The 7 principles of psychoanalytic psychotherapy

Distinguishing Psychoanalysis From Other Mental Health Treatments

Strong empirical evidence supports the thinking that psychoanalysis brings about positive outcomes, including symptom remission, increased psychological and emotional flexibility, strengthened view of self, and improved capacity to engage in healthy and mutually satisfying relationships. Not only is there evidence to show the efficacy psychoanalysis, evidence also points to the continued benefits of psychoanalysis, long after treatment has ended. This is important, since other modes of treatment, such as behavior modification, have higher recidivism rates and therefore, cannot make a similar claim.

So, what is psychoanalysis? Johnathan Shedler, psychologist and author of the important 2010 paper “The Efficacy of Psychodynamic Psychotherapy” writes there are 7 distinctive features of psychoanalysis.

Psychoanalysis Focuses on Affect and Expression of Emotion

The focus is on exploring and expressing the patient’s full range of emotions, including troubling ones, one’s that seem contradictory, and even one’s not initially understood or recognized. Emotional insight, as distinct from intellectual insight, is central in leading to change and takes priority in the treatment.

Psychoanalysis Explores the Patient’s Attempts to Avoid Difficult thoughts

and Feelings

“Resistance” is the term used to describe the complex range of things we all do to avoid difficult or troubling thoughts, feelings, or experiences. Psychoanalysis looks to explore the patient’s resistances. But not in a judgmental or critical way. Rather, Psychoanalysis honors the patient’s need to keep certain painful things away from awareness, and works carefully with each patient not to re-injure or traumatize, while remaining curious and open about all behaviors.

Psychoanalysis Looks to Identify Recurrent Themes and Patterns

Psychoanalysis looks for repeating patterns of behaviors, thoughts, fantasies, and experiences. Often, patients are aware of recurrent themes in their lives, like the woman who is drawn to the unavailable romantic partner, time after time. Often, however, patients are unaware of recurrent themes, and learning about them becomes part of the process of learning about and understanding the self.

Psychoanalysis Explores Past Experience and Personal History

Your personal history is important. Who your parents were, how you were raised, how you were loved, and what your important experiences were all comprise part of who you are today. Exploring your past provides clues to understanding who you are and why you feel and behave as you do. Exploring your past also provides an opportunity to heal some of the scars from past injuries and makes it possible to resume a satisfying life.

Psychoanalysis Examines the Patient’s Interpersonal Relations

Psychoanalysis wants to understand the whole person. How we relate to others, how we feel about others, how we establish—or fail to establish—ties with others, how we conduct our relationships—what, for example, do we do when we are disappointed by others—these are important parts of personality and central to understanding the whole person.

Psychoanalysis Focuses on the Therapy Relationship

What makes Psychoanalysis unique is its focus on the relationship between the patient and the analyst. This is an important interpersonal relationship, and one in which patterns of relating are likely to “show up.” For example, a person who distrusts others may also come to feel distrust for the analyst. Psychoanalysis looks to explore what “shows up” and offers the unique opportunity to rework and correct mis-attunements right then and there, in the living relationship between patient and analyst.

Psychoanalysis Privileges Fantasy and the Unconscious

Psychoanalysis encourages patients to speak freely without limitation about what’s on their mind. Patients are encouraged to talk, to share fantasies, and to bring in their daydreams and night dreams. Often important but hidden aspects of self emerge such as authentic needs and longings that might have been previously banished or forbidden but which were festering and generating painful symptoms.

Psychodynamic Psychotherapy

Psychodynamic Psychotherapy is a psychotherapy that focuses on the role of unconscious conflict that can cause a patient to experience symptoms (e.g. – depression and anxiety). It emphasizes ways in which past experiences shape present situations. Psychodynamic psychotherapy involves the exploration of transference (feelings that the patient has toward another person which they unconsciously redirect toward the therapist) to explore unresolved issues. It is typically used in higher-functioning patients (e.g. – patients are not actively suicidal, have no serious substance-abuse problems, and have no acute instability in their lives).

Psychoanalysis vs. Psychodynamic

Psychoanalytic theory and psychoanalysis refers to the original perspective and theoretical ideas proposed by

Psychoanalytic theory and psychoanalysis refers to the original perspective and theoretical ideas proposed by Sigmund Freud . Psychodynamic theory and psychodynamic therapy refers to the later ideas and perspectives that originated from Sigmund Freud and his followers since then. These two terms are often used interchangeably.

The Mind: Id, Ego, Superego

Id Wishes and desires Ego Manages inner mental life and relationship to the outer environment (the world) Super-Ego Conscience and personal ideals

Since the ego mediates between the desires of the id and the super-ego, it needs tools to do this mediation. These tools are called ego functions, and helps an individual modulate their responses to both internal and external stimuli. Some ego functions protect us from external environment stimuli, while other ego functions protect us from inner stimuli. Ego functions include:

Reality testing and sense of reality
Judgment
Relationships with others
Sensory stimulus regulation
Affect/anxiety tolerance
Impulse control
Capacity for play
Self-awareness and psychological-mindedness (are patients open to the idea of unconscious thoughts affecting their behaviour?)
Self-esteem regulation/accurate self-appraisal
Cognitive functions
Defenses

Not everyone has strong ego functions (i.e. – some people have weak ego function or “weak tools”). They may have poor tolerance, poor relationship with others, and/or difficulty with reality testing. Part of psychotherapy is helping you strengthen these functions. Individuals with strong ego functions are said to have good ego strength.

See main article: Defenses

See main article:

Defense mechanisms are an important part psychodynamic therapy. Defenses are thoughts and behaviors (both voluntary or involuntary) that an individual uses to resolve conflict and prevent undesirable feelings (e.g. – depression). Learning to identify and understand defenses is important in psychodynamic psychotherapy.

For a beginner, a psychotherapy patient should:

Not be actively using substances
No active suicidal or homicidal ideation
No psychotic symptoms
Be psychologically-minded
Be of at least average intellect
The patient should be interested in treatment
Is able to form close relationships
Some degree of awareness of their emotions and how it affects them
The patient is able to tolerate ambiguity and lack of structure

The first few sessions of psychotherapy typically focus on understanding and taking a good relationship history, from childhood up to adulthood. Here are some key topics that need to be addressed during the first session:

Explore why the patient is interested in therapy at this time
Have a discussion about their childhood
A detailed relationship history, involving parents, siblings, friends, and romantic relationships
What was useful about their previous therapy sessions
What symptoms are they hoping will be addressed through therapy?
What symptoms are affecting them now?
A review of substance use and safety

Educate Your Patient on Psychodynamic Therapy!

It can be helpful to first ask your patient what they think psychotherapy is. The following educational pieces might also be helpful for your patient to know:

Every session is different
Important to attend each session
Non-judgmental space, confidential space, to help you understand yourself
Can really talk about whatever, this full hour is your time
It’s okay to be off-topic, the idea is “free association”
You should walk out of a session emboldened, and feel better
Even if you think there’s nothing to talk about, there’s something to talk about
Sometimes might have things to say about this relationship (the therapist-patient relationship), and that’s okay!
Let me know if you feel like things are helping, or things are not working and you would like to see it changed
Psychodynamic therapy can take many years
“You can’t leave somewhere you haven’t arrived at yet”

It can be helpful to first ask your patient what they think psychotherapy is. The following educational pieces might also be helpful for your patient to know:

At a certain point, you will have collected enough social history, and it is time to transition and let your patient know that the therapy will become much less structured. For example, to start this session, you can tell them “I’d like you to talk about whatever comes to your mind, and I will stop taking notes.” It is usually better to not take notes, so your patients are able to freely associate, and reduce biasing your patients in talking about what they think you want to hear.

What Do I Say? What Do I Not Say?

Psychodynamic therapy can be challenging for the novice practitioner due to the lack of structure, and the requirement of having the patient lead the session. Here are some tips to guide you:

If a patient asks: “Should I be feeling this way?” or “Is it normal to feel this way?,” you can validate and say “There are no shoulds or shouldn’ts with feelings. They just are. Feelings make sense.” The same would go for questions like: “Am I over-reacting?” You should tell your patients to show some compassion to themselves for having anger.
When there is a deafening silence during a session, it’s okay to say something like “talk about what feels important to you”
If a patient is very self-critical about a situation or themsleves, it maybe appropriate to probe further and ask: “you seem to be very self-critical about [situation], why?”

Psychodynamic therapy can be challenging for the novice practitioner due to the lack of structure, and the requirement of having the patient lead the session. Here are some tips to guide you:

The following diagram (figure 1) helps illustrate some of the principles described here to visualize just how a psychotherapy session might work:

Fig. 1: Psychodynamic Psychotherapy Visualized

Every psychodynamic therapy relationship with a patient has 4 phases:

Four basic phases of psychotherapy

Evaluation The initial assessment and history-taking phase Induction Beginning the treatment, developing therapeutic relationship, setting goals, helping patient learn to use therapy Mid-phase Majority of treatment time is spent here: the therapist and patient work together to achieve the therapeutic goals set during the induction phase Termination Ending of the treatment: goals are consolidated, treatment is reviewed, the change that has occurred is appraised and role of future change is also evaluated, planning for future therapy, and termination of relationship

Psychodynamic therapy is by definition very unstructured, but there are certain techniques that are frequently employed, the main ones are:

1. Listening: Hear Your Patient

You listen to the content of their speech for particular themes, conflicts, and of course, their concerns. Listen for slips, also known as pararaxes, affects, free associations, transference, defences, unconscious fantasies, and dreams.

2. Reflecting: Process What They Say

After you have heard you patient, you need to process this information and understand its meaning. By understanding, you can decide you to respond and intervene. This process is called reflecting. First, let’s go back to key idea of psychodynamic therapy: unconscious ideas affect conscious thoughts. Using this principle, this means you need to reach the unconscious thoughts first. This is why listening is so key: you listen for clues on the surface, to guide you to deeper towards unconscious thoughts.

All the material that patients give us is helpful in doing that. When reflecting, it is important to attend to three ideas: going from the superficial ideas to deep, identifying which topics contain the most affect (emotion) for the patient, and acknolwedging your counter-transferance (what feelings do you, as the therapist, have towards you patient? – are you reacting strongly to something a patient said because of your own biases/idiosyncrasies?)

3. Intervening: Respond to What They Say

How do you know what to say or if the patient is ready for it? There are 3 principles you can use:

What is the therapeutic alliance? Therapeutic alliance is the amount of trust between a patient and a therapist. Alliance builds over time as therapists show their patients that they understand them. A strong therapeutic alliance allows a therapist to say things that might otherwise be quite painful to a patient had they heard it from the therapist the first time they met.
What is the phase of the treatment? There are 3 phases to psychodynamic therapy: the beginning, the mid-phase, and the termination phase. The further a long a patient is in therapy, the easier it is for the therapist to make certain comments or observations
And what is the patient’s ego function? Is it important to constantly reassess your patient’s ego function, as it will change and fluctuate depending on whether they are regressing, under stress, or medically ill.

Pathological accommodation refers to ways of being that function unconsciously to preserve a needed attachment when that bond has been traumatically threatened. In this sense of the word, “accommodation” means that the individual unconsciously adopts the views and feelings of another at the expense of his or her own experience.

The 7 principles of psychoanalytic psychotherapy

Distinguishing Psychoanalysis From Other Mental Health Treatments

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