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The Therapy Relationship in Psychodynamic Therapy Versus CBT

A good therapy relationship is more than warm feelings.

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

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

This is therapy that changes lives. This is the heart of psychodynamic therapy.

Caroline, 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 been unable to keep an intimate relationship and she suffers from bouts of depression.

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

Colleagues trained in CBT and other “evidence-based” therapies rarely attach much significance to Caroline’s comment about her past therapy relationships. Some venture Caroline may need a secure therapist who won’t be intimidated by her looks or status.

It is irrelevant whether Caroline’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 Caroline’s presence, treat it as information, and use it in the service of understanding.

Such a therapist might say: “You know, you have come here for my help and yet in many of our interactions, I am 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 figure out what it means, and whether it could be a window into understanding something about what happens in other relationships. Perhaps this is something that feels familiar to you.”

And there, real therapy may begin.

Caroline could not have described what went wrong in her relationships: The things she did to try to draw others closer were the very things that precluded connection and intimacy. Women were envious or deferential. Men viewed her as a conquest or out of their league. Either way, intimate connection was impossible.

Caroline couldn’t tell her therapist this; she showed him. What the patient does in the room with the therapist reveals 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 therapies.

A prominent CBT author and thought leader wrote an article about the myths and realities of CBT. One myth, according to the author, is 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 more. The CBT thought leader seemed to have no concept that the therapy relationship is a window into a patient’s inner world, and a relationship laboratory and sanctuary where lifelong patterns can be recognized and understood, and new ones created.

Some people may be satisfied with therapists who “work collaboratively” while conducting therapy according to an instruction manual (read my post about "manualized" therapy here). Those who want to change their destiny will want a therapist with the self-awareness, knowledge, and courage to see and speak about what matters.

Jonathan Shedler, Ph.D., practices psychology in Denver, CO and online by videoconference. He is a clinical associate professor at the University of Colorado School of Medicine in Denver, CO.

To find a therapist, please visit the Psychology Today Therapy Directory.