How Depth Psychotherapy Works

Saturday, February 20, 2016
Glendale, California

Dear Readers,

Clinicians in training at Rose City Center in Pasadena asked me yesterday to describe how I present the depth psychotherapy process to patients. Oftentimes those who consult us, particularly if seeking psychotherapy for the first time, ask, “what will I get out of this?” or “how does this process work?” I devote this posting to answering that question.

Before doing so, I stray briefly into discussing the evolution of depth psychotherapy as a profession. I use to phrase “depth psychotherapy” to describe psychoanalysis, psychoanalytic psychotherapy, or any type of structured conversation that emerged after Sigmund Freud coined the phrase “psychoanalysis” in 1896. In the century prior to that, persons with emotional disturbances gradually transitioned from seeking assistance from clergy to consulting doctors. (For more information on this history, see Szasz'(1988) The Theology of Medicine or Foucault’s Madness and Civilization). In many ways, depth psychotherapists carry on an ancient tradition traceable to shamans, spiritual healers, tribal elders, and the like.

Since the mid-20th century, persons with a wider array of psychological difficulties and even those simply struggling with the complexities of life began consulting depth psychotherapists. Persons feeling alienated, inauthentic, experiencing marital conflicts or having other problems in living cascaded into psychoanalysts’ consulting rooms. Depth psychotherapists found themselves helping persons deal with tragic losses, with fragile senses of self, or with feelings of loneliness just as frequently as they treated individuals with mental disorders. The expansion of psychoanalytic practice paralleled the transition of history from the modern to the postmodern period (Lyotard, 1984)—a transition that transformed the psychoanalytic project. Although the term, postmodernism, carries with it a certain ambiguity of meaning (Rorty, 1999), it consistently refers to dynamism, complexity, and contextualism. In accord, the context for consulting psychoanalysts has changed. Many persons who consult psychoanalysts no longer have conditions that meet the criteria for diagnosable mental disorders. They obtain help from psychoanalysts for reasons other than simply symptom reduction.

Although many psychoanalysts since Freud offer competing models of the unconscious mind, they show surprising agreement regarding the goals of depth psychotherapy processes. Depth psychotherapists strive to bring the unconscious mind into consciousness. They elucidate subjectivities. Of course the unconscious can never be completely uncovered. However, in a sentence or two, this idea unites all of the varied depth psychotherapeutic approaches. In other words, if you suffered from sexual abuse as a child, you may harbor an unconscious fear of intimacy that affects your romantic relationships. If your father died when you were age two, you may struggle with trusting men or with having a secure sense of direction. Unlike the cognitive behavioral approaches, depth psychotherapy defers authority to patients in terms of the unconscious themes. Depth psychotherapists’ knowledge base lies in their capacity to facilitate transformational relationships and their knowledge of metaphors, i.e. ego, id, superego, dynamic structures, the collective unconscious, etc., useful in helping patients understand their unconscious motifs.

At the risk of sounding idealistic, depth psychotherapy’s ultimate goal is to enhance human freedom. The types of unconscious themes I just described typically oppress persons. In the examples I just gave, these persons may experience fears, inhibitions, relational patterns that limit their capacity for fully experiencing life, or other impairments. All this being noted, I now turn to the way I typically explain depth psychotherapy to patients. I begin by advising them that the process is more educational than medical. I explain that we work in a partnership-like fashion in three basic ways:

First, I tell them, they bring in to the sessions whatever might be on their minds. Over time, they will tend to discuss three types of topics: their current relationships (with friends, family members, coworkers, etc.), their past relationships (with parents, siblings, relatives, etc.), and their relationship with me (feeling inferior, superior, competitive, etc.). We will look for patterns in these three sets of relationships. These realms have been terms P for past, C for current, and T for transference. Through discovering common themes, i.e. a tendency to excessively sacrifice, a propensity to be overly self-focused, a pattern of attraction to persons who distance themselves, etc., we will have progressed down the road of elucidating their subjectivity.

Second, and overlapping with the first method, I advise them that, in a phrase, depth psychotherapy addresses self-deception. We all lie to ourselves. We lie about ways we mistreat others or allow ourselves to be mistreated. We lie about our mortality. We lie about the depth that painful, unresolved feelings still haunt us. Much of depth psychotherapy, then, consists of countering these self-deceptive tendencies. If I notice that patients tightly clench their fists when talking about their father, I will gently bring that to their attention. Here, again, the depth psychotherapy process is reducible to expanding conscious awareness and thereby enhancing freedom.

Third, last, and most mysteriously, something ineffable occurs when deeply felt emotion emerges within the context of the structured psychotherapeutic relationship. At this point in explaining how therapy works to my patients, I usually say that my first two concepts can be understood as educational in nature. This last one betrays such a simple understanding. What may occur, I continue to tell them, is that you might one day you may begin to weep about the loss of your father when you were two, or you might become enraged at the childhood sexual abuse that you endured. Something about experiencing this intense affect in the context of the regularly scheduled meetings with psychotherapists alters them. It lessens the emotional inflammation around the real or imagined historical incident. I have often seen persons end psychotherapy with less sadness, less anger, etc, after having these transformative emotional experiences. This last feature of the depth psychotherapy process has less to do with expanding consciousness, and more to do with having a reparative emotional experience. But please note that, in order to access such incomplete mourning, unresolved conflicts, unmet need states, or the like, the process of uncovering unconscious themes must have begun.

I hope and trust that this explanation, oft-repeated in my more than three decades of clinical experience, helps you to understand the process and to explain it to others.

With kind regards on this lovely Saturday morning,

Alan Karbelnig


Foucault, M. (1965). Civilization and madness: A history of insanity in the age of reason. (R. Howard, Trans.). New York:
Vintage Books.

Lyotard, J.F. (1984). The postmodern condition: A report on knowledge. (G. Bennington
& B. Massumi, Trans.). Minnesota: University of Minnesota Press.

Rorty, R. (1999). Philosophy and social hope. New York: Penguin Books.

Szasz, T. (1988). The theology of medicine. Syracuse: University of Syracuse Press.

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