that can actually change the underlying issues.
This article serves as an overview of the theoretical basis behind psychodynamic psychotherapy. My next article will focus on the details of how psychodynamic therapy is actually carried out.
I hope you found this article helpful. If you did, please share it by clicking one of the available share links.
Also, take a look at my parenting checklist, where I summarize my article on my 5-step process to understanding your children.
Thanks for reading,
Jason Dean, MD