What are transference and countertransference?

Transference is unknowingly bringing expectations and feelings from important early relationships to people now, therapist included; countertransference is what the therapist feels in the session. Freud already treated transference as central material for the work, but saw countertransference as something the therapist must recognise and overcome; later analysts came to treat countertransference, too, as a clue to understanding the client.

How long does psychodynamic therapy take?

It depends on the aim. Research usually defines short-term therapy as 40 hours or fewer in total; NICE's version for depression is usually 8 to 16 sessions. Long-standing relationship patterns may take longer, which you and your therapist can weigh up together.

How is it different from CBT?

Studies comparing session recordings found psychodynamic therapy focuses more on feelings, avoidance, recurring patterns, the past, relationships and the therapy relationship, and lets you speak freely; CBT concentrates more on thoughts and beliefs, with more structured sessions. They can complement each other.

How do I find a psychodynamic therapist in Hong Kong?

Look for specific psychodynamic training and supervision, and membership of a professional body. Further down are TreeholeHK's counsellors and psychologists who work psychodynamically; read their backgrounds before you book.

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Therapy approaches, explained

Psychodynamic therapyPDT

Q: Isn't psychoanalysis unscientific?

Some of Freud's theories are hard to test, and the philosopher Karl Popper criticised psychoanalysis as unfalsifiable. But psychodynamic therapy now has dozens of randomised trials: syntheses find it works for depression, anxiety and more, comparably to other established therapies. There are far fewer trials than for CBT, though, and many come from psychodynamic researchers. See the research section above.

We are made of many conflicting forces, most of them outside awareness. What goes unseen tends to replay in our relationships; seeing it gives us more choice.^[5,6]

Start with the basics Find a therapist

Perhaps we are alone in the end. But precisely because we are alone, genuine relationships between people bring us our greatest redemption.

Why push away what we want? How psychodynamic therapy sees it

Have you ever come home from a lovely date, got a friendly message, and then not replied? You tell yourself "I'm busy this week", and a few days later even the wish to reply has faded. Why would we push away, with our own hands, something we wanted?

1The worldview

Behind the unanswered message: defence, feeling and anxiety pulling against each other

Psychodynamic therapy (PDT) grows out of Sigmund Freud's psychoanalysis. Its answer to the opening puzzle comes from its worldview: a person is not one unified self but many conflicting forces, most of them outside awareness. Freud divided the mind into three: the id, which wants satisfaction now; the superego, which says "you mustn't" and "you should"; and the ego, which mediates between them according to reality.^[1,5]

Psychoanalysis is not only Freud. After him, Melanie Klein, Donald Winnicott, Heinz Kohut and others shifted the focus from inner drives to relationships between people. Psychodynamic therapy today means treatments built on psychoanalytic ideas but with less frequent sessions, and often shorter. At its heart is exploring the parts of ourselves we don't fully know, especially as they show up in the relationship with the therapist.^[5,6]

If you walk in, in what order do these skills come up?

Now you know how it sees a person and how it works. The next questions: what is it actually like, does it work, and what is it not for?

There is evidence and there are limits, so what is it like to walk in? Psychodynamic therapy usually meets once or twice a week and can be time-limited or open-ended; traditional psychoanalysis meets far more often. In research, short-term psychodynamic therapy is usually defined as 40 hours or fewer in total. The version the UK's National Institute for Health and Care Excellence (NICE) describes for depression is usually 8 to 16 sessions for less severe depression and 16 for more severe depression. The skills above come up in roughly the order below, and the steps name the skill in use where they can.^[6,26,29]

1Assessment and a first understandingTalk through the difficulty, your life and how you grew up, and sketch together what repeating pattern might sit behind it, such as why a good date turns into silence (a first rough draft of the two triangles).
2

PDT videos

Episodes are in Cantonese.

Want to start on your own? A self-guided psychodynamic path

Not ready to see a therapist yet? Start with these four episodes, and notice your own patterns as you listen.

Courses

Twelve hours rooted in Freud and Jung: the unconscious, then interpretation, transference, countertransference and dream work in practice. For the curious public and helping professionals alike.

Therapists who practise PDT

TreeholeHK's counsellors and clinical psychologists use PDT to fit what you need, alongside other approaches.

Want another angle? The psychoanalytic family, and its neighbours

Psychoanalysis has many schools. The first three share its roots (Jung split from Freud), and object relations and self psychology are the branch described earlier that shifted the focus to relationships; the last two are neighbouring approaches. Each puts the weight somewhere different; start here to learn more.

Klein, Winnicott, Fairbairn: we take early relationships inside us, and use them to make sense of the people we meet now.^[5]
Kohut: we need to be admired, to have someone to look up to, and to have people like us, to build a steady sense of self-worth.^[5]

Other therapy approaches

FAQ

What's the difference between psychoanalysis and psychodynamic therapy?

The terms are often used interchangeably. Broadly, psychoanalysis means the traditional, intensive form; psychodynamic therapy rests on the same ideas but usually meets once or twice a week, time-limited or open-ended.^[6]

Does psychodynamic therapy have to be about childhood?

It often comes up, but not to rake over the past for its own sake. The point is how the past lives on today, such as why you keep being drawn to the same kind of person. Understanding then is for having more choice now.^[6]

Isn't psychoanalysis unscientific?

Want someone alongside you?

You can do the exercises on your own. When you're stuck, a trained therapist can take you further.

3The skills

How do you get near the hidden feeling? Three doors, six skills

With both triangles in view, the next question is how to get near. The three doors are the three corners of the triangle of conflict. Defences once protected us, so they aren't torn down; the work roughly follows this route: notice the defence, tend the anxiety behind it, then reach the hidden feeling and trace it across relationships with the triangle of person. The six skills sit behind the three doors, the last three all serving the hidden feeling. They aren't used in turn but come up together as a course unfolds; the four dialogues below follow one fictional client, the man from the opening puzzle.

Through the defence

Notice how you steer away: changing the subject, "whatever", sudden tiredness. See it first; no rush to dismantle it.

Free association
The therapist invites you to say whatever comes to mind, including thoughts that seem irrelevant, embarrassing or trivial. What matters is not only what you say but where you stop or change the subject: that is often where a defence appears, which makes it the first step in noticing defences.^[6,15]
Hear it in a session
1. Therapist
  As before, today you can say whatever comes to mind, even if it seems irrelevant, scattered or a bit embarrassing.
2. Client
  Hmm… work's been rushed, my boss moved the deadline again. …On Saturday I had dinner with the woman I mentioned. …Nothing special really. Oh, and the Observatory said it would rain that day, and it didn't.
3. Therapist
  I noticed that when you got to Saturday's dinner, you paused, then moved quickly to the weather.
4. Client
  Did I? I was just saying what came up.
5. Therapist
  Maybe so. I'm just curious: what came up inside when you mentioned the dinner?
6. Client
  …(pause) Actually the dinner was lovely. She messaged me when I got home, and I still haven't replied.
7. Therapist
  How do you feel as you say that?
8. Client
  A bit uncomfortable. I don't want to say more.
9. Therapist
  There's no hurry. "Not wanting to say more" is worth noticing too. Shall we keep it in mind and come back to it when you're ready?
10. Client
  OK.
Notice: The therapist sets the invitation, then says little, gently pointing out only the pause and the change of subject, with curiosity rather than correction. The client says a little, then doesn't want to go on; the therapist doesn't press, and notes the "not wanting to" itself as something to come back to.
Method based on^[6,15]
Noticing and interpreting defences
When you move away from a feeling by changing the subject, saying "whatever" or starting to reason it out (like the opening "I'm busy this week"), the therapist gently points it out and wonders with you: what does this help you avoid? Defences once protected you, so the point is to see their cost, not to blame them.^[6,11,16]
Hear it in a session
1. Client
  She messaged again, and I still haven't replied. Never mind, whatever. I don't really need a relationship anyway.
2. Therapist
  You said "whatever" very quickly. Could we pause on that for a moment?
3. Client
  I suppose.
4. Therapist
  Last time you said the evening was lovely. Could it be that "whatever" is easier to bear than "I really want to see her"?
5. Client
  …Not exactly. I don't really want to see her. It's just… if I wanted to and she didn't, that would be humiliating.

Tending the anxiety

A steady relationship that can bear it lets anxiety settle enough to come near the feeling.

Holding and containment
Winnicott wrote of the "holding environment" and Wilfred Bion of "containment". When anxiety is too big, people can only retreat into defence, so therapy first needs a relationship that can bear it. The therapist acts as a container for feelings you can't yet bear, neither fleeing nor retaliating, and gives them back, digested, in a form you can take in. Winnicott also described how, when the other person survives your attacks without retaliating, you slowly find that your anger or need doesn't destroy them.^[12,13,14]

Reaching the hidden feeling

Let the feeling come alive in the relationship, then link out there, in here and back then.

Transference: replayed in the room
Without meaning to, we bring expectations, fears and grievances from important early relationships to the therapist. The therapist doesn't sidestep this but invites you to look: what do you expect me to think of you right now? Is it like before? Living it again in a warm relationship gives the old expectation a chance to loosen.^[3,6,17]
Hear it in a session
1. Client
  (Ten minutes late) Sorry, traffic. …There isn't much to talk about today, really.
2. Therapist
  That's all right. We've just had two weeks off; this is our first session since my break. Did those two weeks affect you at all?
3. Client
  No. It's normal for you to take a holiday.
4. Therapist

The dialogues are illustrative composites, not real clients; skills that stir strong emotion or touch on trauma should be done with a trained therapist.

Does seeing the pattern help? What the research says

The dialogues sound plausible, but do they work? Many people assume psychoanalysis has "no scientific basis". In fact psychodynamic therapy has dozens of well-run controlled trials, though far fewer than for cognitive behavioural therapy (CBT), and the conclusions are debated. A "synthesis" pools many trials into one analysis. Below, claim by claim: what the research found, and how firm the evidence is; the last item tests its central claim, that seeing your patterns helps.

For depression
Compared with waiting lists or usual care, psychodynamic therapy brought a moderate improvement (12 trials, around a thousand people). But that is not a large body of trials, and many of them compare it with no treatment at all.^[20]
Versus other therapies
Across 23 trials its effect was close to that of other treatments with established benefit, inside the researchers' pre-set range for "equivalent". But critics say the evidence for equivalence is limited; in a large comparison of 331 depression trials it did not differ significantly from other therapies, yet ranked low for response and remission.^[21,22,23]
For anxiety, personality and physical symptoms
A review pooling many studies found it beat comparison groups in all three areas, and for anxiety and personality difficulties it did not differ significantly from other established therapies. But each area rested on only 5 to 15 trials, the physical-symptom result may be skewed by good results being published more often, and the review's authors are themselves psychodynamic researchers.^[20]
Do the gains last?
Studies of short-term psychodynamic therapy for depression show the gains broadly hold after treatment, with some measures improving further later on. But these are mostly before-and-after changes in treated people, and include studies without random assignment; a Cochrane review also notes that long-term follow-up data are limited and studies vary widely.^[25,26]
For borderline personality
In a pooled comparison of psychotherapies (33 trials), only dialectical behaviour therapy (DBT) and psychodynamic approaches clearly beat comparison groups. But the authors stress that the effects are small, inflated by biased study design and by good results being published more often, and especially unstable at follow-up.^[24]
Does seeing your own patterns help?
"Seeing your own patterns" is the central claim of psychodynamic therapy. Understanding the links between past and present, relationship patterns and symptoms (insight) goes with better outcomes to a moderate degree, and not only in psychodynamic therapy. But that is an association, not proof that insight itself causes the improvement.^[27]

To be honest: many of the studies supporting this therapy come from psychodynamic researchers. The large comparison above also found it did not clearly beat a placebo pill (a comparison that rested on few trials), and it was no better than other therapies at keeping people in treatment. And most trials test short-term treatment (the Cochrane review, for example, included only courses of 40 hours or fewer); open-ended, long-term psychoanalysis has far fewer well-run trials.^[22,23,26]

References

1.Freud, S. (1961). The ego and the id. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 19, pp. 1–66). Hogarth Press. (Original work published 1923)
2.Freud, S. (1957). The unconscious. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 14, pp. 159–215). Hogarth Press. (Original work published 1915)
3.Freud, S. (1958). The dynamics of transference. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 97–108). Hogarth Press. (Original work published 1912)
4.Freud, S. (1957). The future prospects of psycho-analytic therapy. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 11, pp. 139–151). Hogarth Press. (Original work published 1910)
5.Mitchell, S. A., & Black, M. J. (1995). Freud and beyond: A history of modern psychoanalytic thought. Basic Books.
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7.Blagys, M. D., & Hilsenroth, M. J. (2000). Distinctive features of short-term psychodynamic-interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical Psychology: Science and Practice, 7(2), 167–188. doi.org/10.1093/clipsy.7.2.167
8.Schafer, R. (1992). Retelling a life: Narration and dialogue in psychoanalysis. Basic Books.
9.Malan, D. H. (1979). Individual psychotherapy and the science of psychodynamics. Butterworths.
10.Farnsworth, J., & Maclaurin, G. (2015). Practical psychodynamic formulation. Ata: Journal of Psychotherapy Aotearoa New Zealand, 19(2), 145–158. doi.org/10.9791/ajpanz.2015.14
11.McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press.
12.Winnicott, D. W. (1960). The theory of the parent–infant relationship. International Journal of Psycho-Analysis, 41, 585–595.
13.Winnicott, D. W. (1969). The use of an object. International Journal of Psycho-Analysis, 50, 711–716.
14.Bion, W. R. (1962). Learning from experience. Heinemann.
15.Hoffman, L. (n.d.). Free association. Common Language for Psychotherapy (CLP) Procedures. commonlanguagepsychotherapy.org
16.Hoffman, L. (n.d.). Interpreting defenses against unpleasant feelings. Common Language for Psychotherapy (CLP) Procedures. commonlanguagepsychotherapy.org
17.Harris, T. (n.d.). Transference interpretation. Common Language for Psychotherapy (CLP) Procedures. commonlanguagepsychotherapy.org
18.Holmes, J. (n.d.). Countertransference, use of. Common Language for Psychotherapy (CLP) Procedures. commonlanguagepsychotherapy.org
19.Holmes, J. (n.d.). Linking current, past and transference relationships (triangle of person). Common Language for Psychotherapy (CLP) Procedures. commonlanguagepsychotherapy.org
20.Leichsenring, F., Abbass, A., Heim, N., Keefe, J. R., Kisely, S., Luyten, P., Rabung, S., & Steinert, C. (2023). The status of psychodynamic psychotherapy as an empirically supported treatment for common mental disorders – an umbrella review based on updated criteria. World Psychiatry, 22(2), 286–304. doi.org/10.1002/wps.21104
21.Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry, 174(10), 943–953. doi.org/10.1176/appi.ajp.2017.17010057
22.Cristea, I. A., Cuijpers, P., & Naudet, F. (2017). Equivalence of psychodynamic therapy to other established treatments: Limited supporting evidence and clinical relevance [Letter]. American Journal of Psychiatry, 174(11), 1122–1123. doi.org/10.1176/appi.ajp.2017.17050592
23.Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I. A., & Furukawa, T. A. (2021). Psychotherapies for depression: A network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20(2), 283–293. doi.org/10.1002/wps.20860
24.Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry, 74(4), 319–328. doi.org/10.1001/jamapsychiatry.2016.4287
25.Driessen, E., Hegelmaier, L. M., Abbass, A. A., Barber, J. P., Dekker, J. J. M., Van, H. L., Jansma, E. P., & Cuijpers, P. (2015). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update. Clinical Psychology Review, 42, 1–15. doi.org/10.1016/j.cpr.2015.07.004
26.Abbass, A. A., Kisely, S. R., Town, J. M., Leichsenring, F., Driessen, E., De Maat, S., Gerber, A., Dekker, J., Rabung, S., Rusalovska, S., & Crowe, E. (2014). Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews, 2014(7), CD004687. doi.org/10.1002/14651858.CD004687.pub4
27.Jennissen, S., Huber, J., Ehrenthal, J. C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. American Journal of Psychiatry, 175(10), 961–969. doi.org/10.1176/appi.ajp.2018.17080847
28.Leichsenring, F., Luyten, P., Hilsenroth, M. J., Abbass, A., Barber, J. P., Keefe, J. R., Leweke, F., Rabung, S., & Steinert, C. (2015). Psychodynamic therapy meets evidence-based medicine: A systematic review using updated criteria. The Lancet Psychiatry, 2(7), 648–660. doi.org/10.1016/S2215-0366(15)00155-8
29.National Institute for Health and Care Excellence. (2022). Depression in adults: Treatment and management (NICE guideline NG222). nice.org.uk
30.Halewood, A. (2017). Psychodynamic counselling psychology. In D. Murphy (Ed.), Counselling psychology: A textbook for study and practice (ch. 7). Wiley (BPS Textbooks).
31.Popper, K. R. (1963). Conjectures and refutations: The growth of scientific knowledge. Routledge & Kegan Paul.