The term psychodynamic psychotherapy has no specific referent. It denotes a very heterogeneous range of psychological treatment approaches which arguably have in common an intellectual heritage of psychoanalytic theory. Psychoanalytic theory itself is no longer based on a unitary body of ideas⁽¹⁾ but a number of ideas appear to be core to most psychodynamic approaches. These notions are:

Psychoanalytic theory has evolved from the work of Freud following two broadly separate paths which converged over the past 25 years only to separate again. In the United States followers of the Vienna school in the 1950s and 1960s evolved a systematic psychology of the ego, a conflict-oriented complex psychological model of the mind and its disturbances.⁽¹³⁾ In Europe, only Anna Freud and her followers in London pursued this tradition of psychoanalytic thought.⁽¹⁴⁾ Based on the Berlin school of Karl Abraham, Melanie Klein and her followers established a distinct approach focusing on the understanding of disturbance rooted in infantile destructiveness and sadism.⁽¹⁵⁾ Some psychoanalysts, influenced by Klein and the idea of the pathogenic nature of the experiences of infancy, gradually discarded the mechanistic psychology of drives and psychology of internal structures in favour of theories of intrapsychic interpersonal relationships (object-relations theory).⁽¹⁶⁾

As these schools developed in the United Kingdom, their influence travelled across the Atlantic. First, Kohut, strongly influenced by Winnicott (albeit without explicit acknowledgement), evolved a psychoanalytic psychology of the self.⁽¹⁷⁾ Shortly after, Kernberg arrived at an imaginative integration of ego-psychological and Kleinian ideas.⁽¹⁸⁾ In the meantime, in the United Kingdom, the Kleinian movement rapidly progressed in their understanding of psychoanalytic clinical experience, moving beyond Klein’s original work and integrating some of the key features of the Anna Freudian and the British object-relations traditions.⁽¹⁹⁾ In the United States, disillusionment with the false certainty provided by ego-psychology became intense throughout the late 1970s and early 1980s and a radical change in psychoanalytic thinking took place with the emergence of the interpersonal relational perspective, which is in part rooted in the work of Harry Stack Sullivan.^(20,21) The relational psychoanalysis of the 1980s and 1990s consolidated several lines of thought initiated by justified critiques of traditional analytic theory⁽²²⁾; including feminism, the hermeneutic-constructivist critique of the analyst’s authority, infancy research, and, closely related to this, the intersubjectivist-phenomenological philosophy of mind—as well as a general political movement to improve and democratize access to analytic ideas and training.⁽²³⁾

There are many other new psychoanalytic theoretical approaches, bringing the field increasingly close to total fragmentation.⁽²⁴⁾ This is because the emergence of new approaches in no way signals the demise of any previous orientations, most of which continue to enjoy considerable popularity among specific groups of psychoanalysts.

The history of psychoanalysis as a therapeutic approach is rather different. Broadly speaking, it may be argued that psychoanalysis and other long-term psychodynamic therapies are predominantly verbal, interpretive, insight-oriented approaches which aim to modify or re-structure maladaptive relationship representations. It is implicitly assumed that genetic and early environmental factors give rise to partial, unintegrated, and generally troublesome relationship representations (e.g. a helpless ‘infant’ requiring total care from an adult, a self with exaggerated sense of power, and entitlement requiring constant confirmation from outside) that lie at the root of psychological disturbance. It is believed that the integration of these partial representations into more complex schemata, primarily but not exclusively through the use of insight, leads to improved internal and social adjustment.

Psychoanalysis is the most intensive form of these long-term therapies. The analysand attends treatment three or more times a week over a period of years. The use of the couch and the instruction to the analysand to free associate have been considered hallmarks. The distinction between psychoanalysis and other forms of psychotherapy is normally made in terms of the frequency of sessions rather than in terms of the therapeutic stance of the analyst. It is difficult to avoid the conclusion that in the absence of plausible, theoretically based criteria for what is or is not psychoanalytic, against the background of an overwhelming diversity of theoretical frameworks, psychoanalysts have attempted to find common ground in readily identifiable treatment parameters. This problem arises as a consequence of an extremely loose relationship between psychoanalytic theory and clinical practice.⁽²⁴⁾ It is an indisputable fact that, whereas theory has evolved extremely rapidly in the last half of the twentieth century and continues to change, psychoanalytic practice has, until recently, changed surprisingly little and continues to provide the core of the psychoanalytic identity. On the other hand, the follow-along study by Sandell et al.⁽²⁵⁾ found that psychoanalysis and psychoanalytic psychotherapy were ‘separate things’. When psychotherapy was performed using mainly psychoanalytic techniques, it was less effective than psychotherapy performed with modified and adjusted techniques (that is, not performed as an ‘as-if analysis’). The findings from the Stockholm study suggest that psychoanalysis and psychoanalytic psychotherapy may be separate endeavours, although how exactly they differ is far from clear.

In this chapter we will not consider the theoretical richness of this field but instead will focus on the clinical constructs which run across the diverse intellectual approaches. The intersection of the two is perhaps clearest in one area which we shall consider in some detail—namely, the therapeutic action of long-term psychoanalytically oriented psychotherapeutic treatment.

As is well known, Freud’s discovery of the talking cure⁽²⁶⁾ was really that of an intelligent patient (Anna O) and her physician (Breuer). The patient reported that certain symptoms disappeared when she succeeded in linking up fragments of what she said and did in an altered state of consciousness (which we might now call dissociative) with forgotten impressions from her waking life. Breuer’s remarkable contribution was that he had faith in the reality of the memories which emerged and did not dismiss the patient’s associations as products of a deranged mind. The patient’s response to treatment was probably less complete than Breuer and the young Freud had hoped⁽²⁷⁾ but the ‘treatment’ defined the basic elements of the ‘cathartic’ method-linking memory of trauma (the circumstances of her experience of her father’s death) to her many symptoms.

At first Freud rigorously pursued the traumatogenic origins of neuroses. Later, when confronted by evidently incorrect statements, he modified his theory, assuming consistency between recollection and childhood psychic reality rather than physical reality.⁽²⁸⁾ The issue of accuracy of memories of childhood sexual trauma remains controversial, although its relevance to psychoanalytic technique is at best tangential.⁽²⁹⁾ Freud’s technique, however, was dramatically modified by his discoveries. The intense emotional relationship between patient and physician, which had its roots in catharsis following hypnotic suggestion, had gradually subsided into what was principally an intellectual exercise to reconstruct the repressed causes of psychiatric disturbance from the fragments of material derived from the patient’s associations. It was a highly mechanistic approach reminiscent of a complex crossword puzzle. In the light of therapeutic failures, however, Freud once more restored the emotional charge into the patient-physician relationship.⁽³⁰⁾ However, in place of hypnosis and suggestion, he used the patient’s emotion, signs of transference of affect and affective resistance which were manifest in the analytic relationship. Instead of seeing the patient’s intense emotional reaction to the therapist as an interference, Freud came to recognize the importance of transference as a representation of earlier relationship experiences which could make the reconstruction of those experiences in analysis highly meaningful to that individual.⁽³¹⁾

Freud’s early clinical work evidently lacked some of the rigour which came to characterize classical psychoanalysis.⁽³²⁾ His occasional encouragement to his patients to join him on holiday might now be considered a boundary violation.⁽³³⁾ What is perhaps less well known is that Freud remained somewhat sceptical about the effectiveness of psychoanalysis as a method of treatment.⁽³⁴⁾ Indeed, autobiographies of some of his patients testify to his great flexibility as a clinician and use of non-psychoanalytic techniques, including behavioural methods.⁽³⁵⁾ Nor was Freud the only clinician to use psychoanalytic ideas flexibly. The Hungarian analyst Sandór Ferenczi should be credited with the discovery of the treatment of phobic disorders by relaxation and exposure⁽³⁶⁾ although many of his well-intentioned actions were criticized by contemporaries and more recently on arguable ethical grounds.⁽³⁷⁾

The technique of psychoanalysis after Freud’s death came to be codified. Those (such as Alexander and French and Freda Fromm-Reichmann) who attempted to revive or retain Freud’s original clinical flexibility were subjected to powerful intellectual rebuttals.⁽³⁸⁾ In reality, psychoanalysts probably continued to vary in the extent to which they observed the ideals of therapeutic neutrality, abstinence, and a primarily interpretive stance, but these deviations could no longer be exposed to public scrutiny for fear of colleagues’ forceful condemnation. Personal accounts of analyses with leading figures yield fascinating insights into variations in technique, principally in terms of the extent to which the analyst made use of a personal relationship.⁽³⁹⁾ There has been an ongoing dialectic throughout the history of psychodynamic approaches between those who emphasize interpretation and insight and those who stress the unique emotional relationship between patient and therapist as the primary vehicle of change. The controversy dates back to disputes concerning the work of Ferenczi and Rank⁽⁴⁰⁾ but re-emerged with the first papers of Balint and Winnicott in London opposing a Freudian and Kleinian tradition, and somewhat later in the United States with Kohut and more subtly Loewald opposing classical ego psychology.

In the last two decades, the pluralistic approach of modern psychoanalysis has brought out into the open many important dimensions along which psychoanalysts’ techniques may vary. In particular, the recent trend to consider analyst and patient as equal partners engaged in a mutual exploration of meaning⁽⁴¹⁾ directly challenged many of the classical constructs. The emphasis on the mutual influence of infant and caregiver shaped the emerging relational model of therapy as a two-person process in which there was little room for a detached analyst with pretensions of ‘objectivity’. Drawing on the assumption that humans are predisposed towards two-person co-constructed systems that provide a context for psychic change, the quality of engagement between therapist and patient became the core of therapeutic action. What changes the mind is not the insights gained but learning from the interactional experience of being with another person. Neither the analyst nor the patient can be considered as forging meaning; rather, meaning is co-constructed.

Based in the classical framework of libidinal theory, Freud made an explicit injunction against the analyst giving in to the temptation of gratifying the patient’s sexual desire.⁽⁴²⁾ Obviously, this is primarily an ethical issue. However, within the psychoanalytic context it also justifies the analyst’s stance of resisting the patient’s curiosity or using the therapeutic relationship in any way that consciously or unconsciously could be seen as motivated by the need to gratify their own hidden desires. Within this classical frame of reference, the patient must also agree to forgo significant life changes where these could be seen as relevant to current psychotherapeutic work. In practice, such abstinence on the part of the patient is rare. Yet long-term psychodynamic treatment may founder if the emotional experiences of the therapy are obscured by the upheavals of significant life events.

The primary function of abstinence is to ensure the neutrality of the therapist. The analyst assumes an attitude of open curiosity, empathy, and concern in relation to the patient. The therapist resists the temptation to direct the patient’s associations and remains neutral irrespective of the subject matter of the patient’s experiences or fantasies. While it is easy to take this issue too lightly, (and it is perhaps this aspect of the psychoanalyst’s therapeutic stance which makes them most vulnerable to ridicule), it is probably genuinely critical for the therapist to retain emotional distance from the patient to a degree which enables the latter to bring fantasies and fears of which they feel uncertain. Nevertheless, neutrality at its worst denies the possibility of sensitivity; recent literature on the process and outcome of psychotherapy makes it clear that the therapist’s genuine concern for the patient must become manifest if significant therapeutic change is to be achieved.⁽⁴³⁾ The quality of the alliance is one of the better predictors of outcome⁽⁴⁴⁾ and alliance is impacted by the patient’s attachment style and quality of object-relations.⁽⁴⁵⁾

The term ‘psychic defences’ may risk reification and anthropomorphism (precisely who is defending whom against what?) yet the existence of self-serving distortions of mental states relative to an external or internal reality is generally accepted, and frequently demonstrated experimentally.^(46,47,48) Within classical psychoanalytical theory and its modern equivalent (ego psychology), intra-psychic conflict is seen as the core of mental functioning.⁽⁴⁹⁾ Here defences are seen as adaptations to reduce conflict. Within many object-relations theories, defences are seen as helpful to the individual to maintain an authentic or ‘true’ self-representation or a nuclear self.⁽¹⁷⁾ Models of representations of relationships are of course often defensive. Traumatic experiences may give rise to omnipotent internal working models to address a feeling of helplessness. Within attachment theory, defences are construed as assisting in the maintenance of desirable relationships.⁽⁵⁰⁾ The Klein-Bion model makes limited use of the notion of defence mechanisms but uses the term in the context of more complex hypothetical structures called defensive organizations.⁽¹⁹⁾ The term underscores the relative inflexibility of some defensive structures, which are thus best conceived of as personality types. For example, narcissistic personality disorder combines idealization and destructiveness; genuine love and truth are devalued. Such a personality type may have been protective to the individual at an earlier developmental stage, and has now acquired a stability or autonomy which must be rooted in the emotional gratification which such a self-limiting form of adaptation provides.⁽⁵¹⁾

Irrespective of the theoretical frame of reference, from a therapeutic viewpoint clinicians tend to differentiate between so-called primitive and mature defences based on the cognitive complexity entailed in their functioning.⁽⁵²⁾ In clinical work, primitive defences are often noted together in the same individual. For example, individuals loosely considered ‘borderline’ tend to idealize and then derogate the therapist. Thus they maintain their self-esteem by using splitting (clear separation of good from bad self-perception) and then projection. Projective identification⁽⁵³⁾ is an elaboration of the process of projection. An individual may ascribe an undesirable mental state to the other through projection but when the other can be unconsciously forced to accept the projection and experience its impact, the defence becomes far more powerful and stable. The analyst’s experiencing of a fragment of the patient’s self-state, has in recent years been considered an essential part of therapeutic understanding.⁽⁵⁴⁾

Whether in fantasy or in actualized form, through projective identification the patient can experience a primitive mode of control over the therapist. Bion argued that when the self is experienced as being within another person (the therapist) the patient frequently attempts to exert total control over the recipient of the projection as part of an attempt to control split-off aspects of the self. Bion⁽⁵⁵⁾ also argued that not all such externalizations were of ‘bad’ parts of the self. Desirable aspects of the self may also be projected, and thus projective identification can be seen as a primitive mode of communication in infancy. There are other aspects of projective identification which we commonly encounter clinically. These include the acquisition of the object’s attributes in fantasy, the protection of a valued aspect of the self from internal persecution through its evacuation into the object, and the avoidance or denial of separateness. It is thus a fundamental aspect of interpersonal relationship focused on unconscious fantasy and its appreciation is critical for the adequate practice of long-term psychotherapy.⁽⁵⁶⁾

Classifications of defences have been frequently attempted^{(52, 57,58,59,60,61)} and often as a method for categorizing individuals or mental disorders.^(4,5) An attachment theory-based classification rooted in the notion of habitual deactivation or hyperactivation of the attachment system (‘attachment style’) has achieved general acceptance.^(62,63) Deactivating (‘avoidant’ or ‘dismissing’) strategies include suppression of ideas related to painful attachment experiences, repressing painful memories, minimizing stress and distress, segregated mental systems that result in the defensive exclusion of distressing material from the stream of consciousness.^(64,65) Ingenious experimental studies have shown that individuals who habitually use avoidant defences are more efficient, when instructed, at suppressing conscious thoughts and associated feelings about a romantic partner leaving them for someone else⁽⁶⁶⁾ and are more likely to attribute their own unwanted traits to others (projection) which serves to both increase self-other differentiation and enhance self-worth.⁽⁶⁷⁾ In a further, remarkable study the same group of researchers demonstrated that the above advantages of the suppression strategy of those using avoidant defence fall away in the laboratory situation if a cognitive load is placed on the participant which then leaves them literally defenceless so that they experience a heightened rebound of previously suppressed thought about painful separation.⁽⁶⁸⁾ The cognitive and socio-cognitive strategies associated with reducing anxiety or displeasure and enhancing safety, which both the attachment theory and psychoanalytic literatures tend to refer to as defences, are perhaps better thought of not as independent classes of mental activity or psychological entities but as a pervasive dynamic aspect of complex cognition interfacing with attachment relationships and emotional experience. Some mechanisms of defence are thought to be more characteristic of the less severe psychological disorders (e.g. depression, anxiety, obsessive-compulsive disorders, etc.). It is beyond the scope of this chapter to consider the various defence mechanisms in detail.

The primary mode of the therapeutic action of psychoanalytic psychotherapy is generally considered to be insight.⁽⁶⁹⁾ Insight may be defined as the conscious recognition of the role of unconscious factors on current experience and behaviour. Unconscious factors encompass unconscious feelings, experiences, and fantasies. The psychodynamic model has been seen as a model of the mind that emphasizes repudiated wishes and ideas which have been warded off, defensively excluded from conscious experience. In our view this is a narrow and somewhat misleading way to define the therapeutic mechanism for approaches that are considered as psychodynamic. The psychodynamic approach is better seen as a stance taken to human subjectivity that is comprehensive, and aimed at understanding all aspects of the individual’s relationship with her or his environment, external, and internal. Freud’s great discovery (‘where id was, there ego shall be’, Freud⁽⁷⁰⁾ p. 80), often misinterpreted, points to the power of the conscious mind radically to alter its position with respect to aspects of its own functions, including the capacity to end its own existence through killing the body. Psychodynamic, in our view, refers to this extraordinary potential for dynamic self-alteration and self-correction— seemingly totally outside the reach of non-human species. Engaging with this potential to bring change through understanding, is the science and the art of the psychodynamic clinician.

Conscious insight is more than mere intellectual knowledge^(71,72) or descriptive insights. Prototypically, psychodynamic therapy achieves demonstrated or ostensive insights which represent a more direct form of knowing, implying emotional contact with an event one has experienced previously. Working with what is non-conscious is at the heart of the dynamic approach to bringing about psychological change because of the force that awareness of unconscious expectations can bring to the interpretation of behaviour. Although specific formulations of the effect of insight depend on the theoretical framework in which explanations are couched, there is general agreement that insight has its therapeutic effect by in some way integrating mental structures.⁽⁷²⁾ Kleinian analysts⁽⁷³⁾ tend to see the healing of defensively created splits in the patient’s representation of self and others as crucial. Split or part-objects may also be understood as isolated representations of intentional beings whose motivation is insufficiently well understood for these to be seen as coherent beings.⁽⁷⁴⁾ In this case insight could be seen as a development of the capacity to understand internal and external objects in mental state terms, thus lending them coherence and consistency.⁽⁷⁵⁾ The same phenomenon may be described as an increasing willingness on the part of the patient to see the interpersonal world from a third person’s perspective.⁽⁷⁶⁾

A simple demonstration to the patient of such an integrated picture of self or others is not thought to be sufficient.⁽³¹⁾ The patient needs to ‘work through’ a newly arrived integration. Working through is a process of both unlearning and learning: actively discarding prior misconceptions and assimilating learning to work with new constructions. The technique of working through is not well described in the literature, yet it represents the critical advantage of long-term over short-term therapy.⁽⁷⁷⁾ Working through should be systematic and much of the advantage of long-term treatment may be lost if the therapist does not follow through insights in a relatively consistent and coherent manner.

In contrast to the emphasis on insight and working through are those clinicians who, as we have seen, emphasize the ‘relationship aspect’ of psychoanalytic therapy (Balint, Winnicott, Loewald, Mitchell, and many others). This aspect of psychoanalytic therapy was perhaps most eloquently described by Loewald when he wrote about the process of change as: ‘set in motion, not simply by the technical skill of the analyst but by the fact that the analyst makes himself available for the development of a new ‘objectrelationship’ between the patient and the analyst…’ (Loewald, 1960, pp. 224-5).⁽⁷⁸⁾ Sandler and Dreher⁽⁷⁹⁾ have recently observed ‘while insight is aimed for it is no longer regarded as an absolutely necessary requirement without which the analysis cannot proceed’. There is general agreement that the past polarization of interpretation and insight on the one hand, and bringing about change by presenting the patient with a new relationship on the other, was unhelpful. It seems that patients require both, and both may be required for either to be effective.⁽⁸⁰⁾

Controversy remains even if all accept that neutrality is an impossible and undesirable fiction and that patient and therapist affect each other in myriad mutually influencing ways. Projective identification is seen as occurring in a bidirectional interpersonal field between analyst and patient—a model clearly adapted from Kleinian approaches to infant-caregiver interaction.⁽²³⁾ If we take this perspective seriously, we have to concede that all analytic interventions change the situations into which they are introduced, and their content and style always reflect the analyst’s countertransference/ response to the treatment situation.⁽⁸¹⁾ Relational psychoanalysis advocates making the interactional influence of analyst upon patient explicit. As Levenson⁽⁸²⁾(p. 9) put it, the key therapeutic question is not ‘what does this mean?’ but rather ‘what is going on around here?’ The therapist will ‘act’ on the patient; this is not a therapeutic disaster but rather a potentially progressive and certainly inevitable part of the process.

It has been suggested that change in analysis will always be individualized according to the characteristics of the patient or the analyst.⁽⁸³⁾ For example, Blatt⁽⁸⁴⁾ suggested that patients who were ‘introjective’ (preoccupied with establishing and maintaining a viable self-concept rather than establishing intimacy) were more responsive to interpretation and insight. By contrast, anaclitic patients (more concerned with issues of relatedness than of self-development) were more likely to benefit from the quality of the therapeutic relationship than from interpretation. Taking a second look at large-scale outcome investigations Blatt found strong evidence for the oft made but rarely demonstrated claim of patient personality—therapeutic technique fit.⁽⁸⁵⁾