What it is, how it works, what to expect, and how to know whether it's right for you.
Why a Guide?
One of the things I’ve come to love about the psychoanalytic community is its commitment to communication, dialogue, and elaboration. Through my own writing and working within this community, I have spoken to and with other clinicians who are very familiar with the ins and outs of psychoanalysis. But it struck me recently that there isn’t a lot out there for people who are interested in undergoing this kind of treatment as a client.
This guide is for prospective clients who are interested in psychodynamic therapy, what it means, why it’s around, and if it’s a good fit for them.1
This is not comprehensive, and it is written from my perspective, only one practitioner among an ocean of many. I heard a joke a while back that goes, “If you ask 10 psychiatrists what diagnosis a patient has, you’ll get 11 opinions.” I think this is even more true about therapists and psychoanalysis.
What is Psychodynamic Therapy?
Psychodynamic therapy is a form of talk therapy that explores recurring patterns in your life, feelings that are difficult to recognize or express, and the ways past relationships shape present experience. Throughout this guide, I’ll use “psychodynamic therapy” and “psychoanalytic therapy” interchangeably.
This approach grew out of psychoanalysis and has changed considerably since Freud’s day. The basic invitation, however, remains much the same: come to sessions regularly, speak about your life, and work together with the therapist to understand what’s going on, who you are, and why you suffer.
In my practice, this is an open-ended process. Rather than setting an agenda for each session, I generally follow what you bring and help you explore it. We might stay with a difficult feeling, notice a familiar pattern, or make a connection that hadn’t occurred to you before. I don’t usually assign homework or follow a workbook, though sometimes it is helpful to offer more guidance or suggest something to try outside our sessions.
The concern that brings you to therapy gives us a starting point. As we explore it, we may also begin to understand how it fits into the larger picture of your life: your history, your relationships, your sense of yourself, and the ways you’ve learned to manage painful experiences.
The aim is to relieve suffering and create more room to live as you want to. As you come to understand yourself more fully, patterns that once felt inevitable can become more open to choice. That can mean making decisions that better reflect your aims and desires, finding more satisfying ways to relate to others, and allowing yourself greater freedom for creative self-expression.
What actually happens in a session?
There are at least two ways of answering this, and I’ll give both.
The first is that psychoanalytic therapy is very singular. Every client and every therapist is a unique person, and the relationship that unfolds between them is therefore also unique. Following that, every session may appear a little unique, making it hard to generalize too much. For instance, we can’t say what will be discussed on session 10, or what interventions will be effective from the outset.
The second thing to say is that there are some guiding principles for psychodynamic work. These principles will likely show up regularly, sometimes in every session, for every client. They are the following:
Free association: This one is a loaded term which doesn’t mean simply “say whatever you want”, although sometimes that is how it looks. Free association more specifically means it is the patient’s role to bring to each session what they’d like to talk about. This doesn’t mean planning a week ahead or even an hour ahead. Sometimes people don’t know what they want to talk about until the minute the session starts, and then they start speaking. The point is that the invitation is for the patient to begin to explore their inner world and try to talk about it as much as possible. The other element of free association is that it is best to try to speak without censorship. Sometimes what is coming to mind may feel irrelevant, offensive, or bizarre. Those are important things to give words to as well.
Questions: Psychodynamic therapists ask a lot of questions. This is not all they do, but it’s a big part of it. There are at least two reasons for this. The first is to elicit more information for the therapist to know and to better help them understand their patient’s inner world. The second, following an ancient tradition since Socrates, is that the process of questioning can lead to a better, more thoughtful life. The role of questions in psychoanalytic treatment is akin to adding oil to a stuck machine: it gets it moving again.
Interpretations: This is another loaded term. Interpretations, and the act of interpreting, come from both the patient and the therapist. Both attempt to try make some sense and meaning from the speech and the stories that emerge from the client over time. The key phrase is over time. Making interpretations too quickly closes down exploration and the therapeutic process. Psychoanalytic therapy is much less interested in answers than it is in questions. In fact, the best kind of interpretation is the one that opens up more avenues for questions, thought, and feeling.
Attention to transference: Transference is what happens between the therapist and client. In psychodynamic therapy, transference is important to discuss, to bring out into the open, and to explore. It is about asking what’s going on in the relationship between the therapist and client that can be used to understand broader patterns in the client’s life.
What does it help with?
Psychodynamic therapy can be adapted to a wide range of mental health concerns. The work takes shape around the person seeking help: what they’re struggling with, how they experience it, and what they hope will change. In my experience, it is particularly helpful for addiction and substance use, anxiety and depression, personality disorders, panic, questions about identity and purpose, and relationship struggles. These are some of the concerns this approach can help with, rather than a complete list.
Often, part of the suffering involves feelings or patterns that are hard to understand, put into words, or change—even when we recognize that something is wrong.
Talking about these experiences with an attentive therapist can bring understanding where there has been confusion or self-judgment. As patterns become more recognizable, we can begin to explore how they developed, what keeps them going, and what happens when we respond differently. Over time, this can help relieve distress, make us feel more at ease with ourselves, and give us greater freedom to choose how we act and relate to others.
How long does it take, and how do I know it’s working?
“But psychoanalysis is no way of life. We all hope our patients will finish with us and forget us, and that they will find living itself to be the therapy that makes sense.” (Donald Winnicott, “The use of an Object”, 1969).
This quote from psychoanalyst Donald Winnicott is both vague and very precise when it comes to psychoanalytic treatment. There are no prescribed or fixed notions at the beginning of any treatment of how long it will last or what the effects will be. It is (usually) the patient’s choice to begin and to end treatment when they see fit. This may be done for financial reasons, for time reasons, for therapy having “done enough” and the person begins to feel better, or any number of other reasons. There’s simply no telling how a treatment will end from the vantage at the beginning. And who is to say from the outset how a person finds “living itself to be the therapy that makes sense”?
But, there are practical considerations that a client is considering before they enter long-term psychodynamic treatment: time, money, energy, etc. I don’t think it’s helpful to say something like “Well, who knows, maybe it’ll last forever, and it might not even do anything for you.” That’s not only discouraging to many, it’s simply untrue.
There are things we know and things we don’t know about this kind of treatment. We know that people generally get better throughout and after their work in psychoanalytic therapy.
What we don’t know is what this “better” looks like. Some people may address and resolve the reason they came to therapy in two months, but they want to keep going, driven by a desire for understanding. Others may experience changes in their life that bring new things into therapy as time moves along. Still others find that their presenting concerns were much more entrenched in their personality and subjective dynamics than they had originally assumed, and it needs a lot of therapeutic work to get things unstuck.
After some time, many people report noticing a familiar pattern before repeating it, recovering more readily after conflict, feeling less constrained by shame, or experiencing relief in the difficulty that brought them in. On the other hand, if things feel stagnant, this is worth exploring within the therapeutic frame as well. All is grist, as the saying goes, for the therapeutic mill.
In my practice, an initial ball-park estimate for most people is to expect at least 6 months or one year of meeting once a week. This is a heavy generalization, and should be taken with a grain of salt.
The practical questions: Insurance, fees, scheduling, and privacy
Most therapists these days have responded to the economic needs of their clients, which means accepting insurance. Psychodynamic therapists are no different, and this kind of therapy is often covered by insurance, in my experience.
The difficulty with insurance is that there is more of an administrative burden on both client and therapist, things are less private, and the therapy is more surveyed for administrative reasons. One example of this is that the therapist must document in each note why continuing therapy is “medically necessary”. Given the open-ended invitation of psychoanalytic therapy, this presents some challenges. But this should not present as a barrier to treatment altogether.
If you don’t want to use insurance, there will be a cash pay fee involved. This is either set by the therapist from the outset in a way that makes sense for their livelihood (for example, my fee is $150 for an intake and $120 for continuing sessions, with sliding scale options) or it is worked out entirely on a case-by-case basis, and the therapist will simply ask what the client can afford.
Scheduling: traditional psychoanalysis is done 3 to 5 times per week. More modern approaches and psychodynamic therapy in general trends towards 1 to 2 times per week. That said, I believe that flexibility is essential, and so I and many of my colleagues see clients on varying bases: every other week, once a month, as needed, etc.
Privacy: since psychoanalytic treatment is a psychotherapy, Clients are protected by HIPAA confidentiality laws. Everything in session is private with some exceptions: (a) immediate risk of harm to self or others; (b) child or elder abuse; (c) notes can be subpoenaed; (d) some basic information to an insurance company for coverage if insurance is involved; (e) minimum information necessary to share with a clinical supervisor.
Is psychoanalytic therapy right for me?
This is a tough question to answer without knowing who the “me” is that’s asking the question, but I understand some people are trying to figure out what kind of therapy would be helpful for them. There’s technically only one way to find out if psychoanalytic therapy is right for you, and that’s to try it out as an experiment. You might even say to the therapist something along the lines of, “I’m not quite sure what I need right now, but I want to try this out for a bit.”
In my practice, I work especially well with people who want to understand recurring difficulties in their lives and relationships, including patterns they recognize but have struggled to change. They may be curious about their inner lives, or simply frustrated by feeling stuck and interested in exploring why. My approach offers time and space for that exploration, particularly for people seeking an ongoing therapeutic relationship.
Regular meetings help this work develop. Practical circumstances—such as safety, housing, finances, and other care needs—also shape what is possible and what support would be most helpful. We can talk through these circumstances together during a consultation, including whether my practice is a good fit or whether additional support would help make the work possible.
You don’t need to arrive knowing how to examine your feelings or feeling ready to “go deep.” Part of our work is finding a rhythm and pace at which you can begin to speak freely, feel listened to, and become curious about your own experience.
Where to begin
You don’t need to know exactly what’s wrong or how to put it into words before reaching out. You might have a particular concern, recognize a pattern you want to change, or simply feel that something in your life needs attention. Any of these can be a starting point.
If this approach sounds like something you’d like to explore, you’re welcome to contact me for a consultation. We can talk about what brings you to therapy, what you’re hoping for, and any questions you have about working together. That conversation is also a chance to get a sense of each other and consider whether my practice feels like a good fit.
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1 In keeping with absolute accessibility I’m trying to maintain in this short article, I’m avoiding all the scholarly practices of citations, argumentation, etc. This is an easy-to-digest guide to this kind of therapy, mostly tailored to clients or to referring clinicians.
Image source: https://www.madinamerica.com/2022/10/psychodynamic-therapy-beats-dbt-improved-reflective-functioning/
