What is Psychodynamic Psychotherapy & How Does It Work

Psychodynamic psychotherapy is based on psychoanalytic theory, which explores unconscious processes and past experiences to understand present behavior. Psychodynamic psychotherapy emphasizes self-reflection, emotional insight, and the therapeutic relationship as tools for change.

Psychodynamic psychotherapy emerged from Sigmund Freud's theories and has evolved over the last century to become a more flexible and collaborative approach. Freud’s original premise emphasized unconscious conflicts rooted in childhood experiences. Modern psychodynamic approaches retain the core elements but have adapted to be more practical for contemporary therapeutic settings.

Today, psychodynamic psychotherapy incorporates relational theories, object relations theory, and attachment theory.

Core Principles

1. Unconscious Processes

Unconscious thoughts, feelings, and desires influence behavior and emotions, and they are expressed through defense mechanisms such as repression or projection.

2. Past Influences

Early relationships—especially with primary caregivers—shape how individuals relate to others in adulthood. Clients may unconsciously repeat patterns from their past, known as repetition compulsion.

3. The Therapeutic Relationship as a Tool for Change

The client-therapist relationship provides a safe space for the client to explore emotions and relational patterns. Through transference, clients project feelings from past relationships onto the therapist, creating an opportunity for insight and healing. Therapists may experience countertransference, offering valuable clues about the client’s inner world. Skilled therapists use their own emotional responses to deepen their understanding of the client’s inner world while maintaining appropriate boundaries.

4. Emotional Insight and Self-Understanding

Clients gain insight into the origins of their distress. This greater awareness of unconscious patterns enables them to make more conscious choices.

5. Exploration of Defenses

Defense mechanisms allow clients to avoid painful emotions or conflicts. In session, the therapist identifies and gently challenges these defenses to facilitate emotional growth.

6. Open-Ended and Collaborative Approach:

Sessions are unstructured, allowing clients to explore whatever thoughts and emotions arise. This open-ended approach expands self-reflection and creates opportunities for meaningful discoveries.

How Does Psychodynamic Psychotherapy Work?

Initial Assessment and Treatment Planning—Therapists thoroughly assess the client’s presenting issues, history, and relational patterns, allowing them to determine whether psychodynamic psychotherapy is appropriate. For clients dealing with complex emotional problems, trauma, or unresolved childhood conflicts, this approach can offer profound benefits.

The therapist and client collaboratively set treatment goals, which focus on reducing distressing symptoms, improving emotional regulation, or understanding relationship problems. Goals are often broad and may evolve as the client gains deeper insights.

Session Structure and Techniques—A typical weekly session lasts 45 to 60 minutes, but the frequency can vary based on the client’s needs. Sessions are conversational, with the therapist actively listening and encouraging the client to explore their thoughts and feelings.

Techniques used:

• Free Association. Clients express their thoughts without censorship, helping them uncover unconscious material and patterns that might not be immediately obvious.

• Interpretation. The therapist interprets the client’s thoughts, emotions, and behaviors, helping the client gain insight into unconscious processes.

• Transference Analysis. The therapist notes how the client relates to them, identifying patterns that might reflect unresolved issues from past relationships. This leads to powerful insights and emotional breakthroughs.

• Dream and Fantasy Exploration. Dreams and fantasies are the windows into the unconscious. The therapist helps the client explore symbolic meanings.

How Long Does Psychodynamic Therapy Take?

Psychodynamic therapy is a long-term approach, with treatment typically lasting several months to several years. However, short-term psychodynamic therapy (STPP) has become more common in recent years. STPP focuses on a specific issue within a time-limited framework (usually 12 to 24 sessions).

The pace of therapy depends on the client's needs, level of insight, and the complexity of the problems it is trying to solve. Progress may feel slow, but lasting change often occurs when the client gains deeper emotional insight over time.

Who Benefits from Psychodynamic Psychotherapy?

Psychodynamic therapy can be highly effective for clients dealing with:

• Depression
• Anxiety Disorders
• Relationship Issues
• Personality Disorders
• Trauma and Loss

Challenges and Limitations of Psychodynamic Psychotherapy

Psychodynamic psychotherapy includes limitations that can impact both clients and therapists.

• Length of Treatment: Cost and Time Constraints

Psychodynamic psychotherapy is a long-term treatment requiring months or even years of regular sessions.

• Financial Burden

Therapy can become financially prohibitive, especially for clients without insurance coverage. Even with insurance, co-pays add up over time.

• Time Commitment

Weekly sessions require significant time, and clients with demanding jobs, childcare responsibilities, or other obligations may struggle to fit therapy into their schedules.

To manage these challenges, therapists can explore short-term psychodynamic therapy (STPP) as an option. Another strategy is collaborating with clients to set manageable goals and timelines, such as scheduling sessions every other week to reduce financial and time burdens.

Therapists can discuss the long-term benefits of PDP to help clients understand the investment in their emotional well-being.

1. Emotional Intensity: Engaging with Difficult EmotionsPsychodynamic therapy requires clients to explore unconscious conflicts, early experiences, and painful emotions. This process can be emotionally intense and overwhelming.

• Resistance to Change Some clients may resist engaging with difficult material because it brings up feelings of shame, fear, guilt, or anger.

• Risk of Emotional Overwhelm As clients uncover repressed memories or confront unresolved relational issues, they may feel worse before they feel better.

The therapist can pace the therapeutic process carefully, ensuring the client is not overwhelmed. Grounding techniques and mindfulness practices can help clients stay present during emotionally intense sessions. It’s also essential to normalize the emotional intensity, reassuring the client that experiencing discomfort is part of the healing process. Therapists might say: “I know these emotions are difficult, but they are a sign that you are working through something important.”

2. Lack of Structure: The Open-Ended Nature of Sessions

Psychodynamic psychotherapy is typically open-ended, allowing the client to explore thoughts and feelings freely. This lack of structure can be challenging for clients accustomed to goal-oriented approaches.

• Difficulty Staying Focused Some clients may struggle without a clear agenda or set of tasks.

• Preference for Structure Clients may feel frustrated by the slow, exploratory nature and prefer a more direct, symptom-focused approach.

Therapists can balance exploration with structure by reviewing the client’s progress and clarifying how insights relate to their symptoms. Using themes or patterns (e.g., “It seems like this feeling of being stuck often shows up when we talk about your relationships”) can provide a sense of continuity without rigid structure. Therapists can also collaborate with clients to identify mini goals.

3. Therapist’s Skill: Managing Transference, Countertransference, and Interpretation

This treatment method places high demands on the therapist, requiring skill in managing complex relational dynamics and providing meaningful interpretations. Missteps can limit progress or even harm the therapeutic relationship.

• Transference and Countertransference

Managing these issues requires skill and understanding. Poor handling of these dynamics can disrupt the therapeutic alliance.

• Offering Timely Interpretations Therapists must provide insightful but not overwhelming interpretations. Premature or incorrect interpretations can leave the client feeling misunderstood or alienated.

Effective therapists remain reflective about their own emotional responses, using supervision or personal therapy to manage countertransference. It’s also important to pace interpretations carefully, waiting for the right moment when the client is ready to engage with deeper insights. Instead of rushing to interpret, the therapist might say: “I notice you seem frustrated with me today. Let’s explore what might be behind that.” Gentle inquiry invites the client to reflect on their emotions without overwhelming them.

Practical Tips

To effectively manage challenges, therapists can adopt the following strategies:

1. Set Clear Expectations from the BeginningDuring the initial session, discuss the length, intensity, and open-ended nature of therapy to ensure the client understands what to expect.

2. Collaborate on Goals and Flexibility

While therapy may not have a rigid structure, collaborating with the client to establish overarching goals helps provide some direction. Review progress regularly and adjust goals as needed to keep the client engaged.

3. Offer Emotional Support and Validation

Normalize the emotional intensity of the process by reassuring clients that discomfort is part of meaningful change. Introduce grounding exercises and coping strategies to manage difficult emotions between sessions.

4. Balance Exploration with Practical Tools

Therapists can incorporate practical interventions (e.g., breathing techniques or journaling) to help clients better handle day-to-day stressors.

5. Maintain Reflective Practice

Regular supervision and self-reflection are essential for managing transference and countertransference effectively. Therapists should also be open to clients' feedback about how they experience the therapeutic process.

Incorporating Psychodynamic Therapy into Practice

Mastering key strategies can enhance clinicians' effectiveness and comfort with psychodynamic principles. Below are examples to help clinicians seamlessly integrate psychodynamic elements into their practice.

1. Start with Short-Term Psychodynamic Therapy (STPP)STPP offers a time-limited framework, typically lasting 12 to 24 sessions, making it more manageable. STPP focuses on a specific issue, allowing therapists to practice psychodynamic techniques without the long-term commitment associated with traditional psychodynamic psychotherapy.

• ExampleA therapist working with a client experiencing workplace stress can use STPP to explore how their childhood experiences with authority figures affect their current relationships with supervisors. Instead of exploring all aspects of the client’s past, therapy focuses on a targeted issue over several weeks.

• Implementation TipSTPP is particularly useful for clients who want to explore relationship dynamics or emotional patterns but are not ready for an open-ended commitment. Clinicians can offer STPP as an alternative to long-term therapy, building skills while delivering meaningful outcomes.

2. Develop Strong Reflective Skills

Psychodynamic therapy requires clinicians to engage in ongoing self-reflection and supervision to manage countertransference. Regular reflection helps the therapist remain aware of their biases, emotional triggers, and assumptions, which could interfere with the therapeutic process.

• Example: A therapist might feel frustrated when working with a client struggling to set boundaries. If these emotions are not addressed, the therapist may unknowingly push the client toward setting boundaries prematurely, creating resistance. Reflecting on the frustration through supervision allows the therapist to recognize it as countertransference, stemming from their personal experiences with boundary-setting.

• Implementation Tip: Clinicians can benefit from peer consultation groups or individual supervision to process challenging sessions and gain fresh perspectives. Journaling can also help track emotional responses and identify recurring themes.

3. Balance Structure with Flexibility

Some structure is necessary to maintain focus and align with clients’ goals. Balancing structure with flexibility ensures that therapy remains meaningful without becoming aimless.

• Example: A therapist working with a client going through a divorce might start with an open-ended exploration of patterns in the client’s past relationships. After a few sessions, the therapist and client might agree to focus on a particular theme—such as fear of abandonment—and develop small, attainable goals, such as identifying when that fear arises and practicing self-soothing techniques.

• Implementation Tip: Incorporate periodic progress reviews to ensure therapy aligns with the client’s goals. For example, every six sessions, the therapist can ask, “Are we still focusing on the things that feel most important to you?” This helps maintain direction while allowing flexibility to address emerging concerns.

4. Use a Relational Approach

The dynamics between therapist and client often mirror the client’s relational patterns in other areas of life. By paying attention to these dynamics, therapists can help clients gain insight into their relationships and emotions.

• Example: A client expresses frustration toward the therapist for not offering clear advice, mirroring how they feel unsupported by family members. The therapist recognizes this as transference and gently brings it to the client’s attention: “I wonder if the frustration you’re feeling toward me might be similar to what you experience with your family.” This allows the client to explore how they relate to authority figures and helps them develop healthier ways of expressing their needs.

• Implementation Tip: Therapists must be mindful of countertransference, as their emotional reactions to clients offer valuable clues about the client’s interpersonal patterns. For example, if the therapist feels unusually protective of a client, it may reflect the client’s tendency to elicit caretaking behaviors from others. Recognizing this dynamic helps the therapist respond more thoughtfully and avoid reinforcing unhelpful patterns.

5. Integrate Psychodynamic Principles into Other Modalities

Many clinicians combine psychodynamic principles with other therapeutic approaches, such as CBT, ACT, or mindfulness-based therapies. This approach allows therapists to address the client’s symptoms and underlying emotional patterns.

• Example: A therapist working with a client who experiences panic attacks may use CBT techniques to manage symptoms, such as exposure, relaxation exercises, and thought-challenging. The therapist also explores the underlying emotional triggers—unresolved fears of abandonment—that contribute to the client’s anxiety.

• Implementation Tip: Integrating psychodynamic concepts enhances other modalities by adding depth to symptom management. For example, helping a client recognize perfectionism is a defense against the fear of failure, and it complements CBT techniques to reduce perfectionistic thinking.

6. Manage Expectations and Educate Clients about the Process

Some clients may be unfamiliar with the process of psychodynamic therapy and expect quick symptom relief. Managing expectations from the beginning helps clients stay engaged, even when progress feels slow or unclear.

• Example: During the initial session, a therapist might say, “Psychodynamic therapy often focuses on exploring patterns and gaining deeper insight, so it might feel different from other therapies that focus more on immediate symptom reduction. While progress might not always feel linear, the goal is to create lasting change by addressing the root of your challenges.” This sets a realistic tone and prepares the client for the nature of the work.

• Implementation Tip: Educating clients can increase their commitment to the process. Using metaphors—such as comparing therapy to building a foundation for a house—can help clients understand that meaningful change takes time.

Conclusion

Psychodynamic psychotherapy offers a powerful framework for understanding and addressing complex emotional and relational issues. Focusing on unconscious processes, early experiences, and the therapeutic relationship provides clients lasting emotional insight and the tools to make meaningful and sustainable changes. While this treatment modality requires skill, patience, and commitment from both therapist and client, it remains a valuable option for clients seeking profound, transformative change.

References

Abbass, A., Town, J., & Driessen, E. (2014). Intensive short-term dynamic psychotherapy: A systematic review and meta-analysis of outcome research. Harvard Review of Psychiatry, 22(2), 72-86.

Leichsenring, F., Abbass, A., Luyten, P., Hilsenroth, M., & Rabung, S. (2016). The empirical status of psychodynamic psychotherapy—An update. Psychotherapy and Psychosomatics, 85(3), 129-148.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109.