Psychodynamic Psychotherapy

Abstract

Psychodynamic psychotherapy is a form of psychotherapy that traces present difficulties to unconscious conflict, early relationships, and the defenses a person uses to manage painful feeling. Descended from Freudian psychoanalysis but far briefer and more flexible, it works through the therapeutic relationship: a patient's characteristic ways of relating reappear as transference in the room, where they can be observed, interpreted, and understood. Blagys and Hilsenroth identified seven techniques that reliably distinguish it from cognitive behavioral therapy, among them a focus on affect, on recurring relational patterns, and on the therapy relationship itself. Once dismissed as unevidenced, it is now supported by meta-analyses showing effects comparable to other established treatments, and by a distinctive finding that gains often grow after treatment ends. This article surveys its origins, techniques, mechanisms, forms, and evidence.

Keywords: psychodynamic psychotherapy, transference, insight, empirically supported treatment

What Psychodynamic Psychotherapy Is

Psychodynamic psychotherapy is a type of psychotherapy that seeks lasting change by making conscious the unconscious patterns — of feeling, defense, and relating — that keep a person stuck. MeSH, which classifies it directly under psychotherapy, describes a treatment based on the assumption that symptoms express unconscious conflict, and that bringing that conflict into awareness relieves them. Its aim is not merely to remove a symptom but to alter the enduring structure of experience that produces it, so that the person is left with expanded self-understanding and a wider range of ways to feel and act.

The word dynamic points to the founding idea: that the mind is a field of contending forces, wishes pressing for expression and defenses holding them back, and that psychological trouble arises where that struggle miscarries. The therapy is descended from Freudian psychoanalysis but is distinguished from it by degree rather than kind: it meets once or twice a week rather than daily, sits the patient up rather than on the couch, and pursues focused goals over months rather than the open-ended reconstruction of a character over years (Gabbard, 2017). What it retains from its parent is the conviction that the relationship between patient and therapist is itself the principal instrument of change.

Origins in Psychoanalysis

The conceptual core belongs to Freud. In describing what he called the dynamics of transference, Freud observed that a patient does not merely recall the important relationships of childhood but re-enacts them, unknowingly casting the analyst in the roles once held by parents and rivals, so that the past becomes present in the consulting room and can be worked with directly (Freud, 1912/1958). Around this he built the technical vocabulary the whole tradition still uses: free association as the method of access, resistance as the mind's opposition to it, interpretation as the therapist's tool, and working through as the slow labor of applying an insight across the many situations in which the old pattern recurs.

Classical psychoanalysis was long, intensive, and hard to study. The move to a briefer, testable psychodynamic therapy required making its technique explicit enough to teach and to measure. Luborsky's manual for supportive-expressive treatment was a landmark in that effort: it specified what the therapist should attend to and do, and introduced the core conflictual relationship theme, a structured way of extracting the recurring wish-and-response pattern that organizes a patient's relationships, including the one with the therapist (Luborsky, 1984). Manualization made psychodynamic therapy something a trial could deliver reliably and a researcher could compare against an alternative, which is what eventually allowed its evidence base to be built.

The Distinctive Techniques

For decades the claim that psychodynamic therapy is a distinct practice rested on assertion. Blagys and Hilsenroth put it on firmer ground by reviewing the comparative process literature — studies that actually recorded what therapists did in session — and identifying seven techniques that reliably distinguished psychodynamic therapy from cognitive behavioral therapy in those recordings (Blagys & Hilsenroth, 2000). The list matters because it defines the treatment by observable behavior rather than by theory, and because it shows the psychodynamic clinician emphasizing exactly what a cognitive behavioral one tends to de-emphasize.

The seven distinctive techniques

The process features that reliably separated psychodynamic therapy from cognitive behavioral therapy in recorded sessions (Blagys & Hilsenroth, 2000). Select one to see how each tradition handles it.

Focus on affect and emotional expression

The seven cluster into a coherent stance. Three concern what is attended to: affect and emotional expression, the attempt to avoid distressing topics, and recurring themes across a person's life. Two concern time: an emphasis on past experience and on interpersonal relationship. And two concern the room itself: a focus on the therapy relationship, and on the patient's wishes, dreams, and fantasies. A cognitive behavioral therapist, by contrast, characteristically directs attention to present symptoms, teaches skills, assigns homework, and structures the session — a different and equally legitimate craft. The point of the contrast is not that one is right but that the two are genuinely different treatments, which is the precondition for asking whether they work equally well.

Core Mechanisms

If the techniques describe what the therapist does, the mechanisms describe why it should help. The central one is transference. Because a patient's habitual pattern of relating reappears with the therapist, the therapist becomes a live specimen of the very problem the patient came about: the fear of dependence, the expectation of criticism, the reflexive withdrawal. Naming and exploring that pattern as it happens — rather than only as it is reported — gives the work an immediacy that discussion of outside relationships lacks. The mirror-image reaction in the therapist, countertransference, is treated not as a nuisance but as data about how the patient tends to make others feel.

The intended product of this work is insight: a felt, not merely intellectual, understanding of one's own patterns and their origins. Insight is rarely enough on its own, which is why the tradition stresses working through, the repeated recognition of the same defense mechanism and the same conflict across the range of situations in which they operate, until the pattern loosens. All of this depends on a secure therapeutic alliance (Therapeutic Alliance); the uncovering, interpretive end of the work is only tolerable when the bond is strong enough to hold the anxiety it stirs up, which is precisely why technique slides along the supportive-expressive continuum of Figure 1 according to how much the patient can bear at that moment.

Short-Term and Long-Term Forms

Psychodynamic psychotherapy is not one length. It spans a family of treatments from a dozen focused sessions to open-ended work over years, and the evidence differs by form. The table below sets out the two poles.

The division is clinically real. Brief, focused work suits a circumscribed problem in a reasonably resilient person; the long form is reserved for entrenched, recurrent, or personality-level difficulty, where the argument is that durable change simply takes longer. The strength of evidence runs opposite to the ambition of the treatment: it is strongest for the short forms that are easiest to trial and thinnest for the long forms whose value is hardest to capture in a randomized design.

Worked Example

Meta-analyses report their results as an effect size, usually Cohen's d, the difference between treated and untreated groups expressed in standard deviations. The number is easy to state and easy to misread, so it is worth converting into something concrete. Shedler's review put the overall effect of psychodynamic therapy at about d = 0.97 (Shedler, 2010); take that figure and unpack it.

An effect size of 0.97 means the average treated patient ends up 0.97 standard deviations better off than the average untreated patient. Reading that against the normal distribution gives U3 = Φ(0.97) = 83%: the average treated patient finishes better than 83% of those who received no treatment. A second, often clearer, translation is the common-language effect size, the chance that a randomly picked treated patient is doing better than a randomly picked untreated one: CLES = Φ(0.97 / √2) = 75%. Roughly three times in four, the treated person comes out ahead. Expressed as a number needed to treat, 0.97 corresponds to an NNT of about 2 — treat two patients to gain one good outcome that would not otherwise have occurred.

What an effect size means

Cohen’s d is the gap between the treated and untreated distributions in standard-deviation units. Drag to see the treated curve (gold) shift right of controls (navy), and read off the plain-language translations.

U3 = Φ(d) = 83% of untreated patients do worse than the average treated patient
CLES = Φ(d/√2) = 75% chance a random treated patient beats a random untreated one
NNT ≈ 2.0 patients treated per extra good outcome

These conversions are worth internalizing because effect sizes are the currency of the whole evidence base below, and because d = 0.97 is, by the conventions of the field, a large effect — comparable to the effects reported for the treatments against which psychodynamic therapy is usually contrasted.

The Evidence Base

The modern reappraisal of psychodynamic psychotherapy began with a simple, forceful argument: that the widespread belief in its lack of evidence was itself unevidenced. Shedler assembled the meta-analytic record and showed effect sizes as large as those for the therapies routinely called empirically supported, together with a striking and repeated observation — that the benefits of psychodynamic therapy tend to increase after treatment ends, as though the patient continues the work on their own (Shedler, 2010). Fonagy's update surveyed the growing body of trials and reached a similar, if more measured, conclusion: the evidence is real and expanding, though uneven across conditions (Fonagy, 2015).

Do the gains last after therapy ends?

A distinctive and repeated observation is that psychodynamic therapy’s benefits often increase after termination (Shedler, 2010). Compare that pattern with the two alternatives.

Effect size rises after treatment ends — patients appear to continue the work on their own.

The strongest test is equivalence. Steinert and colleagues ran a meta-analysis designed specifically to ask whether psychodynamic therapy is as good as other empirically supported treatments, using formal statistical tests of equivalence rather than mere failure to find a difference, and found that it was (Steinert et al., 2017). The most recent umbrella review, applying updated and stricter criteria across disorders, concluded that psychodynamic therapy now qualifies as an empirically supported treatment for several common mental disorders, while flagging where the evidence remains thin (Leichsenring et al., 2023). The honest summary is that the case is now solid for the short forms and for common disorders, and weaker — though not absent — for the long forms and complex presentations.

Discussion

Psychodynamic psychotherapy has traveled an unusual arc: from the dominant therapy of the mid-twentieth century, to a period when it was widely written off as pre-scientific, to a present in which it holds a defensible place among evidence-based treatments. What changed was not mainly the therapy but the willingness to specify and test it. Manualization made it deliverable in trials; effect-size meta-analysis made its results comparable; equivalence testing made the comparison fair. The result is a treatment whose distinctive techniques are documented, whose mechanisms are theorized and partly measured, and whose outcomes are, for the conditions best studied, on a par with the alternatives.

Two cautions remain. First, the evidence is strongest exactly where the therapy is least ambitious: brief work for circumscribed problems. The long-term, character-level treatment that is psychodynamic therapy's most distinctive offering is also its least firmly evidenced, because it is the hardest to trial. Second, the finding that gains grow after termination, while genuinely intriguing and repeatedly reported, is drawn largely from follow-up data of varying quality and should be held as a strong hypothesis rather than a settled law. The field's task now is less to defend the therapy's legitimacy than to map precisely where, for whom, and through what mechanism it works best.

Current Directions

The live debate is no longer whether psychodynamic therapy works but how the field should weigh it against cognitive behavioral therapy. Leichsenring and Steinert argued directly against treating any single approach as the gold standard, urging a plurality of evidence-based treatments and research programs on the grounds that no one therapy is best for every patient or problem (Leichsenring & Steinert, 2017). That argument has been strengthened by the equivalence findings: if outcomes are broadly comparable, the interesting questions become matching, mechanism, and patient preference rather than the ranking of brands.

Methodologically, the frontier is the tightening of criteria and the widening of scope. The 2023 umbrella review is the clearest example: rather than pooling yet more trials into a single average, it applied updated, discipline-agreed standards for what counts as empirical support and asked, disorder by disorder, whether psychodynamic therapy meets them (Leichsenring et al., 2023). Alongside this sits continued work on the short forms, where the Cochrane and depression-specific meta-analyses are periodically updated as new trials appear (Abbass et al., 2014; Driessen et al., 2015). The open empirical prize remains the growth-after-termination effect: if it is real and general, it distinguishes psychodynamic therapy from treatments whose gains fade, and identifying the mechanism behind it would be a genuine contribution.

Common Misconceptions

Psychodynamic psychotherapy is the same thing as psychoanalysis.

It grew out of psychoanalysis but differs in intensity and scope: weekly rather than daily sessions, face to face rather than on the couch, and focused goals over months rather than open-ended work over years (Gabbard, 2017).

There is no scientific evidence that it works.

Meta-analyses report effect sizes comparable to other established therapies, and formal equivalence tests find it as efficacious as other empirically supported treatments for the conditions best studied (Steinert et al., 2017).

It only dwells on childhood and ignores the present.

Past experience is one of seven distinctive foci, but the emphasis on the here-and-now therapy relationship — how the patient's patterns show up with the therapist — is equally central (Blagys & Hilsenroth, 2000).

Glossary

Core conflictual relationship theme.

Luborsky's structured method for extracting a patient's recurring pattern of wish, expected response from others, and response of the self, used to focus supportive-expressive treatment.

Countertransference.

The therapist's own emotional reactions to the patient, treated in psychodynamic work as information about how the patient tends to make others feel.

Defense mechanism.

An unconscious strategy that keeps painful feeling or conflict out of awareness; recognizing and loosening rigid defenses is a central aim of the therapy.

Effect size.

A standardized measure of an intervention's magnitude, commonly Cohen's d, the difference between treated and untreated groups expressed in standard-deviation units.

Empirically supported treatment.

A therapy that meets agreed evidentiary criteria, typically demonstrated efficacy in controlled trials for a defined disorder.

Free association.

The basic method of access in which the patient reports whatever comes to mind without censoring it, allowing unconscious material to surface.

Insight.

A felt, not merely intellectual, understanding of one's own patterns and their origins; the intended product of interpretive work.

Interpretation.

The therapist's offering of meaning that links a patient's feeling, defense, or relational pattern to its unconscious source.

Long-term psychodynamic psychotherapy.

Open-ended psychodynamic treatment, often a year or more, aimed at complex, chronic, or personality-level difficulty.

Psychoanalysis.

Freud's original intensive, open-ended treatment and theory of mind from which psychodynamic psychotherapy is descended.

Psychodynamic psychotherapy.

A briefer, more flexible descendant of psychoanalysis that treats unconscious conflict and the therapy relationship as the levers of lasting change.

Resistance.

The mind's opposition to bringing painful material into awareness, expressed as avoidance, silence, or the reflexive dismissal of an interpretation.

Short-term psychodynamic psychotherapy.

Time-limited, focused psychodynamic treatment, typically fewer than forty sessions, with the strongest trial evidence in the family.

Supportive-expressive continuum.

The range along which technique moves, from supporting a fragile patient's defenses to interpreting and uncovering conflict in one who is ready.

Therapeutic alliance.

The collaborative bond and shared goals between patient and therapist, whose strength determines how much interpretive work the patient can tolerate.

Transference.

The patient's redirection onto the therapist of feelings and expectations rooted in earlier relationships, which lets an old pattern be observed and worked with as it happens.

Working through.

The repeated recognition of the same conflict and defense across the many situations in which they operate, until the pattern loosens.

Key Researchers

Peter Fonagy (living). Developer of mentalization-based treatment at University College London; his 2015 update surveyed the contemporary evidence for the psychodynamic psychotherapies. ORCID

Sigmund Freud (1856-1939). Originator of psychoanalysis, whose account of transference, resistance, and the unconscious supplies the conceptual core that the psychodynamic tradition later condensed into briefer, testable therapies. Wikipedia

Glen O. Gabbard (living). Psychoanalyst at Baylor College of Medicine and author of the standard contemporary text on long-term psychodynamic psychotherapy. Wikipedia

Falk Leichsenring (living). Researcher at Justus Liebig University Giessen and lead investigator on the major meta-analyses and the 2023 umbrella review of psychodynamic psychotherapy as an empirically supported treatment. ORCID

Lester Luborsky (1920-2009). Devised the supportive-expressive manual and the core conflictual relationship theme method that made psychodynamic technique specifiable and testable. Wikipedia

Jonathan Shedler (living). Clinical psychologist at the University of California, San Francisco whose 2010 review of the efficacy of psychodynamic psychotherapy reframed the debate over its evidence base. Website

Frequently Asked Questions

What is psychodynamic psychotherapy?
It is a talking therapy that treats present difficulties as expressions of unconscious conflict and early relationship patterns, and works to make those patterns conscious — largely through the relationship with the therapist — so that a person can feel and act with more freedom (Gabbard, 2017).

How is it different from psychoanalysis?
It descends from psychoanalysis but is briefer and more flexible: typically once or twice weekly, face to face, with focused goals over months, rather than daily sessions on the couch over years (Gabbard, 2017).

How is it different from cognitive behavioral therapy?
Blagys and Hilsenroth identified seven techniques that reliably distinguish it, including a focus on emotion, on recurring relational themes, on the past, and on the therapy relationship itself — where CBT tends to emphasize present symptoms, skills, and structured homework (Blagys & Hilsenroth, 2000).

What is transference and why does it matter?
Transference is the patient's redirection onto the therapist of feelings from earlier relationships. It matters because it brings the patient's characteristic pattern of relating into the room, where it can be observed and understood as it happens rather than only described (Freud, 1912/1958).

Does psychodynamic psychotherapy actually work?
Yes, for the conditions best studied. Meta-analyses report effect sizes comparable to other established therapies, and formal equivalence testing finds it as efficacious as other empirically supported treatments (Shedler, 2010; Steinert et al., 2017).

Do the benefits last?
The evidence suggests they do, and a distinctive and repeated finding is that gains often continue to grow after treatment ends, as though the patient carries on the work independently — though this rests on follow-up data of varying quality (Shedler, 2010).

How long does treatment take?
It varies. Short-term forms run fewer than forty sessions and have the strongest trial evidence (Abbass et al., 2014); long-term forms extend over a year or more and are reserved for complex or chronic problems (Leichsenring & Rabung, 2008).

Is it evidence-based for depression?
Yes. A meta-analysis update focused on depression confirmed that short-term psychodynamic psychotherapy is efficacious for depressive disorders, consistent with the broader equivalence findings (Driessen et al., 2015).

References