With a history of over a century, psychoanalytic theory and practice, from which psychodynamic psychotherapy is derived, is diverse. Over the course of its development, contributions from figures such as Klein, Jung, and Lacan (to name just a few of the more recognisable names) have shaped psychoanalysis into an eclectic discipline with broad applications; from psychotherapy, to the examination of art, culture, and politics.

Being such a diffuse and varied field, as you would expect, has fed into “schoolism” and intense disagreements (a prominent example is the British Psychoanalytic Council not recognising Lacanianism as a legitimate form of psychoanalysis [1]). For this reason, I must give a caveat at the start by saying that my intention for this article is to give the reader just a taste of the main features of psychodynamic psychotherapy and my stance as a practitioner. It’s by no means exhaustive or comprehensive in scope, and there may be some practitioners who differ from me in how I choose to frame the work.

For an accessible (and highly watchable) primer to psychodynamic psychotherapy for lay audiences, I recommend Robinson’s Podcast #132 - Jonathan Shedler: Freud, Psychoanalysis, and Psychodynamic Psychotherapy. Shedler is a respected figure in psychodynamic therapy and someone I find myself frequently agreeing with.

Psychodynamic therapy has a reputation for being quite abstract, with some of its elements bordering on the esoteric. It has a mystique about it, which adds to its intrigue, but people are often in the dark as to what it entails. I’d like to address some of the common questions and misconceptions I’ve encountered, and hopefully describe for the reader some of the core principles of psychodynamic therapy in the process.

“What’s the difference between psychoanalysis and psychodynamic psychotherapy?”

Broadly speaking, psychoanalysis is the theory and practice from which modern psychodynamic psychotherapy is derived. Psychoanalysis is an older and more intensive process of psychotherapy. Psychodynamic therapy is a modernised adaptation of it.

“What does psychodynamic therapy mean by “the unconscious”?”

Traditional psychoanalysis defines the unconscious as mental processes that happen outside of our awareness. Beyond this original definition, the concept of the unconscious has been radically expanded upon by other psychoanalysts, such as Carl Jung’s collective unconscious, a kind of blood memory of inherited psychic structures, and Otto Rank’s “existential” unconscious, containing the mysteries of existence and sentience [2].

Awareness of mental processes can perhaps be best understood as a spectrum from fully conscious to fully unconscious. Much of what motivates us exists in the fully unconscious end of the spectrum, and so "the unconscious" is still a useful concept, even if only metaphorically. For example, our sexual desires are not a product of conscious choice, but an unconscious process of complex biological, psychological, and sociocultural factors, shaped by individual experiences from our past.

I would argue that in addition to the unconscious mind, we also work with patients to explore unawareness and not-knowing in a much more broad sense i.e. those things we don’t fully understand or realise, or haven’t considered in nuanced ways. Psychodynamic therapy is an attempt at discovery. We examine our thoughts and emotions, through talking and feeling, to try and gain a greater sense of comprehension. This does not necessarily mean arriving at certainties; the exploration of possibilities, and a greater acknowledgement of what isn't (and maybe cannot be) known is just as important for developing our mind.

“How does just talking help? I thought ruminating was bad.”

Psychodynamic therapy isn’t just talking. Being able to vent can be cathartic, but good psychotherapy also strives for insight. Both you and your therapist should aim towards understanding your thoughts and emotions, not just expressing them for the sake of it. Rumination is getting caught in repetitive negative thinking patterns; good psychotherapy aims to broaden perspectives. The aim is to think and understand in a more expansive way, and to feel more deeply, especially those feelings to which you are less attuned.

There is good evidence to suggest that psychodynamic therapy is effective in the treatment of a wide range of mental health problems [3]. The mechanisms of change are various, but two core mechanisms thought to heavily contribute to it are:

A) Speaking uncensored and freely. This is done with the goal of developing a better understanding of oneself, others, and the world around us. This insight is known technically as mentalisation. Research has implicated deficits in mentalising to a range of psychological problems and disorders [4].

B) Being properly heard. This is important to the fostering of mentalisation, but also to building the therapeutic relationship, which makes significant and consistent contributions to psychotherapy outcomes [5]. 

In popular culture, psychoanalysis is frequently misrepresented. It gets depicted as a process where the patient comes and lies on a couch, talks about their parents, and then the analyst has a breakthrough and elucidates hidden knowledge through a sharp interpretation of the patient’s unconscious.

Good interpretations can be a feature of being properly heard, but if your expectation is to receive solutions or be given straightforward answers that cut to “the root” of the problem, you’ll likely be disappointed. Psychodynamic therapy is a facilitation and process of thinking about thinking, and feeling about feeling. This process is good for our mental health and a means of personal development.

“Is talking and being listened to not what friends and family are for?”

To what extent are you able to be fully yourself, and to what extent are you really being heard?

In our relationships with friends, family, and romantic partners, we try to get our needs met and to meet their needs in return; this may be emotionally, physically, materially, etc.. In order to maintain these relationships, equitable compromises and sacrifices must be made and reciprocated.

Through this reciprocation we build intimacy, but we also become entangled and stifled. The quintessential example of this is a child who has no choice but to yield their personality to suit the whims and idiosyncrasies of their parents, and a parent who suppresses and gives up parts of themselves and their life to meet the needs of their child. Even as adults, we’re not in a position to speak, think, and feel with total freedom. Intimacy has its price, and the line between socialisation and indoctrination is thin.

We are compelled towards certain ways of being, both consciously and unconsciously, in significant part because of our relationships. Where the patient is compelled to re-enact these ways of being with the therapist, and these patterns repeat in the therapeutic relationship, we refer to this technically as the transference, which is something a psychodynamic therapist is trained to watch.

“How does the therapeutic relationship differ from other relationships?”

The therapeutic relationship is unique and specialised. One person’s need to express themself with total candor, and to be understood fully, is the priority. The social reciprocity (and with it, most of the entanglement, but not all) is removed from the equation. Beyond paying the fee and turning up on time, there is no other obligation on the patient. This set-up better facilitates the attempt at insight.

Psychodynamic therapists are expected (as much as possible) to recognise their needs, preferences, and biases, and to put them to one side during the session to create a place for patients to fully explore ideas. We do this, in part, by watching our own inner reactions to the patient. What the patient stirs up in the therapist is referred to as the countertransference.

The therapist watching their countertransference like a hawk, and not allowing it to impede the work in the room, is known as technical neutrality.

This does not mean a blank screen of silence and little response (although orthodox Fruedian analysts may disagree!). We may even reveal our countertransference to our patients at times, if we believe it would be of benefit to them. Technical neutrality, as I practise it, is a position of respect for the autonomy and inner world of the person you are working with. Approaching your patients with curiosity and humility is a prerequisite of all good psychotherapy, I believe.

Our relationships contribute in large part to how our mental world is shaped, which impacts our health. We evolved to be social creatures, and our thoughts, feelings, and behaviours are modulated by the interactions we have with others. Psychodynamic therapists recognise the potential of the interpersonal, and by extension the therapeutic relationship, to be reparative. Theorists, such as Donald Winnicott, have drawn compelling parallels between the parent-infant relationship and the therapist-patient relationship [6].

A reparative therapeutic relationship is not the same thing as always having amiable or warm feelings towards the therapist or the therapy, or the therapist always having them towards the patient. The reparative therapeutic relationship should however, always have trust as its foundation. The patient should trust that they can express every part of themself in therapy, even anger and disappointment towards the therapist, and it will all be met with curiosity and openness. No words are too difficult, no thoughts are too taboo, no feelings are too painful.

There are other elements of the therapeutic relationship that are perhaps more straightforward and self-evident, but no less important: like a personal trainer, a therapist increases a patient's accountability, and is someone who helps to ensure you turn up to do the work regularly. The therapist sets the consistent boundaries of the work (the fee, the time and time limit, the place, the contract, etc.), known as the frame, ensuring the patient feels secure enough to properly explore their thoughts and feelings.

“What are some of the key aspects of psychoanalytic theory? How does it inform the therapy?”

A thread that ties all psychoanalytic theory together is the reality of ambivalence, the need to neglect or deny parts of ourselves in order for us to adapt to our environment, and the drive to wholeness. For the psychoanalyst Melanie Klein, we split the “good breast” from the “bad breast”, because the reality of Mother being that who we both love and hate at once is too much for the vulnerable infant to bear. For Carl Jung, those parts of ourselves we are unable or unwilling to acknowledge exist in the “Shadow” of the self. For Jacques Lacan, the “Objet petit a” represents the lack that keeps us wanting, an attempt at wholeness that is never attained.

There's a poetry to psychoanalytic thought which some people find unscientific and flowery. Personally, the creativity is what drew me to it.

In very general terms, I would summarise the principles of psychodynamic therapy as follows: Psychoanalysis asserts that our motives can be driven by factors that are outside of our awareness. Our thoughts, feelings, and behaviours can be contradictory and in dissonance with what we desire, and to protect against the discomfort of this “unpleasure”, we unconsciously set in place psychic defence mechanisms. In contrast to present-oriented approaches, psychodynamic approaches put emphasis on the developmental aspects of mental health problems, particularly formative relationships. Formative relationships contribute to our cognitive, emotional, and behavioural templates, our typical ways of being, which we unconsciously project onto others and the world, and these projections reemerge in therapy as the transference. Bringing these unconscious defences and transferences into the patient's conscious awareness is done through their interpretation by the therapist, and the “working through” process of the patient talking and feeling.

Defence mechanism is psychodynamic jargon, but it describes commonplace and familiar ways we avoid mental discomfort, such as denial, or rationalising things away, or over-compensating for our perceived shortfalls. You can think of it as ways of coping with the pressures and uncertainties of life that we haven’t fully reckoned with.

What I have described in this article is still just the tip of the iceberg of psychoanalytic theory. Psychoanalysis is extensive, it has many branches and theorists.

“Is psychoanalysis a legitimate science?”

The debate rages on, and has done for decades, but I'm more than happy for psychoanalysis to be positioned squarely into the art and philosophy category, if only to sidestep all the criticisms. The classification of psychoanalysis is largely irrelevant to the work; it's a finely honed method of exploring perceptions, emotions, and meaning, and we know from research it improves people’s mental health.

One of my favourite descriptions of psychoanalysis is by the American literary critic Lionel Trilling [7]. He described it as “a science of tropes, of metaphor and its variants,” and as “the only systematic account of the human mind which, in point of subtlety and complexity, of interest and tragic power, deserves to stand beside the psychological insights which literature has accumulated through the centuries."

“What school of psychoanalysis do you follow?”

My foundational training was Kleinian and British Object Relations, with a heavy slant towards Relational perspectives. However, I don’t consider myself a “Kleinian”, and I remember being quite critical of some of the Relationalist viewpoints I encountered.

Once I finished my training, I branched out, and I don’t subscribe to any particular theorist or school as a practitioner. I enjoy reading them all, and I think they all make important contributions in different ways.

“When should I consider psychodynamic therapy over CBT?”

This isn’t a straightforward question.

In CBT, we set concrete goals, and through the targeting of thoughts and behaviours, we attempt to arrive at predetermined outcomes that the patient has deemed desirable.

There is a real need for this kind of work in psychotherapy; having practical, research-informed ways to target very specific symptoms, or solve very specific problems is a big part of why many people seek therapy in the first place. For example, Obsessive Compulsive Disorder was largely seen as untreatable before some truly brilliant psychologists and researchers developed cognitive and behavioural approaches to tackling it [8].

The problem is, if all we do in therapy is help people achieve exactly what they come to see us for initially, what space is left to explore and grow beyond our preconceived ideas with our patients? How can you zoom out and take a broader view of yourself and your life if you're too zoomed in on a specific goal? 

In the critically acclaimed American crime drama ‘The Sopranos’, a major story arc involves the protagonist Tony Soprano, a crime boss and member of the Mafia, and Dr Jennifer Melfi, his psychodynamic therapist. Tony originally seeks Dr Melfi’s help because of “panic attacks”. Over the course of their work, Dr Melfi comes to see much more of who he really is; a man with antisocial tendencies struggling with himself and his past in ways he cannot fully acknowledge or make sense of. She attempts the almost impossible by working with him, and ends up crossing personal and professional boundaries in the process. 

If Tony had gone to see a CBT therapist, and they stuck strictly to targeting the panic disorder, he might have been taught applied tension for the fainting to keep his blood pressure from dropping, done some kind of exposure for the panic, and been sent on his way after about 20 sessions (not that this wouldn’t have also been useful to him!)

The psychodynamic therapy shown in the series, which spans 7 years, is troubling and extreme (because it makes for good drama rather than good therapy), but its sophisticated depictions of Oedipal undercurrents gone awry between therapist and patient earnt it an award from the American Psychoanalytic Association.

As attractive and necessary at times as it may be for therapy to be goal-oriented, to predetermine its desired outcomes so it can be shown to be effective, we risk reducing the therapy into a pursuit of productivity and the patient into a subject of efficiency. What psychodynamic psychotherapy offers people, through its rejection of goals and prior assumptions, and its embrace of the unknown, is vast space for exploration and reflection. 

References

1. Practice and Theory Requirements for Registrants - British Psychoanalytic Council (2025) British Psychoanalytic Council. Available at: https://www.bpc.org.uk/professionals/registrants-hub/requirements/practice-and-theory-requirements/ (Accessed: 4 April 2025).

2. Kramer, R. (1996) (Ed.). A Psychology of Difference: The American Lectures of Otto Rank. Princeton University Press, pp. 65

3. Yakeley, J. (2018) ‘Psychodynamic psychotherapy: developing the evidence base’, Advances in Psychiatric Treatment, 20(4), pp. 269–279. Available at: https://doi.org/10.1192/apt.bp.113.012054.

4. Luyten, P. et al. (2020) ‘The Mentalizing Approach to Psychopathology: State of the Art and Future Directions’, Annual Review of Clinical Psychology, 16(1), pp. 297–325. Available at: https://doi.org/10.1146/annurev-clinpsy-071919-015355.

5. Norcross, J. C. (2001). Empirically supported therapy relationships: Summary of the Division 29 Task Force [Special issue]. Psychotherapy, 38(4)

Norcross, J. C. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patient needs. New York: Oxford University Press.

6. Winnicott, D.W. (2009) Winnicott On The Child. Da Capo Lifelong Books, pp. 78–79.

7. Trilling, L. (1950) The Liberal Imagination : Essays on Literature and Society. Viking Press.

8. Foa, E. (2010) ‘Obsessive-Compulsive Spectrum Disorders’, Dialogues in Clinical Neuroscience, 12(2). Available at: https://pubmed.ncbi.nlm.nih.gov/20623924/