Three Truths about Psychoanalytic Therapy (Spoiler: It Is Evidence-Based!)

Much of the collective understanding about psychoanalytic therapy (or psychodynamic therapy as it’s also called) comes from clichés, jokes, and New Yorker cartoons. My favorite cartoon shows a dog lying on an analytic couch saying to his therapist, “They throw the ball. I get the ball. They throw the ball. I get the ball. What is the point?” The dog’s existential gloom leapt off the print right into my heart, and then onto my refrigerator door, where the cartoon remained for years, making me giggle whenever I reached for a cold glass of water. 

love wit, but, unfortunately, it doesn’t always leave room for truth. I will continue to laugh at these cartoons and I hope you will too. At the same time, I deeply believe in the power of psychoanalytic therapy not only to heal suffering but also to create a greater sense of freedom. I think there’s plenty of space for humor and truth, but it’s important that the former doesn’t undermine the latter, potentially keeping people from something that could really help them. 

In short psychoanalytic therapy focuses on connecting with emotions or other core aspects of experience that either have not gotten enough attention or have been too painful to feel. Here are three common misconceptions about psychoanalytic therapy and their accompanying truths. I hope they clarify the truth while still leaving in the funny!

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Misconception: Psychoanalytic therapy is only about the past.

Truth: Psychoanalytic therapy focuses on the present. 

Do you know the phrase, “if it’s not one thing, it’s your mother”? In the Saturday Night Live version of my life, which occasionally plays in parallel to my actual life, this is the tagline for psychoanalytic therapy. While it’s catchy, it is, like many commercials we see every day, both true and untrue. 

It’s not true because the focus of psychoanalytic therapy is always on the present. In each moment the therapist is wondering: What is this person’s immediate experience? What is she showing me about herself in how she’s relating to me right now? How has what I just said impacted her? In this way, psychoanalytic therapy is not about mom at all. It’s about what’s occurring right now in the room. 

At the same time, the satirical tagline is true in that the past is always alive in the present. The way people learn to relate to themselves and others is developed in early childhood and, thus, is fundamentally shaped by primary caregivers. Those early relationships are woven into the very fabric of the person’s being and, therefore, can’t help but show up in the present. 

 

Misconception: Psychoanalytic therapists are distant and silent. 

Truth: Psychoanalytic therapists are focused on connecting and can talk a lot. 

A friend recently asked me about psychoanalytic therapists. “Do they talk?” he inquired with complete sincerity. Clearly the makers of the Freud bobble head chose a popular fable to capitalize on: the blank stare, the chin dipping up and down atop the stiff plastic body, the obvious silence. When I shared my friend’s concern with a colleague, she joked, “Sometimes I don’t shut up!” 

Deciding what to say and when to say it is, of course, part of the art of psychotherapy. All talk is not equal, and neither is all silence. Whether the therapist talks a little or a lot, she is always thinking about and feeling with the person’s inner world and trying to make contact with the core of that experience. 

 

Misconception: Psychoanalytic psychotherapy is not evidence-based.

Truth: Psychoanalytic therapy is as empirically supported as other therapies. But, wait, there’s more!

In his paper, “The Efficacy of Psychodynamic Psychotherapy,”[1]Jonathan Shedler surveyed the major research on the effectiveness of psychodynamic therapy and compared it to other therapies, including cognitive behavioral therapy (CBT), which is commonly thought to be the only evidence-based method of psychotherapy. 

He found that psychoanalytic therapy is at least as effective as CBT. For statistics fans, the effect size for psychoanalytic therapy ranges from .69 to 1.46 across studies. In comparison, the effect size for CBT ranges from .58 to 1.0 across studies. For those who fell asleep halfway through the word ‘statistics’, just know that .8 is considered a large effect in psychological research while .5 is considered a moderate effect, so the efficacy of psychoanalytic therapy is actually very high. Shedler also found that the benefits of psychodynamic therapy not only endure, but also increase over time, even after therapy ends. In comparison, the benefits of evidence-based non-psychodynamic therapies tend to decay over time. Put that in your Freudian cigar and smoke it!

Even more fascinating is Shedler’s finding that the methods that make CBT and other non-psychoanalytic therapies effective are psychoanalytic. Wait, what? Yep. When researchers look at what therapists are actually doing (by reviewing videos or transcripts) as opposed to what they state or believe they are doing (“I am a CBT therapist.”), the active ingredients are unacknowledged psychoanalytic elements. These include engaging in unstructured, open-ended dialogue, drawing attention to feelings judged to be unacceptable by the person, and discussing the therapy relationship. 

There are several other misconceptions about psychoanalytic therapy that I’ll address in a later article. But, based on these first three truths, I submit to you that the dog with the existential crisis in my beloved New Yorker cartoon made a smart decision in jumping up on that psychoanalytic couch! If you’d like to learn more about psychoanalytic therapy, call me at 415-824-3242. If you’re looking for a therapist and I’m not the right match for you, I will give you referrals to my trusted colleagues. 


[1]Shedler, J. (2010). The Efficacy of Psychodynamic Psychotherapy. American Psychologist65(2), 98-109.