Psychodynamic psychotherapy and “therapy” in general has a different meaning to both the patients and the professionals providing the treatment. I want to discuss psychodynamic psychotherapy and how it is one of the most beneficial types of therapies available. Most people have some idea who Freud was, and his classic psychoanalytic psychotherapy is the father of moder psychodynamic therapy. Whereas freud had people relax and lay on a couch, that is rarely done nowadays. His main goal was for the patient to have total free association which means people were encouraged to talk about any topic that comes to their mind, even if it did not make complete sense. The reason for the couch was minimizing eye-contact and increasing relaxation-both of which enable someone to be more comfortable to spew out their thoughts.
Psychodynamic psychotherapy emerged as a modern day solution to the modern day patient. Class freudian analysis was done on a daily basis and would go on for many years. Today, people are rarely willing to spend that much time in therapy and the health care system does not cover any of these costs. A few people today will pay out of pocket for classic analysis with one of the few remaining true psychoanalyticly trained psychiatrists but it is a rare occurrence. Psychodynamic psychotherapy usually involves one hour long session per week and the therapy can go on for months or years. Short-term psychodynamic psychotherapy is usually between 10-20 sessions and a specific target goal is set from the first visit and the focus remains on achieving the target. Regular long-term psychodynamic psychotherapy explores a patients mind in much more depth and much more freely-along similar lines to freudian free association but in a toned down fashion.
Psychiatrists are more involved than freud was at adding insight and comments to augment what the patient says. The ultimate goal however is to have the patient gain insight into dysfunctional patterns of behavior or thoughts in their life and ultimately correct these problems with a team approach between the patient and psychiatrist. This is much different than what many people consider “counseling” or “therapy” used in a layman’s sense. Many counselors exist and are not educated or trained to nearly the same degree as a psychiatrist and due to relaxed laws, they are legally allowed to be certified counselors and therapists. The vast majority of people sadly do not know the difference and choose a therapist without considering their background.
The majority of counselors who are not psychiatrists or psychologists provide “supportive” psychotherapy. I call this “feel-good” therapy as the goal is to align yourself with the patient, encourage them, build their self-esteem and provide some basic problem solving techniques to address any ongoing problems in life. Patients almost always leave the session feeling “much better” but this improvement is short lived. The problem with supportive therapy is that there is no evidence that it actually treats the underlying problem. It rather acts as a very temporary band-aid to mask the problems. It is much more comfortable than psychodynamic psychotherapy because the therapist spends the session encouraging the patient rather than delving into painful thoughts from the patients past. The painful thoughts however is almost always the root cause of the dysfunctional behavior or depression that a patient presents with, so without targeting this, the problem is never fully addressed and corrected.
Psychodynamic psychotherapy focuses on early life or past life events that have shaped the way a patient behaves, thinks and interacts within relationships in life. Childhood problems were the cornerstone of freudian analysis and psychodynamic psychotherapy also focuses on this concept but to a lesser degree. The idea behind psychodynamic psychotherapy is to identify past life events that were usually painful and therefore coping with them was difficult. The maladaptive coping skills at the time of painful events leads one to unconsciously (not actively realizing it happening) modify their behaviors and interactions among people to “protect’ themselves from feeling a similar type of pain. In essence it is a built in safety mechanism to prevent further pain given a repeating stimulus. In theory it sounds helpful but in reality, by not properly dealing with emotions throughout life, one never matures to an emotionally stable person who can succeed in relationships and who functions well within the world.
An example is “blocking something out.” This is when someone has minimal or no memory of a painful event in their life. Their brain at the time was unable to cope with the highly painful emotions and ultimately the emotions were “swept under the rug.” The emotional memories are still stored in the brain however they are not readily accessible to the person. However similar to a computer chip, they still are able to control their emotions and behaviors on a long-term basis. Working with a patient to uncover these past emotions, discuss them and then properly process them is the successful strategy of psychodynamic psychotherapy.
Ultimately through long-term therapy a psychiatrist focuses on dealing with every significant painful experience or patterns of similar painful experiences that never were properly dealt with and one by one bring the emotions to the forefront, examine the emotions and process the emotions. This often is painful and why I tell patients that if they walk out of therapy feeling good-you are not getting proper therapy! The benefits however are enormous and can completely re-shape somone’s thoughts and behaviors which make them more successful in relationships and life in general.
There are other types of evidenced based psychotherapy such as insight-oriented therapy and cognitive-behavioral therapy-each having a role in treatment depending on the situation. Cognitive behavioral therapy is often used in conjunction with psychodynamic psychotherapy to provide the best aspects of both to most rapidly help the patient. I almost always combine the two therapy approaches and in an upcoming blog I will discuss cognitive behavioral therapy and how I integrate it into practice with psychodynamic psychotherapy.