A jargon-free introduction to Psychodynamic Therapy

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How to cite:
Shedler, J. (2006). That was then, this is now: Psychoanalytic psychotherapy for the rest
of us. Retrieved from http://jonathanshedler.com/writings/
√ https://jonathanshedler.com

“Look at yourself honestly and unflinchingly to the very bottom of your mind.”
Calligraphy by Shihan Tsutomo Ohshima, Martial Arts Master

Author’s Note
This work-in-progress is a jargon-free introduction to contemporary
psychodynamic thought. It is intended for trainees and for clinicians trained in other
therapy approaches. I wrote it because existing books did not meet my students’ needs.
Many classic introductions to psychoanalytic therapy are dated. They describe the
psychoanalytic thinking of decades ago, not today. Others contain too much jargon to be
accessible or assume prior knowledge that few contemporary readers possess. Still others
have a partisan agenda of promoting one psychoanalytic school of thought over others,
but trainees are ill-served by treating them as pawns in internecine theoretical disputes.
Finally, some otherwise excellent books assume an interested and sympathetic reader—
an assumption that is often unwarranted. Most students today are exposed to
considerable disinformation about psychoanalytic thought and approach it with
inaccurate and pejorative preconceptions.

The title is a double entendre. “That was then, this is now” alludes to a central
aim of psychoanalytic therapy, which is to help free people from the bonds of past
experience in order to live more fully in the present. People tend to react to what was
rather than what is, and psychoanalytic therapy aims to help with this. The title also
alludes to sea changes in psychoanalytic thinking that have occurred over the past
decades. For too many, the term psychoanalysis conjures up century-old stereotypes
that bear little resemblance to what contemporary practitioners think and do.
These chapters were intended as the beginning of a book. I may finish it one day
but the project is on the back burner. For now, this is it.

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Chapter 1:
Roots of Misunderstanding

Psychoanalytic psychotherapy may be the most misunderstood of all therapies. I
teach a course in psychoanalytic therapy for clinical psychology doctoral students, many
of whom would not be there if it were not required. I begin by asking the students to
write down their beliefs about psychoanalytic therapy. Most express highly inaccurate
preconceptions. The preconceptions come not from first-hand encounters with
psychoanalytic practitioners but from media depictions, from undergraduate psychology
professors who refer to psychoanalytic concepts in their courses but understand little
about them, and from textbooks that present caricatures of psychoanalytic theories that
were out of date half a century ago.

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Some of the more memorable misconceptions are: That psychoanalytic concepts
apply only to the privileged and wealthy; that psychoanalytic concepts and treatments
lack empirical support (for a review of empirical evidence, see Shedler, 2010); that
psychoanalysts “reduce everything” to sex and aggression; that they keep patients in
lengthy treatments merely for financial gain; that psychoanalytic theories are sexist,
racist, or classist (insert your preferred condemnation); that Sigmund Freud, the
originator of psychoanalysis, was a cocaine addict who developed his theories under the
influence; that he was a child molester (a graduate of an Ivy League university had gotten
this bizarre notion from one of her professors); and that the terms “psychoanalytic” and
“Freudian” are synonyms—as if psychoanalytic knowledge has not evolved since the early
1900s.

Most psychoanalytic therapists have no idea how to respond to the question (all
too common at cocktail parties), “Are you a ‘Freudian?’” The question has no meaningful
answer and I myself fear that any answer I give will lead only to misunderstanding. In a
basic sense, all mental health professionals are “Freudian” because so many of Freud’s
concepts have simply been assimilated into the broader culture of psychotherapy. Many
Freudian ideas now seem so commonplace, commonsense, and taken-for-granted that
people do not recognize that they originated with Freud and were radical at the time. For
example, most people take it for granted that trauma can cause emotional and physical
symptoms, that our care in the early years shapes our adult lives, that people have
complex and often contradictory motives, that sexual abuse of children occurs and can
have disastrous consequences, that emotional difficulties can be treated by talking, that
we sometimes find fault with others for the very things we do not wish to see in
ourselves, that it is exploitive and destructive for therapists to have sexual relations with
clients, and so on. These and many more ideas that are commonplace in the culture of
psychotherapy are “Freudian.” In this sense, every contemporary psychotherapist is a
(gasp) Freudian, like it or not. Even the practice of meeting with clients for regularly
scheduled appointment hours originated with Freud.

In another sense, the question “Are you a Freudian?” is unanswerable because no
contemporary psychoanalytic therapist is a “Freudian.” What I mean is that
psychoanalytic thinking has evolved radically since Freud’s day—not that you would
know this from reading university textbooks. In the past decades, there have been sea
changes in theory and practice. The field has grown in diverse directions, far from
Freud’s historical writings. In this sense, no one is a “Freudian.” Psychoanalysis is
continually evolving new models and paradigms. The development of psychoanalytic
thought did not end with Freud any more than the development of physics ended with
Newton or the development of the behavioral tradition in psychology ended with
Watson.

There are multiple schools of thought within psychoanalysis with different and
sometimes bitterly divisive views, and the notion that someone could tell you “the”
psychoanalytic view of something is quaint and naïve. There may be greater diversity of
viewpoints within psychoanalysis than within any other school of psychotherapy, if only
because psychoanalysis is the oldest of the therapy traditions. Asking a psychoanalyst for
“the” psychoanalytic perspective may be as meaningful as asking a philosophy professor
“the” philosophical answer to a question. I imagine the poor professor could only shake
her head in bemusement and wonder where to begin. So it is with psychoanalysis.
Psychoanalysis is not one theory but a diverse collection of theories, each of which
represents an attempt to shed light on one or another facet of human functioning.
What it isn’t.

It may be easier to explain what psychoanalysis is not than what it is. For starters,
contemporary psychoanalysis is not a theory about id, ego, and superego (terms,
incidentally, that Freud did not use; they were introduced by a translator). Nor is it a
theory about fixations, or sexual and aggressive instincts, or repressed memories, or the
Oedipus complex, or penis envy, or castration anxiety. One can dispense with every one
of these ideas and the essence of psychoanalytic thinking and therapy would remain
intact. Some psychoanalysts may find some of these concepts helpful, sometimes. Some
psychoanalysts reject every one of them.

If you learned in college that psychoanalysis is a theory about id, ego, and
superego, your professors did you a disservice. Please don’t shoot the messenger for
telling you that you may be less prepared to understand psychoanalytic thought than if
you had never taken a psychology course at all. Interest in that particular model of the
mind (called the “structural theory”) has long since given way to other theories and
models (cf. Person, Cooper, & Gabbard, 2005). There is virtually no mention of it in
contemporary psychoanalytic writings other than in historical contexts. In the late 20th
century, the theory’s strongest proponent eventually concluded that it was no longer
relevant to psychoanalysis (Brenner, 1994). When psychology textbooks present the
theory of id, ego, and superego as if it were synonymous with psychoanalysis, I don’t
know whether to laugh or to cry.

It is fair to ask how so many textbooks could be so out of date and get it all so
wrong. Students have every reason to expect their textbooks to be accurate and
authoritative. The answer, in brief, is that psychoanalysis developed outside the
academic world, mostly in freestanding institutes. For complex historical reasons, these
institutes tended to be insular, and psychoanalysts did little to make their ideas
accessible to people outside their own closed circles. Some of the psychoanalytic
institutes were also arrogant and exclusive in the worst sense of the word and did an
admirable job of alienating other mental health professionals. This occurred at a time
when American psychoanalytic institutes were dominated by a hierarchical medical
establishment (for a historical perspective, see McWilliams, 2004). Psychoanalytic
institutes have evolved but the hostility they engendered in other mental health
professions is likely to persist for years to come. It has been transmitted across
generations of trainees, with each generation modeling the attitudes of its own teachers.
Academic psychology also played a role in perpetuating widespread
misunderstanding of psychoanalytic psychotherapy. A culture developed within
academic psychology that disparaged psychoanalytic ideas—or more correctly, the
stereotypes and caricatures it mistook for psychoanalytic ideas—and made little effort to
learn how psychoanalytic therapists really thought and practiced. Many academic
psychologists were content to use psychoanalysis as a foil or straw man. They’d regularly
win debates with dead theorists who were not present to explain their views (it is fairly
easy to win arguments with dead people). Many academic psychologists still critique
caricatures of psychoanalytic concepts and outdated theories that psychoanalysis has
long since moved beyond (cf. Bornstein, 1988, 1995; Hansell, 2005). Sadly, most
academic psychologists have been clueless about developments in psychoanalysis for the
better part of a century.

Much the same situation exists in psychiatry departments which in recent
decades saw wholesale purges of psychoanalytically-oriented faculty members, and have
become so pharmacologically oriented that many psychiatrists no longer know how to
help patients in any way that does not involve a prescription. Interestingly, being an
effective psychopharmacologist involves many of the same skills that psychoanalytic
therapy requires—for example, the ability to build rapport, create a working alliance,
make sound inferences about things patients may not be able to express directly, and
understand the fantasies and resistances that almost invariably get stirred up around
taking psychiatric medication. There seems to be a hunger among psychiatry trainees for
more comprehensive ways of understanding patients and for alternatives to biologically
reductionistic treatment approaches.

It may be disillusioning to discover that your teachers misled you, especially if
you admired those teachers. You may even be experiencing some cognitive dissonance
just now (and dissonance theory predicts that you might be tempted to disregard the
information I am providing, to help resolve the dissonance). I remember my own
struggle to come to terms with the realization that professors I admired had led me
astray. I wanted to look up to these professors, to share their views, to be one of them. It
also made me feel bigger and more important to think like the did and believe what they
believed, and I felt personally diminished when they seemed diminished in my eyes. I
suspect I am not alone in this reaction. I have often wondered whether this is one reason
otherwise thoughtful and open-minded students sometimes turn a deaf ear to ideas
labeled “psychoanalytic.”

A comment on terminology
Throughout this book I use the terms “psychoanalytic” and “psychodynamic”
interchangeably. The term psychodynamic was introduced after World War II at a
conference on medical education and used as a synonym for psychoanalytic. I am told
the intent was to secure a place for psychoanalysis in psychiatry residency training
without unduly alarming training directors who may have regarded “psychoanalysis”
with some apprehension (R. Wallerstein, personal communication; Whitehorn et al.,
1953). In short, the term psychodynamic was something of a ruse. The term has evolved
over time to refer to a range of treatments based on psychoanalytic concepts and
methods but which do not necessarily take place five days per week or involve lying on a
couch.

At the risk of offending some psychoanalysts, a few words are also in order about
psychoanalysis versus psychoanalytic psychotherapy. In psychoanalysis, sessions take
place three to five days per week and the patient lies on a couch. In psychoanalytic
psychotherapy, sessions typically take place once or twice per week and the patient sits in
a chair. Beyond this, the differences are murky. Psychoanalysis is an interpersonal
process not an anatomical position. It refers to a special kind of interaction between
patient and therapist. It can facilitate this interaction if the patient comes often and lies
down but this is neither necessary nor sufficient. Frequent meetings facilitate, in part
because patients who come often tend to develop more intense feelings toward the
therapist, and these feelings can be utilized constructively in the service of
understanding and change. Lying down can also facilitate for some patients, because
lying down (rather than staring at another person) encourages a state of reverie in which
thoughts can wander more freely. I will take up these topics in the next chapter.
However, lying down and meeting frequently are only trappings of
psychoanalysis, not its essence (cf. Gill, 1983). With respect to the couch, psychoanalysts

Now recognize that lying down can impede as well as facilitate psychoanalytic work (e.g.,
Goldberger, 1995; Schachter & Kächele, 2013). With respect to frequency of meetings,
it is silly to maintain that someone who attends four appointments per week is “in
psychoanalysis” but someone who attends three cannot be. Generally, the more
frequently a patient comes, the richer the experience. But there are patients who attend
five sessions per week and lie on a couch and nothing goes on that remotely resembles a
psychoanalytic process. Others attend sessions once or twice per week and sit in a chair
and there is no question a psychoanalytic process is taking place. It really has to do with
who the therapist is, who the patient is, and what happens between them.
Finally, I will generally use the term patient rather than client. In truth, both
words are problematic, but patient seems to me the lesser of evils. The origin of the
word patient is “one who suffers.” But for some, the word has come to imply a
hierarchical power relationship, or conjures up images of authoritarian doctors
performing procedures on disempowered recipients. These connotations are
troublesome because psychoanalytic therapy is a shared, collaborative endeavor between
two human beings, neither of whom has privileged access to truth. On the other hand,
the term client does not seem to do justice to the dire, sometimes life-and-death
seriousness of psychotherapy or the enormity of the responsibility therapists assume.
My hairdresser, accountant, and yoga teacher have “clients” but none to my knowledge
has ever hospitalized a suicidal person, received a desperate phone call from a terrified
family member of someone decompensating into psychosis, or struggled to help
someone make meaning of the experience of being raped by her own father.
Neither word is ideal and some colleagues I respect prefer one word and some the
other. I have tried to explain the reasons for my own preference. Readers with an
aversion to patient may substitute the word client where they wish. The choice of
terminology is less important than reflecting on the meanings and implications of our
choice.1

1 Nancy McWilliams (personal communication) has commented on the irony that many people
have come to associate the mercantile rather than the medical metaphor with greater compassion
and humanity.

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