In plain words
People often know what they do without knowing all of why they do it. Someone keeps choosing partners who leave, or goes quiet whenever they are annoyed, or feels flat after good news. Psychodynamic therapy is a way of listening for the patterns underneath those experiences, especially feelings and expectations a person has learned to keep at a distance, and of noticing how the same patterns show up between client and therapist.
The work is collaborative. Therapist and client build a shared understanding, test it against experience, and use the relationship itself as a place where old expectations can be noticed and new responses become possible.
The next section explains the core ideas in order, starting from the basic vocabulary. After that you'll meet Mara, a fictional client whose therapy runs through the rest of the guide.123
Core ideas
Where this approach came from
Psychodynamic therapy grew out of psychoanalysis, the method Sigmund Freud developed in Vienna in the late 1800s and early 1900s. Freud's central idea was that some of what drives us happens outside our awareness, and that painful feelings and wishes can go on shaping our lives even when we don't think about them.
Over the following century, many clinicians kept that idea and disagreed with much of the rest. They formed several schools, which are introduced at the end of this section. Today psychodynamic is an umbrella word for that whole family of therapies.
Four words this guide uses constantly
Almost every idea in this guide is built from four words. Each one comes up again below.
- Unconscious doesn't mean a locked vault of buried memories. It means feelings, wishes, and fears a person has learned not to notice, usually because noticing them once felt dangerous, embarrassing, or useless.
- Conflict means wanting two things that feel incompatible. Someone wants to object to unfair treatment and wants to keep the relationship.
- Anxiety, in this guide, means the uneasy alarm that rises when a difficult feeling starts to surface.
- Defense means anything a person does, usually automatically, to keep a difficult feeling at a distance: joking, changing the subject, explaining the other person's side, going quiet. Defenses aren't bad. They usually protected something once. They become a problem when they are rigid and cost more than they save.15
Feeling, anxiety, and defense: the triangle of conflict
David Malan, a British psychiatrist who studied brief psychodynamic therapy at the Tavistock Clinic in London, drew these ideas as a triangle. One corner is a feeling or wish, such as hurt, anger, longing, or wanting care. The second is the anxiety that feeling stirs up, such as shame or fear of rejection. The third is the defense that calms the anxiety by moving away from the feeling. This is the triangle of conflict.
Here's how it can look. A client describes being interrupted in a meeting, laughs, and says it was nothing. The therapist might ask what the interruption felt like before the laugh. If she says, "Annoyed, and then I worried I'd seem difficult," the triangle is visible: annoyance (feeling), worry about seeming difficult (anxiety), laughing it off (defense).
The defense also keeps the problem going. If someone always waves away disappointment, they never find out whether the other person could have heard it, and they leave feeling vaguely unseen without knowing why.
The triangle organizes questions; it doesn't decode people. A laugh can be a defense, or just a laugh. The therapist checks each step with the client. The aim isn't to strip away defenses or prove there is anger under everything. It is to give the person more freedom to notice what they feel and choose what to do with it.526
Where a pattern shows up: the triangle of persons
Malan drew a second triangle to show where a pattern appears. Its corners are current relationships (a partner, friend, or boss), the relationship with the therapist, and important past relationships, often family. This is the triangle of persons.
Suppose a client expects people to get irritated whenever she asks for something. That expectation might show up with her partner, with the therapist, and in memories of a busy parent. Each corner adds something different:
- the past suggests where the expectation came from
- current relationships show what it costs her now
- the therapy relationship lets both people see it while it is happening
Transference and countertransference
Transference is the word for the ways a person's past relationships shape how they experience the therapist. A client who grew up expecting criticism may hear criticism in a neutral question.
Countertransference is the word for the therapist's own reactions to the client: boredom, protectiveness, irritation, a wish to rescue or impress. These reactions can be useful clues about what is happening between the two people. They are not a window into the client's mind. They can just as easily come from the therapist's own history, a long day, or a full caseload.
Modern psychodynamic therapists treat the relationship as something both people shape. If a client keeps asking for reassurance and the therapist keeps giving it, the useful question isn't only why does she need reassurance? It is also what are we doing together, and why isn't the reassurance landing? When both people slip into acting out a familiar pattern before either notices, that is called an enactment.284
What the therapist actually does
Psychodynamic therapists rely on a few basic moves, listed here from least to most interpretive:
- Clarification: asking for detail so both people understand what happened. "What did you feel when you saw her message?"
- Confrontation, in the technical sense: gently pointing out something the person may not be noticing. It isn't aggressive. "You smiled just now while describing something painful."
- Process comment: describing something happening between therapist and client right now, without explaining it yet. "You agreed with me very quickly just then."
- Interpretation: offering a possible connection the person hasn't made, often between a feeling and a defense, or between one relationship and another. "I wonder if saying it's fine protects you from feeling like a burden, the way it did at home." An interpretation is a guess offered for the client to test. Quick agreement doesn't prove it right.
- Support: helping the person stay steady enough to use the session, through encouragement, practical problem-solving, or slowing down.
Glen Gabbard, an American psychiatrist who wrote a standard training text, describes these moves along an expressive–supportive continuum. Support and interpretation aren't levels of depth. They meet different needs. Someone who is overwhelmed, grieving, or in crisis may need more support; someone who is steady may get more from exploration. The same person can need different things in different weeks.247
Ruptures and repair
A rupture is a strain in the working relationship between therapist and client: a misunderstanding, a moment when the client feels criticized, or a slow drift into going through the motions. Ruptures can be loud, like a complaint or an angry email. More often they're quiet: suddenly agreeing with everything, going vague, or canceling.
Jeremy Safran and Christopher Muran, psychologists who researched therapy relationships, showed how much repair matters. Repair usually starts with the therapist noticing the strain, owning their part, and inviting the client to say what didn't feel right. For a client who usually hides disagreement, having it heard without punishment can be a genuinely new experience.8
The frame
The frame is the set of practical agreements that keep therapy steady: when and how often you meet, fees, contact between sessions, privacy, and what the work is for. A dependable frame means hard feelings can come up without the arrangements themselves being up for grabs. It also makes changes stand out. When the schedule is steady, a sudden urge to cancel is noticeable and can be talked about.
Formulation
A formulation is the therapist's working explanation of this person: why they struggle in this particular way, now, and what might help. It's different from a diagnosis. Two people with the same diagnosis of depression can be stuck for completely different reasons. One may be grieving a loss they have never let themselves feel; another may be caught in harsh self-criticism that began long before any loss.
A psychodynamic formulation pulls together repeating patterns, defenses, important relationships, strengths, and circumstances, including real-world conditions like discrimination, money, or an unsafe workplace. The therapist shares it, checks it with the client, and changes it as they learn more. "Meet the case" shows a full formulation for Mara, and "How a clinician thinks" walks through building one.794
How change happens
Psychodynamic therapy assumes many problems are patterns that once protected the person but now limit them. Someone who learned not to ask for help, so they wouldn't be humiliated, may end up feeling that no one is ever there.
Change tends to come from three things working together:
- Understanding: recognizing the pattern, what it protects, and what it costs.
- Feeling: being able to experience, with someone present, the feelings the pattern was built to avoid.
- A different experience in a relationship: for example, disagreeing with the therapist and finding that the relationship survives.
The main schools, briefly
The psychodynamic family has several branches. They often look at the same session and ask different questions:
- Object relations: what inner pictures of self and others does the person carry, such as a critical boss and a disappointing child, and how do they play out? (Object here is an old technical word for an important person as you experience them.)
- Relational: what are both people creating together in the room?
- Mentalization-based: can the person still think about their own and others' minds when emotions run high? If not, restore that capacity first.
- Brief dynamic: pick one focus, such as a recurring relationship pattern, and work on it within a set number of sessions.
Meet the case
Reason for referral
Mara is a 28-year-old graphic designer at a mid-sized branding studio. She refers herself for weekly psychodynamic psychotherapy after a friend who has been in therapy suggests it. What finally prompts the call is small and painful: her closest friend, Nadia, canceled Mara’s birthday dinner the afternoon it was planned, and two weeks later Mara still hasn’t answered her messages. Mara says she doesn’t understand why she’s “being so weird about it,” and that the silence is starting to feel like the friendship is ending without anyone deciding it should.
Presenting concerns
Mara describes two linked problems. First, when someone disappoints her, she goes quiet. She doesn’t argue or complain; she tells herself the other person has good reasons, says it’s fine, and then finds she has less and less to say to them. She has let at least two friendships fade this way. Second, at work she holds back. She is respected for her designs but rarely pitches her own ideas in meetings, and she is unsure whether to apply for a senior designer role that her manager has mentioned.
In her words: “I don’t want to be the needy one. I’d rather just handle it.” In the first session she sits upright, smiles often, and speaks quickly about deadlines before mentioning the dinner almost in passing. She calls it “nothing,” explains how overloaded Nadia is, and then apologizes for using therapy time on something so small. When the therapist slows down on the cancellation, Mara’s voice drops and she says she felt “a bit stupid for caring.”
Background and history
Mara grew up as the elder of two children. Her mother worked long shifts as a nurse and later cared for Mara’s grandmother at home; her father was affectionate but often away for work. Mara describes herself as “the easy one.” She learned to do homework without help, to keep her own disappointments short, and to notice when her mother was too tired for more. She doesn’t describe neglect or harsh treatment, and she speaks warmly about both parents. What she remembers most is a feeling that wanting more attention would add to someone’s burden.
In college she was well liked and productive, with a few close friendships that she worked hard to maintain. Her one long relationship ended two years ago when her partner said he never knew what she wanted. She reports no prior therapy, no significant medical problems, and moderate alcohol use on weekends with no pattern of concern.
Current life and strengths
Mara lives alone in a one-bedroom apartment and has a small, loyal social circle. Nadia has been her closest friend since college. Work is demanding, with frequent late deadlines over the past three months, and Mara reports sleeping about six hours on weeknights and feeling worn down by Thursday. She has one colleague, Dani, whom she can ask for help directly without feeling awkward, which she notices as unusual.
Her strengths are real and useful in therapy: she is thoughtful, loyal, perceptive about other people’s feelings, and willing to question an explanation that doesn’t fit. She keeps commitments and arrives on time.
Assessment
The first two sessions combine relational exploration with ordinary assessment. Mara reports low mood on some evenings, mostly linked to work fatigue and loneliness, without loss of interest in things she enjoys, changes in appetite, or hopelessness. She denies thoughts of suicide or self-harm, now or in the past. Concentration is good outside of tired evenings. The therapist also asks about workload, sleep, and whether anyone at work treats her badly; the workload is heavy but not abusive. The picture is of a capable person whose relationships and confidence are being narrowed by a repeated way of handling wanting and disappointment, with exhaustion adding to it.
Working conceptualization
A conceptualization is a working explanation of the person’s difficulties and a plan for what therapy will focus on. The person and clinician review it together and change it as they learn more.
A psychodynamic formulation starts from what repeats. With Nadia, with past friends, at work, and with her former partner, the sequence looks similar: Mara wants something (to be celebrated, to be chosen, to be known), the wish meets a disappointment or a risk of being seen, and she quickly moves to understanding the other person and shrinking her own need. The relationship is preserved in the short term, but she ends up more alone and more resentful than she lets herself feel.
Malan’s triangle of conflict gives the therapist questions to test. The feeling corner may hold hurt, sadness, and some anger at being let down. The anxiety corner may hold shame about needing and a fear that wanting will make her a burden or drive people away. The defense corner holds what she does to manage that anxiety: minimizing, explaining the other person’s side, being agreeable, and withdrawing. The triangle of persons (see Core ideas) asks whether the same shape shows up in current relationships (Nadia, work), in the therapy relationship, and in remembered ones (being “the easy one” at home).
The therapist holds this as a working hypothesis, not a diagnosis of her motives or a settled story about childhood. It predicts that Mara may agree too quickly with the therapist, say things are fine when they aren’t, and find disagreement in therapy especially hard. If so, those moments in the room become some of the most useful material, because they can be explored as they happen and handled differently.
Goals and treatment plan
- Notice and name what she feels when she is disappointed, before she explains it away
- Tell someone close to her what she wants or didn’t like, and see what actually happens
- Decide about the senior role based on what she wants and the real application process
- Be able to disagree with the therapist and keep the relationship
Weekly 50-minute sessions at a fixed time, with a review of goals at Session 12. The therapist will follow Mara’s own words and recent specific events, check tentative links with her rather than announce them, and attend to what happens between them, including the therapist’s own mistakes. Practical problems such as workload and sleep stay on the table alongside the relational work.
What would change the picture
The formulation should change if Mara’s exhaustion turns out to explain more than the pattern does, if Nadia or her workplace is treating her poorly in ways that make withdrawal reasonable, or if Mara offers an explanation that fits better. A therapist who keeps finding the same pattern everywhere may be repeating it, by becoming the authority who knows best while Mara agrees.
The illustrated course of therapy
The story below follows five moments in this fictional course of therapy. Each scene names the interventions and shows the conversation and clinical reasoning. Session numbers show when events happen; they are not a schedule to copy.
How a clinician thinks
This section shows how a psychodynamic clinician builds a formulation (see Core ideas): first what the formulation covers, then two ways of describing personality, then Mara.
A psychodynamic formulation usually covers: what brings the person now and why now; recurring patterns in feelings and relationships; conflicts and any difficulties in regulating emotion or reflecting on minds; characteristic defenses and how flexible they are; identity and self-esteem; attachment and relationships; strengths; culture, context, and power; and risk and safety.
Personality is described along two dimensions. Personality organization concerns how integrated a person’s sense of self and others is, especially under stress. Personality style describes recurring themes, such as a depressive style organized around self-criticism or an obsessive-compulsive style organized around control and thinking (a personality style, not the anxiety disorder OCD). Nancy McWilliams, an American psychoanalyst whose textbook on personality is widely used in training, presents these as ways of deepening empathy and guiding technique, not as boxes to tick.
A descriptive diagnosis, such as major depressive disorder, names a pattern of symptoms and helps with communication, research, and treatment planning. A psychodynamic formulation adds how the person functions and experiences their difficulties. The Psychodynamic Diagnostic Manual (PDM), a reference written by psychodynamic clinicians to sit alongside standard diagnostic manuals and now in its third edition, organizes this as personality patterns, a profile of mental functioning, and the person’s subjective experience of symptoms.67124
Start with what Mara actually did, not with a theory about her motives. After her friend cancels, she laughs, explains her friend's side, tenses up, and briefly tears up. In the session, the therapist asks what each of those moments felt like to her.
A working guess: hurt, sadness, or anger stirs up anxiety, and staying agreeable protects a relationship she values. The triangle of conflict names that sequence. The triangle of persons asks whether something similar happens with friends, with the therapist, and in her memories of family. Neither triangle explains why the pattern began.
Keep other explanations open. Her laugh might be ordinary social habit, her tears might be grief, and the therapist suggesting anger might itself feel intrusive. Ask what fits her experience and what doesn't before choosing a response.
When the therapist starts late, the first step is acknowledging that real lapse. If Mara says it's fine but goes quiet, the therapist invites her experience before linking it to other relationships. New information changes the formulation, and if anxiety starts to scramble her thinking, the therapist slows down instead of pressing.527
Examples of the core ideas
These moments from Mara’s therapy illustrate different concepts. One case across sessions follows the course of therapy in order.
What this illustrates: Mara moves away from a painful feeling by laughing and explaining her friend’s side. The example connects an observable response to the triangle of conflict.
The therapist says, “When she canceled, I wonder if that stung.” Mara laughs. “I’m not an angry person.” She rubs her neck and begins listing how busy her friend has been: a new job, a sick parent. Then her eyes fill, and she says, “Anyway.”
Placed on the triangle, held loosely: defense (laughing, excusing her friend, “anyway”), anxiety (neck tension, speeding up), feeling (hurt, possibly anger, and grief about not being a priority).
What this illustrates: The example compares Mara’s response to her friend, her therapist, and remembered family relationships. The therapist’s late start is a real event to acknowledge before exploring older expectations.
The therapist starts five minutes late and apologizes. Mara says, “No problem at all,” and is quieter than usual. Later, talking about a coworker, she says her mother “always had a lot on her plate,” and that she learned early to be “low-maintenance.”
Current: she withdrew after her friend canceled. Therapist: “No problem at all” after a real lapse, then quiet. Past: a remembered role as the child who needed little.
What this illustrates: Mara’s quick agreement and later cancellation prompt the therapist to ask how the previous session felt. The response opens a conversation about strain in their relationship.
After the therapist links Mara’s stepping back at work to her role with her mother, Mara agrees immediately, then cancels the next session by email. The therapist recognizes a withdrawal rupture and, at the next meeting, says: “Last time I said a lot about your mother and you agreed very quickly. I wonder if some of it didn’t sit right, or felt like I was telling you what’s wrong.” Mara pauses, then says it did feel a bit like being graded.
In the room
Choose what you want to work on. Each intervention includes an explanation and three worked examples with Mara. Meet the case gives the background. These groups are options, not a treatment sequence.
Build an understanding with the person
Explain the purpose of the work, listen to specific experiences, and develop a tentative account of the recurring difficulty. Malan’s triangles can help connect feelings, anxiety, protective responses, and relationships without treating a hypothesis as a fact.
Explain the work in the person’s own terms
Intervention
Explain the work in the person’s own terms
Explain how this kind of therapy could help with what the person came for. Mara wants closer friendships and more confidence at work, but she goes quiet after disappointment. You might suggest noticing those moments together, understanding what makes speaking up hard, and practicing saying what she wants. That explanation is called a treatment rationale. Be honest about uncertainty: exploring a pattern won't prove one childhood cause, and understanding alone may not change behavior. Explain the frame too (see Core ideas): when you meet, how often, fees, contact between sessions, privacy, and how you'll check together whether the work is helping. Mention other options. A good rationale invites an informed choice. It isn't a sales pitch.
What you do or say
- Ask what the client understands and what they want explained.
- Connect the proposed method to their concrete goals.
- Define relevant theoretical ideas in plain language.
- Explain the session schedule, contact arrangements, privacy, and how you will review progress together.
- Discuss alternatives and invite doubts about fit.
- Revisit the rationale using the client’s experience of the work.
One possible response: You want less withdrawal. We’re examining what happens between disappointment and pulling away.
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
After several sessions Mara asks why they keep returning to moments of disappointment rather than receive a list of coping techniques. She wants less withdrawal and more confidence at work, and she worries that talking about her mother will become endless. The therapist has noticed a possible link between wanting, shame, and accommodation but hasn't discussed the rationale clearly. Mara's question is reasonable feedback about informed participation. It is also an opportunity to clarify the weekly treatment frame and how they will evaluate whether the work helps. The therapist can describe exploring a repeated pattern while also practicing different responses and addressing practical obstacles. Mara may prefer more structure or another treatment. The explanation needs to connect to her goals and leave her free to question the method, rather than interpreting the question as resistance.
When to use it, and when not
Use it at the start, and again whenever goals, the schedule, or the fit change. Don't use a theory lecture to quiet her doubts, and don't treat preferring another approach as a sign she is avoiding something.
What the clinician is tracking
Check that Mara understands what you're proposing, has really chosen it, and agrees on the goals. Notice whether you are explaining a useful idea or defending your way of working.
Three example exchanges
- Mara
- Why talk about the friendship again?
- Therapist
- You want less withdrawal. We’re examining what happens between disappointment and pulling away.
- Mara
- So it should connect to what I do differently.
- Therapist
- Yes. We’ll review whether it helps you recognize and choose those moments.
The rationale is tied to a current goal.
More examples
- Mara
- Will finding the childhood cause fix it?
- Therapist
- There may be several influences. Understanding can help, but new responses usually need to be lived and practiced.
- Mara
- I want to know we’re getting somewhere.
- Therapist
- Let’s choose signs of useful change and a time to review them.
The therapist avoids a guaranteed insight cure.
- Mara
- I want a more structured approach.
- Therapist
- That may be a good fit. What structure feels missing here?
- Mara
- Clear actions between meetings.
- Therapist
- We can discuss adding them and consider another approach if that suits your goals better.
Preference is treated as feedback, not pathology.
Common slips
- Promising insight will automatically remove symptoms.
- Leaving the treatment frame vague.
- Interpreting every doubt as resistance.
Ask without deciding what the answer means
Intervention
Ask without deciding what the answer means
Ask what happened and what it was like before deciding what it means. When Mara says she agreed with a friend but felt hurt afterward, ask about that one exchange: what she wanted to say, what she expected would happen if she said it, and what she did instead. Psychodynamic therapists call this therapeutic inquiry. The word dynamic refers to feelings and wishes pulling in different directions, here wanting closeness and fearing she'll ask for too much. Stay close to her words and leave time for her to answer or correct you. Inquiry also covers the ordinary things: mood, sleep, physical health, practical pressures, and safety. Over several conversations, you and Mara build an explanation together that you can both revise.
What you do or say
- Identify one specific event or change in the account.
- Describe what you observed and ask Mara what was happening for her.
- Ask an open question about that moment.
- Follow the person’s words into feeling, meaning, or context.
- Ask Mara what you have missed and consider other explanations together.
- Summarize a tentative understanding and invite revision.
One possible response: What was it like when you first saw her message?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Mara is 28 and works as a graphic designer. At her first session she sits upright, smiles, and describes a difficult deadline before mentioning that her closest friend canceled her birthday dinner. She says it was fine and immediately explains how overwhelmed the friend is. Two weeks have passed without Mara replying to the friend's messages. When the therapist notices that distance, Mara apologizes for bringing something so small into therapy. The therapist could assume anger, depression, or fear of rejection, but none has been established. Mara also reports genuine exhaustion at work. A question about the moment she saw the cancellation can make room for disappointment, irritation, indifference, or another experience. The therapist needs to hear her language and assess broader functioning, rather than make her story prove a psychodynamic idea.
When to use it, and when not
Use it from the first session, and any time you notice you've become too sure what something means. Don't press for private meanings before there is enough trust. If there are urgent safety or practical concerns, ask about those directly first.
What the clinician is tracking
Keep what you observed separate from what you're guessing. Notice whether your question helps Mara say more, or makes her search for the answer she thinks you want. When she corrects you, treat it as useful information.
Three example exchanges
- Mara
- It was fine. I just haven’t answered.
- Therapist
- What was it like when you first saw her message?
- Mara
- I felt silly for expecting the dinner.
- Therapist
- What made expecting it feel silly?
The question opens personal meaning without prescribing anger.
More examples
- Mara
- You’re making it sound like I’m punishing her.
- Therapist
- I don’t know that. What has kept you from answering?
- Mara
- I’ve been too exhausted to answer anyone.
- Therapist
- Then we need to understand that exhaustion and whether this friendship feels different.
Practical and relational possibilities remain separate.
- Mara
- You keep asking whether I’m angry.
- Therapist
- I’ve been steering toward my guess. Let’s leave it. What stands out to you?
- Mara
- Feeling unimportant.
- Therapist
- We can start with that rather than make anger the answer.
Inquiry recovers from the therapist’s premature theory.
Common slips
- Turning an inference into a fact.
- Asking several questions before listening to one answer.
- Using curiosity to avoid ordinary clinical assessment.
Build a recurring pattern from specific events
Intervention
Build a recurring pattern from specific events
Build a picture of a repeating pattern from several real events. One useful map is the cyclical maladaptive pattern, from time-limited dynamic psychotherapy, a brief psychodynamic model developed by Hans Strupp and Jeffrey Binder and later taught widely by Hanna Levenson. It traces five steps: what the person wishes for, what they expect others to do, what they do, how others actually respond, and what they then conclude about themselves. For Mara: she wants recognition, expects to seem demanding, says little, gets little acknowledgment, and concludes she doesn't matter. Cyclical means the outcome strengthens the expectation, so the loop repeats. It doesn't mean she causes how others treat her. Map one event at a time, compare them, and pay attention to exceptions, like the colleague who welcomes her ideas.
What you do or say
- Choose a concrete event and identify the person’s wish.
- Ask about the expected response and the action taken.
- Ask what the other person did and what Mara then thought or felt about herself.
- Compare with another event, including the therapy relationship if relevant.
- Look for exceptions, context, and alternative explanations.
- Offer a working map and identify a possible different next action.
One possible response: What do you expect would happen if you asked?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Earlier in the illustrated case (Session 7: include the therapist’s real lapse): The therapist owns the delay and asks about its impact. A tentative comparison with the friendship partly fits. Mara adds that a paid professional relationship should be different, and that correction goes into the formulation.
By Session 12 Mara has described the canceled birthday dinner, agreeing quickly in therapy, and stepping back from a promotion. Each involves wanting something and then minimizing the wish, but the circumstances differ. The friend has actual competing demands, the therapist holds professional authority, and work has an explicit application process. Mara recognizes that being low-maintenance often preserves harmony while leaving her resentful and unseen. She also describes a colleague with whom she can ask directly and feel respected. That exception is important evidence, not a detail to discard because it weakens the pattern. The therapist invites Mara to map one event at a time and compare them. A useful formulation should predict where another response could help and where the external situation needs action, rather than provide a polished story about her personality.
When to use it, and when not
Use it once there are enough examples to compare. Don't turn one event into a verdict on her personality, and don't let a relationship pattern explain away discrimination, exhaustion, or someone else's behavior.
What the clinician is tracking
Compare events step by step: what Mara wanted, expected, did, and heard back. Look for times the sequence went differently. Ask whether the map makes sense to her and points to something she could try.
Three example exchanges
- Mara
- I never ask, then I feel forgotten.
- Therapist
- What do you expect would happen if you asked?
- Mara
- They’d think I was demanding.
- Therapist
- So not asking protects you from that fear and also leaves the wish invisible.
The cycle contains both protection and cost.
More examples
- Mara
- I can ask my colleague directly.
- Therapist
- What’s different with her?
- Mara
- She tells me clearly what she can do.
- Therapist
- Then reliable boundaries may make wanting safer; the pattern isn’t fixed everywhere.
The colleague’s clear responses show when Mara can ask directly. That exception suggests what may make asking easier in other relationships.
- Mara
- You’re saying it’s my fault people ignore me.
- Therapist
- That’s not a fair conclusion. Others’ actions and constraints matter too.
- Mara
- I need that in the picture.
- Therapist
- Let’s redraw it with what you control and what you don’t, including where people have failed you.
The therapist acknowledges that other people's behavior matters and separates it from the choices Mara can make herself.
Common slips
- Using a pattern label instead of a sequence.
- Ignoring exceptions and environmental conditions.
- Equating participation in a cycle with blame.
Explore feeling, protection, and imagination
Follow how the person experiences a feeling and what makes it difficult to express. Images and imagined situations can offer another way to understand that experience, when they are meaningful to the person.
Understand what a protective habit does
Intervention
Understand what a protective habit does
Notice a protective habit and wonder, with the person, what it does for them. Mara starts to describe feeling hurt, then quickly explains how busy her friend was. You might say, "You moved from what it was like for you to what it was like for her. What happened in between?" Pointing out a defense means showing its possible purpose kindly and tentatively, not catching someone being dishonest. Defenses aren't bad: humor, understanding others, and restraint are often valuable. The useful question is when a habit has become automatic and costs more than it protects. Start with what you can both see, acknowledge what the habit protects, then explore the cost. Respecting the protection makes change easier to consider.
What you do or say
- Describe the repeated protective move concretely.
- Recognize its useful or understandable purpose.
- Ask what happens just before it appears.
- Ask whether Mara's response helps her avoid a feeling or protect a relationship, and listen to her explanation.
- Explore what it leaves out and whether another response is tolerable.
- Offer support and change your explanation when Mara's response shows you have missed something.
One possible response: Understanding her matters to you. Does it also help put your disappointment aside?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Mara describes another canceled plan and spends several minutes listing her friend's pressures. When the therapist asks what the cancellation meant to her, she smiles and says she doesn't want to be unfair. She has already shown that considering others matters deeply to her. The same habit, however, seems to leave little room for her own disappointment. When she briefly says she wanted to matter, she immediately explains that everyone is busy. The therapist can notice how quickly understanding the friend follows naming a wish. The possible function is protecting the friendship and avoiding shame about needing, but this remains a hypothesis. Mara may also know real details the therapist lacks. The intervention should respect her loyalty and learn what it protects, rather than announce that being considerate is merely an excuse for suppressed anger.
When to use it, and when not
Use it when a repeated protective habit is limiting the conversation and the relationship can bear naming it. Don't take apart someone's coping before they have other support, and don't treat culturally meaningful restraint as a problem. If your guess about its purpose doesn't fit, drop it.
What the clinician is tracking
Track what the habit gains and costs, what anxiety shows up when it loosens, and whether Mara recognizes the purpose you suggested. Notice the difference between a free choice and an automatic narrowing.
Three example exchanges
- Mara
- She has so much going on.
- Therapist
- Understanding her matters to you. Does it also help put your disappointment aside?
- Mara
- Maybe. Then I don’t have to ask for anything.
- Therapist
- What would feel risky about letting the disappointment have a little room?
The therapist asks how explaining the friend’s position helps Mara put her disappointment aside, then explores what asking for something might risk.
More examples
- Mara
- I chose not to raise it because she’s ill.
- Therapist
- That real circumstance matters. Is the choice settled, or are you also feeling unable to say anything?
- Mara
- This time it’s settled.
- Therapist
- Then we shouldn’t assume the same pattern explains every situation.
The clinician respects a flexible decision.
- Mara
- You said I’m being defensive.
- Therapist
- That sounded accusatory. I meant to understand what helps you cope.
- Mara
- It made me feel dishonest.
- Therapist
- Let’s leave that label and look at what I actually noticed, if you want to.
Repair restores curiosity after harmful wording.
Common slips
- Treating defenses as tricks to expose.
- Ignoring their adaptive function.
- Pressing for emotion after coping becomes overwhelmed.
Help a feeling become clearer without forcing it
Intervention
Help a feeling become clearer without forcing it
Help the person stay with a feeling long enough to know what it is. This doesn't mean making someone cry or turning up the intensity. It means moving from talking about a feeling in general to recognizing what it is like in a specific moment. When Mara laughs about the canceled dinner and her eyes fill, you might ask, "What was that moment like, just before the laugh?" The triangle of conflict (see Core ideas) can guide you: a feeling, the anxiety it brings, and the defense that pushes it away. Follow her sequence instead of assigning meanings. The feeling might be hurt, loneliness, relief, or anger. If anxiety starts to scramble her thinking, slow down and offer support. Understanding matters more than drama.
What you do or say
- Describe the specific change you noticed and ask about it.
- Ask whether the person wants to stay with that moment.
- Invite their description of feeling and meaning.
- Explore anxiety or a protective response tentatively.
- Check that Mara can follow the conversation and reflect on what she feels. Slow down if she becomes overwhelmed.
- Summarize what Mara has described more clearly and ask whether you understood her.
One possible response: What feels embarrassing about wanting it?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Earlier in the illustrated case (Session 1: understand the event before explaining it): The therapist asks about wanting and embarrassment, then asks about sleep, mood, and work. Mara says it's easier to have her own words followed than to be told she's angry. They agree on goals and a regular weekly time.
In Session 4 Mara returns to the birthday cancellation. She laughs as she explains why her friend had no choice, rubs her neck, and says she isn't an angry person. A moment later her eyes fill and she looks away. The therapist notices several possible changes: explaining, tension, tears, and the statement about anger. Mara can still think clearly and reflect, but the therapist doesn't know whether the tears mean hurt, loneliness, frustration, or something unrelated. When invited to slow down, she says that wanting a celebration feels embarrassing. The clinician can help her find words for that wish and the feeling attached to it. A triangle of conflict may later organize the sequence; it should not turn the conversation into a demonstration where Mara must produce the emotion the therapist expects.
When to use it, and when not
Use it when a feeling seems close but hard to name, and Mara wants to explore it. Don't push through overwhelm, numbing out, or a request to stop. Paying attention to the body is optional, not better evidence.
What the clinician is tracking
Follow her words, the feeling as it changes, and whether she can still think clearly. Watch whether your invitation helps her get closer to the feeling or just makes her comply.
Three example exchanges
- Mara
- It’s embarrassing to want a birthday dinner.
- Therapist
- What feels embarrassing about wanting it?
- Mara
- Wanting someone to make a fuss over me.
- Therapist
- What feeling comes with letting yourself want that?
The invitation follows her stated meaning.
More examples
- Mara
- You think I’m angry, but I’m lonely.
- Therapist
- Lonely is the word that fits. What is that loneliness like here?
- Mara
- Like I shouldn’t need anyone.
- Therapist
- We can understand that judgment without replacing loneliness with anger.
Her account revises the emotional hypothesis.
- Mara
- I can’t think when you keep asking.
- Therapist
- Then we’ll slow down. Would it help to return to the concrete event?
- Mara
- Yes. I need less pressure.
- Therapist
- Let’s do that and decide together whether to revisit the feeling.
When Mara says she cannot think, the therapist stops asking for more feeling and returns to the event at a pace she chooses.
Common slips
- Equating tears or intensity with useful progress.
- Deciding what a bodily sign must mean.
- Treating a stop request as a defense to overcome.
Explore an image without decoding it
Intervention
Explore an image without decoding it
When the person uses an image, explore it in their own words instead of decoding it. Mara says it feels as if she's waiting outside a room while other people decide whether to let her in. Ask what the room is like, what she hopes will happen, and which part of the picture feels most important. A metaphor like this can make a hard-to-name feeling easier to see, but its meaning belongs to her. There's no symbol dictionary. If you offer an image of your own, treat it as a suggestion she can reject: when you compare it to standing in line, she may say she isn't in line at all. Then come back to real life, such as the actual promotion process, and see what the image helped clarify.
What you do or say
- Notice an image the person already uses.
- Ask which detail feels most important.
- Explore feeling, wish, and feared response within the image.
- Offer your own comparison only tentatively and with permission.
- Accept correction, no meaning, or a preference for concrete facts.
- Return to what happened and summarize what Mara now understands more clearly.
One possible response: What tells you that you’re not welcome to go in?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Earlier in the illustrated case (Session 7: include the therapist’s real lapse): The therapist owns the delay and asks about its impact. A tentative comparison with the friendship partly fits. Mara adds that a paid professional relationship should be different, and that correction goes into the formulation.
In Session 12 Mara describes not applying for a promotion. She says everyone else seems to know when they are allowed to ask for things, while she waits for permission. Then she pictures herself outside a meeting room where someone else decides when to call her in. The therapist could see exclusion, passivity, fear of envy, or real organizational barriers, but the image doesn't establish any of those meanings. Mara says the hardest part is not knowing whether she is welcome. When the therapist offers a comparison with standing in line, Mara corrects it: she isn't in a line at all, because she hasn't put herself forward. The therapist needs to follow that correction, learn what being outside means to Mara, and return to the actual application process and relationships at work.
When to use it, and when not
Use it when the client offers an image or welcomes a small comparison. Don't impose a meaning, treat an image as evidence of past events, or keep using an analogy once it stops helping.
What the clinician is tracking
Notice whether the image is clarifying her experience or showing off your interpretation. Keep the picture separate from the facts, and welcome changes to it.
Three example exchanges
- Mara
- I’m waiting outside the room.
- Therapist
- What tells you that you’re not welcome to go in?
- Mara
- Nobody has invited me.
- Therapist
- What would it mean to ask whether you could enter?
The client supplies the image’s meaning.
More examples
- Mara
- It isn’t a line. I’m not even applying.
- Therapist
- That changes the picture. What keeps you outside before a decision is made?
- Mara
- I don’t want people to see me wanting it.
- Therapist
- The visible wish seems important to understand.
Correction deepens inquiry rather than weakening the therapist.
- Mara
- I don’t want another image. I need the rules.
- Therapist
- Then let’s examine the rules. What have you been told?
- Mara
- Anyone can apply.
- Therapist
- We can separate that information from what makes applying difficult for you.
Metaphor yields to a practical task.
Common slips
- Decoding images as fixed symbols.
- Insisting that a vivid analogy proves a cause.
- Replacing actual circumstances with symbolic interpretation.
Ask about an imagined wish or feared response
Intervention
Ask about an imagined wish or feared response
Explore an imagined scene, and keep it separate from what actually happened. Mara pictures her friend rolling her eyes if she asks to reschedule, and her manager mocking her if she applies for a promotion. In psychodynamic language, a fantasy is an imagined scene, wish, or fear that shapes present choices. It isn't a memory, and it isn't a plan. Ask what she imagines the other person saying and what that would mean to her. Make room for wishes as well as fears: she may wish her friend would notice without being asked. Then compare the imagined response with what the person has actually said or done. Sometimes the evidence supports her caution. Let Mara decide how much private material to share.
What you do or say
- Clarify whether the scene happened, is remembered, or is imagined.
- Ask permission to explore its personal meaning.
- Ask Mara about the wish and how she expects the other person to respond. Let her choose how much to discuss.
- Explore the feeling and protective action that follow.
- Compare Mara's expectation with what the other person has said or done and consider other possibilities.
- Ask what Mara wants to do now and revisit any explanation about the past that no longer describes her experience.
One possible response: Has she done that with you, or is it the scene you picture?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Mara wants to ask her friend to arrange another dinner but pictures the friend rolling her eyes and saying she is demanding. She hasn't made the request and acknowledges that this exact exchange hasn't occurred. At the same time she has seen the friend respond impatiently to another person's needs. The therapist needs to preserve both the imagined scene and the real relational evidence. Mara also privately wishes the friend would notice without being asked, because that would mean she matters spontaneously. Saying the wish aloud feels childish to her. The clinician can explore its significance without promising that it will be fulfilled or judging it unrealistic. The aim is to understand how wish and anticipated rejection affect Mara's choices, then consider what she actually knows about the friendship and what response she wants to make.
When to use it, and when not
Use it when an imagined scene seems to be steering a decision and Mara wants to look at it. Don't demand fantasies, treat them as memories, or assume intentions from imagination. Real safety concerns need direct assessment, not symbolic interpretation.
What the clinician is tracking
Keep four things apart: what happened, what she expects, what she wishes, and what she intends. Notice what the scene helps her understand and what it might hide about her real situation.
Three example exchanges
- Mara
- She’ll roll her eyes if I ask.
- Therapist
- Has she done that with you, or is it the scene you picture?
- Mara
- It’s what I picture.
- Therapist
- What feeling arrives as you imagine it?
The scene is explored without being confirmed as fact.
More examples
- Mara
- I want her to notice without being told.
- Therapist
- What would noticing on her own mean to you?
- Mara
- That I matter without making a case.
- Therapist
- That longing deserves understanding even if she can’t always know without asking.
The wish is respected without promising its fulfillment.
- Mara
- You keep treating it like a fantasy, but she mocked someone last week.
- Therapist
- I left out evidence you’d given me. What happened?
- Mara
- She called a friend needy for asking.
- Therapist
- That changes how we understand your caution and the options available.
The therapist adds the friend’s actual mocking comment to the account, so caution is considered alongside the imagined response.
Common slips
- Treating imagination as memory or intention.
- Demanding disclosure of private scenes.
- Ignoring actual evidence that supports caution.
Work with what happens between you
Notice the actual encounter before drawing links to other relationships. Explore expectations and check whether a different experience in therapy matters to the person.
Describe a moment happening between you
Intervention
Describe a moment happening between you
Describe one thing happening between you right now, and ask about it. If Mara agrees before you finish speaking, you might say, "You said yes quite quickly. What was going through your mind?" This is a process comment: it names what is happening in the conversation before trying to explain it. It is different from an interpretation, which offers a reason, such as linking the quick agreement to how she learned to keep the peace at home. Starting with plain description keeps a theory from replacing the real moment, and it leaves room for ordinary explanations like tiredness. Remember you are part of the process too: a pushy question or a long explanation of yours may have caused the shift. Use process comments sparingly so Mara doesn't feel watched.
What you do or say
- Locate a specific observable interaction.
- Describe the words or actions you noticed in a short sentence.
- Acknowledge your part where relevant.
- Ask what the moment was like for the client.
- Listen to Mara's correction or disagreement and use it to revise your understanding.
- Adjust the work and review whether contact improves.
One possible response: You agreed quickly, and then the conversation became quieter. What happened for you?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
The therapist offers a possible explanation for Mara's hesitation about applying for a promotion. Mara immediately says it makes sense, but her voice becomes quieter and her answers shrink. The therapist notices the change yet feels relieved that the interpretation was accepted. After several minutes Mara asks whether there is anything else she should understand. This can look like productive insight while actually reducing contact. The clinician doesn't know whether Mara disagrees, feels ashamed, is tired, or simply needs time. A process comment can describe the rapid agreement and the later quiet without calling her avoidant. The therapist also needs to examine whether the explanation was too certain or too long. Mara should be able to discuss its effect, or choose another topic, without proving that she has correctly understood the therapist.
When to use it, and when not
Use it when something you can both observe is affecting the work, or keeps repeating. Don't comment on every pause, and don't turn to the relationship when she needs help with a practical problem. Name your own part before guessing at hers.
What the clinician is tracking
Notice what happens just before and after your comment: does Mara say more, go quiet, or ask what answer you want? Her reaction tells you what to explore next. It doesn't prove your explanation was right.
Three example exchanges
- Mara
- That explanation makes sense.
- Therapist
- You agreed quickly, and then the conversation became quieter. What happened for you?
- Mara
- I wasn’t sure I could question it.
- Therapist
- I want your questions more than quick agreement.
The comment makes an interaction discussable.
More examples
- Mara
- You think I’m withdrawing.
- Therapist
- I noticed shorter answers, but I don’t know why.
- Mara
- I have a migraine.
- Therapist
- Then let’s discuss what would make today manageable.
Observation is kept separate from interpretation.
- Mara
- You comment on everything I do.
- Therapist
- That has made the room feel scrutinizing. I need to change the pace.
- Mara
- I want to finish talking about work.
- Therapist
- Let’s return to it, and you can tell me when my attention gets intrusive.
The therapist recognizes that repeated comments felt intrusive and lets Mara finish describing work.
Common slips
- Naming motives instead of describing the interaction.
- Using the present relationship to crowd out the client’s life.
- Overlooking your real contribution.
Explore an expectation of the therapist
Intervention
Explore an expectation of the therapist
When something real has happened between you, deal with what you actually did before exploring what it stirred up. If you start five minutes late, acknowledge it, then ask Mara what the wait was like. If she says it was fine but seems quieter, you might add, "I wonder whether there was anything about it that wasn't fine." Only then consider a link to transference (see Core ideas), for example that she expected disappointment would make her a burden, the way it seemed to with her mother. Offer that as a tentative interpretation and ask whether it fits. Similar feelings across relationships can support a guess, but they don't prove a historical cause. A useful interpretation helps Mara think and feel more freely. Quick agreement isn't the sign it worked.
What you do or say
- Acknowledge real therapist behavior and its impact.
- Ask about the client’s experience before interpreting it.
- Name a possible expectation of you tentatively.
- Ask whether Mara sees a connection with another relationship before exploring it further.
- Invite correction and examine what the interpretation evokes.
- Change your understanding when Mara gives new information, and address any mistake in your own behavior.
One possible response: I was late, and your time matters. What was that like for you?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Earlier in the illustrated case (Session 4: map feeling, anxiety, and protection): The therapist acknowledges the loyalty in Mara's concern for her friend and invites her to say a little about the disappointment. When the questions start to feel like too many, the therapist slows down. Mara names loneliness without being pushed toward anger.
In Session 7 the therapist begins five minutes late and apologizes. Mara says there is no problem but becomes quieter and asks fewer questions. Later she says her mother always had a lot on her plate and that Mara learned to be low-maintenance. The therapist now sees a possible similarity with the friend who canceled the birthday dinner: Mara may protect an important relationship by minimizing disappointment. Yet lateness was real, and the mother's demands haven't been explored enough to establish a cause. Mara might also be tired or uncertain about therapy. The clinician asks how the delay felt before linking anything. If Mara recognizes an expectation that expressing disappointment will burden the therapist, they can examine that expectation here, without requiring her to agree that every relationship repeats childhood.
When to use it, and when not
Use it when there's enough shared evidence for a relationship pattern and Mara can look at it with you. Don't recast fair criticism of you as transference, and don't force a childhood link. Start with your own conduct and stay open to being wrong.
What the clinician is tracking
Keep real events separate from expectations she brings. Judge any link by whether Mara adds to it, corrects it, or opens up, not by whether she agrees straight away.
Three example exchanges
- Mara
- It’s fine that we started late.
- Therapist
- I was late, and your time matters. What was that like for you?
- Mara
- I didn’t want to make you feel bad.
- Therapist
- Could we understand what you expected would happen if you said you were disappointed?
Accountability comes before a relational hypothesis.
More examples
- Mara
- I try not to need too much here.
- Therapist
- Does that feel similar to staying low-maintenance with your friend, or different?
- Mara
- Similar, though you’re being paid to listen.
- Therapist
- That difference matters. What makes having needs here still feel risky?
Mara identifies both a similarity and an important difference: this is a paid professional relationship. The therapist includes that difference before asking more.
- Mara
- This isn’t about my mother. You were late.
- Therapist
- You’re right that my lateness is the event we need to address. I moved away from it.
- Mara
- I wanted you to hear that I was upset.
- Therapist
- I hear it, and I need to protect the appointment time more reliably.
The therapist stops using theory to evade responsibility.
Common slips
- Explaining away real harm as transference.
- Treating agreement as proof.
- Making a historical link before enough shared evidence exists.
Recognize a different way of being in a relationship
Intervention
Recognize a different way of being in a relationship
Notice when the relationship goes differently from what the person expected, and ask what that was like. Mara expects disagreement to bring criticism or withdrawal. When she tells you your explanation hurt, and you listen, acknowledge your mistake, and keep working with her, something new has happened. Psychodynamic writers call an experience like this a corrective emotional experience: a relationship turning out differently from an old painful expectation, in a way that can gradually change it. It doesn't mean promising perfect acceptance or becoming a substitute parent. Mara may feel relieved, suspicious, or both, and one moment won't settle it. Ask what it meant to her, keep the usual boundaries, and see whether things change over later sessions and outside therapy.
What you do or say
- Identify a moment when the relationship went differently from what Mara expected.
- Ask what the encounter felt like and what was unexpected.
- Accept doubt, anger, or an incomplete repair.
- Ask about Mara's wish and fear, and discuss what the therapist can realistically offer.
- Connect the experience tentatively to possible choices elsewhere.
- Keep the treatment boundaries clear and review whether the different experience helps Mara over time.
One possible response: What was it like that we could stay with your account?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
At the next attended session Mara says the promotion interpretation felt like another person telling her who she is. She expected the therapist to defend it and almost canceled again. The therapist acknowledges moving too quickly and asks what was missed. Mara says she is afraid of envy at work but doesn't recognize the proposed family connection. The therapist accepts that distinction and agrees to keep hypotheses tentative. Mara looks surprised and asks whether the therapist is now annoyed. She is able to remain in contact while disagreeing, but the clinician doesn't know whether this will feel reliable next week. The moment may offer a different experience of authority and disagreement. It needs curiosity, follow-through, and the ordinary treatment frame, rather than a celebration that assumes the old pattern has been transformed.
When to use it, and when not
Use it when something genuinely different has happened and Mara can explore what it meant. Don't encourage dependence, promise never to disappoint her, or declare a repair successful before hearing from her.
What the clinician is tracking
Follow what the moment meant to her, her mixed feelings about it, and what changes afterward. Check that your own behavior stays consistent over time.
Three example exchanges
- Mara
- I thought you’d argue when I disagreed.
- Therapist
- What was it like that we could stay with your account?
- Mara
- Relieving, though I’m waiting for you to get annoyed.
- Therapist
- Both reactions deserve room. We don’t have to call it settled.
The clinician recognizes change without erasing uncertainty.
More examples
- Mara
- Maybe I could tell my friend I was disappointed.
- Therapist
- What feels newly possible, and what remains different with her?
- Mara
- I know I can say it here. I don’t know her response.
- Therapist
- That distinction can help you choose how and whether to ask.
Experience informs choice without promising the same external outcome.
- Mara
- You called it a breakthrough, but I still feel hurt.
- Therapist
- I named success before hearing you. What still needs attention?
- Mara
- You were so sure about my family.
- Therapist
- Then the repair needs more than my apology. Let’s understand its effect and change how I offer ideas.
The therapist continues accountability rather than claiming a cure.
Common slips
- Declaring an experience corrective for the client.
- Promising perfect care or erasing boundaries.
- Assuming one repair changes every outside relationship.
Reflect on your contribution
Your reactions can inform the work, but they also need examination. Use reflection and supervision to distinguish a useful observation from something you are imposing on the encounter.
Notice your own reaction before acting on it
Intervention
Notice your own reaction before acting on it
Notice your own reaction, and pause before acting on it. If Mara agrees with everything you say, you might first feel pleased, then impatient, then oddly unnecessary. Those reactions are countertransference (see Core ideas). They might reflect Mara's habit of keeping people happy, your own wish to be helpful, a rushed afternoon, or all three. The reaction is a clue to think about, not proof of what she intends. The skill is creating a gap between feeling the urge and acting on it, whether the urge is to reassure, push, pull back, or tell her how you feel. Think it through privately, take it to supervision when needed, and check any idea about the relationship against Mara's own experience.
What you do or say
- Notice bodily and emotional changes in yourself.
- Name the impulse privately before acting on it.
- Consider personal, contextual, and relational explanations.
- Examine what you have already contributed to the interaction.
- Choose a response that helps you understand Mara's experience. Discuss your own unresolved reactions in supervision.
- Use supervision and review the effect on the client.
One possible response: I’m tempted to offer another answer. Could we first hear what you’re leaning toward?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Earlier in the illustrated case (Session 4: map feeling, anxiety, and protection): The therapist acknowledges the loyalty in Mara's concern for her friend and invites her to say a little about the disappointment. When the questions start to feel like too many, the therapist slows down. Mara names loneliness without being pushed toward anger.
During Session 6 Mara agrees with almost every suggestion before the therapist finishes speaking. She then reports doing none of the suggested experiments between meetings. The therapist feels an increasing urge to explain more clearly and notices irritation when Mara smiles. At first this seems like proof that Mara is evasive. Looking more closely, the therapist recognizes that she has offered several solutions without asking what Mara actually wants. Mara may be agreeing to preserve harmony; the therapist may be seeking confirmation that the session is useful. A demanding workday has also shortened the therapist's patience. Mara watches her expression and asks whether she is disappointed. This is a moment to regulate the therapist's own contribution and investigate the interaction, rather than confront Mara with a character judgment or disclose irritation to obtain reassurance.
When to use it, and when not
Use it when you notice a strong feeling, an urge you keep having, or yourself slipping into an unusual role. Don't expect Mara to manage your feelings, and don't treat your reaction as proof of her motive. If your own distress is high, get support for it outside the session.
What the clinician is tracking
Track three things separately: what you feel, what you're tempted to do, and what you actually do. Ask which part comes from your own life or circumstances, which part the interaction may be stirring up, and what would show you were wrong.
Three example exchanges
- Mara
- Just tell me what I should do.
- Therapist
- I’m tempted to offer another answer. Could we first hear what you’re leaning toward?
- Mara
- I don’t want to disappoint you.
- Therapist
- That expectation may matter more than another suggestion.
Awareness changes conduct without a lengthy disclosure.
More examples
- Mara
- You seem impatient.
- Therapist
- I rushed my questions. How did that affect you?
- Mara
- I stopped saying what didn’t fit.
- Therapist
- Then slowing down and hearing disagreement needs to be part of today’s work.
The therapist owns observable behavior.
- Mara
- Are you upset with me?
- Therapist
- You don’t need to manage my feelings. I want to understand what made you wonder.
- Mara
- You sighed when I said I hadn’t done it.
- Therapist
- I did, and it could feel critical. Let’s examine that rather than ask you to reassure me.
The therapist acknowledges the sigh and its possible effect, so Mara can describe what she noticed without having to reassure the therapist.
Common slips
- Using your feeling as proof of the client’s intention.
- Disclosing to relieve your own discomfort.
- Ignoring fatigue or institutional pressure in the formulation.
Use supervision to recognize a repeated enactment
Intervention
Use supervision to recognize a repeated enactment
An enactment happens when a familiar pattern stops being something the client describes and starts happening between you, usually before either of you notices. Say you give Mara a confident explanation linking her work fears to her family. She agrees right away, then cancels the next session. You feel disappointed and want to send a message persuading her back. You may be playing the authority who knows best while she plays the agreeable one who then withdraws. Supervision helps you see this from outside: what you each said, what you felt, and other explanations, such as a real scheduling problem. Bring the exact words. Then go back to Mara by asking how the session felt and owning your part, rather than announcing what supervision concluded about her. Peer practice can't replace supervision.
What you do or say
- Present a concrete interaction with both participants’ words and actions.
- Name your feelings, impulses, and relevant context.
- Ask how your conduct may support the repeated sequence.
- Consider other explanations and ask what information would change your view.
- Agree on a small change to try and explain how it stays within the treatment boundaries.
- Review Mara's response with your supervisor and revise your understanding if needed.
One possible response: What did you say, and how much room did she have to disagree?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
After a confident interpretation linking promotion anxiety to Mara's family role, Mara agrees and cancels the following session. The therapist first feels disappointed and then wants to send a persuasive message explaining why continuing matters. In supervision, the clinician describes the exact words, the quick agreement, the cancellation, and their urge to convince. The supervisor asks what evidence showed Mara had found the interpretation useful and whether she had room to disagree. The therapist notices that uncertainty was missing from the explanation. A possible reenactment emerges: the clinician becomes the authority who knows, Mara accommodates, and then withdraws to preserve her own position. This isn't established as the only meaning of the cancellation; scheduling and other factors still need inquiry. The next clinical task is an accountable invitation to discuss the impact, not a message that interprets the cancellation.
When to use it, and when not
Use it when an interaction keeps repeating, a role you're in won't shift, or your options feel narrow. Don't use supervision to diagnose an absent client from impressions, or just to vent. Share clinical details only within proper confidentiality.
What the clinician is tracking
Write down exactly what you said or did and what Mara did next. Notice the pull to repeat your response. In supervision, consider another explanation and choose a small change you can check with her.
Three example exchanges
- Practitioner
- She agreed, then canceled. I want to explain more.
- Supervisor
- What did you say, and how much room did she have to disagree?
- Practitioner
- I sounded certain about the family link.
- Supervisor
- Start by examining that certainty rather than interpreting the cancellation.
The supervisor asks for the therapist’s actual words before explaining Mara’s cancellation, drawing attention to how certainty may have limited disagreement.
More examples
- Practitioner
- It must be withdrawal after my interpretation.
- Supervisor
- What other information do you have?
- Practitioner
- She also mentioned a changing work schedule.
- Supervisor
- Keep both possibilities open and ask without making cancellation prove the theory.
The supervisor guards against confirmation bias.
- Practitioner
- Should I tell her we reenacted her family pattern?
- Supervisor
- That would repeat the certainty. What could you own first?
- Practitioner
- That I moved too fast and may have sounded critical.
- Supervisor
- Then invite her account and see whether the relational hypothesis is useful later.
The plan changes conduct before adding another interpretation.
Common slips
- Seeking confirmation rather than examining your contribution.
- Presenting supervisory speculation as established truth.
- Substituting peer practice for clinical supervision.
One case across sessions
Follow Mara through the sessions below. Return to the case background and treatment plan.
Session 1: understand the event before explaining it
What happened
Mara describes deadlines, then briefly mentions the canceled birthday dinner. She calls it fine, changes topic, and apologizes for taking time over something small. Two weeks have passed without replying to the friend. The therapist hears a possible pattern but also needs ordinary assessment of exhaustion and mood.
Interventions in this scene
- Therapist
- What was it like when you saw the cancellation?
- Mara
- I felt silly for expecting her to celebrate me.
- Therapist
- What made that expectation feel silly?
- Mara
- Wanting someone to make a fuss feels embarrassing.
What the clinician is thinking
The therapist separates what is known from what is guessed. Mara described the cancellation, her silence, and her apology. Whether she feels anger, or whether an old pattern is involved, isn't known yet. The therapist is curious about what she wanted and what she fears, while also checking ordinary explanations such as exhaustion.
How the clinician applies the intervention
The therapist asks about wanting and embarrassment, then asks about sleep, mood, and work. Mara says it's easier to have her own words followed than to be told she's angry. They agree on goals and a regular weekly time.
Where it goes next
Next they will compare specific times Mara withdrew, including times she didn't, and check whether exploring helps her find a response she actually wants.
Session 4: map feeling, anxiety, and protection
Before this scene: Since Session 1, Mara and the therapist have agreed on goals and a weekly time.
What happened
A second canceled plan brings the friendship back into the room. Mara excuses the friend, laughs, rubs her neck, and says she isn't angry. Her eyes then fill. She can still think clearly but worries that disappointment makes her selfish. The therapist asks whether she wants to slow down with the moment.
Interventions in this scene
- Mara
- She’s busy. I shouldn’t make it about me.
- Therapist
- You understand her situation. Is there also something you wanted?
- Mara
- To matter without asking. That’s embarrassing.
- Therapist
- We can understand that wish without deciding it’s selfish.
What the clinician is thinking
The triangle of conflict (see Core ideas) offers a map to test: a feeling or wish, anxiety about it, and a defense. Explaining her friend's busy life may protect the friendship and spare her shame. But neck tension doesn't prove anxiety, and tears don't prove anger. Mara's own description is what tests the map.
How the clinician applies the intervention
The therapist acknowledges the loyalty in Mara's concern for her friend and invites her to say a little about the disappointment. When the questions start to feel like too many, the therapist slows down. Mara names loneliness without being pushed toward anger.
Where it goes next
They will watch for where this sequence happens and where it doesn't, going at a pace Mara can manage.
Session 7: include the therapist’s real lapse
Before this scene: In Session 4, Mara named loneliness without being pushed toward anger.
What happened
The therapist starts five minutes late and apologizes. Mara says there is no problem, then gives shorter answers. She later describes learning to be low-maintenance with her overburdened mother. The clinician notices an urge to reassure her and to declare the similarity with the canceled dinner immediately.
Interventions in this scene
- Notice your own reaction before acting on it
- Describe a moment happening between you
- Explore an expectation of the therapist
- Therapist
- I was late. What was that like for you?
- Mara
- I didn’t want to make you feel bad.
- Therapist
- What did you expect if you said you were disappointed?
- Mara
- You’d think I was difficult, even though this is my appointment.
What the clinician is thinking
The triangle of persons (see Core ideas) invites a comparison: her friend, the therapist, and her mother. But the lateness was real, and the similarity doesn't prove her mother's role. The therapist also notices their own urge to reassure her and to point out the parallel right away. That is countertransference to think about, not evidence of Mara's motive.
How the clinician applies the intervention
The therapist owns the delay and asks about its impact. A tentative comparison with the friendship partly fits. Mara adds that a paid professional relationship should be different, and that correction goes into the formulation.
Where it goes next
The therapist keeps the appointment time more reliably and watches whether Mara can voice needs and disagreement here, while staying aware of the real power difference between them.
Session 12: revise the pattern at work
Before this scene: After the therapist's lateness, Mara began to question whether she had to keep her needs small.
What happened
Mara didn't apply for a promotion and says a colleague deserves it more. She imagines herself outside a room where others decide who belongs. She fears being seen wanting success and pictures coworkers resenting her. The therapist hears a familiar withdrawal but needs the actual application rules and workplace evidence.
Interventions in this scene
- Explore an image without decoding it
- Ask about an imagined wish or feared response
- Build a recurring pattern from specific events
- Therapist
- What happens in the picture when you ask to enter?
- Mara
- Everyone notices I want it and thinks I’m entitled.
- Therapist
- Has someone said that, or is it what you imagine?
- Mara
- Mostly what I imagine. One colleague actually encouraged me.
What the clinician is thinking
One way to map this is a cyclical maladaptive pattern: what Mara wishes for, what she expects others to do, what she does, how they actually respond, and what she concludes about herself. Here, wanting success may lead to fearing envy, stepping back, and feeling unseen. Her image of waiting outside a room helps describe the feeling, but it isn't proof. The colleague who encouraged her is an exception that can change the map.
How the clinician applies the intervention
They separate the workplace's actual rules from what Mara fears they mean, and compare this situation with the friendship. Mara sees some similarity but says ambition brings a different fear, and the therapist includes that difference instead of forcing one explanation.
Where it goes next
They consider a small conversation with the encouraging colleague and explore what it would mean to ask.
Sessions 15–17: repair the therapist’s certainty
Before this scene: In Session 12, Mara noticed a colleague who supports her ambition.
What happened
A later interpretation links promotion anxiety firmly to Mara's childhood role. She agrees quickly and cancels the next session. In supervision the therapist examines the certainty, the quick agreement, and an urge to persuade her back. Scheduling remains another possible reason; the cancellation alone cannot establish a rupture.
Interventions in this scene
- Describe a moment happening between you
- Use supervision to recognize a repeated enactment
- Recognize a different way of being in a relationship
- Mara
- Your explanation felt like you already knew who I was.
- Therapist
- I moved too quickly and sounded certain. What did I miss?
- Mara
- I recognize the work fear, not the family explanation.
- Therapist
- Then that distinction needs to change our understanding.
What the clinician is thinking
An enactment may be happening: the therapist pressed a confident explanation while Mara agreed and then withdrew. Supervision helps the therapist look at their own part and at other explanations, such as a real scheduling problem. If Mara can disagree and be heard without being punished, that could be a corrective emotional experience, but only she can say what it means.
How the clinician applies the intervention
The therapist acknowledges the impact without defending the interpretation. Mara is still hurt, and also relieved that her correction is accepted. They agree to treat ideas as tentative and check how they land, with the usual schedule unchanged.
Where it goes next
They will see whether this becomes reliable and whether it helps Mara speak up elsewhere. One apology or one good moment doesn't guarantee repair; what matters is what happens over time.
Common mistakes and misconceptions
- It is not one school. Contemporary practice includes relational, attachment-informed, mentalization-based, object relations, short-term, and supportive approaches.
- It does not require a couch, years of treatment, or several sessions a week. Many of the treatments studied in research are brief, often a few months of weekly sessions.
- It is not about blaming parents or recovering buried memories. The focus is on patterns that are active now.
- Therapists are not silent blank screens. Contemporary clinicians are engaged, warm, and open about their part in what happens.
- Hypotheses about hidden feelings are not facts. Good psychodynamic work keeps checking them with the client.
Evidence: the best current read
Psychodynamic psychotherapy has an evidence base spanning depression, anxiety, somatic symptom disorders and personality disorders. Research includes broad reviews, comparisons with other established therapies, and trials of specific treatments such as transference-focused psychotherapy (TFP) and mentalization-based treatment (MBT). The findings need to be read by treatment, population and outcome.2627
Source 26Review
How to read this section
- Randomized trial: people are assigned by chance to different treatments, so differences in results are more likely due to the treatment.
- Meta-analysis: a study that combines the results of many trials. An umbrella review is a review of several reviews.
- Control condition: what a treatment is compared with, such as a waitlist, usual care, or another therapy. Beating a waitlist is a lower bar than matching another active treatment.
- Effect size (g or d): how big the difference between groups is. As a rough guide, about 0.2 is small, 0.5 medium, and 0.8 large.
- 95% CI (confidence interval): the range the true result probably falls in. If it crosses zero, the study can't rule out no difference.
- Equivalence or noninferiority: a formal test that one treatment is about as good as another, within a margin set in advance. It is stronger than simply finding no significant difference.
- Heterogeneity: how much results differ from study to study. High heterogeneity makes an average less trustworthy.
- Risk of bias and certainty (GRADE): ratings of how much the study design could have skewed results, and how much confidence the overall evidence deserves.
Shedler and the broader evidence base
Jonathan Shedler, an American psychologist, wrote a 2010 review that brought together existing outcome research and challenged the claim that psychodynamic psychotherapy lacked empirical support. It described substantial improvement and evidence that benefits could persist or grow after treatment. It is an influential synthesis of earlier studies, rather than a new randomized trial.28
Later work extends that discussion. Leichsenring and colleagues’ 2023 umbrella review examined reviews of randomized trials across depressive, anxiety, somatic symptom and personality disorders. Using updated criteria and evidence-quality ratings, its authors concluded that psychodynamic therapy qualifies as an empirically supported treatment. They rated the evidence against control conditions high quality for depressive and somatic symptom disorders, and moderate quality for anxiety and personality disorders.26
Comparisons with other established treatments
Steinert and colleagues’ 2017 meta-analysis included 23 randomized trials and 2,751 patients. It formally tested whether differences in target symptoms fell within a small, prespecified range and found equivalence with established comparison treatments at treatment completion and follow-up. That is a different result from simply failing to find a statistically significant difference. It concerns average outcomes in the included trials; it does not make all therapies interchangeable for every person.27
Transference-focused psychotherapy (TFP)
TFP has its own randomized-trial evidence for borderline personality disorder. Clarkin and colleagues’ 2007 trial compared TFP, dialectical behavior therapy (DBT) and supportive treatment: all three improved several outcomes, while their patterns of change differed. In Doering and colleagues’ 2010 trial of 104 women, TFP had lower dropout and better results on borderline symptoms, functioning and personality organization than treatment by experienced community therapists.2930
Source 29Study
Crotty and colleagues’ 2024 systematic review included TFP among treatments with evidence of benefit over usual care, while rating that evidence low certainty. Direct comparisons did not establish one psychotherapy as consistently better than the others.31
Mentalization-based treatment (MBT)
MBT also has a distinct research program. Bateman and Fonagy’s 2009 trial compared 18 months of MBT with structured clinical management for borderline personality disorder. Both groups improved; MBT showed greater reductions on several measures, including suicide attempts and hospitalization. A 2025 review identified 14 randomized MBT trials. The reviewers rated all 14 trials at high risk of bias; samples were predominantly European and female. Those limitations affect confidence in the results and how widely they can be applied.3233
Source 32Study
Research extends beyond borderline personality disorder. The 2025 MOAM trial studied 313 men with antisocial personality disorder under community probation. An adapted MBT program added to probation reduced aggression more than probation alone at 12 months. That finding concerns a specific program, population and outcome; it is not a trial of general psychodynamic therapy or of MBT against another specialist psychotherapy.34
Source 34Study
Brief and experiential dynamic therapies beyond depression
A 2025 review of experiential dynamic therapies included 57 randomized trials across several clinical problems. It found substantial benefits against inactive controls. Differences from active treatments were smaller, with an advantage at follow-up; results varied considerably between studies. These findings concern a family of affect-focused dynamic treatments, not proof that every model within that family has the same evidence.35
A 2026 review focused specifically on social anxiety and included 11 randomized trials. Short-term psychodynamic therapy outperformed waitlist controls; average differences from active treatments were not statistically significant. Depression remains an important research area too: a September 2026 paper describes a collaborative patient-level database and analyses examining efficacy and who benefits.3637
Source 36Review
Longer treatment and what happens after therapy ends
Two questions need separating: do benefits last after therapy, and does a longer course produce more benefit than a shorter or different treatment? Follow-up findings in broad reviews support lasting benefit. The Tavistock Adult Depression Study also found some benefits of adding long-term psychoanalytic psychotherapy that became clearer after treatment ended, although full remission remained uncommon.2638
Comparisons of treatment length are harder to summarize with one answer. The 2012 Smit review found mixed results and no clear overall advantage over specialized alternatives. This does not show that longer treatment cannot help; it limits a general claim that more sessions necessarily produce better outcomes. The clinical problem, comparison treatment, follow-up period and outcome being measured all matter.39
Study details and comparisons
| Question and design | Finding | Limitation |
|---|---|---|
| Short-term psychodynamic psychotherapy for social anxiety disorder: a meta-analysis of randomized controlled trials (opens in a new tab) What do randomized trials show for short-term psychodynamic therapy for social anxiety disorder? Random-effects meta-analysis of randomized trials; quality and risk-of-bias assessments. | Psychodynamic treatment outperformed waitlist; the pooled active-treatment comparison showed no significant difference (g = 0.01, 95% CI −0.14 to 0.15). Available follow-up data suggested maintained gains. | Few studies in subgroups; lower-quality studies showed larger effects against passive controls. Absence of a significant difference is not itself a formal equivalence test.Full appraisalWho was studied: 11 randomized trials, 1,167 participants. Treatment: Short-term psychodynamic psychotherapy. Compared with: Waitlist and active treatment conditions. Outcomes measured: Social anxiety symptoms, depressive symptoms and dropout. Follow-up: Available follow-up data examined maintenance and further change. |
| Examining Who Benefits from Short-Term Psychodynamic Psychotherapy for Depression: Insights from a Series of Individual Participant Data Meta-analyses (opens in a new tab) How is patient-level research refining what is known about brief psychodynamic treatment for depression? Overview of a series of individual-participant-data meta-analyses; not one new pooled comparison of all 43 trials. | The overview reports efficacy relative to controls and antidepressants and as an addition to medication; episode duration and baseline severity moderated outcomes. The abstract gives no pooled effect size. | A project overview rather than a single definitive treatment comparison. Moderator findings should not be treated as a validated prescribing rule.Full appraisalWho was studied: A collaborative database of 43 trials and 4,155 participants, used across a series of analyses. Treatment: Short-term psychodynamic psychotherapy, alone or added to antidepressants. Compared with: Control conditions and antidepressant medication, depending on the analysis. Outcomes measured: Depressive symptoms and baseline characteristics associated with different outcomes. Follow-up: Varied across the contributing analyses. |
| The Efficacy of Experiential Dynamic Therapies: A 10‐Year Systematic Review and Meta‐Analysis Update (opens in a new tab) What does updated randomized evidence show for experiential dynamic therapies? Systematic review and meta-analysis. | See the paper for the pooled results. | Models and populations differ; a pooled family-of-treatments result does not establish the efficacy of any particular AEDP intervention.Full appraisalWho was studied: Trials across multiple EDT models and clinical concerns. Treatment: Experiential dynamic therapies, a broader category than AEDP. Compared with: Not applicable or varied. Outcomes measured: Clinical symptom and functioning outcomes. Follow-up: See the paper. |
| Mentalization-Based Therapy for Borderline Personality Disorder: State-Of-The-Science and Future Directions (opens in a new tab) What does the randomized-trial literature show about MBT for borderline personality disorder? Narrative review of randomized trials, updating the seven trials identified in the 2020 Cochrane review. | Some trials reported improvement in BPD symptoms and interpersonal functioning. The reviewers rated all included trials at high risk of bias. No single pooled treatment effect was reported. | Predominantly European and female samples; attention, attrition and allegiance bias; incomplete attention to severity, comorbidity and developmental stage.Full appraisalWho was studied: 14 randomized trials identified through April 1, 2025. Treatment: Mentalization-based therapy for BPD. Compared with: Comparison treatments differed across trials. Outcomes measured: BPD symptoms, interpersonal functioning and methodological quality. Follow-up: Varied across trials. |
| Mentalisation-based treatment for antisocial personality disorder in males convicted of an offence on community probation in England and Wales (Mentalization for Offending Adult Males, MOAM): a multicentre, assessor-blinded, randomised controlled trial (opens in a new tab) Can MBT adapted for antisocial personality disorder reduce aggression when added to probation? Pragmatic, multicentre, assessor-masked randomized superiority trial. | Adjusted difference in aggression at 12 months: −73.5 points (95% CI −113.7 to −33.2), favoring MBT-ASPD plus probation; reported effect size 0.74. | This tests an adapted program in men under probation, against probation rather than another specialist psychotherapy. Generalization and durability require further study.Full appraisalWho was studied: 313 men aged 21 or older with antisocial personality disorder, convictions and elevated aggression, across 13 England/Wales probation sites. Treatment: 12 months of weekly group MBT-ASPD and monthly individual sessions, plus probation. Compared with: Probation as usual. Outcomes measured: Primary outcome: aggression on the Overt Aggression Scale–Modified at 12 months. Follow-up: Primary endpoint at 12 months; assessments extended to 24 months. |
| Psychotherapies for the treatment of borderline personality disorder: A systematic review (opens in a new tab) What do comparative studies show about psychotherapy options for borderline personality disorder? Systematic review with searches through July 14, 2022; GRADE certainty ratings. | Low-certainty evidence favored TFP and several other treatments over usual care. Head-to-head evidence was low or very low certainty and did not establish one psychotherapy as the most beneficial. | Single-study comparisons and low-certainty evidence limit treatment rankings; a 2024 publication does not imply a search through 2024.Full appraisalWho was studied: 25 studies with 2,545 participants aged 13 or older. Treatment: Commonly used psychotherapies, including TFP. Compared with: Treatment as usual or another psychotherapy. Outcomes measured: BPD severity, symptoms and functioning. Follow-up: Varied across included studies; not pooled in the abstract. |
Practice with a partner
Practice with fictional scenarios and take turns responding. Agree on a word either person can use to pause the exercise. Keep crisis scenarios and intensive personal exercises out of peer practice. These exercises support learning; they do not replace clinical supervision.
Choose an intervention below. Each rehearsal reminds you what it is, sets the scene, and offers three rounds with feedback.
Build an understanding with the person
Explain the work in the person’s own terms
Intervention
Explain the work in the person’s own terms
Explain how this kind of therapy could help with what the person came for. Mara wants closer friendships and more confidence at work, but she goes quiet after disappointment. You might suggest noticing those moments together, understanding what makes speaking up hard, and practicing saying what she wants. That explanation is called a treatment rationale. Be honest about uncertainty: exploring a pattern won't prove one childhood cause, and understanding alone may not change behavior. Explain the frame too (see Core ideas): when you meet, how often, fees, contact between sessions, privacy, and how you'll check together whether the work is helping. Mention other options. A good rationale invites an informed choice. It isn't a sales pitch.
Read the full intervention and worked examples
What you do or say
- Ask what the client understands and what they want explained.
- Connect the proposed method to their concrete goals.
- Define relevant theoretical ideas in plain language.
- Explain the session schedule, contact arrangements, privacy, and how you will review progress together.
- Discuss alternatives and invite doubts about fit.
- Revisit the rationale using the client’s experience of the work.
One possible response: You want less withdrawal. We’re examining what happens between disappointment and pulling away.
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Case outline, treatment focus, and earlier sessions
After several sessions Mara asks why they keep returning to moments of disappointment rather than receive a list of coping techniques. She wants less withdrawal and more confidence at work, and she worries that talking about her mother will become endless. The therapist has noticed a possible link between wanting, shame, and accommodation but hasn't discussed the rationale clearly. Mara's question is reasonable feedback about informed participation. It is also an opportunity to clarify the weekly treatment frame and how they will evaluate whether the work helps. The therapist can describe exploring a repeated pattern while also practicing different responses and addressing practical obstacles. Mara may prefer more structure or another treatment. The explanation needs to connect to her goals and leave her free to question the method, rather than interpreting the question as resistance.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Connect the method to a goal
Intervention: Explain the work in the person’s own terms
Opening line in this scene: Why talk about the friendship again?
See one possible exchange and why it helps
- Mara
- Why talk about the friendship again?
- Therapist
- You want less withdrawal. We’re examining what happens between disappointment and pulling away.
- Mara
- So it should connect to what I do differently.
- Therapist
- Yes. We’ll review whether it helps you recognize and choose those moments.
The rationale is tied to a current goal.
Explain uncertainty
Intervention: Explain the work in the person’s own terms
Opening line in this scene: Will finding the childhood cause fix it?
See one possible exchange and why it helps
- Mara
- Will finding the childhood cause fix it?
- Therapist
- There may be several influences. Understanding can help, but new responses usually need to be lived and practiced.
- Mara
- I want to know we’re getting somewhere.
- Therapist
- Let’s choose signs of useful change and a time to review them.
The therapist avoids a guaranteed insight cure.
Respect another preference
Intervention: Explain the work in the person’s own terms
Opening line in this scene: I want a more structured approach.
See one possible exchange and why it helps
- Mara
- I want a more structured approach.
- Therapist
- That may be a good fit. What structure feels missing here?
- Mara
- Clear actions between meetings.
- Therapist
- We can discuss adding them and consider another approach if that suits your goals better.
Preference is treated as feedback, not pathology.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Explain the work in the person’s own terms? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Check that Mara understands what you're proposing, has really chosen it, and agrees on the goals. Notice whether you are explaining a useful idea or defending your way of working.
- Try again with one change. Check this common slip: Promising insight will automatically remove symptoms.
Try this with a partner
Ask without deciding what the answer means
Intervention
Ask without deciding what the answer means
Ask what happened and what it was like before deciding what it means. When Mara says she agreed with a friend but felt hurt afterward, ask about that one exchange: what she wanted to say, what she expected would happen if she said it, and what she did instead. Psychodynamic therapists call this therapeutic inquiry. The word dynamic refers to feelings and wishes pulling in different directions, here wanting closeness and fearing she'll ask for too much. Stay close to her words and leave time for her to answer or correct you. Inquiry also covers the ordinary things: mood, sleep, physical health, practical pressures, and safety. Over several conversations, you and Mara build an explanation together that you can both revise.
Read the full intervention and worked examples
What you do or say
- Identify one specific event or change in the account.
- Describe what you observed and ask Mara what was happening for her.
- Ask an open question about that moment.
- Follow the person’s words into feeling, meaning, or context.
- Ask Mara what you have missed and consider other explanations together.
- Summarize a tentative understanding and invite revision.
One possible response: What was it like when you first saw her message?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Case outline, treatment focus, and earlier sessions
Mara is 28 and works as a graphic designer. At her first session she sits upright, smiles, and describes a difficult deadline before mentioning that her closest friend canceled her birthday dinner. She says it was fine and immediately explains how overwhelmed the friend is. Two weeks have passed without Mara replying to the friend's messages. When the therapist notices that distance, Mara apologizes for bringing something so small into therapy. The therapist could assume anger, depression, or fear of rejection, but none has been established. Mara also reports genuine exhaustion at work. A question about the moment she saw the cancellation can make room for disappointment, irritation, indifference, or another experience. The therapist needs to hear her language and assess broader functioning, rather than make her story prove a psychodynamic idea.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Stay close to the event
Intervention: Ask without deciding what the answer means
Opening line in this scene: It was fine. I just haven’t answered.
See one possible exchange and why it helps
- Mara
- It was fine. I just haven’t answered.
- Therapist
- What was it like when you first saw her message?
- Mara
- I felt silly for expecting the dinner.
- Therapist
- What made expecting it feel silly?
The question opens personal meaning without prescribing anger.
Distinguish exhaustion
Intervention: Ask without deciding what the answer means
Opening line in this scene: You’re making it sound like I’m punishing her.
See one possible exchange and why it helps
- Mara
- You’re making it sound like I’m punishing her.
- Therapist
- I don’t know that. What has kept you from answering?
- Mara
- I’ve been too exhausted to answer anyone.
- Therapist
- Then we need to understand that exhaustion and whether this friendship feels different.
Practical and relational possibilities remain separate.
Repair a leading question
Intervention: Ask without deciding what the answer means
Opening line in this scene: You keep asking whether I’m angry.
See one possible exchange and why it helps
- Mara
- You keep asking whether I’m angry.
- Therapist
- I’ve been steering toward my guess. Let’s leave it. What stands out to you?
- Mara
- Feeling unimportant.
- Therapist
- We can start with that rather than make anger the answer.
Inquiry recovers from the therapist’s premature theory.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Ask without deciding what the answer means? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Keep what you observed separate from what you're guessing. Notice whether your question helps Mara say more, or makes her search for the answer she thinks you want. When she corrects you, treat it as useful information.
- Try again with one change. Check this common slip: Turning an inference into a fact.
Try this with a partner
Build a recurring pattern from specific events
Intervention
Build a recurring pattern from specific events
Build a picture of a repeating pattern from several real events. One useful map is the cyclical maladaptive pattern, from time-limited dynamic psychotherapy, a brief psychodynamic model developed by Hans Strupp and Jeffrey Binder and later taught widely by Hanna Levenson. It traces five steps: what the person wishes for, what they expect others to do, what they do, how others actually respond, and what they then conclude about themselves. For Mara: she wants recognition, expects to seem demanding, says little, gets little acknowledgment, and concludes she doesn't matter. Cyclical means the outcome strengthens the expectation, so the loop repeats. It doesn't mean she causes how others treat her. Map one event at a time, compare them, and pay attention to exceptions, like the colleague who welcomes her ideas.
Read the full intervention and worked examples
What you do or say
- Choose a concrete event and identify the person’s wish.
- Ask about the expected response and the action taken.
- Ask what the other person did and what Mara then thought or felt about herself.
- Compare with another event, including the therapy relationship if relevant.
- Look for exceptions, context, and alternative explanations.
- Offer a working map and identify a possible different next action.
One possible response: What do you expect would happen if you asked?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Earlier in the illustrated case (Session 7: include the therapist’s real lapse): The therapist owns the delay and asks about its impact. A tentative comparison with the friendship partly fits. Mara adds that a paid professional relationship should be different, and that correction goes into the formulation.
Case outline, treatment focus, and earlier sessions
By Session 12 Mara has described the canceled birthday dinner, agreeing quickly in therapy, and stepping back from a promotion. Each involves wanting something and then minimizing the wish, but the circumstances differ. The friend has actual competing demands, the therapist holds professional authority, and work has an explicit application process. Mara recognizes that being low-maintenance often preserves harmony while leaving her resentful and unseen. She also describes a colleague with whom she can ask directly and feel respected. That exception is important evidence, not a detail to discard because it weakens the pattern. The therapist invites Mara to map one event at a time and compare them. A useful formulation should predict where another response could help and where the external situation needs action, rather than provide a polished story about her personality.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Map a sequence
Intervention: Build a recurring pattern from specific events
Opening line in this scene: I never ask, then I feel forgotten.
See one possible exchange and why it helps
- Mara
- I never ask, then I feel forgotten.
- Therapist
- What do you expect would happen if you asked?
- Mara
- They’d think I was demanding.
- Therapist
- So not asking protects you from that fear and also leaves the wish invisible.
The cycle contains both protection and cost.
Use an exception
Intervention: Build a recurring pattern from specific events
Opening line in this scene: I can ask my colleague directly.
See one possible exchange and why it helps
- Mara
- I can ask my colleague directly.
- Therapist
- What’s different with her?
- Mara
- She tells me clearly what she can do.
- Therapist
- Then reliable boundaries may make wanting safer; the pattern isn’t fixed everywhere.
The colleague’s clear responses show when Mara can ask directly. That exception suggests what may make asking easier in other relationships.
Repair blame
Intervention: Build a recurring pattern from specific events
Opening line in this scene: You’re saying it’s my fault people ignore me.
See one possible exchange and why it helps
- Mara
- You’re saying it’s my fault people ignore me.
- Therapist
- That’s not a fair conclusion. Others’ actions and constraints matter too.
- Mara
- I need that in the picture.
- Therapist
- Let’s redraw it with what you control and what you don’t, including where people have failed you.
The therapist acknowledges that other people's behavior matters and separates it from the choices Mara can make herself.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Build a recurring pattern from specific events? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Compare events step by step: what Mara wanted, expected, did, and heard back. Look for times the sequence went differently. Ask whether the map makes sense to her and points to something she could try.
- Try again with one change. Check this common slip: Using a pattern label instead of a sequence.
Try this with a partner
Explore feeling, protection, and imagination
Understand what a protective habit does
Intervention
Understand what a protective habit does
Notice a protective habit and wonder, with the person, what it does for them. Mara starts to describe feeling hurt, then quickly explains how busy her friend was. You might say, "You moved from what it was like for you to what it was like for her. What happened in between?" Pointing out a defense means showing its possible purpose kindly and tentatively, not catching someone being dishonest. Defenses aren't bad: humor, understanding others, and restraint are often valuable. The useful question is when a habit has become automatic and costs more than it protects. Start with what you can both see, acknowledge what the habit protects, then explore the cost. Respecting the protection makes change easier to consider.
Read the full intervention and worked examples
What you do or say
- Describe the repeated protective move concretely.
- Recognize its useful or understandable purpose.
- Ask what happens just before it appears.
- Ask whether Mara's response helps her avoid a feeling or protect a relationship, and listen to her explanation.
- Explore what it leaves out and whether another response is tolerable.
- Offer support and change your explanation when Mara's response shows you have missed something.
One possible response: Understanding her matters to you. Does it also help put your disappointment aside?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Case outline, treatment focus, and earlier sessions
Mara describes another canceled plan and spends several minutes listing her friend's pressures. When the therapist asks what the cancellation meant to her, she smiles and says she doesn't want to be unfair. She has already shown that considering others matters deeply to her. The same habit, however, seems to leave little room for her own disappointment. When she briefly says she wanted to matter, she immediately explains that everyone is busy. The therapist can notice how quickly understanding the friend follows naming a wish. The possible function is protecting the friendship and avoiding shame about needing, but this remains a hypothesis. Mara may also know real details the therapist lacks. The intervention should respect her loyalty and learn what it protects, rather than announce that being considerate is merely an excuse for suppressed anger.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Name protection respectfully
Intervention: Understand what a protective habit does
Opening line in this scene: She has so much going on.
See one possible exchange and why it helps
- Mara
- She has so much going on.
- Therapist
- Understanding her matters to you. Does it also help put your disappointment aside?
- Mara
- Maybe. Then I don’t have to ask for anything.
- Therapist
- What would feel risky about letting the disappointment have a little room?
The therapist asks how explaining the friend’s position helps Mara put her disappointment aside, then explores what asking for something might risk.
Distinguish choice
Intervention: Understand what a protective habit does
Opening line in this scene: I chose not to raise it because she’s ill.
See one possible exchange and why it helps
- Mara
- I chose not to raise it because she’s ill.
- Therapist
- That real circumstance matters. Is the choice settled, or are you also feeling unable to say anything?
- Mara
- This time it’s settled.
- Therapist
- Then we shouldn’t assume the same pattern explains every situation.
The clinician respects a flexible decision.
Repair a shaming label
Intervention: Understand what a protective habit does
Opening line in this scene: You said I’m being defensive.
See one possible exchange and why it helps
- Mara
- You said I’m being defensive.
- Therapist
- That sounded accusatory. I meant to understand what helps you cope.
- Mara
- It made me feel dishonest.
- Therapist
- Let’s leave that label and look at what I actually noticed, if you want to.
Repair restores curiosity after harmful wording.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Understand what a protective habit does? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Track what the habit gains and costs, what anxiety shows up when it loosens, and whether Mara recognizes the purpose you suggested. Notice the difference between a free choice and an automatic narrowing.
- Try again with one change. Check this common slip: Treating defenses as tricks to expose.
Try this with a partner
Help a feeling become clearer without forcing it
Intervention
Help a feeling become clearer without forcing it
Help the person stay with a feeling long enough to know what it is. This doesn't mean making someone cry or turning up the intensity. It means moving from talking about a feeling in general to recognizing what it is like in a specific moment. When Mara laughs about the canceled dinner and her eyes fill, you might ask, "What was that moment like, just before the laugh?" The triangle of conflict (see Core ideas) can guide you: a feeling, the anxiety it brings, and the defense that pushes it away. Follow her sequence instead of assigning meanings. The feeling might be hurt, loneliness, relief, or anger. If anxiety starts to scramble her thinking, slow down and offer support. Understanding matters more than drama.
Read the full intervention and worked examples
What you do or say
- Describe the specific change you noticed and ask about it.
- Ask whether the person wants to stay with that moment.
- Invite their description of feeling and meaning.
- Explore anxiety or a protective response tentatively.
- Check that Mara can follow the conversation and reflect on what she feels. Slow down if she becomes overwhelmed.
- Summarize what Mara has described more clearly and ask whether you understood her.
One possible response: What feels embarrassing about wanting it?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Earlier in the illustrated case (Session 1: understand the event before explaining it): The therapist asks about wanting and embarrassment, then asks about sleep, mood, and work. Mara says it's easier to have her own words followed than to be told she's angry. They agree on goals and a regular weekly time.
Case outline, treatment focus, and earlier sessions
In Session 4 Mara returns to the birthday cancellation. She laughs as she explains why her friend had no choice, rubs her neck, and says she isn't an angry person. A moment later her eyes fill and she looks away. The therapist notices several possible changes: explaining, tension, tears, and the statement about anger. Mara can still think clearly and reflect, but the therapist doesn't know whether the tears mean hurt, loneliness, frustration, or something unrelated. When invited to slow down, she says that wanting a celebration feels embarrassing. The clinician can help her find words for that wish and the feeling attached to it. A triangle of conflict may later organize the sequence; it should not turn the conversation into a demonstration where Mara must produce the emotion the therapist expects.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Follow her feeling
Intervention: Help a feeling become clearer without forcing it
Opening line in this scene: It’s embarrassing to want a birthday dinner.
See one possible exchange and why it helps
- Mara
- It’s embarrassing to want a birthday dinner.
- Therapist
- What feels embarrassing about wanting it?
- Mara
- Wanting someone to make a fuss over me.
- Therapist
- What feeling comes with letting yourself want that?
The invitation follows her stated meaning.
Accept a different emotion
Intervention: Help a feeling become clearer without forcing it
Opening line in this scene: You think I’m angry, but I’m lonely.
See one possible exchange and why it helps
- Mara
- You think I’m angry, but I’m lonely.
- Therapist
- Lonely is the word that fits. What is that loneliness like here?
- Mara
- Like I shouldn’t need anyone.
- Therapist
- We can understand that judgment without replacing loneliness with anger.
Her account revises the emotional hypothesis.
Respect capacity
Intervention: Help a feeling become clearer without forcing it
Opening line in this scene: I can’t think when you keep asking.
See one possible exchange and why it helps
- Mara
- I can’t think when you keep asking.
- Therapist
- Then we’ll slow down. Would it help to return to the concrete event?
- Mara
- Yes. I need less pressure.
- Therapist
- Let’s do that and decide together whether to revisit the feeling.
When Mara says she cannot think, the therapist stops asking for more feeling and returns to the event at a pace she chooses.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Help a feeling become clearer without forcing it? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Follow her words, the feeling as it changes, and whether she can still think clearly. Watch whether your invitation helps her get closer to the feeling or just makes her comply.
- Try again with one change. Check this common slip: Equating tears or intensity with useful progress.
Try this with a partner
Explore an image without decoding it
Intervention
Explore an image without decoding it
When the person uses an image, explore it in their own words instead of decoding it. Mara says it feels as if she's waiting outside a room while other people decide whether to let her in. Ask what the room is like, what she hopes will happen, and which part of the picture feels most important. A metaphor like this can make a hard-to-name feeling easier to see, but its meaning belongs to her. There's no symbol dictionary. If you offer an image of your own, treat it as a suggestion she can reject: when you compare it to standing in line, she may say she isn't in line at all. Then come back to real life, such as the actual promotion process, and see what the image helped clarify.
Read the full intervention and worked examples
What you do or say
- Notice an image the person already uses.
- Ask which detail feels most important.
- Explore feeling, wish, and feared response within the image.
- Offer your own comparison only tentatively and with permission.
- Accept correction, no meaning, or a preference for concrete facts.
- Return to what happened and summarize what Mara now understands more clearly.
One possible response: What tells you that you’re not welcome to go in?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Earlier in the illustrated case (Session 7: include the therapist’s real lapse): The therapist owns the delay and asks about its impact. A tentative comparison with the friendship partly fits. Mara adds that a paid professional relationship should be different, and that correction goes into the formulation.
Case outline, treatment focus, and earlier sessions
In Session 12 Mara describes not applying for a promotion. She says everyone else seems to know when they are allowed to ask for things, while she waits for permission. Then she pictures herself outside a meeting room where someone else decides when to call her in. The therapist could see exclusion, passivity, fear of envy, or real organizational barriers, but the image doesn't establish any of those meanings. Mara says the hardest part is not knowing whether she is welcome. When the therapist offers a comparison with standing in line, Mara corrects it: she isn't in a line at all, because she hasn't put herself forward. The therapist needs to follow that correction, learn what being outside means to Mara, and return to the actual application process and relationships at work.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Follow her image
Intervention: Explore an image without decoding it
Opening line in this scene: I’m waiting outside the room.
See one possible exchange and why it helps
- Mara
- I’m waiting outside the room.
- Therapist
- What tells you that you’re not welcome to go in?
- Mara
- Nobody has invited me.
- Therapist
- What would it mean to ask whether you could enter?
The client supplies the image’s meaning.
Let it change
Intervention: Explore an image without decoding it
Opening line in this scene: It isn’t a line. I’m not even applying.
See one possible exchange and why it helps
- Mara
- It isn’t a line. I’m not even applying.
- Therapist
- That changes the picture. What keeps you outside before a decision is made?
- Mara
- I don’t want people to see me wanting it.
- Therapist
- The visible wish seems important to understand.
Correction deepens inquiry rather than weakening the therapist.
Leave the analogy
Intervention: Explore an image without decoding it
Opening line in this scene: I don’t want another image. I need the rules.
See one possible exchange and why it helps
- Mara
- I don’t want another image. I need the rules.
- Therapist
- Then let’s examine the rules. What have you been told?
- Mara
- Anyone can apply.
- Therapist
- We can separate that information from what makes applying difficult for you.
Metaphor yields to a practical task.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Explore an image without decoding it? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Notice whether the image is clarifying her experience or showing off your interpretation. Keep the picture separate from the facts, and welcome changes to it.
- Try again with one change. Check this common slip: Decoding images as fixed symbols.
Try this with a partner
Ask about an imagined wish or feared response
Intervention
Ask about an imagined wish or feared response
Explore an imagined scene, and keep it separate from what actually happened. Mara pictures her friend rolling her eyes if she asks to reschedule, and her manager mocking her if she applies for a promotion. In psychodynamic language, a fantasy is an imagined scene, wish, or fear that shapes present choices. It isn't a memory, and it isn't a plan. Ask what she imagines the other person saying and what that would mean to her. Make room for wishes as well as fears: she may wish her friend would notice without being asked. Then compare the imagined response with what the person has actually said or done. Sometimes the evidence supports her caution. Let Mara decide how much private material to share.
Read the full intervention and worked examples
What you do or say
- Clarify whether the scene happened, is remembered, or is imagined.
- Ask permission to explore its personal meaning.
- Ask Mara about the wish and how she expects the other person to respond. Let her choose how much to discuss.
- Explore the feeling and protective action that follow.
- Compare Mara's expectation with what the other person has said or done and consider other possibilities.
- Ask what Mara wants to do now and revisit any explanation about the past that no longer describes her experience.
One possible response: Has she done that with you, or is it the scene you picture?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Case outline, treatment focus, and earlier sessions
Mara wants to ask her friend to arrange another dinner but pictures the friend rolling her eyes and saying she is demanding. She hasn't made the request and acknowledges that this exact exchange hasn't occurred. At the same time she has seen the friend respond impatiently to another person's needs. The therapist needs to preserve both the imagined scene and the real relational evidence. Mara also privately wishes the friend would notice without being asked, because that would mean she matters spontaneously. Saying the wish aloud feels childish to her. The clinician can explore its significance without promising that it will be fulfilled or judging it unrealistic. The aim is to understand how wish and anticipated rejection affect Mara's choices, then consider what she actually knows about the friendship and what response she wants to make.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Separate imagination and fact
Intervention: Ask about an imagined wish or feared response
Opening line in this scene: She’ll roll her eyes if I ask.
See one possible exchange and why it helps
- Mara
- She’ll roll her eyes if I ask.
- Therapist
- Has she done that with you, or is it the scene you picture?
- Mara
- It’s what I picture.
- Therapist
- What feeling arrives as you imagine it?
The scene is explored without being confirmed as fact.
Make room for a wish
Intervention: Ask about an imagined wish or feared response
Opening line in this scene: I want her to notice without being told.
See one possible exchange and why it helps
- Mara
- I want her to notice without being told.
- Therapist
- What would noticing on her own mean to you?
- Mara
- That I matter without making a case.
- Therapist
- That longing deserves understanding even if she can’t always know without asking.
The wish is respected without promising its fulfillment.
Accept real evidence
Intervention: Ask about an imagined wish or feared response
Opening line in this scene: You keep treating it like a fantasy, but she mocked someone last week.
See one possible exchange and why it helps
- Mara
- You keep treating it like a fantasy, but she mocked someone last week.
- Therapist
- I left out evidence you’d given me. What happened?
- Mara
- She called a friend needy for asking.
- Therapist
- That changes how we understand your caution and the options available.
The therapist adds the friend’s actual mocking comment to the account, so caution is considered alongside the imagined response.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Ask about an imagined wish or feared response? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Keep four things apart: what happened, what she expects, what she wishes, and what she intends. Notice what the scene helps her understand and what it might hide about her real situation.
- Try again with one change. Check this common slip: Treating imagination as memory or intention.
Try this with a partner
Work with what happens between you
Describe a moment happening between you
Intervention
Describe a moment happening between you
Describe one thing happening between you right now, and ask about it. If Mara agrees before you finish speaking, you might say, "You said yes quite quickly. What was going through your mind?" This is a process comment: it names what is happening in the conversation before trying to explain it. It is different from an interpretation, which offers a reason, such as linking the quick agreement to how she learned to keep the peace at home. Starting with plain description keeps a theory from replacing the real moment, and it leaves room for ordinary explanations like tiredness. Remember you are part of the process too: a pushy question or a long explanation of yours may have caused the shift. Use process comments sparingly so Mara doesn't feel watched.
Read the full intervention and worked examples
What you do or say
- Locate a specific observable interaction.
- Describe the words or actions you noticed in a short sentence.
- Acknowledge your part where relevant.
- Ask what the moment was like for the client.
- Listen to Mara's correction or disagreement and use it to revise your understanding.
- Adjust the work and review whether contact improves.
One possible response: You agreed quickly, and then the conversation became quieter. What happened for you?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Case outline, treatment focus, and earlier sessions
The therapist offers a possible explanation for Mara's hesitation about applying for a promotion. Mara immediately says it makes sense, but her voice becomes quieter and her answers shrink. The therapist notices the change yet feels relieved that the interpretation was accepted. After several minutes Mara asks whether there is anything else she should understand. This can look like productive insight while actually reducing contact. The clinician doesn't know whether Mara disagrees, feels ashamed, is tired, or simply needs time. A process comment can describe the rapid agreement and the later quiet without calling her avoidant. The therapist also needs to examine whether the explanation was too certain or too long. Mara should be able to discuss its effect, or choose another topic, without proving that she has correctly understood the therapist.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Name the sequence
Intervention: Describe a moment happening between you
Opening line in this scene: That explanation makes sense.
See one possible exchange and why it helps
- Mara
- That explanation makes sense.
- Therapist
- You agreed quickly, and then the conversation became quieter. What happened for you?
- Mara
- I wasn’t sure I could question it.
- Therapist
- I want your questions more than quick agreement.
The comment makes an interaction discussable.
Allow an ordinary explanation
Intervention: Describe a moment happening between you
Opening line in this scene: You think I’m withdrawing.
See one possible exchange and why it helps
- Mara
- You think I’m withdrawing.
- Therapist
- I noticed shorter answers, but I don’t know why.
- Mara
- I have a migraine.
- Therapist
- Then let’s discuss what would make today manageable.
Observation is kept separate from interpretation.
Repair feeling watched
Intervention: Describe a moment happening between you
Opening line in this scene: You comment on everything I do.
See one possible exchange and why it helps
- Mara
- You comment on everything I do.
- Therapist
- That has made the room feel scrutinizing. I need to change the pace.
- Mara
- I want to finish talking about work.
- Therapist
- Let’s return to it, and you can tell me when my attention gets intrusive.
The therapist recognizes that repeated comments felt intrusive and lets Mara finish describing work.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Describe a moment happening between you? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Notice what happens just before and after your comment: does Mara say more, go quiet, or ask what answer you want? Her reaction tells you what to explore next. It doesn't prove your explanation was right.
- Try again with one change. Check this common slip: Naming motives instead of describing the interaction.
Try this with a partner
Explore an expectation of the therapist
Intervention
Explore an expectation of the therapist
When something real has happened between you, deal with what you actually did before exploring what it stirred up. If you start five minutes late, acknowledge it, then ask Mara what the wait was like. If she says it was fine but seems quieter, you might add, "I wonder whether there was anything about it that wasn't fine." Only then consider a link to transference (see Core ideas), for example that she expected disappointment would make her a burden, the way it seemed to with her mother. Offer that as a tentative interpretation and ask whether it fits. Similar feelings across relationships can support a guess, but they don't prove a historical cause. A useful interpretation helps Mara think and feel more freely. Quick agreement isn't the sign it worked.
Read the full intervention and worked examples
What you do or say
- Acknowledge real therapist behavior and its impact.
- Ask about the client’s experience before interpreting it.
- Name a possible expectation of you tentatively.
- Ask whether Mara sees a connection with another relationship before exploring it further.
- Invite correction and examine what the interpretation evokes.
- Change your understanding when Mara gives new information, and address any mistake in your own behavior.
One possible response: I was late, and your time matters. What was that like for you?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Earlier in the illustrated case (Session 4: map feeling, anxiety, and protection): The therapist acknowledges the loyalty in Mara's concern for her friend and invites her to say a little about the disappointment. When the questions start to feel like too many, the therapist slows down. Mara names loneliness without being pushed toward anger.
Case outline, treatment focus, and earlier sessions
In Session 7 the therapist begins five minutes late and apologizes. Mara says there is no problem but becomes quieter and asks fewer questions. Later she says her mother always had a lot on her plate and that Mara learned to be low-maintenance. The therapist now sees a possible similarity with the friend who canceled the birthday dinner: Mara may protect an important relationship by minimizing disappointment. Yet lateness was real, and the mother's demands haven't been explored enough to establish a cause. Mara might also be tired or uncertain about therapy. The clinician asks how the delay felt before linking anything. If Mara recognizes an expectation that expressing disappointment will burden the therapist, they can examine that expectation here, without requiring her to agree that every relationship repeats childhood.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Begin with the real lapse
Intervention: Explore an expectation of the therapist
Opening line in this scene: It’s fine that we started late.
See one possible exchange and why it helps
- Mara
- It’s fine that we started late.
- Therapist
- I was late, and your time matters. What was that like for you?
- Mara
- I didn’t want to make you feel bad.
- Therapist
- Could we understand what you expected would happen if you said you were disappointed?
Accountability comes before a relational hypothesis.
Offer a link tentatively
Intervention: Explore an expectation of the therapist
Opening line in this scene: I try not to need too much here.
See one possible exchange and why it helps
- Mara
- I try not to need too much here.
- Therapist
- Does that feel similar to staying low-maintenance with your friend, or different?
- Mara
- Similar, though you’re being paid to listen.
- Therapist
- That difference matters. What makes having needs here still feel risky?
Mara identifies both a similarity and an important difference: this is a paid professional relationship. The therapist includes that difference before asking more.
Repair an imposed history
Intervention: Explore an expectation of the therapist
Opening line in this scene: This isn’t about my mother. You were late.
See one possible exchange and why it helps
- Mara
- This isn’t about my mother. You were late.
- Therapist
- You’re right that my lateness is the event we need to address. I moved away from it.
- Mara
- I wanted you to hear that I was upset.
- Therapist
- I hear it, and I need to protect the appointment time more reliably.
The therapist stops using theory to evade responsibility.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Explore an expectation of the therapist? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Keep real events separate from expectations she brings. Judge any link by whether Mara adds to it, corrects it, or opens up, not by whether she agrees straight away.
- Try again with one change. Check this common slip: Explaining away real harm as transference.
Try this with a partner
Recognize a different way of being in a relationship
Intervention
Recognize a different way of being in a relationship
Notice when the relationship goes differently from what the person expected, and ask what that was like. Mara expects disagreement to bring criticism or withdrawal. When she tells you your explanation hurt, and you listen, acknowledge your mistake, and keep working with her, something new has happened. Psychodynamic writers call an experience like this a corrective emotional experience: a relationship turning out differently from an old painful expectation, in a way that can gradually change it. It doesn't mean promising perfect acceptance or becoming a substitute parent. Mara may feel relieved, suspicious, or both, and one moment won't settle it. Ask what it meant to her, keep the usual boundaries, and see whether things change over later sessions and outside therapy.
Read the full intervention and worked examples
What you do or say
- Identify a moment when the relationship went differently from what Mara expected.
- Ask what the encounter felt like and what was unexpected.
- Accept doubt, anger, or an incomplete repair.
- Ask about Mara's wish and fear, and discuss what the therapist can realistically offer.
- Connect the experience tentatively to possible choices elsewhere.
- Keep the treatment boundaries clear and review whether the different experience helps Mara over time.
One possible response: What was it like that we could stay with your account?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Case outline, treatment focus, and earlier sessions
At the next attended session Mara says the promotion interpretation felt like another person telling her who she is. She expected the therapist to defend it and almost canceled again. The therapist acknowledges moving too quickly and asks what was missed. Mara says she is afraid of envy at work but doesn't recognize the proposed family connection. The therapist accepts that distinction and agrees to keep hypotheses tentative. Mara looks surprised and asks whether the therapist is now annoyed. She is able to remain in contact while disagreeing, but the clinician doesn't know whether this will feel reliable next week. The moment may offer a different experience of authority and disagreement. It needs curiosity, follow-through, and the ordinary treatment frame, rather than a celebration that assumes the old pattern has been transformed.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Hear the new experience
Intervention: Recognize a different way of being in a relationship
Opening line in this scene: I thought you’d argue when I disagreed.
See one possible exchange and why it helps
- Mara
- I thought you’d argue when I disagreed.
- Therapist
- What was it like that we could stay with your account?
- Mara
- Relieving, though I’m waiting for you to get annoyed.
- Therapist
- Both reactions deserve room. We don’t have to call it settled.
The clinician recognizes change without erasing uncertainty.
Connect without prescribing
Intervention: Recognize a different way of being in a relationship
Opening line in this scene: Maybe I could tell my friend I was disappointed.
See one possible exchange and why it helps
- Mara
- Maybe I could tell my friend I was disappointed.
- Therapist
- What feels newly possible, and what remains different with her?
- Mara
- I know I can say it here. I don’t know her response.
- Therapist
- That distinction can help you choose how and whether to ask.
Experience informs choice without promising the same external outcome.
Repair a premature success story
Intervention: Recognize a different way of being in a relationship
Opening line in this scene: You called it a breakthrough, but I still feel hurt.
See one possible exchange and why it helps
- Mara
- You called it a breakthrough, but I still feel hurt.
- Therapist
- I named success before hearing you. What still needs attention?
- Mara
- You were so sure about my family.
- Therapist
- Then the repair needs more than my apology. Let’s understand its effect and change how I offer ideas.
The therapist continues accountability rather than claiming a cure.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Recognize a different way of being in a relationship? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Follow what the moment meant to her, her mixed feelings about it, and what changes afterward. Check that your own behavior stays consistent over time.
- Try again with one change. Check this common slip: Declaring an experience corrective for the client.
Try this with a partner
Reflect on your contribution
Notice your own reaction before acting on it
Intervention
Notice your own reaction before acting on it
Notice your own reaction, and pause before acting on it. If Mara agrees with everything you say, you might first feel pleased, then impatient, then oddly unnecessary. Those reactions are countertransference (see Core ideas). They might reflect Mara's habit of keeping people happy, your own wish to be helpful, a rushed afternoon, or all three. The reaction is a clue to think about, not proof of what she intends. The skill is creating a gap between feeling the urge and acting on it, whether the urge is to reassure, push, pull back, or tell her how you feel. Think it through privately, take it to supervision when needed, and check any idea about the relationship against Mara's own experience.
Read the full intervention and worked examples
What you do or say
- Notice bodily and emotional changes in yourself.
- Name the impulse privately before acting on it.
- Consider personal, contextual, and relational explanations.
- Examine what you have already contributed to the interaction.
- Choose a response that helps you understand Mara's experience. Discuss your own unresolved reactions in supervision.
- Use supervision and review the effect on the client.
One possible response: I’m tempted to offer another answer. Could we first hear what you’re leaning toward?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Earlier in the illustrated case (Session 4: map feeling, anxiety, and protection): The therapist acknowledges the loyalty in Mara's concern for her friend and invites her to say a little about the disappointment. When the questions start to feel like too many, the therapist slows down. Mara names loneliness without being pushed toward anger.
Case outline, treatment focus, and earlier sessions
During Session 6 Mara agrees with almost every suggestion before the therapist finishes speaking. She then reports doing none of the suggested experiments between meetings. The therapist feels an increasing urge to explain more clearly and notices irritation when Mara smiles. At first this seems like proof that Mara is evasive. Looking more closely, the therapist recognizes that she has offered several solutions without asking what Mara actually wants. Mara may be agreeing to preserve harmony; the therapist may be seeking confirmation that the session is useful. A demanding workday has also shortened the therapist's patience. Mara watches her expression and asks whether she is disappointed. This is a moment to regulate the therapist's own contribution and investigate the interaction, rather than confront Mara with a character judgment or disclose irritation to obtain reassurance.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Pause the urge to rescue
Intervention: Notice your own reaction before acting on it
Opening line in this scene: Just tell me what I should do.
See one possible exchange and why it helps
- Mara
- Just tell me what I should do.
- Therapist
- I’m tempted to offer another answer. Could we first hear what you’re leaning toward?
- Mara
- I don’t want to disappoint you.
- Therapist
- That expectation may matter more than another suggestion.
Awareness changes conduct without a lengthy disclosure.
Check a relational guess
Intervention: Notice your own reaction before acting on it
Opening line in this scene: You seem impatient.
See one possible exchange and why it helps
- Mara
- You seem impatient.
- Therapist
- I rushed my questions. How did that affect you?
- Mara
- I stopped saying what didn’t fit.
- Therapist
- Then slowing down and hearing disagreement needs to be part of today’s work.
The therapist owns observable behavior.
Avoid burdening the client
Intervention: Notice your own reaction before acting on it
Opening line in this scene: Are you upset with me?
See one possible exchange and why it helps
- Mara
- Are you upset with me?
- Therapist
- You don’t need to manage my feelings. I want to understand what made you wonder.
- Mara
- You sighed when I said I hadn’t done it.
- Therapist
- I did, and it could feel critical. Let’s examine that rather than ask you to reassure me.
The therapist acknowledges the sigh and its possible effect, so Mara can describe what she noticed without having to reassure the therapist.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Notice your own reaction before acting on it? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Track three things separately: what you feel, what you're tempted to do, and what you actually do. Ask which part comes from your own life or circumstances, which part the interaction may be stirring up, and what would show you were wrong.
- Try again with one change. Check this common slip: Using your feeling as proof of the client’s intention.
Try this with a partner
Use supervision to recognize a repeated enactment
Intervention
Use supervision to recognize a repeated enactment
An enactment happens when a familiar pattern stops being something the client describes and starts happening between you, usually before either of you notices. Say you give Mara a confident explanation linking her work fears to her family. She agrees right away, then cancels the next session. You feel disappointed and want to send a message persuading her back. You may be playing the authority who knows best while she plays the agreeable one who then withdraws. Supervision helps you see this from outside: what you each said, what you felt, and other explanations, such as a real scheduling problem. Bring the exact words. Then go back to Mara by asking how the session felt and owning your part, rather than announcing what supervision concluded about her. Peer practice can't replace supervision.
Read the full intervention and worked examples
What you do or say
- Present a concrete interaction with both participants’ words and actions.
- Name your feelings, impulses, and relevant context.
- Ask how your conduct may support the repeated sequence.
- Consider other explanations and ask what information would change your view.
- Agree on a small change to try and explain how it stays within the treatment boundaries.
- Review Mara's response with your supervisor and revise your understanding if needed.
One possible response: What did you say, and how much room did she have to disagree?
Vignette: the intervention in context
Fictional case: Mara
Case background and conceptualization
Mara is a 28-year-old graphic designer. She pulls back from friends and stays agreeable when she feels criticized. She is the same fictional person as the practice case “Fear of rejection.”
Working conceptualization
Mara wants closeness but often protects relationships by minimizing disappointment and staying agreeable. The working hypothesis is that hurt or anger brings anxiety, and withdrawal or accommodation makes that anxiety easier to bear. Malan’s triangle of conflict maps feeling, anxiety, and protection; the triangle of persons asks whether a similar pattern appears with friends, the therapist, and remembered relationships. These are questions to test with Mara, not established childhood causes.
Case outline, treatment focus, and earlier sessions
After a confident interpretation linking promotion anxiety to Mara's family role, Mara agrees and cancels the following session. The therapist first feels disappointed and then wants to send a persuasive message explaining why continuing matters. In supervision, the clinician describes the exact words, the quick agreement, the cancellation, and their urge to convince. The supervisor asks what evidence showed Mara had found the interpretation useful and whether she had room to disagree. The therapist notices that uncertainty was missing from the explanation. A possible reenactment emerges: the clinician becomes the authority who knows, Mara accommodates, and then withdraws to preserve her own position. This isn't established as the only meaning of the cancellation; scheduling and other factors still need inquiry. The next clinical task is an accountable invitation to discuss the impact, not a message that interprets the cancellation.
One partner plays the fictional person in this scene; the other practices the therapist’s response. Choose one round below. Say the opening line, respond once, then pause for feedback and retry before swapping roles. Each round is a different version of the same scene. Choose one to practice.
Choose a round
Describe your contribution
Intervention: Use supervision to recognize a repeated enactment
Opening line in this scene: She agreed, then canceled. I want to explain more.
See one possible exchange and why it helps
- Practitioner
- She agreed, then canceled. I want to explain more.
- Supervisor
- What did you say, and how much room did she have to disagree?
- Practitioner
- I sounded certain about the family link.
- Supervisor
- Start by examining that certainty rather than interpreting the cancellation.
The supervisor asks for the therapist’s actual words before explaining Mara’s cancellation, drawing attention to how certainty may have limited disagreement.
Include an alternative
Intervention: Use supervision to recognize a repeated enactment
Opening line in this scene: It must be withdrawal after my interpretation.
See one possible exchange and why it helps
- Practitioner
- It must be withdrawal after my interpretation.
- Supervisor
- What other information do you have?
- Practitioner
- She also mentioned a changing work schedule.
- Supervisor
- Keep both possibilities open and ask without making cancellation prove the theory.
The supervisor guards against confirmation bias.
Plan accountable repair
Intervention: Use supervision to recognize a repeated enactment
Opening line in this scene: Should I tell her we reenacted her family pattern?
See one possible exchange and why it helps
- Practitioner
- Should I tell her we reenacted her family pattern?
- Supervisor
- That would repeat the certainty. What could you own first?
- Practitioner
- That I moved too fast and may have sounded critical.
- Supervisor
- Then invite her account and see whether the relational hypothesis is useful later.
The plan changes conduct before adding another interpretation.
Increase difficulty only by agreement. Either partner can pause or choose a simpler response.
Feedback and retry
- Did the response carry out this intervention: Use supervision to recognize a repeated enactment? Describe the words or action that did it.
- What did you notice in the fictional person’s response? Compare it with what the clinician is tracking: Write down exactly what you said or did and what Mara did next. Notice the pull to repeat your response. In supervision, consider another explanation and choose a small change you can check with her.
- Try again with one change. Check this common slip: Seeking confirmation rather than examining your contribution.
Try this with a partner
Going deeper
Optional topics for when the core ideas feel familiar. Open any that interest you.
Optional: separate case examples
These optional examples introduce different people to show contrasting clinical situations. They are separate cases, not later events in the main case.
What this illustrates: Theo’s losses, sleep difficulties, strengths, and coping require a different working understanding from Mara’s.
Theo is a 47-year-old civil engineer. He has insomnia and irritability after a separation and his father’s dementia diagnosis. He is precise and thoughtful, and describes painful events with little visible feeling.
Theo, 47, is referred for insomnia and irritability. In the past year he separated from his wife and his father was diagnosed with dementia. He visits his father three times a week, manages his medications, and keeps a spreadsheet of appointments. He tells the story with precise dates and occasional dry jokes. When the therapist asks how it has been to watch his father change, he says, “It’s a progressive disease. You plan for it.”
He has a close relationship with his son, now at college, and long friendships from work. He has never been in therapy and says he is here “because my doctor asked nicely.”
Presenting problem and why now: insomnia and irritability after two major losses within a year.
Pattern: competence and organization in the face of loss; feelings described, not shown.
Defenses and flexibility: intellectualization (thinking about feelings instead of feeling them) and isolation of affect appear reliable and useful at work; humor eases tension. Do they ever give way?
Organization: identity seems stable, relationships long-lasting, reality testing (telling inner experience apart from outside reality) intact. Clinicians in this tradition would call this a “neurotic-level” organization, an old technical term for a stable, well-integrated personality, not an insult. Hold it as a hypothesis.
Style: obsessive-compulsive features, meaning a personality style organized around control, thinking over feeling, and conscientiousness, not the anxiety disorder OCD. Possibly a depressive thread too: does he blame himself for the separation?
Strengths: loyalty, reliability, humor, a warm bond with his son.
Context: caregiving load, a son leaving home, no prior experience of therapy, a referral he did not choose.
Uncertainties: medical causes of insomnia, alcohol or other substances, mood severity, safety. What would change the formulation? Evidence of heavy drinking, a sleep disorder, or major depression would shift the focus and the pacing.
Insomnia at midlife can reflect sleep apnea, alcohol, medications, depression, or the sheer logistics of caregiving. His precision might partly reflect temperament or neurodivergent traits rather than defense, and “you plan for it” might be a sincere and adaptive stance. A good formulation names these and does not assume every behavior is defensive.
Session 6: Theo mentions he has been drinking three or four glasses of wine most nights to sleep. The formulation now includes alcohol as part of the cycle that maintains poor sleep and low mood. The plan adds a careful substance-use assessment and, with his consent, coordination with his physician. Emotional exploration is paced so it does not increase drinking.
What this illustrates: Jess and the therapist have not reached a clear agreement about contact between sessions. This example shows the strain that follows; it does not yet show a repair.
Jess is a 24-year-old retail supervisor. Her relationships are intense and shifting, and her views of others and of the therapist swing between admiration and disappointment. A safety plan is in place and reviewed regularly.
Jess, 24, asks whether she can text the therapist between sessions “just when it gets bad.” The therapist, unsure, says, “We’ll see.” Two weeks later Jess misses a session without notice and then emails: “You obviously don’t care, like everyone else.”
The therapist feels a strong pull to write a long, reassuring reply, and then, reading the email again, irritation.
What this illustrates: With Theo, changes in the therapist’s attention offer something to reflect on. They do not by themselves establish what Theo feels or why.
Theo is a 47-year-old civil engineer. He has insomnia and irritability after a separation and his father’s dementia diagnosis. He is precise and thoughtful, and describes painful events with little visible feeling.
As Theo describes his father’s medication schedule in careful detail, the therapist notices feeling drowsy. When Theo mentions his son’s first week at college, the therapist feels alert again, and notices Theo’s voice warming.
Contemporary psychodynamic traditions
Psychodynamic therapy today is a family of approaches that share some assumptions: much of mental life is outside awareness, people are often in conflict, relationships carry patterns forward, and the therapy relationship is a place to understand and change those patterns. They differ in what they emphasize, how active the therapist is, how long treatment lasts, and how interpretation is used.
Relational and intersubjective approaches see both people as participants who influence each other. Attachment-informed models such as time-limited dynamic psychotherapy focus on recurring interpersonal patterns and new relational experiences. Mentalization-based treatment strengthens the capacity to understand minds under stress. Contemporary object relations work, including transference-focused psychotherapy, uses a clear contract to work with rapidly shifting views of self and others. Short-term dynamic approaches, from Malan’s lineage to intensive short-term dynamic psychotherapy and dynamic interpersonal therapy, work with a defined focus in limited time. Supportive psychodynamic therapy strengthens functioning and adaptive defenses.81511104041
What this illustrates: One moment with Jess, read through each tradition. The same sentence leads each school to a different next step.
Jess is a 24-year-old retail supervisor. Her relationships are intense and shifting, and her views of others and of the therapist swing between admiration and disappointment. A safety plan is in place and reviewed regularly.
Jess says, “Last week you were the only person who got me. Today you’re just like the rest.”
Relational and intersubjective
Focus: Mutual influence, enactment, repair
What the therapist does: Metacommunication; therapist owns contributions.
Training: Broad clinical training; no single manual.
Time-limited dynamic psychotherapy
Focus: Cyclical maladaptive patterns, attachment
What the therapist does: Pattern naming; new relational experience.
Training: Brief model; Levenson’s writing and training.
Mentalization-based treatment
Focus: Restoring mentalizing under stress
What the therapist does: Not-knowing stance; short, curious interventions.
Training: Structured training; developed for borderline personality disorder and adapted widely.
Transference-focused psychotherapy
Focus: Bringing together all-good and all-bad pictures of self and others
What the therapist does: Contract; clarification, confrontation, and interpretation of what is happening in the room right now.
Training: Specialized training and supervision.
Short-term dynamic psychotherapy (STDP) and intensive short-term dynamic psychotherapy (ISTDP)
Focus: Feeling, anxiety, defense in a defined focus
What the therapist does: Active work with defenses and affect.
Training: ISTDP requires specialized training with recorded supervision.
Dynamic interpersonal therapy
Focus: An interpersonal affective focus linked to depression
What the therapist does: Manualized brief sessions.
Training: Practitioner training program.
Supportive psychodynamic
Focus: Functioning, adaptive defenses, alliance
What the therapist does: Empathy, encouragement, clarification, advice when useful.
Training: General psychodynamic training.
Context and adaptation: when context changes the interpretation
Interpretations can go wrong when they treat a reasonable response to the world as only a sign of inner conflict. A client who is careful with a therapist from a more powerful group may be showing good judgment, not just transference. Context belongs inside the formulation, not in a footnote.
This means asking about race, culture, religion, sexuality, gender, class, disability, neurodivergence, immigration history, institutions, and trauma when they matter to the person, and noticing how the therapist’s own identity and assumptions shape the room. Pratyusha Tummala-Narra proposes bringing psychoanalytic thinking together with multicultural and feminist psychology for exactly this purpose.
Context also changes the frame. Remote sessions raise questions about privacy and safety. Shift work and income affect missed sessions and fees. Autistic clients may avoid eye contact for reasons that have nothing to do with defense. Substance use can be both a way of managing feelings and a physiological problem that needs its own care.94
What this illustrates: A question shaped by the therapist’s assumption misses what is actually happening to Kofi. Context has to enter the formulation.
Kofi is a 31-year-old Ghanaian-American doctoral student in chemistry. He experiences panic attacks before lab meetings and long stretches of procrastination. He is polite and guarded with his white therapist.
Kofi, 31, a Ghanaian-American chemistry doctoral student, comes for panic attacks before lab meetings and long stretches of procrastination. He is polite and careful. When the therapist, who is white, asks, “Are your parents putting a lot of pressure on you about the PhD?” Kofi pauses and says they have been supportive.
In session 4 he describes being singled out in lab meetings, repeatedly mistaken for another Black student, and a complaint that went nowhere. He adds that he wasn’t sure he could tell the therapist this.
Further separate situations: the following brief examples are not events from the main case.
Separate example: Eye contact
An autistic client rarely makes eye contact. The therapist’s early note reads “avoidant, possible shame.” Asked directly, the client explains that eye contact makes it harder to think. The interpretation is dropped; the frame adapts.
Separate example: Sessions from a car
A client joins remote sessions from a parked car because home is not private. The therapist discusses safety, privacy, and a plan if the connection drops, and stays curious about what it means to have nowhere private without assuming it is a defense.
Separate example: Missed sessions and shift work
A client on rotating shifts misses sessions. Before exploring meaning, the therapist checks whether the schedule or fee policy is realistic for the client’s work and income.
Separate example: An assumption about a partner
A therapist asks a client about “your girlfriend.” The client’s partner is a man. The client goes quiet. The therapist repairs by naming the assumption and inviting the client’s experience of it.
Separate example: Drinking to sleep
Theo’s nightly wine is part of how he manages grief and part of a physiological sleep problem. Psychodynamic exploration continues, alongside substance-use assessment and medical coordination.
What “unconscious” means now
Cognitive science accepts that most mental processing happens outside awareness. The psychodynamic addition is that some processes are motivated: people push away painful wishes, fears, and feelings, and those processes still shape choices. Contemporary writers emphasize ongoing avoidance rather than a store of repressed memories.1
How clinicians judge an inference
Confidence grows when the same pattern appears in several places, when the client recognizes it and adds detail, and when naming it leads to more emotional contact or new memories rather than intellectual agreement. Confidence should fall when the client’s response is only compliance or when the idea needs constant defending.2
Multiple function
A single behavior can serve several purposes at once, a principle psychoanalysts call multiple function or overdetermination. Mara’s withdrawal might protect the friendship, punish the friend a little, and spare her the embarrassment of needing. Holding several meanings protects against forcing one.1
Different ideas of what sits at the bottom
Some short-term models emphasize anger and grief that were not safe to feel in early relationships. Experiential models such as AEDP emphasize adaptive core emotions and the relief of feeling them with someone. Relational models emphasize wishes for connection and recognition. The corner’s content is a clinical question, not a given.15
Anxiety pathways in ISTDP
Allan Abbass, a Canadian psychiatrist who teaches intensive short-term dynamic psychotherapy (ISTDP), and colleagues describe specific ways anxiety shows in the body and in thinking, and use them to decide how hard to press. A published review of his book praises its clarity and questions parts of the anxiety model and the enthusiasm of its evidence presentation. Treat this as an advanced model requiring training.41
Combining the triangles
Malan described the most complete interpretations as linking both triangles: a feeling, its anxiety, and its defense, across therapist, current, and past relationships. In practice, contemporary clinicians build these links slowly and often never say them in one sentence. A complete interpretation delivered too early tends to sound like a theory about the client rather than an understanding shared with them.5
Where the historical model needs qualification
Research does not support the idea that more transference interpretation is always better. In one randomized study that compared therapy with and without this one ingredient, average outcomes were the same with or without transference interpretation, while people with long-standing relationship difficulties appeared to benefit more from it. A rupture-repair review cautions that frequent transference interpretation can harm and that quality matters more than quantity.2142
The relational correction
Relational and intersubjective approaches stress that the therapist corner is co-created. The therapist’s real behavior, identity, and reactions are part of what the client responds to. This does not replace the triangle; it adds the therapist into it.8
Levels of organization and technique
Otto Kernberg, an Austrian-born American psychiatrist known for his work on personality disorders, and writers influenced by him, including Nancy McWilliams and the developers of transference-focused psychotherapy, describe how identity integration, typical defenses, and reality testing guide technique. More integrated functioning often allows exploratory work; less integrated functioning often calls for structure, a clear contract, and mentalizing or supportive interventions. These are tendencies, not rules.610
The PDM-3 approach
PDM-3 sections cover infancy, childhood, adolescence, early adulthood, adulthood, and older age. For adults its contents list a personality axis, a profile of mental functioning, and a subjective-experience axis, plus psychodiagnostic charts for assessment. It is meant to be used alongside standard diagnostic systems.12
Formulation as a core problem
Richard Summers, Jacques Barber, and Sigal Zilcha-Mano, psychodynamic researchers and teachers, organize formulation around a core psychodynamic problem and connect it to the mechanisms of change most likely to help. This keeps formulation tied to treatment choices.4
Fees, absences, and endings as themes
Fees, lateness, and missed sessions are practical and can carry meaning about worth, need, and anger. Endings can stir earlier losses. Gabbard’s text devotes chapters to getting started and to working through and termination, and treats these as part of the work rather than administration.2
Stage models of repair
Safran and Muran describe repair as a sequence: the rupture, disengaging from the stuck pattern, exploring the client’s experience, and reaching the wish or need underneath. Their main tool is metacommunication: talking openly about what is happening between therapist and client right now.8
Projective identification, carefully
In object relations writing, projective identification describes a process in which the client’s way of relating stirs up in the therapist a feeling the client can’t bear to hold. For example, a client who can’t tolerate their own helplessness may relate in a way that leaves the therapist feeling helpless and incompetent. It is useful in supervision and easily misused as a way to blame clients for the therapist’s feelings. Learn it from primary texts and with supervision.4310
Erotic and hostile transference
Strong romantic, sexual, or hostile feelings toward the therapist are understandable and require especially clear boundaries and supervision. They are not peer-practice material beyond recognizing the need to consult.43
Evidence across traditions
Experiential dynamic therapies
Several models, including Leigh McCullough’s affect phobia therapy, experiential short-term dynamic psychotherapy, and accelerated experiential dynamic psychotherapy (AEDP), use the triangles while emphasizing emotional experience. AEDP has its own path in Three Sides.5
Integrating multicultural practice
The Multicultural Practice path in Three Sides develops cultural humility and broaching (raising race, culture, and identity openly with clients) in more depth. Psychodynamic writers in this area emphasize that identity is complex and lived differently by each person, and that the therapist’s identity is part of the relational field.9
Remote practice
The second edition of Summers, Barber, and Zilcha-Mano adds remote and hybrid treatment, reflecting how common it now is.4
Free demonstrations
Sentio University offers webinars on psychodynamic inquiry, emotional experience, defenses, process comments and the therapy relationship. These are supporting resources.451416
Object relations and transference-focused psychotherapy
Object relations theory looks at how important relationships become part of a person's inner world. Object means a person as experienced and remembered, not a thing. Someone might walk into every new job expecting an accusing authority and feeling like a disappointing child. The roles can flip quickly: the same person may become sharply critical of others when they feel dependent.
Transference-focused psychotherapy (TFP), developed by Otto Kernberg, an Austrian-born American psychiatrist, with Frank Yeomans and John Clarkin, applies these ideas to people with more severe personality difficulties. It uses a clear treatment contract and pays close attention to sudden swings, from trust to suspicion or admiration to contempt, as they happen with the therapist.108
Mentalizing: when strong emotion shuts down thinking
Mentalizing means making sense of behavior, your own and other people's, in terms of feelings, beliefs, and intentions, while remembering you can't know another mind for certain. Under strong emotion this capacity can collapse: a guess starts to feel like a fact, and an unanswered text becomes proof of rejection.
Mentalization-based treatment (MBT), developed by Anthony Bateman and Peter Fonagy in London, helps rebuild the capacity rather than supplying the "correct" interpretation. Imagine a client who concludes the therapist wants them gone because the therapist glanced at the clock. The therapist can explain the practical reason and then slowly retrace with the client what they noticed, felt, and concluded. A complex interpretation would only overload someone who is already too upset to think. MBT calls this curious, open approach the not-knowing stance.4611
Donnel Stern: experience that hasn't taken shape yet
Donnel Stern, an American psychoanalyst in the interpersonal tradition, writes about unformulated experience: feelings and meanings that haven't yet become clear enough to put into words. A person may sense something is wrong without having a hidden thought they are keeping back. The therapist's job is then to help the experience take shape, not to dig for a fully formed secret.
What "field" means in psychoanalysis
Some psychoanalysts talk about the field: the shared emotional situation that develops between therapist and client, including moods and meanings neither chose on purpose. Field approaches ask not just what does the client's story say about them? but what becomes possible, or impossible, between us while it is being told?
There are two main versions. Stern's interpersonal version focuses on how the relationship opens or closes room for new experience. Giuseppe Civitarese, an Italian psychoanalyst, builds on Wilfred Bion, a British psychoanalyst who wrote about how people process emotional experience, and stresses unconscious communication between the two people. Both put the therapist's participation at the center, but they explain it differently.4950
The field today
A map of selected published perspectives, the people developing them, and questions to compare as you read.
Schools of thought
Relational and interpersonal perspectives
These traditions examine how expectations and meanings develop between people, including therapist and client. Jessica Benjamin, an American psychoanalyst, emphasizes mutual recognition and what happens when two people break down into opposing positions; Stern investigates experience that has not yet become available in words. Participation does not mean equal professional responsibility or unrestricted self-disclosure.5147
Personality and mental functioning
McWilliams and Lingiardi organize clinical understanding around personality, capacities, and subjective experience. This is a formulation tradition that asks how a person functions, not simply which symptom criteria they meet. Gabbard connects that understanding with decisions about support, interpretation, and boundaries.122
Mentalization-based and transference-focused treatments
Bateman and Fonagy focus on recovering the ability to consider minds when emotional pressure disrupts it. Yeomans, Clarkin, and Kernberg work with extreme, all-good or all-bad pictures of self and others as they appear in the treatment relationship. These are distinct formulations and training traditions, not alternative names for generic dynamic therapy.1110
Focused dynamic work
Malan’s conflict formulation, Abbass’s intensive short-term work, and dynamic interpersonal therapy (DIT) provide different ways to focus treatment. Their clinicians differ about how directly to approach defenses and how much to concentrate on a particular interpersonal pattern. A time limit alone does not identify which model is being practiced.54140
Field perspectives from Bion’s and Stern’s traditions
Civitarese, building on the British psychoanalyst Wilfred Bion, emphasizes unconscious communication within a shared analytic field. Stern’s contemporary interpersonal field account investigates how emotional participation makes new meaning possible. These positions meet around participation and emergence but retain different theories of unconscious process; “field” should not conceal their differences.5049
People to know
Nancy McWilliams. Personality, formulation, and psychoanalytic supervision.25
Glen O. Gabbard. Long-term dynamic treatment and the clinical frame.2
Jessica Benjamin. Mutual recognition, and “thirdness”: the shared space two people can create when neither has to dominate.51
Anthony Bateman. Mentalization-based treatment.11
Peter Fonagy. Mentalizing and its clinical applications.11
Frank E. Yeomans. Transference-focused psychotherapy.10
Otto F. Kernberg. Object relations and personality organization.10
Alessandra Lemma. Dynamic interpersonal treatment and contemporary applications.40
Pratyusha Tummala-Narra. Culture, identity, and psychoanalytic understanding.9
Giuseppe Civitarese. Bionian field theory and unconscious communication.50
Live debates
These questions bring the different clinical priorities above into conversation.
How much should the therapist participate?
Relational clinicians make mutual influence explicit; more restrained positions worry that disclosure can shift attention away from the patient. The practical issue is what a particular intervention enables or forecloses, rather than whether participation can be eliminated.512
Interpretation, relationship, or both?
Some formulations emphasize understanding conflict and recurring meanings; others emphasize the experience of a different relationship. Integrative accounts investigate how understanding, support, and new experience work together rather than making insight and relationship exclusive alternatives.48
Depth and focus
Focused treatments seek a clear, workable target; open-ended work can accommodate material that emerges slowly or changes the treatment’s purpose. The disagreement concerns what is gained and lost by narrowing attention, not whether brief work can be serious.402
Culture inside the formulation
Intrapsychic accounts illuminate subjective meaning; cultural and relational critiques ask when they overlook oppression or the therapist’s assumptions. A contemporary formulation needs room for both personal history and conditions that are happening now.912
What institute trainees read
A reading route into these traditions. Individual institutes set their own syllabi.
Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, 2nd ed.
The standard teaching text for thinking about personality along two dimensions: the level of organization and the characteristic style. It is meant to deepen empathy and guide technique, not to sort people into labels.6
Long-Term Psychodynamic Psychotherapy: A Basic Text, 3rd ed.
A compact training text organized around core competencies. The publisher lists chapters on key concepts; assessment, indications, and formulation; getting started; therapist interventions; goals and therapeutic action; resistance; dreams and fantasies; countertransference; working through and termination; supervision; and evaluating competencies.2
Psychodynamic Diagnostic Manual, 3rd ed. (PDM-3)
A psychodynamic diagnostic reference that sits beside, not in place of, descriptive diagnosis. Its contents pair a personality axis (P), a profile of mental functioning (M), and the person’s subjective experience of symptoms (S), with separate sections for childhood, adolescence, early adulthood, and older adults. This third edition replaces PDM-2 (2017) as the current version.12
Beyond Doer and Done To: Recognition Theory, Intersubjectivity and the Third
Develops mutual recognition, breakdown, acknowledgment, and thirdness in relational psychoanalysis.51
On Coming into Possession of Oneself: Transformations of the Interpersonal Field
Develops contemporary interpersonal field theory, meaning-making, and the analyst’s emotional participation.49
Mentalization-Based Treatment for Personality Disorders: A Practical Guide
The practical guide to mentalization-based treatment. Read it for the not-knowing stance and for why insight-oriented interpretation can backfire when someone’s capacity to reflect has collapsed under stress.11
Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide
The clinical guide to a contemporary object-relations treatment. Useful for seeing how a clear treatment contract and a focus on the here-and-now relationship organize work with more complex personality functioning.10
Brief Dynamic Interpersonal Therapy: A Clinician’s Guide, 2nd ed.
A manualized brief psychodynamic treatment developed for mood disorders and offered for depression in the UK NHS. The second edition adds chapters on complex care, functional and somatic disorders, and internet-delivered work.40
Psychoanalytic Field Theory: A Contemporary Introduction
Introduces the Bionian field perspective and its account of unconscious communication and clinical change.50
Psychoanalytic Theory and Cultural Competence in Psychotherapy
Proposes a framework that brings psychoanalytic thinking together with multicultural and feminist psychology, so that social context is part of the formulation rather than a footnote.9
Read, watch, listen
Books
Long-Term Psychodynamic Psychotherapy: A Basic Text, 3rd ed. (opens in a new tab)
A compact training text organized around core competencies. The publisher lists chapters on key concepts; assessment, indications, and formulation; getting started; therapist interventions; goals and therapeutic action; resistance; dreams and fantasies; countertransference; working through and termination; supervision; and evaluating competencies.
Paid · Purchase or library. Source details
Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, 2nd ed. (opens in a new tab)
The standard teaching text for thinking about personality along two dimensions: the level of organization and the characteristic style. It is meant to deepen empathy and guide technique, not to sort people into labels.
Paid · Purchase or library. Source details
Psychoanalytic Case Formulation (opens in a new tab)
A practical companion to Psychoanalytic Diagnosis focused on building an individualized understanding of a person rather than a category.
Paid · Purchase or library. Source details
Psychoanalytic Supervision (opens in a new tab)
Useful for understanding what supervision adds to peer practice: a more experienced view of the trainee, the client, and the relationship between them.
Paid · Purchase or library. Source details
Podcasts
Psychiatry & Psychotherapy, episode 171 — Nancy McWilliams on Mental Health, Transference, and Dissociation (opens in a new tab)
Discusses mental health, transference and dissociation.
Free. Source details
Episode 144: Psychodynamic Psychotherapy with Jonathan Shedler, PhD (opens in a new tab)
Discusses psychodynamic processes across therapy traditions.
Free. Source details
Transference-Focused Psychotherapy (TFP), BPD, & Narcissism with Dr. Frank Yeomans (opens in a new tab)
Explores how a TFP clinician understands personality and the therapy relationship.
Free. Source details
Shrink Rap Radio 459: Reaching Through the Resistance in Psychotherapy with Allan Abbass (opens in a new tab)
Introduces an ISTDP clinician’s approach to emotional avoidance and resistance.
Free. Source details
Episode 184: Does Analysis Work? A Conversation with Jonathan Shedler, PhD (opens in a new tab)
An analyst and researcher discuss psychodynamic treatment and evaluating psychotherapy research.
Free. Source details
Transforming Trauma, episode 114: Championing Relational Therapeutic Solutions in a Quick-Fix World With Dr. Jonathan Shedler (opens in a new tab)
Hear Shedler’s perspective on the therapeutic alliance, transference and countertransference, and the relationship between psychotherapy research and clinical practice.
Free. Source details
Transforming Trauma, episode 143: What Good Psychotherapy Looks Like With Dr. Jonathan Shedler (opens in a new tab)
Continues the conversation about the working alliance, individual understanding and the conditions that make difficult therapeutic exploration possible.
Free. Source details
Videos
Psychoanalytic Psychotherapy for Personality Disorders: An Interview with Otto Kernberg, MD (opens in a new tab)
A clinical interview about personality organization and psychoanalytic treatment.
Paid · Purchase or library. Source details
Effectively Intervening with Violent Behavior: An Interview with Dr. Peter Fonagy (opens in a new tab)
Discusses violence, mentalizing and therapeutic reasoning.
Paid · Purchase or library. Source details
EP21 Clinical Demonstration 04: Transference Focused Psychotherapy (opens in a new tab)
A recorded clinical demonstration of transference-focused psychotherapy.
Paid · Purchase or library. Source details
The Efficacy of Psychoanalytic Therapy: The Talking Cure in the Era of Evidence-Based Practice (opens in a new tab)
A recorded lecture about interpreting psychoanalytic psychotherapy research.
Library or purchase. Source details
Psychoanalytic Therapy (opens in a new tab)
A demonstration of psychoanalytic listening and case understanding.
Paid · Purchase or library. Source details
Articles
The efficacy of psychodynamic psychotherapy. (opens in a new tab)
Introduces a widely discussed account of psychodynamic research; pair it with the published critical responses.
Free. Source details
Short-term psychodynamic psychotherapies for common mental disorders (opens in a new tab)
Reviews short-term psychodynamic treatment trials and their different comparison conditions.
Library or purchase. Source details
Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder (opens in a new tab)
A randomized comparison of mentalization-based treatment and structured clinical management for borderline personality disorder.
Journal or institutional access. Source details
Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria (opens in a new tab)
Applies explicit review criteria to psychodynamic treatment trials across several diagnostic groups.
Journal or institutional access. Source details
Psychodynamic Therapy: As Efficacious as Other Empirically Supported Treatments? A Meta-Analysis Testing Equivalence of Outcomes (opens in a new tab)
Examines whether treatment comparisons satisfy a prespecified statistical definition of equivalence.
Journal or institutional access. Source details
The status of psychodynamic psychotherapy as an empirically supported treatment for common mental disorders – an umbrella review based on updated criteria (opens in a new tab)
A preregistered umbrella review that rated the certainty of evidence with GRADE. It is the most current broad summary, written by researchers closely identified with psychodynamic therapy.
Free. Source details
Evaluating three treatments for borderline personality disorder: A multiwave study (opens in a new tab)
Compared transference-focused psychotherapy, DBT, and supportive psychodynamic therapy. All three helped with depression, anxiety, and functioning; they differed in which other domains changed.
Journal or institutional access. Source details
The Efficacy of Experiential Dynamic Therapies: A 10‐Year Systematic Review and Meta‐Analysis Update (opens in a new tab)
A review of the broader family of experiential dynamic therapies (EDT), not of AEDP alone.
Free. Source details
Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial (opens in a new tab)
How did TFP compare with experienced community therapists for borderline personality disorder?
Journal or institutional access. Source details
Psychotherapies for the treatment of borderline personality disorder: A systematic review (opens in a new tab)
What do comparative studies show about psychotherapy options for borderline personality disorder?
Journal or institutional access. Source details
Mentalization-Based Therapy for Borderline Personality Disorder: State-Of-The-Science and Future Directions (opens in a new tab)
What does the randomized-trial literature show about MBT for borderline personality disorder?
Free. Source details
Mentalisation-based treatment for antisocial personality disorder in males convicted of an offence on community probation in England and Wales (Mentalization for Offending Adult Males, MOAM): a multicentre, assessor-blinded, randomised controlled trial (opens in a new tab)
Can MBT adapted for antisocial personality disorder reduce aggression when added to probation?
Journal or institutional access. Source details
Short-term psychodynamic psychotherapy for social anxiety disorder: a meta-analysis of randomized controlled trials (opens in a new tab)
What do randomized trials show for short-term psychodynamic therapy for social anxiety disorder?
Free. Source details
Examining Who Benefits from Short-Term Psychodynamic Psychotherapy for Depression: Insights from a Series of Individual Participant Data Meta-analyses (opens in a new tab)
How is patient-level research refining what is known about brief psychodynamic treatment for depression?
Journal or institutional access. Source details
More from the training institutes and publishers
Sources
Three Sides is independently produced and is not affiliated with or endorsed by the authors or publishers listed here. These publications are supporting readings; the teaching scenes and partner rehearsals were written for Three Sides. Fictional dialogue and case progress are illustrations, not study results.
Show all 90 references
That Was Then, This Is Now: Psychoanalytic Psychotherapy for the Rest of Us (opens in a new tab)
A plain-language introduction that separates contemporary psychodynamic thinking from stereotypes. It explains mental life outside awareness, ordinary defenses, conflict and ambivalence, symptoms as old solutions, transference, and the therapist’s responsibility to examine their own contribution. It is an advocate’s overview; read it with the critiques in the evidence lesson.
Long-Term Psychodynamic Psychotherapy: A Basic Text, 3rd ed. (opens in a new tab)
A compact training text organized around core competencies. The publisher lists chapters on key concepts; assessment, indications, and formulation; getting started; therapist interventions; goals and therapeutic action; resistance; dreams and fantasies; countertransference; working through and termination; supervision; and evaluating competencies.
Deliberate Practice in Psychodynamic Psychotherapy (opens in a new tab)
A psychodynamic skills-rehearsal book covering therapeutic inquiry, emotional experience, defenses and the therapy relationship.
Psychodynamic Therapy: A Guide to Evidence-Based Practice, 2nd ed. (opens in a new tab)
A pragmatic, research-informed model that organizes formulation around a person’s core psychodynamic problem and links it to likely mechanisms of change. The second edition adds remote and hybrid treatment.
Individual Psychotherapy and the Science of Psychodynamics, 2nd ed. (opens in a new tab)
The source most associated with the two triangles. Read it as a historical clinical text: it shows how brief dynamic therapists linked feeling, anxiety, defense, and relationships, before attachment, relational, and mentalization research reshaped the field.
Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, 2nd ed. (opens in a new tab)
The standard teaching text for thinking about personality along two dimensions: the level of organization and the characteristic style. It is meant to deepen empathy and guide technique, not to sort people into labels.
Psychoanalytic Case Formulation (opens in a new tab)
A practical companion to Psychoanalytic Diagnosis focused on building an individualized understanding of a person rather than a category.
Negotiating the Therapeutic Alliance: A Relational Treatment Guide (opens in a new tab)
The foundational account of alliance ruptures, therapeutic metacommunication, and stage-process models of repair. Its chapters move from rethinking the alliance to rupture resolution, brief relational therapy, and training.
Psychoanalytic Theory and Cultural Competence in Psychotherapy (opens in a new tab)
Proposes a framework that brings psychoanalytic thinking together with multicultural and feminist psychology, so that social context is part of the formulation rather than a footnote.
Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide (opens in a new tab)
The clinical guide to a contemporary object-relations treatment. Useful for seeing how a clear treatment contract and a focus on the here-and-now relationship organize work with more complex personality functioning.
Mentalization-Based Treatment for Personality Disorders: A Practical Guide (opens in a new tab)
The practical guide to mentalization-based treatment. Read it for the not-knowing stance and for why insight-oriented interpretation can backfire when someone’s capacity to reflect has collapsed under stress.
Psychodynamic Diagnostic Manual, 3rd ed. (PDM-3) (opens in a new tab)
A psychodynamic diagnostic reference that sits beside, not in place of, descriptive diagnosis. Its contents pair a personality axis (P), a profile of mental functioning (M), and the person’s subjective experience of symptoms (S), with separate sections for childhood, adolescence, early adulthood, and older adults. This third edition replaces PDM-2 (2017) as the current version.
Psychoanalytic Psychotherapy: A Practitioner’s Guide (opens in a new tab)
A readable account of how a psychodynamic therapist works and why, including the attitudes behind technique.
Therapeutic Inquiry (single-skill webinar) (opens in a new tab)
A focused session on curious, open inquiry, the skill behind the first lesson.
Brief Dynamic Therapy, 2nd ed. (opens in a new tab)
An overview of time-limited dynamic psychotherapy, an integrative brief model drawing on attachment, experiential learning, and systems ideas. A good bridge from the triangles to a contemporary interpersonal formulation.
Working With Defenses (single-skill webinar) (opens in a new tab)
Pairs with the lesson on naming a defense’s function without attacking it.
Deepening Emotional Experience (single-skill webinar) (opens in a new tab)
Pairs with the triangle-of-conflict lesson on helping feeling become experienced rather than explained.
Metaphors (single-skill webinar) (opens in a new tab)
An advanced skill for staying close to the client’s own imagery.
Exploring Fantasy (single-skill webinar) (opens in a new tab)
An advanced skill for exploring wishes and fears through imagined scenarios.
Making Process Comments (single-skill webinar) (opens in a new tab)
Pairs with the frame and relationship lesson.
Transference Interpretations in Dynamic Psychotherapy: Do They Really Yield Sustained Effects? (opens in a new tab)
One of very few experiments on a specific psychodynamic technique. Average benefit was the same with or without transference interpretation, but people with long-standing relationship difficulties appeared to benefit more from it.
Transference Interpretations (single-skill webinar) (opens in a new tab)
Pairs with the transference and the intervention-and-timing lessons.
Countertransference management and effective psychotherapy: Meta-analytic findings. (opens in a new tab)
Supports a central lesson: reactions acted on without reflection relate to worse outcomes, while managing them through self-awareness and understanding relates to better ones.
Countertransference (single-skill webinar) (opens in a new tab)
Pairs with the transference and countertransference lesson.
Psychoanalytic Supervision (opens in a new tab)
Useful for understanding what supervision adds to peer practice: a more experienced view of the trainee, the client, and the relationship between them.
The status of psychodynamic psychotherapy as an empirically supported treatment for common mental disorders – an umbrella review based on updated criteria (opens in a new tab)
A preregistered umbrella review that rated the certainty of evidence with GRADE. It is the most current broad summary, written by researchers closely identified with psychodynamic therapy.
Psychodynamic Therapy: As Efficacious as Other Empirically Supported Treatments? A Meta-Analysis Testing Equivalence of Outcomes (opens in a new tab)
Examines whether treatment comparisons satisfy a prespecified statistical definition of equivalence.
The efficacy of psychodynamic psychotherapy. (opens in a new tab)
Introduces a widely discussed account of psychodynamic research; pair it with the published critical responses.
Evaluating three treatments for borderline personality disorder: A multiwave study (opens in a new tab)
Compared transference-focused psychotherapy, DBT, and supportive psychodynamic therapy. All three helped with depression, anxiety, and functioning; they differed in which other domains changed.
Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial (opens in a new tab)
How did TFP compare with experienced community therapists for borderline personality disorder?
Psychotherapies for the treatment of borderline personality disorder: A systematic review (opens in a new tab)
What do comparative studies show about psychotherapy options for borderline personality disorder?
Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder (opens in a new tab)
A randomized comparison of mentalization-based treatment and structured clinical management for borderline personality disorder.
Mentalization-Based Therapy for Borderline Personality Disorder: State-Of-The-Science and Future Directions (opens in a new tab)
What does the randomized-trial literature show about MBT for borderline personality disorder?
Mentalisation-based treatment for antisocial personality disorder in males convicted of an offence on community probation in England and Wales (Mentalization for Offending Adult Males, MOAM): a multicentre, assessor-blinded, randomised controlled trial (opens in a new tab)
Can MBT adapted for antisocial personality disorder reduce aggression when added to probation?
The Efficacy of Experiential Dynamic Therapies: A 10‐Year Systematic Review and Meta‐Analysis Update (opens in a new tab)
A review of the broader family of experiential dynamic therapies (EDT), not of AEDP alone.
Short-term psychodynamic psychotherapy for social anxiety disorder: a meta-analysis of randomized controlled trials (opens in a new tab)
What do randomized trials show for short-term psychodynamic therapy for social anxiety disorder?
Examining Who Benefits from Short-Term Psychodynamic Psychotherapy for Depression: Insights from a Series of Individual Participant Data Meta-analyses (opens in a new tab)
How is patient-level research refining what is known about brief psychodynamic treatment for depression?
Pragmatic randomized controlled trial of long‐term psychoanalytic psychotherapy for treatment‐resistant depression: the Tavistock Adult Depression Study (TADS) (opens in a new tab)
Shows why follow-up matters: differences that were not significant at the end of treatment widened over the next two years. Also a clear example of limitations that temper the result.
The effectiveness of long-term psychoanalytic psychotherapy—A meta-analysis of randomized controlled trials (opens in a new tab)
An important counterweight on treatment length. It found recovery rates similar to various controls and judged the evidence for long-term psychoanalytic psychotherapy limited and at best conflicting.
Brief Dynamic Interpersonal Therapy: A Clinician’s Guide, 2nd ed. (opens in a new tab)
A manualized brief psychodynamic treatment developed for mood disorders and offered for depression in the UK NHS. The second edition adds chapters on complex care, functional and somatic disorders, and internet-delivered work.
Reaching Through Resistance: Advanced Psychotherapy Techniques (opens in a new tab)
A dense guide to intensive short-term dynamic psychotherapy (ISTDP). The linked review by David Hellerstein (Society for the Advancement of Psychotherapy, 2016) is a balanced entry point: it praises the method’s clarity and cautions that the book assumes prior training and presents evidence with the enthusiasm of an originator.
Repairing alliance ruptures. (opens in a new tab)
An early meta-analysis on rupture repair with clear practice recommendations, including the caution that frequent transference interpretation can harm and that the quality of an interpretation matters more than how often it is used.
Episode 254: Countertransference and Transference with Frank Yeomans, MD (opens in a new tab)
A transference-focused psychotherapy perspective on transference, concordant and complementary countertransference, and projective identification. Compare it with the mentalization lens in the contemporary traditions lesson.
Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis (opens in a new tab)
An independent and critical review: dialectical behavior therapy and psychodynamic approaches outperformed controls, but effects were small, inflated by risk of bias and publication bias, and unstable at follow-up.
Deliberate Practice in Psychodynamic Psychotherapy (overview webinar) (opens in a new tab)
An introductory webinar on practicing psychodynamic skills.
Mentalization-Based Treatment (opens in a new tab)
The developers explain mentalizing, the therapeutic stance, and basic clinical interventions.
Unformulated Experience: From Dissociation to Imagination in Psychoanalysis (opens in a new tab)
Examines experience that has not yet been articulated and the relational conditions of meaning-making.
What does “unconscious” mean? Unformulated experience and the interpersonal field (opens in a new tab)
Stern revisits his theory of unformulated experience and the place of relational and nonverbal change.
On Coming into Possession of Oneself: Transformations of the Interpersonal Field (opens in a new tab)
Develops contemporary interpersonal field theory, meaning-making, and the analyst’s emotional participation.
Psychoanalytic Field Theory: A Contemporary Introduction (opens in a new tab)
Introduces the Bionian field perspective and its account of unconscious communication and clinical change.
Beyond Doer and Done To: Recognition Theory, Intersubjectivity and the Third (opens in a new tab)
Develops mutual recognition, breakdown, acknowledgment, and thirdness in relational psychoanalysis.
Psychiatry & Psychotherapy, episode 171 — Nancy McWilliams on Mental Health, Transference, and Dissociation (opens in a new tab)
Discusses mental health, transference and dissociation.
Episode 144: Psychodynamic Psychotherapy with Jonathan Shedler, PhD (opens in a new tab)
Discusses psychodynamic processes across therapy traditions.
Transference-Focused Psychotherapy (TFP), BPD, & Narcissism with Dr. Frank Yeomans (opens in a new tab)
Explores how a TFP clinician understands personality and the therapy relationship.
Shrink Rap Radio 459: Reaching Through the Resistance in Psychotherapy with Allan Abbass (opens in a new tab)
Introduces an ISTDP clinician’s approach to emotional avoidance and resistance.
Episode 184: Does Analysis Work? A Conversation with Jonathan Shedler, PhD (opens in a new tab)
An analyst and researcher discuss psychodynamic treatment and evaluating psychotherapy research.
Transforming Trauma, episode 114: Championing Relational Therapeutic Solutions in a Quick-Fix World With Dr. Jonathan Shedler (opens in a new tab)
Hear Shedler’s perspective on the therapeutic alliance, transference and countertransference, and the relationship between psychotherapy research and clinical practice.
Transforming Trauma, episode 143: What Good Psychotherapy Looks Like With Dr. Jonathan Shedler (opens in a new tab)
Continues the conversation about the working alliance, individual understanding and the conditions that make difficult therapeutic exploration possible.
Psychoanalytic Psychotherapy for Personality Disorders: An Interview with Otto Kernberg, MD (opens in a new tab)
A clinical interview about personality organization and psychoanalytic treatment.
Effectively Intervening with Violent Behavior: An Interview with Dr. Peter Fonagy (opens in a new tab)
Discusses violence, mentalizing and therapeutic reasoning.
EP21 Clinical Demonstration 04: Transference Focused Psychotherapy (opens in a new tab)
A recorded clinical demonstration of transference-focused psychotherapy.
The Efficacy of Psychoanalytic Therapy: The Talking Cure in the Era of Evidence-Based Practice (opens in a new tab)
A recorded lecture about interpreting psychoanalytic psychotherapy research.
Psychoanalytic Therapy (opens in a new tab)
A demonstration of psychoanalytic listening and case understanding.
Short-term psychodynamic psychotherapies for common mental disorders (opens in a new tab)
Reviews short-term psychodynamic treatment trials and their different comparison conditions.
Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria (opens in a new tab)
Applies explicit review criteria to psychodynamic treatment trials across several diagnostic groups.
Expanding Your Clinical Repertoire: Psychoanalytic Ideas You Can Use to Help Patients (opens in a new tab)
Listed here so learners know it is coming. It is not yet published and has not been reviewed.
Psychodynamic Psychotherapy: A Clinical Manual, 2nd ed. (opens in a new tab)
A step-by-step teaching manual used in many residency programs. Pair it with Gabbard for a structured beginner sequence.
Malan triangles (opens in a new tab)
A tertiary summary of where the triangles came from: Malan placed Henry Ezriel’s three-part account of group attitudes (simplified to defense, impulse, and anxiety) beside Karl Menninger’s triangle of insight. It also notes the criticism that the triangles can be applied mechanically and intellectually. Use it for orientation, then check its cited books.
The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update (opens in a new tab)
A depression-specific review that includes Pim Cuijpers, a prominent meta-analyst not identified with psychodynamic advocacy.
Comparative Effectiveness of Cognitive Therapy and Dynamic Psychotherapy for Major Depressive Disorder in a Community Mental Health Setting: A Randomized Clinical Noninferiority Trial (opens in a new tab)
Tested brief dynamic therapy against cognitive therapy with community clinicians and patients, the kind of setting many trainees work in.
The alliance in adult psychotherapy: A meta-analytic synthesis. (opens in a new tab)
The best-known synthesis linking alliance to outcome across therapies. It supports careful attention to the relationship in every approach, while reminding us that correlation is not proof that the alliance causes change.
Methods and mechanisms in the efficacy of psychodynamic psychotherapy. (opens in a new tab)
A methodological comment on claims about psychodynamic therapy. The separate Thombs, Jewett and Bassel comment has its own reference.
Episode 241: Depressive Personality Style with Jonathan Shedler (opens in a new tab)
A long clinical conversation about a depressive personality style. Useful alongside the personality formulation lesson and the longitudinal case of Mara.
Episode 265: Primitive Defense Mechanisms Explained (opens in a new tab)
A clinician discussion of defenses often seen with more complex personality functioning, including when the same defense is adaptive or costly.
Episode 249: Intergenerational Trauma Explained: The Role of Reflective Function and Mentalization in Healing Attachment (opens in a new tab)
A research-oriented episode on reflective function and disorganized attachment, with sections on TFP, MBT, and Minding the Baby.
Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up (opens in a new tab)
Examine the research question, comparison conditions and limits of this study of DBT.
Psychological therapies for people with borderline personality disorder (opens in a new tab)
Examine the research question, comparison conditions and limits of this study of DBT.
Outpatient Psychotherapy for Borderline Personality Disorder: Randomized Trial of Schema-Focused Therapy vs Transference-Focused Psychotherapy (opens in a new tab)
Examine the research question, comparison conditions and limits of this study of Schema Therapy.
Efficacy of experiential dynamic therapy for psychiatric conditions: A meta-analysis of randomized controlled trials. (opens in a new tab)
A review of the broader experiential dynamic therapy family. Its pooled results are not AEDP-specific randomized evidence; a 2025 update is listed separately.
Is there room for criticism of studies of psychodynamic psychotherapy? (opens in a new tab)
Supporting conceptual source; not a treatment-outcome trial.
Finding the right fit for intensive short term dynamic psychotherapy: A book review (opens in a new tab)
A critical review of Abbass’s Reaching through resistance; distinct from the book itself.
Development and validation of a self-report measure of mentalizing: The Reflective Functioning Questionnaire (opens in a new tab)
Distinguishes the RFQ self-report instrument from interview-rated reflective functioning.
Jonathan Shedler — Selected writings (opens in a new tab)
Author-hosted route to clinical explanations, research papers, and commentary; identify each source's genre before drawing conclusions.
Jonathan Shedler — That Was Then, This Is Now, Part 1 (2026) (opens in a new tab)
An updated introduction aimed at trainees; its index covers unconscious life, conflict, past/present, transference, defense, and causation.
APA author webinar — Deliberate Practice in Psychodynamic Psychotherapy (opens in a new tab)
APA links an author demonstration and discussion; use the companion book to interpret criteria rather than inventing them.
Psychiatry & Psychotherapy, episode 205 — Beginning Treatment with Jonathan Shedler (opens in a new tab)
The host publishes an edited role-play excerpt about missed appointments, shame, and making room for reflection.
Psychodynamic Therapy: As Efficacious as Other Empirically Supported Treatments? A Meta-Analysis Testing Equivalence of Outcomes (opens in a new tab)
Which disorders, comparison treatments, and trial quality were included?
What is the window of tolerance? (opens in a new tab)
Public education resource describing the window as a model of arousal; not a validation of a diagnostic threshold.
Treating Affect Phobia: A Manual for Short-Term Dynamic Psychotherapy (opens in a new tab)
A neighboring experiential dynamic model integrating work on emotional avoidance and relationships.
Talks on Psychoanalysis (opens in a new tab)
Browse the official collection for additional talks, interviews and training resources.