Each year I sit down with trainees to review our goals for supervision and collaborate around areas of growth. For many, learning about psychodynamic psychotherapy is often at the top of the list. 

This post discusses different dimensions of psychodynamic therapy that present-day practitioners think about when they work with their patients and provides practical questions to aid in addressing these dimensions in practice. 

What’s notable is what isn’t on this list. Psychodynamic psychotherapy is built upon a lengthy history with plenty of room for myths and misunderstandings. Frequent misgivings often result from negative cultural stereotypes and a lack of knowledge regarding current research and practice. Ultimately, the ways psychodynamic clinicians practice today are often far different from the early days of psychoanalysis.

For example, the pronounced shift toward relational psychoanalysis and intersubjectivity in the early 1980s sometimes seems to go unnoticed. Moreover, assumptions about the therapist as a blank slate, extended silences, and lofty interpretations as the standard elements of practice remain a common misperception amongst some students and practitioners.    

One of the challenges in educating and training involves translating theory into practice. In my experience, this can be particularly difficult when teaching psychodynamic therapy. In contrast to more structured approaches — where explicit training can be provided through the use of thought records, cognitive restructuring exercises, and skill-based strategies — psychodynamic interventions are sometimes less tangible.

Likewise, approaches aimed at reducing observable symptoms are typically easier to measure. Although identifying and reducing symptoms is a common goal for most approaches, psychodynamic therapy adds emphasis on understanding the origin and function of symptoms. I wrote about this in a previous blog post.

Furthermore, goals such as developing greater autonomy, expanding capacities for affect tolerance and regulation, deepening self-understanding, exploring inner conflicts, and promoting realistic and reliable self-esteem are common goals that may not always translate well to concrete interventions or manualized protocols.        

The following dimensions and questions were assembled in an attempt to help make psychodynamic psychotherapy more accessible by providing concrete starting points within key areas important to understanding and working with clients in therapy. Thinking about therapy through these domains – and through these questions – can facilitate case conceptualization and lead to useful considerations in planning interventions or responding to the here-and-now in the therapy process. Generally, these questions should be thought of as useful starting points and not manualized instructions.

Adaptive Functioning

Psychological symptoms often have multiple causes and can serve multiple purposes or have multiple functions [1]. Psychodynamic therapists generally view symptoms as related to previously adaptive attempts to manage or deal with distress, provide some form of a solution, and fulfill more than one unconscious function. Understanding the role symptoms and behaviors play in adaptation and how they came to have a negative impact on current functioning is an important component of psychodynamic psychotherapy as this helps elucidate the underlying factors that sustain or perpetuate symptoms.  

The following questions allow for thinking more deeply about adaptive functioning:

What are the functions of the current systems?

How can the client’s underlying core issues be brought into conscious awareness?

How can you help the client loosen the grip of past experiences to create new perspective and opportunities?

Defenses

Freud first wrote about psychological defenses in Studies on Hysteria [2] where he described defenses as “warding off” or “fending off.” Since inception, defenses have been seen as unconscious attempts to avoid or fend off powerful, threatening emotions and distress.  According to McWilliams (2011) defenses are unconsciously used for the “(1) avoidance or management of some powerful, threatening feeling, usually anxiety, but sometimes overwhelming grief, shame, envy, and other disorganizing emotional experiences; and (2) the maintenance of self-esteem” [3].

Understanding and illuminating defenses is an important step in working to address underlying issues or painful feelings that have been avoided so that the client can work through and make more deliberate and thoughtful choices while making room for more adaptive defenses.

When considering defenses, it is also important to examine how groups of defenses function together or what is are referred to as “characteristic defenses.” Suggestions for further reading about defenses include George Vaillant’s 1992 book Ego Mechanisms of Defense and Nancy McWilliam’s 2011 book Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process.

The following questions allow for thinking more deeply about defenses:

How does the client avoid or disavow what is distressing?

What aspects of the client’s experience are disavowed? 

How are attempts to avoid reinforced and perpetuated in the life of the client?

How are the client’s attempts to avoid what is painful reflected in their personality or characteristic ways of thinking, feeling, acting, coping, and relating?

How does the client (knowingly or unknowingly) engage in activities that hinder the progress of therapy?

What does a client’s resistance tell us about their personality or character structure? 

Relationship templates, patterns, schemas

According to object relations theory, human beings are shaped in relation to the significant others surrounding them, particularly in childhood. Subsequently, internal representations or templates of self and other relationships acquired in childhood are later played out in adulthood. Bowlby (1988) highlights the importance of exploring representational models and attachment figures so that these models can be reappraised and restructured based on insights that occur within the therapeutic relationship [4].

Exploring and understanding these templates and patterns of relationships can lead to greater flexibility and new ways of relating to others as a client comes to understand their attachment patterns and the impact of these patterns on their overall functioning. Suggestions for further reading on object relations and attachment include Steven Wallin’s 2015 book Attachment in Psychotherapy, and David E. Scharff’s 1996 book Object Relations Theory and Practice, which provides a broad introduction covering many of the major figures in psychoanalytic theory. 

The following questions allow for thinking more deeply about relationships:

How does the client view the present through the lens of past experiences?

How do past childhood experiences, past unresolved conflicts, and historical relationships significantly affect a person’s present life situation?

How are patterns in the client’s interpersonal functioning repeated over time, settings, and with various people?

How do the client’s relationships promote or interfere with their ability to fulfill their basic needs and wishes?

Inner conflict, contradiction, and ambivalence

Inner conflict is generally seen as a primary cause of psychological distress. Exploring inner conflict with the goal of working through and processing ambivalence to achieve a new level of insight and awareness often leads to a reduction of symptoms and more adaptive solutions to problems. The goal is generally not to eliminate conflicts, but to work towards more effective and adaptive solutions [5].

The following questions allow for thinking more deeply about conflict:

What inner conflicts do you find with this client?

What seems irreconcilable or contradictory about the client’s inner experiences? 

What two or more opposing views, values, or options is the client attempting to reconcile? 

How does the client experience or manage inner conflict or ambivalence?

How does inner conflict or ambivalence contribute to psychological distress and maladaptive behaviors?

Transference

We all carry our attachment history or expectations into new relationships. For this reason, a client is likely to reenact or engage with the therapist in ways that repeat as they bring previous templates and scripts into the therapy situation. Therefore, the therapy relationship becomes a useful tool for understanding the ways a client relates to others and the problems that might arise in relationships.

The following questions allow for thinking more deeply about transference:

How is the client relating to you?

How are old patterns, expectations, desires, and schemas activated or enacted in the therapy sessions? 

How can we help the client examine, understand, and rework them?

What role(s) does your client assign to you and how do they play it out?

Countertransference  

As a therapist, we likewise carry a history of attachment patterns and object relationships as well as unique inner conflicts and beliefs about ourselves, others, and the world. We also have reactions to our clients in a way that is similar to a client’s transference. Knowing ourselves and the role of our psychology in the therapy room is helpful, as it allows for us to better understand how our reactions are typical for us or related to our past object relationships versus unique to the presentation and interpersonal dynamics of a client.

This knowledge can help us to further understand a client’s inner world as well as the ways a client impacts others and how their patterns of relating unfold in ways that are either helpful or harmful. This is also a primary reason why therapy for the therapist is an important element of personal and professional development.

The following questions allow for thinking more deeply about countertransference:

How are you relating to the client?

How are your own conflicts and relationship templates being activated or enacted in the therapy session and with the therapy relationship? 

What is going on in the relational dynamics of therapy?

Self-esteem, Self-regulation, Self-efficacy

Heinz Kohut (1978) identified the maturation of a cohesive nuclear self and core of the personality as central to development and includes a person’s perception of their experience of self, as well as the presence or lack of a sense of self-esteem, as important [6]. A coherent sense of self has been defined as one that is stable, adaptive, flexible and energized [7].

Self-esteem is understood as rooted in childhood experiences related to the responsiveness of early caregivers in promoting a secure attachment [8]. Therefore, supporting a therapy client in both solidifying and living more and more from within a coherent self with a realistic and reliable sense of self-esteem is common goal in psychotherapy.

Likewise, assisting a client in developing a realistic and reliable sense of self-esteem means supporting one that is based on a reasonable set of criteria for self-evaluation and consistently protects a person from becoming devastated by criticism or easily manipulated by excessive praise [9]. 

The following questions allow for thinking more deeply about sense of self:

How does the client experience themselves? 

How does the client tolerate and manage ambiguity and uncertainty?

Does the client experience internal restraints and rigidities that are problematic?

How are the client’s thoughts, feelings, and actions part of larger, more general patterns and themes? 

Emotion and Affect

Focusing on affect and the expression of emotion has long been a key component of psychodynamic therapy [10]. Emotional awareness or emotional intelligence is also recognized as a significant component of healthy psychological functioning [11]. Furthermore, a number of approaches, most notably Dialectical Behavior Therapy, have focused on expanding the capacity and skills necessary to improve emotion regulation [12]. Understanding how a client experiences, expresses, and manages emotion is therefore an important part of therapy, as are the goals around expanding the capacity to identify emotion and regulate affect with increasingly adaptive defenses [9]. Regulating or tolerating painful affect instead of taking self-destructive actions to manage them is particularly relevant to therapy and an important area to address as defenses are lowered and focus on expressing emotion is encouraged. 

The following questions allow for thinking more deeply about emotion and affect:

What does the client feel?

How does the client experience and manage affect?

What does the client communicate implicitly and nonverbally?

Is the client able to access and enjoy a full range of emotion?

What are the client’s beliefs and historical templates for emotions and emotional expression?

How can you help the client find a way to express, understand, and be comfortable with their intense feelings?

Conclusion

The questions outlined above aim to make psychodynamic psychotherapy more accessible by providing questions or prompts as entry points. Asking these questions can help illuminate several core constructs of psychodynamic theory and assist in better understanding how these concepts appear in practice. Ultimately, the answers to these questions can facilitate case conceptualization and lead to useful considerations in planning interventions or responding to the here-and-now in the therapy process.

Readers interested in learning more about psychodynamic theory and practice as described in this article might consider reading Nancy McWilliam’s 2004 book Psychoanalytic Psychotherapy: A Practitioner’s Guide and well as her 2011 book Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, 2nd Edition.

Teri Quatman’s 2015 book Essential Psychodynamic Psychotherapy: An Acquired Art and Karen J. Maroda’s 2009 book Psychodynamic Techniques: Working with Emotion in the Therapy Relationship are also accessible and useful for learning more about psychodynamic theory and practice.

Glen O. Gabbard’s 2010 book Long-term Psychodynamic Psychotherapy: A Basic Text 2nd Edition is a useful basic introduction. Jonathan Shedler’s 2010 article The Efficacy of Psychodynamic Psychotherapy is an excellent summary of empirical evidence supporting the efficacy of psychodynamic therapy.   

References

[1] Waelder, R. (2007). The principle of multiple function: Observations on over-determination. The Psychoanalytic Quarterly LXXVI(1), 75-92.

[2] Freud, S. (1895). Studies on Hysteria, SE, 2. With Josef Breuer. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (pp. 1953-1974). Hogarth Press.

[3] McWilliams, Nancy (2011). Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd ed.). New York: Guilford Press.

[4] Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. Basic Books.

[5] Gabbard, G. O. (2010). Long-term psychodynamic psychotherapy: A basic text (2nd ed.)

[6] Kohut, H., & Wolf, E.S. (1978). The Disorders of the Self and their Treatment: An Outline. The International Journal of Psychoanalysis, 59(4), 413-425.

[7] Wallin, D. J. (2007). Attachment in psychotherapy. New York: Guilford Press.

[8] Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.

[9] McWilliams, Nancy (2021). Psychanalytic supervision. The Guilford Press.

[10] Blagys, M.D. & Hilsenroth, M.J. (2000). Distinctive of short-term psychodynamic-interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical Psychology: Science and Practice, 7(2), 167-189.

[11] Goleman, D. P. (1995). Emotional intelligence: Why it can matter more than IQ for character, health and lifelong achievement. New York: Bantam Books. [12] Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.


Thomas Lindquist, PsyD, ATR