The classic form of psychotherapy, psychodynamic psychotherapy, is familiar to many of us from popular culture, from shows like In Treatment or The Sopranos, cartoons and jokes, and maybe also from personal experience or from other people's stories. Yet although this approach, originating in the work of Sigmund Freud over a century ago and continuing to evolve ever since, is a well-established, widely practiced, and research-supported form of psychotherapy, many people are still unclear about what actually happens in it. It is sometimes perceived as a place where you "just talk" or "dig into the past," in contrast to newer therapeutic approaches, particularly cognitive-behavioural therapies, which are often regarded as more practical and as offering patients concrete tools and coping strategies.
The question of how psychodynamic therapy works, and which tools it actually offers, can be approached from many angles, and different therapists would likely answer it differently. I'll try to answer it, partially, using a concept that isn't usually associated with psychodynamic therapy: the concept of mindfulness.
What is mindfulness?
Mindfulness is an ancient concept rooted in Buddhism that, in recent decades, has "migrated" and become popular in Western culture in general, and in psychological therapy in particular, after countless studies found beneficial effects of mindfulness practice on mental and physical health.
Mindfulness is defined as the process of deliberately and non-judgmentally directing our attention to what's happening in the present moment. This process has several features. The first is actively directing attention — that is, observing what's happening. The second is non-judgmental attention: observing the whole of our experience without favouring one part over another, and recognizing things as they are, without labelling them as good or bad, wanted or unwanted. The third part of the definition is attending to the present moment, to what's happening right here, right now. Two further elements, not included in the formal definition but central to the practice, are curiosity: looking at things with a "beginner's mind," like a child discovering something for the first time, and compassion, toward ourselves and toward others.
Evenly suspended attention
So much for mindfulness. What does all of this have to do with psychodynamic psychotherapy?
Psychodynamic psychotherapy rests, to a large extent, on listening. That is, on a particular and special way in which the therapist listens to the patient. How can we characterize this kind of listening? How is it different from the way a close friend, or a partner, listen? Freud called this special kind of listening "evenly suspended attention": a way of listening in which the therapist stays open to taking in the full range of the patient's experience, equally, without favouring one piece of content over another or one emotion over another, and neutrally, that is, refraining from judging and labelling the content as good or bad.
Sound familiar? Indeed, there are meaningful parallels between the idea of mindfulness and the idea of "evenly suspended attention," the stance of the therapist in psychodynamic therapy. It's quite plausible that Freud, who was very much interested in culture, history, and anthropology, had read Buddhist texts (and, from the other direction, it's plausible that the founders of newer mindfulness-based therapies had read Freud).
Who is doing the listening?
But who is doing the listening and the observing in therapy? In Freud's classical approach, it was the therapist. The patient's role was to freely associate — to speak freely about whatever came to mind, and the therapist's role was to listen from a stance of evenly suspended attention, and to interpret. In contemporary psychodynamic therapy, though, things are seen a little differently: therapy is understood as a place where therapist and patient listen and observe together, both the experiences the patient describes, and those unfolding here and now, in the therapy session. In other words, it isn't only the therapist who holds this stance of suspended attention, or mindfulness. Over time, the patient also develops the capacity to hold it.
The following example illustrates this idea. (It is a fictional example, that does not represent any specific patient).
During her therapeutic session, Nurith is telling her therapist about something her partner did that morning that upset her. Suddenly she pauses for a moment, and then sums up: "So that's it, really. It's silly, not such a big deal."
Michal, her therapist, who noticed the brief pause, the shift in Nurith's tone, and the sudden break in Michal's speech, says: "It seems like something happened just now. Right in this moment."
Nurith is quick to dismiss it: "It's nothing, really," but then, hesitantly, says: "Honestly, it's not a big deal, but you glanced at the clock a minute ago, and it threw me off. Suddenly, everything I was talking about felt pointless, boring."
Nurith and Michal can now deepen, together, their observation of the whole of Nurith's experience. They can observe the sense of interruption Nurith felt due to the shift in Michal's gaze when she glanced at the clock, the thought that she's boring, the feelings that arose in her, and her attempts to wave them away. And from this, Nurith develops a similar capacity for observing herself in her everyday life as well.
Why dig into the past?
If the focus of dynamic therapy is on what's happening here and now, in the therapeutic session, then why do therapists "dig into the past"? Why is there so much talk about childhood, about relationships with parents, about various life events? This question can also be addressed in various ways. But one of the answers has to do with the non-judgmental element of mindfulness. "Non-judgmental attention" sounds great, but in practice, turning our attention toward difficult feelings, toward patterns that get in our way, and toward thoughts we'd rather not think, usually brings up judgment and self-criticism.
Often, the way to soften our judgment of our own thoughts, feelings, and patterns, and to relate to them with more compassion, begins with understanding ourselves better — understanding our history, and how these patterns came to be.
In our example, Nurith might think, or say to Michal: "It's so silly that I'm making a big deal out of you glancing at the clock. I do this with friends too. I pick up on some tiny sign that someone isn't listening to me, and I just go quiet. I'm totally overreacting." Here Nurith is turning her attention to what's happening to her — but with a lot of judgment and self-criticism.
Michal, based on what she already knows about Nurith, might say: "I remember you telling me that as a kid, you felt your parents were busy with their own worries and struggles, and weren't really available to you. You told me about that experience of suddenly realizing, in the middle of a game or a conversation, that they'd drifted off into their own concerns and weren't with you. It is only natural that you'd still be very sensitive to that today. It makes perfect sense."
And later in therapy, perhaps, Nurith will tell Michal: "Something similar to what we talked about happened this week. I was sitting with a friend at a café, and while I was talking to her, she looked around for the waitress and raised her hand to call her over. I immediately thought I was boring her, and that I should just stop talking. Then I realized that it was exactly like what happened here in therapy. And then I managed to keep talking with her, and it actually turned into a good conversation."
In this way, within the protected space of the therapy room, within a safe relationship, through a combination of looking at the past and observing what's happening in the present moment, psychodynamic therapy develops the capacity to pause and observe, with curiosity and compassion, without judgment, with mindfulness, what's happening within ourselves, and within our relationships with others.