LAUGHING STOCK/CORBIS LAUGHING 52 SCIENTIFIC AMERICAN MIND November/December 2010 © 2010 Scientific American Getting to Know Me Psychodynamic therapy has been caricatured as navel-gazing, but studies show powerful bene!ts By Jonathan Shedler effrey (not his real name) came to treatment complaining of depression, anxiety and trouble getting along with others. Colleagues in the engineer- ing department where he worked complained he was “not a team player,” and his wife saw him as distant and hypercritical. Beyond this, he carried Jwith him a constant feeling of dread, no matter how well things were going. I agreed with Jeffrey that his dread seemed out of proportion to anything that was actually happening in his life and suggested it might “When you turned to your father for help, he humil- be in proportion to something that was not imme- iated you. Perhaps a part of you expects the same diately obvious to either of us. I asked him to tell me treatment from me.” Jeffrey began to connect with about himself. Among other things, I learned that old emotions, speaking of the terror he had felt dur- his father had been an alcoholic who would attack ing his father’s outbursts. His sense of dread began without warning, driving Jeffrey to leave home at to make sense—and then slowly dissipated. Jeffrey an early age. gradually recognized—not just intellectually but in It was one thing for Jeffrey to tell me of his unhap- a way that truly sank in emotionally—that the beat- py past, but soon this old relationship pattern came to ings were over. The world began to feel less danger- life, as Jeffrey began responding to me as if I were an ous, and he started letting others “in” in ways he nev- unpredictable, angry adversary. Consciously, he saw er had before. His work relationships improved, and me as an ally with his welfare at heart. Yet he seemed he and his wife became closer than either had previ- constantly poised to “protect” himself by fending me ously thought possible. He began to enjoy his life. off, as though he expected I would use what he said The treatment that helped Jeffrey, known as against him. His responses were so ingrained that he psychoanalytic or psychodynamic therapy, traces did not recognize them as out of the ordinary. its heritage to psychoanalysis in the famous drap- I did not regard Jeffrey’s attitude as an obstacle. ery-hung study of Sigmund Freud in Vienna. But On the contrary, reliving this relationship pattern psychodynamic therapy as practiced today bears with me was central to his recovery. I would fre- little resemblance to the world of Oedipal con!ict, quently point out that Jeffrey was responding as if I penis envy and castration anxiety that has been so were an enemy, and he gradually began to notice, lampooned in New Yorker cartoons and Woody Al- too. In those moments, his thoughts and feelings of- len "lms. Patients do not lie on a couch free-associ- ten ran to his father. I helped him connect the dots: ating as an inscrutable therapist silently looks on, www.ScientificAmerican.com/Mind SCIENTIFIC AMERICAN MIND 53 © 2010 Scientific American © 2010 Scientific American The term “psycho- nor must they commit to four or "ve sessions a week Over the past decades psychologists have con- analysis” conjures for years on end. ducted thousands of studies that showed the effec- images of Freud’s Freud’s legacy is not a speci"c theory but rather tiveness of cognitive-behavior therapy. The ap- couch (top left), but contemporary psy- a sensibility: an appreciation of the depth and com- proach initially seemed to promise quick cures—a chodynamic therapy plexity of mental life and a recognition that we do promise that dovetailed with the interests of health (top right) is not the not fully know ourselves. It is also an acknowledg- insurers, who wanted to pay as little as possible for psychoanalysis of yesteryear. It has ment that what we do not know is nonetheless man- mental health care. CBT was portrayed as the gold evolved new meth- ifested in our relationships and can cause suffer- standard, and many practitioners wrote off psycho- ods and may be the ing—or, in a therapy relationship, can be examined dynamic therapy as antiquated and unscienti"c. But best way to tackle and potentially reworked. as I recently showed in a research review published recurring problems. But the modernization of psychodynamic ther- in American Psychologist, the prestigious !agship apy has gone largely unnoticed. For years psycho- journal of the American Psychological Association, analysts did little to disseminate ideas outside their psychodynamic therapy has been not only misun- own circles, and this self-imposed exile from aca- derstood but vastly underestimated. demic research left a void, into which was born an The reality is that psychodynamic therapy has alternative: cognitive-behavior therapy (CBT). In proved its effectiveness in rigorous controlled stud- this newer approach, therapists focused on speci"c ies. Not only that, but research shows that people problems and readily observable thoughts and be- who receive psychodynamic therapy actually con- haviors, rather than embracing the messy, emotion- tinue to improve after therapy ends—presumably be- al complexity of people’s mental lives. cause the understanding they gain is global, not tar- ) geted to encapsulated, one-time problems. Thanks right to misinformation and entrenched interests, howev- ( FAST FACTS er, much of this research has been overlooked. The Value of Self-Examination Enhancing Self-Awareness Psychodynamic therapy is not the psychoanalysis of Freud’s There is no end of cartoons spoo"ng psycho- Images Getty >> day: patients sit on a chair instead of lying on a couch, have analysis: Santa Claus on the couch confessing, “I DLEY 1 A sessions once or twice—not four or !ve times—a week, and may don’t believe in myself anymore,” or a house on a !nish in months as opposed to years. couch telling the dispassionate analyst, “My bubble burst!” But cartoons are not reality. Psychodynamic BR JON ); left Though often dismissed as too open-ended to solve spe- therapy is practical, and it helps free people from ( 2>> ci!c problems, psychodynamic therapy alleviates symp- suffering. So what is it that makes psychodynamic toms as effectively as newer, more targeted therapies. therapy so powerful? By analyzing tapes from hun- Corbis N A dreds of hours of actual therapy sessions, research- I AM People who undergo psychodynamic therapy continue ers have identi"ed seven distinctive features. H A R 3>> to make gains after the therapy ends, perhaps because Exploring emotions. Psychodynamic therapists P it addresses underlying psychological patterns that affect many encourage patients to explore their full emotional areas of life. range—including contradictory feelings, feelings that A PETER 54 SCIENTIFIC AMERICAN MIND November/December 2010 © 2010 Scientific American I kept encountering patients who had been shunted from one “quick !x” treatment to another, with little lasting bene!t. are troubling or threatening, and feelings they may ini- da, psychodynamic therapists encourage patients to tially be unable to express. A CBT practitioner might speak freely about whatever is on their minds. Fan- respond to emotional dif"culty with homework as- tasies, dreams and daydreams provide a rich source signments and worksheets or seek to persuade pa- of information about their hopes, desires and tients that irrational thinking has skewed their feel- fears. ings. Psychodynamic therapists, in contrast, are like- All successful therapies must relieve symptoms ly to invite patients to explore their feelings further. such as anxiety or depression. But psychodynamic Examining avoidances. Efforts to avoid dis- treatment aims for more: it focuses on building core tressing or threatening thoughts and feelings can be psychological strengths—such as the capacity to obvious, as when patients miss sessions or fall si- have more ful"lling relationships, to make more ef- lent. They can also be subtle, as when people focus fective use of one’s abilities, and to face life’s chal- on facts and events to the exclusion of emotions or lenges with greater freedom and !exibility. emphasize external circumstances instead of their own role in shaping events. Psychodynamic thera- Scienti!c Evidence pists encourage patients to examine why and how I delved into the research supporting psychody- they avoid what is distressing. namic therapy because I kept encountering patients Identifying recurring patterns. Sometimes peo- who had been shunted from one “quick "x” treat- ple are acutely aware of painful or self-defeating ment to another, with little or no lasting bene"t. In patterns—like choosing romantic partners who are my experience, the brief therapies promoted as “em- unavailable or sabotaging themselves when success pirically supported” were often failing, despite is at hand—but feel unable to escape them. Some- claims that their bene"ts are scienti"cally proven. times they need help to recognize the patterns. Cognitive-behavior therapists may also incor- Discussing past experience. Related to identi- porate some of the seven features described above, fying recurring patterns is the recognition that past but not to the same extent as psychodynamic thera- experiences affect our experience of the present. By pists. Instead of encouraging patients to speak free- exploring how early experiences color present-day ly, they may teach exercises or skills. Instead of ex- perceptions, psychodynamic therapists help pa- ploring feelings in depth, they are more likely to fo- tients free themselves from the bonds of the past cus on thoughts. Instead of examining how past and live more fully in the present. Focusing on relationships. Psychodynamic ther- apists recognize that mental health problems tend to Different Ways to Feel Better be rooted in problematic relationship patterns.