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The Therapy Relationship in Psychodynamic Therapy Versus CBT

A good therapy relationship is more than warm feelings.

We repeat our relationship patterns throughout our lives. Our patterns are shaped by our earliest attachments, which provide the templates for our subsequent relationships. Because they are present from the beginning, our patterns can be as invisible to us as water to a fish.

Psychotherapy is a relationship and patients bring their templates and patterns into it. As psychotherapists, we enter the gravitational field of our patients’ problematic relationship patterns, experiencing and participating in them. Through recognizing our own unavoidable participation in these patterns, we help our patients understand and rework them.

This is how psychotherapy changes lives. This is the heart of psychodynamic therapy.

Vanessa, a woman in her late 30s, is elegant, educated, and successful. She carries herself with a regal bearing and looks and dresses like a Vogue model. She is pursued by the kind of men most women only fantasize about. Yet she is lonely. She has never been able to keep an intimate relationship and she suffers from chronic low-grade depression.

Vanessa has attempted therapy several times. She says, unhappily, that it has never changed anything, and that the therapists always end up wanting her approval.

Colleagues trained in CBT rarely attach much significance to Vanessa's comment about her past therapy relationships. Some venture that she may need a secure therapist who won’t be intimidated by her looks or status.

In fact, it is irrelevant whether Vanessa's therapist is personally secure or insecure. She doesn’t need a secure therapist. She needs a therapist with the self-awareness and courage to notice that twinge of insecurity in her presence, treat it as important information, and use it in the service of understanding and change.

Such a therapist might say: “You know, you have come here for my help and yet in many of our interactions, I'm aware of a vague feeling of wanting to impress you or gain your approval, which of course doesn’t help you at all. I’m trying to understand what it means, and whether it might be a window into understanding something about what happens in your other relationships. Perhaps this is something that feels familiar to you.”

And there, real therapy may begin.

Vanessa cannot tell the therapist what goes wrong in her relationships because she does not know. Instead, she shows him by recreating her relationship patterns in the therapy relationship. The things she does to try to draw others closer—automatically maneuvering for status—are the very things that keep them at a distance. Women feel envious or deferential. Men view her as a conquest or out of their league. Either way, real intimacy is impossible.

What the patient does in the room with the therapist reveals their lifelong relationship patterns. And in the therapy relationship, these patterns can be recognized, understood, and reworked.

This is central to psychodynamic therapy—and notably absent from other therapy approaches.

A prominent CBT thought leader wrote an article about myths and realities of CBT. According to the author, it's a myth that CBT downplays the therapy relationship. To counter this, the author explained that CBT therapists “do many things to build a strong alliance. For example, they work collaboratively with clients… ask for feedback… and conduct themselves as genuine, warm, empathic, interested, caring human beings.”

I expect that much from my hair stylist or real estate broker. From a psychotherapist, I expect something else and something more. The CBT thought leader seemed to have no concept that the psychotherapy relationship offers a window into a patient’s relationship patterns and inner world—and can become a relationship laboratory and sanctuary where lifelong patterns can be recognized, understood, and reworked.

Some people may be satisfied with therapists who “work collaboratively” while providing standardized interventions from an instruction manual (read my post about "manualized" therapy here). But those who want to change their destiny will want a psychotherapist with the self-awareness, training, and courage to see and speak about what matters.

Jonathan Shedler, PhD practices psychology in San Francisco and provides clinical supervision and consultation to mental health professionals worldwide. He is a Clinical Professor in the Department of Psychiatry and Behavioral Sciences at the University of California, San Francisco.

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