What is psychodynamic psychotherapy?

Where the method comes from

Psychodynamic psychotherapy is a daughter of psychoanalysis. It takes over the founding assumption — that an unconscious conflict stands behind a symptom — and gives up nearly everything that makes psychoanalysis costly: the couch, the high frequency of sessions, the years, the ambition to rebuild the personality. What remains is a procedure conducted sitting up, confined to a single focus, and pursuing a goal fixed in advance.

Its special standing in Germany is owed to one woman and to an argument that at first has little to do with psychotherapy. Annemarie Dührssen, psychiatrist and psychoanalyst at the Institute for Psychogenic Illness of the Berlin regional health insurance fund, published in 1962 a follow-up study of 1,004 patients¹ and in 1965, together with Eduard Jorswieck, an empirical and statistical investigation into the performance of psychoanalytic treatments.² What they showed convinced the insurers: patients who received outpatient psychotherapy spent fewer days in hospital.

On May 3, 1967, the Guidelines on the provision of psychotherapy in statutory outpatient care came into force — a text of three and a half typewritten pages that established a system of care existing in this form in no other country.³

Two things about this are remarkable. First, Dührssen was ahead of her time: she was among the first anywhere to test psychotherapy empirically, at a period when the profession regarded the question of evidence as impolite. Second, the decisive argument was one of health economics rather than of clinical outcome. Payment followed not because symptoms demonstrably disappeared but because hospital days demonstrably fell. That setting of the points still shapes the system today.

How a course of psychodynamic psychotherapy proceeds

The German Psychotherapy Guideline describes the procedure as comprising “etiologically oriented forms of therapy by which the unconscious psychodynamics of currently effective neurotic conflicts and structural disorders are treated, with attention to transference, countertransference and resistance”. A concentration of the process is to be achieved “by limiting the treatment goal, by a predominantly conflict-centered approach, and by restricting regressive processes”.⁴

In plain language: the therapist looks for the one conflict that carries the present complaints, and stays with it. He notes how the patient draws him into the matter — that is what transference and countertransference mean — but does not make this relationship the principal subject. And he prevents the patient from falling back into childlike ways of behaving, rather than encouraging it as psychoanalysis does.

In practice it looks like this. The two sit facing each other. The session lasts fifty minutes, as a rule once a week, less often twice; more than three hours a week is permitted by the Guideline in no procedure at all. The patient talks, the therapist listens, asks, and interprets — that is, he draws connections between what is happening now and what happened earlier. In doing so he is markedly more active than an analyst would be.

Treatment is preceded by an application. The therapist writes a report to an independent assessor, who decides on authorization. Up to 60 hours are granted first, and up to 100 at a second step.⁵ Ahead of that stand up to four trial sessions in which both sides establish whether they wish to work together.

An example

The following account is an anonymized composite of typical cases.

A woman of about forty comes with recurring stomach complaints. The internist has found nothing; two examinations, nothing. She is, she says, simply sensitive.

The first sessions are about work. She describes a superior who does not keep his commitments, and describes saying nothing about it. Then she describes the job before that. It was similar. And the one before that too.

The therapist holds on to this. He asks when she first sensed that contradiction was dangerous. The answer does not come at once, but it comes: with her father, who understood contradiction not as an opinion but as an attack. She never tried. And because she never tried, she does not know to this day what would have happened.

After some months she says in a meeting, for the first time, that she remembers a commitment differently. Nothing happens. The stomach complaints grow less frequent.

What has been achieved here is no small thing: a stomach pain without medical findings becomes an intelligible pattern, and a pattern becomes an action.

This achievement, however, is not the exclusive property of the procedure. Cognitive psychotherapy likewise looks for the fabric of relationships and the patterns of thought that steer a behavior, and it looks for them with the same claim to completeness — only more purposefully, because it knows from the outset what it is looking for. Where the procedures really differ is shown in the section on limits.

Where is psychodynamic psychotherapy effective?

The evidence is better than critics occasionally claim. It is not, however, the evidence it is taken to be — more on that in the following section.

What is examined internationally is short-term psychodynamic psychotherapy. In 2001 Falk Leichsenring compared six studies on depression and found the approach equivalent to cognitive behavioral therapy; because of the small number of studies he himself described the result as preliminary.⁶ A Cochrane review of 2014 concluded that short-term psychodynamic psychotherapy is effective for common mental disorders.⁷ An update of 2015 confirmed its efficacy in depression⁸, and a 2017 meta-analysis tested specifically for equivalence with other empirically supported treatments and found it confirmed.⁹

That is a respectable record, and it should not be talked down. Anyone claiming that psychodynamic procedures are ineffective goes beyond the data.

Which studies are actually meant

Now comes the point that appears in no practice brochure. The studies just cited do not examine psychodynamic psychotherapy in the sense of the German Guideline. They examine another procedure that resembles it.

Short-term psychodynamic psychotherapy, as studied in this literature, is something other than the German guideline version. What matters here is not the number of sessions — in the meta-analysis by Driessen and colleagues it ranged from three to eighty — but a condition for inclusion in the analysis: only treatments whose duration was fixed from the outset were considered, expressly not those in which the limit emerged only in retrospect. The German guideline version does not meet that condition. There the duration follows from successive authorization steps, first up to 60 hours and then up to 100, and the Guideline requires no manual in any case.

That the transfer is nevertheless made everywhere without comment is the real blind spot of the German debate.

To this comes a finding from within the same line of research that is seldom cited alongside it. An earlier meta-analysis by the same working group compared short-term psychodynamic psychotherapy directly with other forms of psychotherapy, among them behavior therapy and cognitive therapy, across thirteen studies with 735 participants. The other procedures proved statistically superior: the pooled difference was −0.30, with a confidence interval of −0.54 to −0.06. At the three-month and twelve-month follow-ups the advantage persisted but was no longer statistically reliable.

The British database of quality-assessed reviews noted that the authors' conclusion — that short-term psychodynamic psychotherapy is effective for depression — does not take this finding into account and therefore does not fully match the data presented.¹⁰

And finally: in Germany, psychodynamic psychotherapy has never undergone assessment by the criteria of evidence-based medicine. In 2008 the Federal Joint Committee undertook to re-examine the procedures already admitted, and in 2019 it discontinued that undertaking.¹¹

None of this shows that the procedure does not work. It shows that the certainty of the statement is lower than the citation practice suggests.

Where it reaches its limits

The first limit is uncontested and stands in every textbook. In acute psychosis, in acute danger to the self, and in severe structural impairment the procedure is not indicated; there a more closely supervised setting and different means are needed.

The second limit lies in the conception of what heals. Psychodynamic psychotherapy treats insight itself as the effective agent: whoever has understood the conflict need not repeat it. That does happen — only not reliably and not always quickly. Between “I understand why I say nothing” and “I say something” lies, for many people, a considerable distance that has to be overcome.

Cognitive psychotherapy treats insight as a finding and not as a treatment. It asks further: does the conviction that carries the pattern hold true? Is contradiction in fact dangerous? What happened when the woman contradicted her superior in the meeting? It tests the conviction against reality and corrects it where it does not hold — and only this cognitive correction leads to the overcoming of the old behavior and makes the new behavior a matter of course.

How quickly either succeeds is often decided, in clinical observation, by the experience of the therapist who has seen such a pattern many times before.

The third limit is duration. A hundred hours at one hour a week comes to roughly two years. That is the ceiling and not the rule — but it is the order of magnitude in which the procedure thinks. How much of it is necessary and how much is owed to custom cannot be said without comparative studies, and for the German guideline version there are none.

Psychodynamic psychotherapy or behavior therapy?

This is the question most people face when a place is offered to them. Both procedures are covered by insurance, both are practiced about equally often, and the choice frequently falls to whoever has an appointment free first.

	Psychodynamic psychotherapy	Behavior therapy
Subject	the unconscious conflict behind the symptom	behavior, and under the Guideline thinking as well
Approach	conversation, interpretation, relationship	cognitive restructuring, practice, confrontation
Who structures	rather the patient	rather the therapist
Maximum allowance	100 hours	80 hours
Base of studies	narrower	broadest
Most suited to	recurring relational patterns	circumscribed disorders such as anxiety, panic and obsessive-compulsive disorder

The last row is the one that matters most in practice. Anyone suffering from panic disorder, a phobia or obsessive-compulsive disorder will find for behavior therapy by far the broadest base of evidence and the shortest documented treatment times. Anyone who notices that the same thing keeps happening to him in relationships may find readier access through a conflict-centered procedure.

Both answers remain incomplete, however, so long as no one asks what becomes of the thinking that steers the phobic behavior and the relational behavior alike.

In detail: What is behavior therapy?¹² and What is cognitive psychotherapy?¹³

The difference from psychoanalysis

Under the Guideline both belong to the group of psychoanalytically grounded procedures, and both go back to Freud. Three decisions separate them.

The goal. Psychoanalysis aims at a structural change in the personality; psychodynamic psychotherapy at a treatment goal limited in advance.

The frame of time. Interpretation here is directed chiefly at what is presently unconscious, there at what was unconscious in the past.

The expenditure. Up to 100 hours sitting up, against up to 300 hours at up to three sessions a week, usually lying down.⁵

All the procedures side by side, with insurance status and hour allowances: What forms of psychotherapy are there?¹⁴

Frequently asked questions about psychodynamic psychotherapy

Does health insurance pay for psychodynamic psychotherapy?

Yes. In Germany it has been covered by the statutory health insurance system since 1967; private insurers generally cover it as well.³ In Switzerland, since the physician-referral model of 2022, it is not the procedure that decides but the physician's referral.

How long does psychodynamic psychotherapy take?

Up to 60 hours are authorized first, and up to 100 at a second step.⁵ At one hour a week that comes to roughly two years. These are upper limits, not standard durations; shorter courses are possible and common.

What does the abbreviation TP mean?

TP stands for tiefenpsychologisch fundierte Psychotherapie, the German name of the procedure. Colloquially one also hears tiefenpsychologische Therapie or Tiefenpsychologie; the same guideline procedure is meant.

Do you lie on a couch?

No. Unlike psychoanalytic therapy, the work is done sitting up, facing each other. The couch belongs to psychoanalysis, where it serves to encourage free association.

What happens in the first session?

Before treatment proper come the psychotherapeutic consultation and up to four trial sessions. In these the complaints are recorded, a diagnosis is made, and both sides establish whether they wish to work together. Only then is the application filed.

What is the assessor procedure?

For authorization the therapist writes an anonymized report, which an independent assessor examines. The assessor does not know the patient and decides on the necessity of the hours applied for solely on the basis of that report.

What is the difference from cognitive psychotherapy?

Both want to understand why someone acts as he does. The difference lies in what happens after the understanding.

Psychodynamic psychotherapy looks for the unconscious conflict. Once it has been found and understood, insight itself is supposed to bring about the change.

Cognitive psychotherapy looks for the self-defeating conviction — for instance: “contradiction is dangerous”. For it, understanding is only the beginning. What follows is a test of whether the conviction holds true at all, and where it does not, it is corrected. Only this cognitive correction changes the behavior.

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