Psychodynamic Psychotherapy

Written by Doug Berger, M.D., Ph.D.

Psychodynamic psychotherapy is often taken to refer to therapy that is based on the Ego-Psychological model of psychological functioning described by Freud and others, but also includes the Self-Psychological model proposed by Heinz Kohut, and the Object Relations Model developed by Melanie Klien, Otto Kernberg, and others.

The Ego-Psychological model is based on the idea that people have 1.) an unconscious, 2.) a "transference" of relationship style with significant others from childhood to other relationships in adulthood (the relationship with the therapist is the paradigm for the patient's transference), and 3.) "defenses" that attempt to prevent the emergence of uncomfortable emotions.

The unconscious holds ideas and feelings that are often conflictual, and usually attempts to satisfy both needs in some compromise. This results in both maladaptive (symptoms and personality pathology), and adaptive (one's general style of pleasure, productivity and healthy relationships) traits at the same time. Talking to patients over time forms a relationship where clues are offered about unconscious habitual patterns of thinking and feeling. Dreams are also a very useful way of gaining an understanding about one's unconscious. The aim is to find a small number of pervasive issues that run through the course of the patient's pathology that can be traced back through his or her personal history. Therapy attempts to help the patient work through their conflicts in a more optimal way by analyzing the patient's transference and defenses. This process can sometimes be difficult because of unconscious resistance the patient has to giving up the defensive style that they have used for so long.

Psychological conflict often arises from the need for both love and independence from one's parents. For example, if one's parents are intrusive, expressing the need for love to them can be difficult. A teenager with "over-neat" parents who keeps their room messy is expressing both the need to be independent (not doing it their parent's way), and the need for love and care (mom has to come in and clean up) at the same time. They may have symptoms including anger and irritability or anxiety and depression when others don't continue to provide affection in the face of their oppositionalism (both a defense against directly expressing their conflictual anger and love to their parent, and their unconscious "transference" style-maladaptive in this case).

When defenses fail, psychological symptoms (i.e., anxiety, depression) may emerge, and relationships with others may not go well when defenses are maladaptive. For example, when boasting as a defense against unconscious feelings of inadequacy fails, depressed feelings can appear and relationships can sour because it is not an adaptive way to relate.

The Self-Psychological model is somewhat less structured, but basically consists of the need for children to be "mirrored", or supported and praised, by their parents as they strive to achieve. Empathic failures are thought to distort and inhibit the development of an adequate sense of self (both conscious and unconscious), that then leads to symptoms and impairs one's relationship style with others. Again, defenses attempt to compensate for these failures of self-development. Empathy is the main therapeutic tool in the Self-Psychological model that is used to help the patient resolve their feelings of inadequacy. Analysis of the patient's transference and defensive style is used in therapy in order to understand the origin of the empathic failures, and to improve any maladaptive relationship styles that are thought to be based on the underlying feelings of inadequacy.

Further reading on psychodynamics can be found in: The Psychodynamic Formulation: Its Purpose, Structure, and Clinical Application. By Samuel Perry, M.D., Arnold M. Cooper, M.D., and Robert Michels, M.D., American Journal of Psychiatry, 1987;144:5:543-550.