A Brief History

Psychoanalysis was established in the early 1890s by the neurologist Sigmund Freud. Based on psychoanalytic theory, models of shorter-term psychodynamic therapy were developed (e.g. Messer & Warren, 1995) Psychoanalytic concepts are also used beyond the clinical situation in areas such as literature or film criticism (e.g. Gabbard, 2001), cultural phenomena, fairy tales (Bettelheim, 1991), and philosophical perspectives. Psychoanalysis and psychodynamic therapy encompass a set of theories of mental organization and a variety of therapeutic techniques for the treatment of mental disorders. Since the early times of psychoanalysis, psychoanalytic and psychodynamic theory and technique have undergone considerable developments described below. Unfortunately, however, many misunderstandings concerning psychoanalysis and psychodynamic therapy still exist (Abbass et al., 2017). One of the central assumptions of psychoanalysis and psychodynamic therapy differentiating them from all other forms of psychotherapy is that most mental processes are regarded as unconscious. Unconscious wishes or processes are expressed, for example, in dreams, “Freudian” slips or in the unconscious repetition of relational experiences. Modern neuroscience has confirmed this central assumption (Carhart-Harris & Friston, 2010; LeDoux, 1998, p. 17): “Freud was right on the mark when he described consciousness as the tip of the mental iceberg”. Psychoanalytic theory encompasses different models to explain the various forms of psychopathology. Generally, Freud assumed a complemental series between constitution and psychological factors (Freud, 1905). The classical structural model assumes a dynamic interplay between the id, which represents basic instincts and operates according to the pleasure principle and the primary process, the ego, which mediates between the id and the reality of the external world, operating on the reality principle, and the superego which represents internalized norms and ideals (Freud, 1923). Consistent with this model, Freud conceptualized mental disorders as the result of unresolved unconscious conflicts and psychological symptoms as a compromise between a sexual or aggressive impulse which is prohibited by the superego and therefore leads to anxiety that is reduced by the ego in applying defense mechanisms distorting and disguising the original impulse (Zerbe, 1990). Turning aggression towards an important figure against the self leading to depressive symptoms may serve as an example. This concept of symptom formation was later operationalized and empirically supported by Luborsky (1984) and his method of the core conflictual relationship theme (CCRT). A CCRT consists of a wish, an expected responses from others and a responses of the self which include the patient’s defense mechanisms and the resulting symptoms (Luborsky, 1984). Thus, the CCRT method also allows to operationalize another central psychoanalytic concept, that of transference (Luborsky, 1984), that is experiencing another person in way similar to important figures of the past. 

Classical psychoanalytic techniques encompass instructing patients to try to say what’s on their mind (free association), confrontation (drawing the patient’s attention to a particular phenomenon), clarification (exploring a phenomenon in more detail) and interpretation (making an unconscious meaning conscious), and repeatedly addressing a conflict or process (working through)) (Greenson, 1967; Sandler et al., 2002). In classical psychoanalysis, the patient lies on the couch and the analyst sits just behind out of sight. Classical psychoanalysis is usually carried out with 2-5 sessions a week for several years. According to two other central assumptions of psychoanalytic theory, the patient regresses (moves to earlier forms of experiencing and behavior) and develops a transference towards the analyst. Transference (CCRT) allows to understand the patient’s symptoms and problems in the here-and now from their early experiences. As the patient’s transference expectations are usually not confirmed by the analyst but answered in an alternative way, he or she makes a new emotional experience which allows them to find better solutions for their conflicts beyond symptom formation. Countertransference represents the analyst’s feelings and fantasies about the patient which need to be reflected and may help to understand the patient’s dynamics. Although patients seek relief from their symptoms and distress psychoanalysis and psychodynamic therapy assume that they also exert resistance, impeding the therapeutic process. They do so for different reasons (Sandler et al., 2002), they may resist, for example, to giving up adaptive solutions including the symptoms. Psychoanalytic theory and techniques has been extended to the treatment of children and adolescents (Freud, 1928; Klein, 1932), groups (Burrow, 1927; Foulkes & Anthony, 1957) families (e.g. Ackerman, 1958) and couples (e.g. Dicks, 1967) Already in 1919 Freud noted that not all mental disorders can be treated by the same technique (Freud, 1919). For phobias and obsessive compulsive disorder Freud (1919) emphasized that patients need to expose themselves to the feared situation. For very severely disordered patients Freud (1919) regarded it as necessary to complement psychoanalytic technique by some forms of psychoeducation, referring to patients who today are regarded as showing severe impairments in ego-functioning. Consistent with these changes in technique, Freud recommended to alloy the gold of psychoanalysis with the copper of suggestion for the mass application of psychoanalysis (Freud, 1919). 

During the 20th century it became more and more clear that not all mental disorders can be explained by unresolved conflicts. Instead, their psychopathology may be better explained by impairments in ego-functions and object relationships. For this reason psychoanalytic theory and treatment was extended by focusing on ego functions (Bellak et al., 1973; Blanck & Blanck, 1974; Eagle, 2022; Hartmann, 1958), object relations (e.g. Kernberg, 1976), self psychology (e.g. Kohut, 1971), mentalization (Bateman & Fonagy, 2004) or attachment (Bowlby, 1973). Relational psychoanalysis examines how the patient’s object relations relationship patterns are re-enacted in the relationship between the analyst and the patient (e.g. Mitchell, 1997). These changes in understanding the psychopathology led to corresponding changes in psychoanalytic techniques, e.g. expressing an emotional attunement to the patient, selective self-disclosure if necessary, recognizing the analyst’s participation in and contribution to the therapeutic process (e.g. McWilliams, 2011 ). 

This widening of the scope of psychoanalysis and psychodynamic therapy allowed to treat more severely disturbed patients, that is patients whose psychopathology is based on impaired ego functions as well as on traumatic experiences. Furthermore, the need of shorter and more focused forms of treatments arose. In the 1960ies psychodynamic treatments based on psychoanalytic theory were developed which were more focused and of a shorter duration (Balint et al., 1972; Davanloo, 1980; Malan, 1963; Mann, 1973; Messer & Warren, 1995; Sifneos, 1978; Strupp, 1975). In contrast to psychoanalysis, regression is often restricted (e.g. Luborsky, 1984) and the focus is not on the past unconscious but on the present unconscious (Sandler & Sandler, 1985), on repetitive relationship patterns and impairments in ego-functions. These psychodynamic treatments are carried out in a face-to-face setting with one or two sessions a week. 

Thus, psychoanalysis and psychodynamic therapy operate on a supportive-interpretive continuum (Gabbard, 2004). The use of more interpretive or supportive interventions depends on a patient's needs and mental capacities (Gabbard, 2004). While interpretive interventions enhance the person's insight about repetitive conflicts sustaining his/ her problems, supportive interventions aim to strengthen psychosocial abilities (ego-functions) that are currently not accessible to the person. 

In addition, manual-guided psychodynamic treatments were developed which meanwhile cover most common mental disorders (e.g. Leichsenring, Leweke, et al., 2015). Many of these manual-guided treatments were tested in randomized controlled trials and have proved to be efficacious (Fonagy, 2015; Leichsenring et al., 2023; Leichsenring, Leweke, et al., 2015; Leichsenring, Luyten, et al., 2015). Evidence for psychoanalysis and long-term psychodynamic exists as well, but fewer studies are available and further research is required. (Heim et al., in press; Huber et al., 2012; Leichsenring et al., 2013; Leichsenring & Rabung, 2011; Leuzinger-Bohleber et al., 2019). Today, psychodynamic therapy is among the most frequently applied methods of psychotherapy in clinical practice (Norcross & Rogan, 2013).