Psychodynamic psychotherapy is one of the most commonly practiced forms of psychotherapy in the United States. It developed from psychoanalysis, beginning with the work of Sigmund Freud and evolving substantially through the contributions of later psychoanalytic and psychodynamic clinicians. Although contemporary psychodynamic therapy differs in many respects from traditional psychoanalysis, it retains a central idea: problems such as anxiety, depression, difficulties with behavior, and troubled relationships often make more sense when we understand the thoughts, feelings, expectations, and ways of coping that contribute to them.
Problem-Focused Psychodynamic Psychotherapy (PrFPP) grew out of this tradition but was developed to make psychodynamic treatment more focused, practical, and understandable. Traditional psychodynamic concepts can be complex, and treatment can sometimes become so open-ended that patients and therapists lose track of the problems they originally intended to address. PrFPP begins instead with a straightforward question: What are the problems you want help with? Therapist and patient then work together to understand what contributes to those problems and what can be changed.
What Problems Can Be Treated?
PrFPP is not designed for a single psychiatric disorder. It can be used to address several broad types of problems.
Some are symptoms, such as anxiety, depression, panic, excessive guilt, or low self-esteem. Others involve behavior. A person may repeatedly avoid situations that make them uncomfortable, procrastinate, become inhibited when they need to speak up, act impulsively, or engage in perfectionistic behavior that makes it difficult to complete tasks.
Still other problems involve relationships. Someone may repeatedly become involved with critical or unavailable partners, have difficulty expressing anger, become excessively dependent on others, avoid closeness because of fears of rejection, or find themselves having similar conflicts in relationship after relationship. Finally, some difficulties are broader and more longstanding, involving personality patterns such as chronic self-criticism, sensitivity to rejection, difficulty trusting others, or persistent expectations of being criticized or abandoned.
Frequently these problems overlap. Someone who becomes depressed after criticism at work, for example, may also have difficulty standing up for herself, be highly sensitive to rejection, and avoid relationships in which she fears being judged. Rather than assuming these are unrelated problems, PrFPP examines how they may be connected.
What Does Treatment Look Like?
Treatment usually begins by identifying and defining the patient's major problems. This sounds simple, but it can be an important part of therapy. A patient might initially say, "I'm unhappy," or "My relationships don't work." Therapist and patient work together to make the problem more specific: When does the person become unhappy? What happens in the relationships? What situations repeatedly create difficulties?
They then examine the contexts and triggers surrounding each problem. If someone becomes anxious, for example, when does the anxiety occur? What was happening just before it began? What was the person thinking and feeling? Does criticism trigger it? Conflict? Feeling ignored? Having to depend on someone? Being expected to perform?
Over time, therapist and patient develop a map of the factors contributing to the person's problems. The map may include childhood experiences that continue to influence present reactions, negative views of oneself, expectations of how other people will respond, difficult or conflicted feelings, and ways of coping that may reduce distress temporarily but create additional problems.
Consider someone who becomes extremely anxious whenever her boss criticizes her. Exploring her history might reveal that she grew up with a highly critical father and developed a longstanding belief that she was inadequate. She may expect authority figures to judge her harshly and consequently experience relatively ordinary criticism as evidence that she has failed.
But understanding the childhood connection is only part of the work. The therapist might help her examine her current belief that she is inadequate, including evidence that contradicts it. They might discover that she is angry with her boss but has difficulty acknowledging anger because she fears that expressing it will lead to rejection or retaliation. Instead, she suppresses her anger, criticizes herself, and becomes increasingly anxious and depressed.
The same pattern may appear in therapy. She might assume that her therapist is disappointed in her or will criticize her if she disagrees. Examining this expectation in the therapeutic relationship can help her recognize how strongly she anticipates criticism even when another person is not actually being critical. This is one way that transference, the carrying forward of expectations and patterns from earlier relationships into current ones, can become useful in treatment.
How Does Psychodynamic Therapy Produce Change?
PrFPP aims for more than simply discovering why a problem developed. Understanding is useful when it helps a person respond differently.
Patients learn to recognize situations that trigger their problems before they become overwhelmed by them. They become better able to identify what they are feeling rather than experiencing only anxiety, depression, or an urge to act. They learn to recognize negative assumptions such as "I'm inadequate," "If I'm angry, people will reject me," or "If I need someone, I'll be disappointed."
Treatment also examines ways of coping. Coping strategies generally develop for understandable reasons and may provide short-term relief. Avoiding conflict, for example, can reduce anxiety. But if avoidance prevents someone from expressing reasonable needs, resentment may accumulate and relationships may deteriorate. Similarly, perfectionism may protect against fears of criticism while producing excessive pressure, procrastination, and feelings of failure.
Therapy therefore involves trying different ways of responding. A patient who habitually avoids conflict might experiment with expressing disagreement. Someone who assumes others will be critical might begin checking that expectation rather than automatically withdrawing. Someone who suppresses anger might learn to recognize it, tolerate it, and express it constructively.
I refer to the capacities developed through this process as psychodynamic skills. These include learning to step back and think about problems; recognize their triggers; identify and manage difficult emotions; understand how childhood experiences influence current reactions; question negative views of oneself and expectations of others; recognize problematic ways of coping; and experiment with healthier behaviors and ways of relating.
An important goal is for patients eventually to be able to use these skills without the therapist. Successful treatment should leave people not only feeling better but also with a clearer understanding of how their problems develop and what they can do when those problems begin to recur.
How Does Medication Fit In?
Psychodynamic psychotherapy and psychiatric medication are not competing approaches. For many patients, they can be used together.
Medication may directly reduce symptoms such as depression, anxiety, panic, sleep disturbance, or severe emotional distress. Reducing symptoms can itself be extremely important and may also make it easier for a person to engage in psychotherapy. Someone who is severely depressed, for example, may find it easier to examine painful feelings and make behavioral changes once medication has reduced the intensity of the depression.
Psychotherapy addresses somewhat different questions. Why does criticism from a boss precipitate such a severe reaction in this particular person? Why does someone repeatedly assume that others will reject them? Why is it so difficult to express anger or ask for help? Why does the person repeatedly cope by withdrawing, becoming self-critical, or acting impulsively?
Medication may reduce the intensity of symptoms without necessarily changing these underlying patterns. Psychotherapy can help patients understand and modify the psychological processes that contribute to symptoms and to behavioral and relationship problems. When both treatments are indicated, medication can help reduce symptoms while PrFPP helps patients develop new ways of understanding and managing the problems that contribute to them.
The central aim of Problem-Focused Psychodynamic Psychotherapy is therefore practical: to help people understand the problems that interfere with their lives, develop a map of what contributes to them, and acquire the skills they need to address those problems more effectively, both during treatment and after therapy has ended.