“Give me a child until he is seven and I will show you the man.”

Aristotle

Psychodynamic therapy and psychoanalytic therapy are sometimes used interchangeably, as there is more overlap than difference between them.  One distinction is that psychoanalytic therapy is highly associated with Freud and his contemporaries, whereas psychodynamic therapy may be more associated with “neo-Freudians” who came afterward, such as Karen Horey, Alfred Adler, Erik Erikson, and Harry Stack Sullivan.  Freud / psychoanalysis emphasized that human anxiety happens when needs (he called “drives”) were unfulfilled.  Freud emphasized sexual and other biological drives/needs and outlined “stages of psychosexual development.”  Neo-Freudians emphasized the need of human attachment and psychosocial development from family and culture as the primary focus.  

Object relations theory is another label that is also often used interchangeably with psychodynamic theory.  The word “objects” refers to the internal mental-emotional models that we form as children that are based on our first relationships with our caregivers (e.g. mother), providing us with a template of what to expect from people generally.  Therapy is seen as a correction of faulty and unhelpful object models that are created when being neglected or mistreated early in life.

For me, the three orientations of psychoanalysis, object relations, and psychodynamic therapy are close enough to group together under one umbrella and distinguish from theories that have far less in common with them (e.g. cognitive-behavioral therapy, narrative therapy, etc).  The label I like the best of the three is psychodynamic therapy, so it is the one I use for this cluster of psychotherapy theory.

Key aspects of psychodynamic therapy

Nancy McWilliams outlines seven characterizations of psychodynamic therapy⁽¹⁾:

1. Focus on emotion
2. Focus on interpersonal experience
3. Focus on past experiences
4. Exploration of resistance (efforts to avoid certain topics or engage in activities that prevents therapy progress) and defenses (ways of being that prevent us from feeling old emotional injuries)
5. Identification of the client’s patterns of actions, thoughts, emotions, and relationships.
6. Focus on the relationship happening between the therapist and the client (transference, countertransference, immediacy, etc)
7. Exploration of the unconscious (e.g. wishes, dreams, fantasies, impulses) – the parts of ourselves that are not yet readily available to our conscious awareness.

These differences are dimensional, not categorical.  In other words, therapists who practice from other theoretical orientations (e.g. cognitive-behavioral therapy) often also touch on these aspects of therapy.  The distinction is one of degree (psychodynamic therapists tend to do these things more).

Another distinction may be that psychodynamic therapists tend to emphasize self-awareness and addressing the deeper roots of a psyche/mind over more surface-level symptom relief (e.g. the amelioration of anxiety or depression).  In fact, one of the reasons for the popularization of cognitive-behavioral therapy around the 1960’s was that many therapists (e.g. Beck, Ellis), felt that clients were still struggling with life functioning despite having thorough and sophisticated theories about the childhood origins of their struggles resulting from several dozen therapy sessions.  As one joke goes, “A bartender has a bet with a psychotherapist that he can cure a client’s fear of monsters under the bed faster and far more inexpensively than the psychotherapist.  He wins by immediately cutting off the legs of the client’s bed so it is resting on the ground.”

Because of it’s emphasis on process and inner development over outward signs of change, I consider psychodynamic to be a more psychospiritual approach than purely cognitive or behavioral work.  The word psychodynamic is derived from linguistic roots “psyche” and “dynamis” which refer to “soul” and “power” respectively.  So the word could be translated as relating to the power of the soul.  The soul is often associated with the unconscious parts of ourselves that seem to arise from the deepest parts of our beings.  I believe it is possible to nourish and relate to our soul without seeing immediate positive changes in one’s apparent life situation.  And sometimes, in the short term, we may feel we are functioning less well as we heal from childhood attachment wounds or traumas, similarly to how we heal from a viral infection while being bedridden with a fever for a few days.

I see a lot of overlap between psychodynamic therapy and humanistic therapy due to its emphasis on interpersonal relationships and dynamics.  Humanistic therapy is more present-oriented, focusing on empathy, genuineness, and positive regard taking place between the therapist and client.  While psychodynamic therapy also utilizes the relationship between the therapist and client as the agent of change, it also puts a great deal of attention on past relationships that the client has had that lacked healthy qualities and created damaging internal models of others that are projected onto people in inaccurate ways.

Transference and countertransference projections

When a client projects such negative assumptions onto the therapist (e.g. my father was cold and distant and now I experience my therapist as similarly uncaring), it is called transference.  When I am working with a client, especially a new one, I am aware that there are assumptions being made about me, and an overarching goal of therapy for me is to gradually transition the client’s projected image of me to a more accurate image of me.  This is done implicitly by simply being myself and letting the projections fall away, as well as sometimes explicitly by collaboratively naming the projections and exploring where they might have come from in the client’s past.  There is great value in doing this, as projections are generally applied toward others, so that when we see the flaws in our assumptions applied to one person (e.g. the therapist), we start to doubt our inaccurate projections toward others outside of therapy.  This helps us give others more of a chance to be allies and friends, rather than instinctively and defensively writing them off too early.  Or, in fewer cases, it could help us be more discerning about people (e.g. if the projection is to be overly naive and trusting).

Psychodynamic therapy requires that therapists also examine their own projections, which are called countertransference.  Countertransference is discussed less in therapy, after all, it is not the client’s job to cure and heal the therapist.  Therapists generally work through their own issues in their own therapy or with trusted colleagues who have done this kind of inner work themselves.  However in some cases it is appropriate, I think, for a therapist to own his/her unfair assumptions to a client so that the client 1) does not need to doubt or second guess their correct intuitions and 2) to model the mature and effective relationship skill of acknowledging when we have incorrectly assumed something about someone.

Attachment wounds

The word attachment in psychology refers to the connection that we feel in our relationships (romantic, family, friendship, etc).  In a healthy attachment, we can both connect satisfactorily with others without losing our individual nature, and also separate from them without damage to the trust in the emotional bond.

Attachment wounds are the relationship traumas, that range from small to large, that result from harmful experiences in relationships.  The impact of harmful experience depends on both the severity of the harm as well as our vulnerability to it, which is largely a function of our age (the younger the child, the more vulnerable they are).  Attachment wounds in general interfere with our ability to use our emotional hearts to enjoy vital connection to others, similarly to how physical wounds generally interfere with our ability to use our bodies optimally.

I specify attachment wounds rather than simply “wounds” to distinguish between a physical wound like a broken bone and a psychological wound such as a negative self-image or pervasive fear of engaging with others.  Psychotherapy deals with psychological wounds, which are relational by nature.

I find it useful to think of two basic categories of attachment wounds:

1. being neglected / abandoned / ignored / left
2. being overly restricted / “engulfed” / smothered / trapped

I find that most people are more sensitive to one of these two basic attachment wound categories.  Some of us are more sensitive to being abandoned (if that was how we were wounded as children) and some of us are more sensitive to being smothered.  In the first case there was not enough connection (love, warmth, and attention).  In the second case there was not enough separation (freedom and autonomy).  We need a balance of these opposite poles of relationship, and we need to feel that our caregivers were attuned to the timing of our needs.  Ideally, we got connection when we needed that and got separation when we needed that.

Secure attachment

A central goal of psychodynamic therapy is to shift clients from insecure attachment to secure attachment.  

Secure attachment refers to our sense that we can depend on others, to a reasonable extent, to be there for us when we need them and to let us go our own way and be autonomous individuals when we need that.  Life is an oscillation between these two states of connection and separation.

Insecure attachment refers to a tendency to have anxiety that our attachment needs (connection or separation) won’t be met.  When someone has a general fear that they will be abandoned, it’s called anxious attachment.  The general fear of being smothered and trapped in relationships is called avoidant attachment.  These both fall under the umbrella of insecure attachment.  A third category of insecure attachment, called disorganized attachment, is some combination of anxious and avoidant attachment.

From a psychodynamic therapy paradigm, the most impactful way to help a client form and practice secure attachments with others is to give them the experience of a secure attachment in the therapy relationship between the therapist and client.  Some ways that I try to meet my clients’ connection needs are through empathy, attunement, attention, caring, and offering thoughtful and accurate feedback.  Some ways I try to meet my clients’ separation (autonomy) needs are by welcoming opinions and feelings that are different from mine, giving ample space in session for my clients’ self-expression, and accommodating an amount of time between sessions that feels comfortable to the client.

A more secure attachment style can be developed in any healthy relationship outside of therapy, so I often work with clients to understand some basic attachment theory, what their attachment needs are, and how to shift their communication and behavior so that their needs are more likely to be met in their relationships.  

Defenses (“survival skills”)

A defense is a pattern of thinking, feeling, relating, or behaving that serves to protect us from pain or discomfort that results from an attachment wound being “touched” or triggered.

As an analogy, if an attachment wound is like a sprained ankle, a defense is like a limp.  The limp is not the wound, it is a modified behavior that is present because the wound or injury has not been healed.  If the wound is healed, the defense goes away as it is no longer needed.

In psychotherapy the two types of wounds explained before can result in many defenses.  In psychodynamic therapy, symptoms such as self-consciousness, worry, or depressed moods are typically seen as resulting from a defense or group of defenses.  For example, self-consciousness could result as a way to ward off criticism and judgment from parents or peers.  If we self-monitor and inhibit ourselves, it’s less likely we will step out of our small scripted box and invoke others’ disapproval or ridicule.

Sometimes people don’t relate to the word “defense” as well as other terms such as “survival skills”.

The survival skill of depressed moods (emotional numbing) and overly negative thinking might be a way of protecting (defending) against continual disappointments from a dismal context, or grief from neglect or continual loss.

The survival skills of worry, obsessions, and hypervigilance, can be a way to prevent real danger from transpiring, or a way of protecting against uncomfortable fear in the body by giving us the illusion that we are keeping ourselves safer than we are – an illusion that might serve to reduce chronic and harmful stress.

An illustrative metaphor defenses is a very heavy wood raft that we painstakingly build from trees to cross a raging whitewater river, but then carry it on our backs for mile after backbreaking mile, just in case we run into another river.  The river represents the difficult context of childhood or other stressful stages of life as adults (although childhood tends to be the most impactful).  The raft could be any defense that include patterns of thinking, feeling, behaving, and relating to others that served well once in the past but no longer helps us and actually hinders our progress.

Addictions to drugs, media, porn, sex, gaming, or even thinking itself – can all be seen as defenses or survival skills we picked up to cope with stressful life events, but wind up hurting us in the long run because they 1) carry harmful side effects and 2) prevent us from addressing the core wound so we no longer need the defense.

Karen Horney created a useful model of three categories of defenses that she called 1) moving toward 2) moving against and 3) moving away ⁽²⁾.  Moving toward might be described as people pleasing, being passive, or being placating or submissive.  Moving against is rather being dominant, aggressive, and controlling or possessive of others.  And moving away is being distant, aloof, overly self-reliant, and disengaged from others.  All of these kinds of defenses have in common that they are subconscious attempts to avoid emotional pain and hurt from attachment wounding.  Being passive or aggressive or distant can all be attempts to prevent being abandoned or controlled.  The irony is that they so often lead to the eventual outcomes that they are intended to safeguard against, and they also prevent true intimacy.  It’s impossible to have very nourishing relationships if we are wearing an emotional suit of armor that prevents deep contact with others.

The catch-22 is that we need to drop the defense before we are fully healed in order to focus on the pain of the wound enough to heal the wound.  We need to stop worrying and emotionally numbing ourselves long enough to feel the emotional wounds in our hearts and bodies.  We need to stop the addictive behaviors in order to get in touch with the reasons they are there in the first place so we can address them.  We need to put down the raft in order to realize how heavy it is and that we’ll be okay without it.

Split off parts

Split off parts refers to the parts of us that are forgotten or atrophied due to our defenses.  For example, someone who tends toward the defense of being passive or placating may have forgotten their innate ability to be assertive or self-reliant or express healthy anger.  Someone who tends toward being controlling and dominating may have split off their ability to be empathetic towards others’ needs and to surrender to what’s outside of their control, which is needed in a universe that is so much bigger than ourselves.  Someone who defends by being distant and solitary may have split off the part of them who knows how to connect with others and enjoy the warmth of intimate relationship.  Someone who has delt with wounds via anxiety may have forgotten their ability to be care-free and serene.  Someone who has coped with longstanding depression may have forgotten their ability to feel zest and enthusiasm.  Psychodynamic therapy aims to recover the lost parts of ourselves so that we can be more whole, complete, integrated, and adaptable to a greater array of situations, challenges, and contexts.  This is essentially done through the gradual process of examining and understanding our wounds, the defenses that protect them and their origins, realizing intellectually that we don’t need them anymore, and then doing the courageous work of dropping them little by little so we can prove that to ourselves emotionally and experientially.

References

1. McWilliams, N. (2004).  Psychoanalytic Psychotherapy: A Practitioner’s Guide
2. Horney, K. (1950).  Neurosis and Human Growth: The Struggle toward Self-Realization
3. Frederickson, J. (2013). Co-Creating Change: Effective Dynamic Therapy Techniques