Episode 144: Psychodynamic Psychotherapy with Jonathan Shedler, Ph.D
Claire Baker, David Puder, MD
Dr. Jonathan Shedler and David Puder have no conflicts of interest to report for the audio that goes with this article.
Introduction
In this episode, Dr. Puder interviews Jonathan Shedler, Ph.D. Their conversation covers the ideal length of therapy treatment, the efficacy of psychodynamic therapy, and the role of psychodynamic processes in multiple therapeutic modalities.
Dr. Shedler is an internationally known author, lecture consultant and master clinician. An expert in psychodynamic therapy and personality pathology, he has over 25 years of experience practicing therapy and teaching and supervising mental health professionals. He wrote the pivotal paper “The Efficacy of Psychodynamic Psychotherapy”, which validated psychodynamic therapy as an evidence-based treatment. He is also the creator of the Shedler-Westen Assessment Procedure (SWAP) for personality diagnosis and clinical case formulation and is prolific on Twitter at the handle @jonathanshedler.
Psychodynamic Therapy
Psychodynamic therapy is a form of talk therapy focused on exploring the patient’s inner experience, which encompasses emotions, dreams, implicit drives and beliefs and relationships, including the patient-therapist relationship. Dr. Shedler notes that while psychodynamic therapy has a public image of being obscure and possibly even esoteric, in reality it deals with the phenomena of everyday life and realities about the mind and interpersonal connection, with which we all have experience. The things we all deal with are inside us and all around us, so there’s nothing esoteric or unusual about psychodynamic therapy. By employing the use of psychodynamic therapy, we have a way of understanding things about the life of the mind and human connection and interaction. Indicatively, this type of therapy really applies everywhere; it’s not just applicable in a certain kind of therapy or for a certain kind of person. It’s applicable to therapy in general and to life in general.
Projection
A central concept in psychodynamic theory is that all people have contradictory impulses: the desire to be compassionate, helpful and kind; the desire to destroy, to inflict pain and damage. Psychologically healthy individuals are able to recognize and accept that they have these contradictory impulses within themselves, and keep the most extreme desires in check. Comparatively, individuals with personality pathology are often unable to accept these contradictory impulses and may instead project the impulses onto another person, idea or institution. Unable to recognize their own capacity for hate, they repeatedly see it in things outside of themselves. The projection is “the capacity for hate isn’t in me, it’s out there.”
As more serious kinds of personality disturbances are considered, the boundaries between fantasy and action become very murky. Rather than see their own destructiveness, they project it onto other people or things outside of themselves. If they proceed to act destructively on that perception, it will become very problematic.
Dr. Shedler writes that individuals with a tendency towards pathological behaviors like projection will often find “camouflage” in communities where that behavior is normalized and validated. He notes that “disturbance finds camouflage.” These individuals find a community that seems to normalize or validate the dysfunctional behaviors. This applies across the board and we can see it playing out every day.
Camouflage can be especially common on social media and in online communities, where anonymity enables users to engage in abusive behavior towards strangers with reduced fear of social consequences. For example, someone who suddenly finds themselves the target of intense, vicious hatred by an individual they don’t know may question how they suddenly became so important to this person. They may wonder how it is possible for them to be treated as though this person knew them intimately, knowing their thoughts, motives and intentions, when they are, in fact, complete strangers. This is where the psychoanalytic concept of projection comes in (as the stranger may be projecting all sorts of things).
Through prolonged psychotherapy, patients can become more aware of their destructive impulses and reduce the shame that would drive them into the unconscious. When we deny them we may act them out but at the same time justify ourselves. When we don’t understand our impulses it is easy to respond reactively, potentially in destructive ways; with greater clarity around these impulses, we can keep them as thoughts that don’t harm others.
Projective Identification
Projective identification is a phenomenon that may follow projection. It occurs when an individual projects onto another person, and that other person begins to identify with the projection and act differently than they normally would. Dr. Shedler describes it to mean that a person believes they can release their anger and hatred without restraint on another person to where they react and become angry, in a way making the projection become true. For example, if a therapy patient repeatedly accuses his therapist of hating him, the therapist may notice herself actually feeling frustration or resentment towards the patient where she previously felt neutral or positive.
Therapists may be familiar with the experience of noticing that with a particular patient, they act, feel or think in ways that are out of character for them. Perhaps they will feel an impulse to act out, cross a boundary or collude with the patient. In that moment, the therapist may be identifying with the patient’s projection. The psychoanalysts Glen Gabbard and Thomas Ogden described this experience as “the analyst’s mind [being] colonized by the patient’s internal world” (Gabbard, 2009). This occurs often during psychotherapy, but can also occur outside the confines of therapy between individuals.
When projective identification occurs during therapy, the work of the therapist is first to notice what is occurring. Once they recognize that they are reacting in an unusual way, the clinician can work on finding their way back to their own thoughts and feelings, and aim to make use of the interaction constructively. Moments of projection and projective identification can be used to help patients gain insight into their internal experience and how it plays out in their interpersonal relationships.
How Long Does Effective Therapy Take?
Dr. Shedler has also written on the question of how much time is needed for therapy to produce meaningful change. In the article “The Tyranny of Time: How Long Does Effective Therapy Really Take?,” Dr. Shedler and co-author, psychologist Enrico Gnaulati, present evidence that effective therapy takes significantly longer than the 8- to 16-week treatments often used in controlled trials. Because of the incredibly difficult nature of studying psychotherapy, researchers typically chose shorter periods of time, 8- and 16-week trials, to study, but not on the basis of research that shows these are inherently beneficial time frames to begin with. Consequently, there are hundreds of studies on treating depression alone, all based on treatments of <16 sessions.
A study of over 10,000 therapy clients, assessed session-to-session with a validated outcome instrument, found that it took 21 sessions or about six months of weekly therapy to see clinically significant changes in 50% of patients. Only after 40 sessions, or almost a year of weekly therapy, did researchers see significant changes in 75% of patients (Lambert, 2001). Research has also called into question the long-term efficacy of brief therapy (Shedler, 2020). Yet brief manualized therapies are still frequently viewed as the standard of care, and most research on psychotherapy continues to focus on abbreviated therapy.
Multiple factors explain the continued predominance of brief therapy. One issue is a lack of communication between researchers and clinicians. Few studies have asked practicing therapists how long it takes for therapy to show significant effects, and when the question is asked, they find that practitioners generally see better results with long-term therapy. An Emory University survey of 270 experienced psychotherapists found that their last completed therapies “in which patient and therapist agreed that the outcome was reasonably successful” required a median of 52 to 75 sessions (Morrison, Bradley & Westen, 2003).
Compared to brief therapy, long-term therapy is also simply less studied. Practical constraints are partly to blame: studies of long-term therapy are expensive, methodologically complex, and resource-intensive. But the relative lack of research on long-term therapy also creates a self-fulfilling prophecy: when “less-studied” is falsely equated to “less evidence-based”, it perpetuates the stereotype that long-form therapy is not evidence-based.
Dr. Shedler concludes that real therapists operating in the real world recognize that therapy takes time and that people don’t come packaged with single DSM disorder categories. People are complex and there is a need to create a relationship with the patient over time. The actual schism is between practicing clinicians and researchers who operate in cognitive parallel universes.
Evidence for Psychodynamic Therapy & Strategies
Despite methodological constraints, psychodynamic therapy is supported by significant evidence. As Dr. Shedler writes in his article, The Efficacy of Psychodynamic Psychotherapy, not only is psychodynamic therapy evidence-based, but other psychotherapy modalities, including CBT, may be effective partly because they use psychodynamic techniques.
An abundance of studies have found that different psychotherapy modalities show similar efficacy (Seligman, 1995) and one potential explanation for this is the existence of common factors driving efficacy of multiple modalities.
Some researchers have investigated this question by looking past broader “brand names” and assessing specific features in individual therapy sessions (Goldfried & Wolfe, 1996). There isn’t incentive to study the historically effective basic treatment methods; the incentive comes from essentially creating a commodity out of new therapy models that are, at the most basic level, comprised of the same fundamental principles. A number of studies have used the Psychotherapy Process Q-Set, a standardized instrument, to analyze the methods actually used in therapy sessions (PQS; Jones, 2000). In multiple studies, Enrico Jones and colleagues used the PQS to analyze CBT and psychodynamic therapy sessions, and repeatedly found that the use of psychodynamic techniques was correlated with successful outcomes, regardless of whether the therapist was working under a CBT or psychodynamic model (Jones & Pulos, 1993; Ablon & Jones, 1998).
Further studies have not only replicated these findings, but also provided clues as to what elements of psychodynamic therapy may be responsible for its efficacy. In one critical study, CBT sessions conducted according to Beck’s treatment model were assessed for the presence of multiple “Process Variables” (Castonguay et al., 1996). These variables included therapeutic alliance, implementation of the cognitive model, and a variable called “experiencing” which closely relates to the psychodynamic model.
Dr. Shedler remarks that therapeutic alliance is central to all effective treatment models and it cannot be commodified; it simply takes time to form these real relationships. Both therapeutic alliance and experiencing were associated with the greatest improvement. In other words, therapists working within a CBT model had better outcomes when they focused mostly on exploring the patient’s emotions, inner experience and self-knowledge, as well as the therapist-client relationship.
Ingredients of Effective Therapy
Dr. Shedler particularly emphasizes the importance of the therapeutic relationship, which he describes as a shared understanding between therapist and patient about the purpose of their work and methods they’re using to achieve that purpose. And he notes that a strong working alliance can be especially impactful for patients who have significant difficulties with interpersonal relationships. If a patient normally distances herself from others using slights and attacks, she is likely used to others attacking back or ending the relationship. When she takes this approach towards her therapist, and the therapist instead responds by noticing what’s occurring and responding with curiosity and empathy, it helps her develop insight into her relationship patterns.
The therapist-client relationship is an irreplaceable element of therapy, but is also affected by the therapist’s skills and experience. Three factors are particularly key to the development of a master clinician: experience, quality supervision, and personal therapy. Dr. Shedler points out that learning psychotherapy is basically an apprenticeship model, which is the quality supervision; discussing your patients with a senior clinician can develop our insight in how to navigate their struggles.
Personal therapy is important because, through coming to know ourselves more deeply, we not only grow as people but also deepen our ability to empathize with patients. Clinicians are not exempt from the effect of these psychological concepts; these concepts apply to all people. An element of personal therapy that is especially helpful is it allows us to identify our own projections, before unseen to us. Understanding ourselves in this way creates deeper insight into the struggles of our patients.
Additionally, the therapist-client relationship provides a new relational “template”, as Dr. Shedler refers to it, for the patient to see another example of how a relationship can be. The patient may not have had healthy or safe relationships previously and therapy is an opportunity for them to safely be vulnerable and unmasked in a relationship, free of consequences, from an individual who expresses compassion and empathy without judgment.
Summary
Psychodynamic concepts can be useful for enriching our therapy practice, self-knowledge, and understanding of everyday life. Evidence supports the efficacy of both long-form therapy and psychodynamic therapy specifically. A focus on psychodynamic principles, particularly the therapist-patient relationship and fostering patients’ self-knowledge, can lead to better outcomes in therapy of any modality.
Supplemental material in our resource library:
More information about Dr. Shedler’s work can also be found on his website, jonathanshedler.com.
Cited articles and further reading:
Ablon, J., & Jones, E. (1998). How expert clinicians' prototypes of an ideal treatment correlate with outcome in psychodynamic and cognitive-behavioral therapy. Psychotherapy Research, 8(1), 71-83.
Elkin, I. (1994). The NIMH Treatment of Depression Collaborative Research Program: Where we began and where we are.
Gabbard, G. O., & Ogden, T. H. (2009). On becoming a psychoanalyst. The International Journal of Psychoanalysis, 90(2), 311-327.
Goldfried, M. R., & Wolfe, B. E. (1996). Psychotherapy practice and research: Repairing a strained alliance. American Psychologist, 51(10), 1007-1016.
Jennings, L., & Skovholt, T. M. (1999). The cognitive, emotional, and relational characteristics of master therapists. Journal of counseling psychology, 46(1), 3.
Jones, E. E., & Pulos, S. M. (1993). Comparing the process in psychodynamic and cognitive-behavioral therapies. Journal of Consulting and Clinical Psychology, 61(2), 306-316.
Lambert, M.J., Hansen, N.B., Finch, A.E. (2001). Patient-Focused Research: Using Patient Outcome Data to Enhance Treatment Effects. Journal of Consulting and Clinical Psychology, 69, 1590-172.
Morrison, K. H., Bradley, R., & Westen, D. (2003). The external validity of controlled clinical trials of psychotherapy for depression and anxiety: A naturalistic study. Psychology and Psychotherapy: Theory, Research and Practice, 76(2), 109-132.
Seligman, M. E. (1995). The effectiveness of psychotherapy: The Consumer Reports study. American psychologist, 50(12), 965.