Getting to Know Me: What's Behind Psychoanalysis

Jeffrey (not his real name) came to treatment complaining of depression, anxiety and trouble getting along with others. Colleagues in the engineering department where he worked complained he was “not a team player,” and his wife saw him as distant and hypercritical. Beyond this, he carried with him a constant feeling of dread, no matter how well things were going.

I agreed with Jeffrey that his dread seemed out of proportion to anything that was actually happening in his life and suggested it might be in proportion to something that was not immediately obvious to either of us. I asked him to tell me about himself. Among other things, I learned that his father had been an alcoholic who would attack without warning, driving Jeffrey to leave home at an early age.

It was one thing for Jeffrey to tell me of his unhappy past, but soon this old relationship pattern came to life, as Jeffrey began responding to me as if I were an unpredictable, angry adversary. Consciously, he saw me as an ally with his welfare at heart. Yet he seemed constantly poised to “protect” himself by fending me off, as though he expected I would use what he said against him. His responses were so ingrained that he did not recognize them as out of the ordinary.

I did not regard Jeffrey’s attitude as an obstacle. On the contrary, reliving this relationship pattern with me was central to his recovery. I would frequently point out that Jeffrey was responding as if I were an enemy, and he gradually began to notice, too. In those moments, his thoughts and feelings often ran to his father. I helped him connect the dots: “When you turned to your father for help, he humiliated you. Perhaps a part of you expects the same treatment from me.” Jeffrey began to connect with old emotions, speaking of the terror he had felt during his father’s outbursts. His sense of dread began to make sense—and then slowly dissipated. Jeffrey gradually recognized—not just intellectually but in a way that truly sank in emotionally—that the beatings were over. The world began to feel less dangerous, and he started letting others “in” in ways he never had before. His work relationships improved, and he and his wife became closer than either had previously thought possible. He began to enjoy his life.

The treatment that helped Jeffrey, known as psychoanalytic or psychodynamic therapy, traces its heritage to psychoanalysis in the famous drapery-hung study of Sigmund Freud in Vienna. But psychodynamic therapy as practiced today bears little resemblance to the world of Oedipal conflict, penis envy and castration anxiety that has been so lampooned in New Yorker cartoons and Woody Allen films. Patients do not lie on a couch free-associating as an inscrutable therapist silently looks on, nor must they commit to four or five sessions a week for years on end.

Freud’s legacy is not a specific theory but rather a sensibility: an appreciation of the depth and complexity of mental life and a recognition that we do not fully know ourselves. It is also an acknowledgment that what we do not know is nonetheless manifested in our relationships and can cause suffering—or, in a therapy relationship, can be examined and potentially reworked.

But the modernization of psychodynamic therapy has gone largely unnoticed. For years psychoanalysts did little to disseminate ideas outside their own circles, and this self-imposed exile from academic research left a void, into which was born an alternative: cognitive-behavior therapy (CBT). In this newer approach, therapists focused on specific problems and readily observable thoughts and behaviors, rather than embracing the messy, emotional complexity of people’s mental lives.

Over the past decades psychologists have conducted thousands of studies that showed the effectiveness of cognitive-behavior therapy. The approach initially seemed to promise quick cures—a promise that dovetailed with the interests of health insurers, who wanted to pay as little as possible for mental health care. CBT was portrayed as the gold standard, and many practitioners wrote off psychodynamic therapy as antiquated and unscientific. But as I recently showed in a research review published in American Psychologist, the prestigious flagship journal of the American Psychological Association, psychodynamic therapy has been not only misunderstood but vastly underestimated.

The reality is that psychodynamic therapy has proved its effectiveness in rigorous controlled studies. Not only that, but research shows that people who receive psychodynamic therapy actually continue to improve after therapy ends—presumably because the understanding they gain is global, not targeted to encapsulated, one-time problems. Thanks to misinformation and entrenched interests, however, much of this research has been overlooked.

Enhancing Self-Awareness
There is no end of cartoons spoofing psychoanalysis: Santa Claus on the couch confessing, “I don’t believe in myself anymore,” or a house on a couch telling the dispassionate analyst, “My bubble burst!” But cartoons are not reality. Psychodynamic therapy is practical, and it helps free people from suffering. So what is it that makes psychodynamic therapy so powerful? By analyzing tapes from hundreds of hours of actual therapy sessions, researchers have identified seven distinctive features.

Exploring emotions. Psychodynamic therapists encourage patients to explore their full emotional range—including contradictory feelings, feelings that are troubling or threatening, and feelings they may initially be unable to express. A CBT practitioner might respond to emotional difficulty with homework assignments and worksheets or seek to persuade patients that irrational thinking has skewed their feelings. Psychodynamic therapists, in contrast, are likely to invite patients to explore their feelings further.

Examining avoidances. Efforts to avoid distressing or threatening thoughts and feelings can be obvious, as when patients miss sessions or fall silent. They can also be subtle, as when people focus on facts and events to the exclusion of emotions or emphasize external circumstances instead of their own role in shaping events. Psychodynamic therapists encourage patients to examine why and how they avoid what is distressing.

Identifying recurring patterns. Sometimes people are acutely aware of painful or self-defeating patterns—like choosing romantic partners who are unavailable or sabotaging themselves when success is at hand—but feel unable to escape them. Sometimes they need help to recognize the patterns.

Discussing past experience. Related to identifying recurring patterns is the recognition that past experiences affect our experience of the present. By exploring how early experiences color present-day perceptions, psychodynamic therapists help patients free themselves from the bonds of the past and live more fully in the present.

Focusing on relationships. Psychodynamic therapists recognize that mental health problems tend to be rooted in problematic relationship patterns. For example, some people do not express their emotional needs for fear of rejection and consequently cannot get them met—a recipe for depression vulnerability.

Examining the patient/therapist relationship. In other therapies, patients’ emotional reactions to the therapist may be seen as distractions. In psychodynamic therapy, they are the heart of the work. This is because a person’s habitual way of being in relationships inevitably emerges in the therapy relationship as well—psychodynamic therapists call this phenomenon “transference.” For example, a person who has trouble with intimacy may struggle to open up to the therapist, and one who fears rejection may strive to be an especially “good” patient. Recognizing transference offers patients a unique opportunity to rework old patterns.

Valuing fantasy life. In contrast to CBT, in which therapists may follow a predetermined agenda, psychodynamic therapists encourage patients to speak freely about whatever is on their minds. Fantasies, dreams and daydreams provide a rich source of information about their hopes, desires and fears.

All successful therapies must relieve symptoms such as anxiety or depression. But psychodynamic treatment aims for more: it focuses on building core psychological strengths—such as the capacity to have more fulfilling relationships, to make more effective use of one’s abilities, and to face life’s challenges with greater freedom and flexibility.

Scientific Evidence
I delved into the research supporting psychodynamic therapy because I kept encountering patients who had been shunted from one “quick fix” treatment to another, with little or no lasting benefit. In my experience, the brief therapies promoted as “empirically supported” were often failing, despite claims that their benefits are scientifically proven.

Cognitive-behavior therapists may also incorporate some of the seven features described above, but not to the same extent as psychodynamic therapists. Instead of encouraging patients to speak freely, they may teach exercises or skills. Instead of exploring feelings in depth, they are more likely to focus on thoughts. Instead of examining how past and present are interrelated, they are more likely to focus on current events. These approaches often do not address root problems, so patients may feel better temporarily, then continue replaying patterns that cause suffering.

When I was preparing my American Psychologist paper, I was amazed by how strong the scientific evidence was in support of psychodynamic therapy. One of the most rigorous studies I described in my paper was led by psychiatrist Allan Abbass of Dalhousie University in Nova Scotia and published in 2006 in the prestigious Cochrane Library. Abbass examined the effectiveness of psychodynamic treatments that lasted for fewer than 40 sessions. His team compiled the results of 23 randomized controlled trials—the kind of carefully orchestrated, rigorous study that medical researchers use to test new drugs. These trials involved 1,431 patients who suffered from depression, anxiety, stress-related physical ailments and other psychological problems.

This kind of investigation is called a meta-analysis because it compiles the findings of numerous other studies. Abbass’s meta-analysis found an “effect size” of 0.97 for overall psychiatric improvement. What does that mean? Effect size measures the amount of treatment benefit. In this type of study, an effect size of 0.2 is considered small, 0.5 moderate and 0.8 large, so the benefit Abbass found is huge. Seven other meta-analyses, collectively including 160 studies and a wide range of mental health conditions, also showed substantial benefits for psychodynamic therapy. These studies included both randomized controlled trials—in which groups of patients who receive treatment are compared with groups who do not—as well as studies that evaluated the same patients before and after treatment.

In contrast, a recent (and fairly representative) meta-analysis of 33 rigorously conducted studies of cognitive-behavior therapy for depression and anxiety showed an effect size of 0.68.

Even more intriguing, Abbass’s meta-analysis also looked at patient assessments conducted nine months or more after therapy ended. The effect size grew from 0.97 to 1.51. Now, this is astonishing. In fact, six separate meta-analyses reported data from follow-up assessments, and all showed benefits that kept growing after treatment ended. This continued improvement suggests that psychodynamic therapy sets in motion psychological processes that lead to ongoing change.

Secret Ingredients
Therapy is not a pill you swallow to feel better; it is a delicate and complex process that reflects the patient’s and therapist’s unique personal qualities and interactions. The relationship between therapist and patient—what therapists call the “working alliance”—is critical to success.

In several 1996 studies Pennsylvania State University psychologist Louis Castonguay and his associates found that depressed patients improved more when the working alliance was strong and when therapy put patients on a trajectory of deepening self-examination that led to awareness of previously unconscious feelings and meanings—a core principle of psychodynamic therapy.

In contrast, attempting to change negative thoughts—a foundational feature of CBT—actually predicted worse results.

And in a study that at this writing was in press in the journal Psychotherapy: Research, Theory, Practice, and Training, leading psychotherapists and researchers teamed up to ask: What happens in therapy that helps or hinders progress? Over an 18-month period, patients and therapists separately filled out cards after each session, describing memorable interactions. According to therapists and patients alike, the most helpful interventions were those that yielded emotional, not just intellectual, insight.

Of particular note—given the field’s knee-jerk approbation of cognitive-behavior therapy—is research conducted in the 1990s by the late psychologist Enrico Jones of the University of California, Berkeley. His team analyzed recordings of hundreds of therapy sessions, both psychodynamic and CBT. They found that the more the therapists drew on key psychodynamic principles such as addressing patients’ avoidances or defenses, exploring emotions and fantasies, identifying recurring themes, and discussing the therapy relationship, the better patients fared—in both psychodynamic and cognitive-behavior therapy. In contrast, the use of bedrock CBT methods such as teaching skills and strategies or assigning homework showed no benefits.

In other words, when CBT was successful, it was largely because therapists departed from their official playbook and did the kinds of things psychodynamic therapists do.

Ultimately, there are basic truths of human psychology that most people understand intuitively. We do not fully know ourselves; the things we do not know can cause suffering; and there is benefit in self-awareness.

Psychodynamic therapy is based on these truths and has demonstrated its benefits scientifically. It’s time for academic researchers to examine their resistance to the truth.