What is psychodynamic therapy and what happens in sessions? Learn its key concepts, how it differs from CBT and psychoanalysis, and who it may suit.
You have changed jobs for the third time, and in all three the trouble began at the same point: when a manager raises their voice a little, something inside you shuts down, and you either swallow it and stay silent or explode with unexpected anger. Your reason says, "This isn't worth making such a fuss about," but your body tells a different story. Psychodynamic therapy is concerned with exactly these kinds of recurring reactions that people cannot explain even to themselves. In this article we look at what psychodynamic therapy is, which core ideas it rests on, what happens in a session, how it differs from other schools of therapy and who it may be meaningful for. If you are comparing schools of therapy, we will also touch on questions that will help you decide.
What Is Psychodynamic Therapy?
Psychodynamic therapy is a psychotherapy approach which holds that a significant part of a person's current feelings, thoughts and relationship patterns is influenced by processes operating outside their awareness, and which tries to make these processes understandable through talking. The word "dynamic" expresses the idea that opposing wishes, fears and needs within the mind are constantly interacting. For example, wanting closeness on the one hand while fearing it on the other may explain why a person always takes a step back in their relationships.
The roots of the approach lie in Sigmund Freud's psychoanalysis. Today's psychodynamic work, however, also takes in many theories developed after Freud: object relations theory, which examines how early relationships settle in our inner world as "internal representations"; attachment theory; self psychology, which is concerned with how self-worth develops; and relational approaches are among them. For this reason the approach can be thought of less as a single technique than as a family of therapies sharing a common outlook.
The essence of this outlook can be summed up as follows: the ways of relating we learned in the past repeat themselves today with different people and in different circumstances. Noticing and understanding this repetition opens the way to being less captive to it.
Key Concepts: The Unconscious, Defences and Transference
To understand how this approach works, it helps to know a few core concepts.
Unconscious processes
We are not always aware of what we feel or why we behave as we do. The psychodynamic approach sees the points where a person says, "I don't know why I did that," as important clues. These processes are not mysterious; they are often feelings and wishes we keep out of our attention because they are painful.
Defence mechanisms
The mind develops various ways of protecting itself from feelings that are hard to bear: denying, attributing a feeling to someone else, explaining everything logically to avoid feeling it, or redirecting anger towards a safer target. These ways may once have worked; but in adulthood they can begin to narrow a person's life. We discuss this subject in more detail in our article on defence mechanisms.
Recurring relationship patterns
Many people notice that they go through the same kind of conflict with different people: always choosing someone critical, always carrying other people's burdens, pushing away everyone who comes close at some point. The therapist follows these patterns and is curious about their origins.
Transference
When a client unknowingly directs feelings and expectations towards the therapist that were originally aimed at someone important in the past, this is called transference. For example, interpreting the therapist's silence as "They're bored of me" may be an echo of experience with an inattentive parent in childhood. In this work such feelings are not suppressed; they are talked about in the session and used as a live example of relationship patterns. For more detail, see our article what is transference.
Insight and working through
Insight is when a person notices a connection about themselves that they could not see before. However, a single "aha" moment is rarely enough. The same connection needs to be seen again and again in different situations, experienced emotionally, and turned into new behaviour. This is called "working through", and it is where the real effort of therapy is spent.
What Happens in a Session?
Sessions usually take place face to face, sitting up, once or twice a week, and last around 45 to 50 minutes. The couch is specific to psychoanalysis; here client and therapist mostly sit facing each other. The first few meetings are usually devoted to getting acquainted and understanding the person's concerns, life story and relationships; during this time, whether it makes sense to work together is also assessed.
A distinctive feature of the sessions is that the agenda is largely set by the client. The therapist does not arrive with a prepared worksheet; they listen to whatever comes to the client's mind, their dreams, the feelings they had between sessions, and even arriving late or repeatedly glossing over a subject, as important information. From time to time the therapist makes connections, asks questions or offers an interpretation: "Have you noticed that your voice always drops when you talk about your mother?"
Imagine a university student who seeks help because they cannot study during exam periods. In the first sessions the issue seems to be simply procrastination. Over time it emerges that even when they studied and succeeded, their family would say, "You could have done better," and so failing without trying hurts less than trying and still being found lacking. Recognising this connection helps them understand that their procrastination is not laziness but a precaution against an old wound. The work that follows is built on recognising this wound and developing a new attitude.
Short-term and long-term work
This therapy does not always last for years. There are also short-term psychodynamic therapies that focus on a particular area of conflict, with a limited number of sessions planned in advance. Long-term work, on the other hand, may be preferred for more entrenched personality patterns and recurring relationship difficulties. The length is decided according to the person's needs and goals.
Differences Between Psychodynamic Therapy, CBT and Psychoanalysis
A question on the minds of many people researching schools of therapy is how these approaches differ from one another.
How it differs from psychoanalysis: Psychoanalysis is more intensive; sessions usually take place three or four times a week, on the couch, and can last for years. The psychodynamic approach draws on the same theoretical roots but is more flexible, less intensive and often more focused.
How it differs from cognitive behavioural therapy: CBT targets present-day thoughts and behaviours, uses structured sessions and homework, and openly measures the reduction of specific symptoms. Psychodynamic work, by contrast, is less structured, puts more weight on in-depth exploration of feelings and relationship patterns, and devotes more time to the links between past and present.
Although these differences are sometimes presented as a rivalry, in reality many therapists draw on different schools. Schema therapy, for example, brings together cognitive behavioural methods and ideas from psychodynamic and attachment theories. Research also shows that, regardless of which school is applied, a relationship of trust between therapist and client plays an important part in change. Whatever the school, a relationship in which you feel understood and safe is one of the most important foundations of therapy.
What is the scientific basis?
For a long time psychodynamic approaches were viewed at a distance on the grounds that they were "hard to measure". Over the last few decades, however, controlled research on short-term psychodynamic therapies in particular has increased. These studies suggest that this approach, too, can bring meaningful improvement in depression and some anxiety problems, and that in some clients the gains may continue after therapy has ended. At the same time, it is worth bearing in mind that the evidence is not equally strong for every problem, and that much of the research has been carried out with specific, clearly defined forms of therapy. A therapist claiming that "our school helps with everything" should be treated with caution, whichever school they belong to.
The point of talking about the past is not to find someone to blame, but to understand why we are still stuck in the same place today.
Who Might Psychodynamic Therapy Suit?
This approach can be used across a wide range of difficulties. Research shows it may be helpful particularly for depression, some anxiety problems and interpersonal difficulties. It may be a meaningful option in the following situations:
- Beyond your symptoms, you are looking for an in-depth answer to the question, "Why am I always like this?"
- The same kinds of conflict keep recurring in your relationships
- You find it difficult to name or express what you feel
- You carry a chronic sense of emptiness, meaninglessness or inadequacy
- You have previously had short-term, structured therapy and, although your symptoms eased, you still feel a need to understand yourself
That said, if you are looking for fast, structured work on a focused problem such as a specific phobia or panic attacks, cognitive behavioural approaches might be considered first. The right choice depends on the nature of your problem, your goals, your time and how you would like to work.
What Can You Do to Notice Your Own Patterns?
Even before starting therapy, you can apply some elements of the psychodynamic outlook to your own life:
- Note the repetition: Think of the three relationships or events that have hurt you most in the last few years. Is there a common theme? Always being overlooked, or always taking on too much responsibility, for example.
- Be curious about your exaggerated reactions: When you react to something far more strongly than expected, ask yourself, "When did this feeling first become familiar to me?"
- Write down your dreams and daydreams: You do not have to interpret them; it is enough to look at the feelings they carry.
- Pay attention to the subjects you avoid: Which subjects do you always skate over when talking with friends? An avoided subject often points to an important feeling.
- Watch your body's reactions: Your stomach tightening when you hear a particular person's name, or a headache before a family gathering, may be the first sign of a feeling that has not yet been put into words. Noting these reactions without judging them is the first step towards understanding them.
These exercises are valuable on the path to self-knowledge; but when done alone, the same defences can get in the way. Someone else's perspective, especially that of a trained therapist, makes it easier for us to see our own blind spots.
When Should You Seek Professional Support?
You might consider speaking with a mental health professional in the following situations:
- Your emotional distress has lasted for weeks and is affecting your work, studies or home life
- The same relationship problems keep recurring and do not change through your own efforts
- Difficult experiences from your past still stir up intense feelings today
- You constantly feel empty, inadequate or alone
- There are marked changes in your sleep, appetite or energy
In Turkey, therapists who work psychodynamically can be found in private practice, in the psychotherapy units of some university hospitals and through referrals from psychotherapy training associations. When you meet a therapist, it is entirely normal to ask which institution they trained with, how many years their psychotherapy training lasted and whether they receive regular supervision; these questions help you understand their actual area of expertise beyond the title "psychologist".
To decide which therapy approach will suit you, do not hesitate to ask the professional in the first meeting how they work, which school they draw on and why they are recommending this path for your problem.
How Are the Traces of the Past Addressed in Therapy?
Psychodynamic therapy is practised by therapists with specific training in this field. Clinical Psychologist Eda Erkan Alapala is a clinical psychologist who completed four years of Cognitive Behavioural Therapy training to EABCT standards with the Association for Cognitive and Behavioural Therapies (KDTD); her work is based on a cognitive behavioural framework. Even so, the influence of past experience on the present holds an important place in her work too: in her master's thesis she examined the role of early maladaptive schemas in psychological resilience and coping with stress. A schema-focused perspective tries to understand how needs that went unmet in childhood are reflected in today's relationship and emotional patterns; in this respect it shares a common curiosity with psychodynamic approaches.
In individual therapy, the approach to be used is decided together with the client after the assessment in the first sessions. If you are looking for long-term psychodynamic work, help can also be offered with a referral to a therapist trained in that field.
Frequently Asked Questions
Is it all about childhood in this therapy?
No. Childhood experiences matter, but much of the time most of the session is about current relationships, working life and everyday feelings. The past is discussed to the extent that it helps make sense of the present.
How long does psychodynamic therapy last?
Short-term psychodynamic therapies may cover a few months of work, while long-term work can go on for more than a year. The length is assessed together with the therapist according to the nature of the problem, the goals and the person's circumstances.
Why does the therapist say so little in sessions?
Psychodynamic therapists may be less directive in order to make room for the client's own flow of thought. This silence does not mean a lack of interest. If the silence makes you uncomfortable, raising this in the session can become a valuable part of the work.
Can psychodynamic therapy be done online?
Yes, many therapists also carry out this work by video call. What matters is having an uninterrupted, private setting and keeping the sessions regular.
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Eda Erkan Alapala
Klinik Psikolog. İstanbul Kent Üniversitesi Klinik Psikoloji Tezli Yüksek Lisans mezunu; bilişsel davranışçı terapi, çocuk merkezli oyun terapisi ve çocuk-ergen psikoterapisi alanlarında eğitimlerini tamamlamıştır.
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