“I'm wondering if therapy is actually unhealthy for me... I told her how I literally have psycho meltdowns... like, throwing things/screaming and she says ‘your emotions and responses are valid.’ Are they tho? You don’t think maybe I should just get a grip? Idk
—Instagram post

Many people think psychotherapists are supposed to say things like, “Your feelings are valid.”

No, they’re not.

A lot of things are now called therapy and sold as therapy. That doesn’t mean they are psychotherapy.

The phrase “your feelings are valid” does not invite curiosity or deeper self-understanding, which is the point of psychotherapy. It is the mirror image of “stop whining and get a grip.” One sounds warm and one sounds harsh, but neither deepens self-awareness.

A skilled psychotherapist wouldn’t say either of those things.

I’ve said things to patients like, “Of course you feel that way. I don’t know how anyone could experience what you did and not be furious.”

My words communicate that I “get” their experience and invite them to tell me more. I may say it when a patient mistakenly believes their feelings are aberrant, or berates themselves for having them. It is never a canned response. Also: I phrase it this way because that is how normal people speak.

Who actually says, “your feelings are valid?” Most people don’t talk that way, and neither do good psychotherapists. When skilled therapists speak, they sound like people, not “like therapists.”

Here’s another problem with telling patients their feelings are valid: who appointed the therapist arbiter of what is and isn’t “valid?” A therapist who arrogates to themselves the right to decide what is valid also claims the right to decide what is not. They are no longer feeling with the patient, but assuming the role of judge.

The therapist in the opening quotation makes a further mistake by extending the cliché phrase to “your emotions and responses are valid.” She says this to an adult who is screaming and throwing things.

Feelings and behaviors are not the same thing, and every legitimate psychotherapy tradition emphasizes the distinction. The therapist’s words blur it.

The patient’s feelings may be normal and understandable, but it is hard to imagine a world where screaming and throwing things will make her life better. Does it help her regulate her emotions? Develop stable relationships? Help her find intimacy or love?

The answer to these questions is a hard no.

Psychotherapists aren’t in the business of deciding what is or isn’t “valid.” Our job is to help people develop greater self-awareness and change self-defeating patterns so they can live more satisfying lives. It is unclear that the therapist is working toward that.

Someone could reasonably argue that I am reading too much into a turn of phrase. We don’t know what the therapist intended. Perhaps she shares my understanding of psychotherapy and really is working toward insight and psychological change. Maybe her words were just a starting point.

But here’s the thing: psychotherapy is a treatment in words. They are the tools of our trade (not the only ones, but crucial ones). Skilled therapists don’t use words carelessly, or default to rote responses and stock phrases. Skilled therapists choose their words based on their psychological understanding of each individual patient.

When therapists reflexively say “your feelings are valid”—or use any stock phrase reflexively—they are no longer thinking clinically. They are not considering the psychology of the patient in front of them, how that person is likely to hear those words, and whether they advance or impede the work of self-understanding.

At that moment, psychotherapy becomes performative. There may be two people talking and one of them may use the title “therapist,” but the work of psychotherapy is not happening.

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• Why Psychotherapy Gets Stuck (January 19, 2026)

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“The patient may not fully ‘know’ that their mind or body belongs to them and that access to either occurs by invitation and consent.”

Some patients have difficulty creating a private space for their online therapy appointments: they don’t close the door when other people are in the house; they close it but allow others to walk in anyway; they let children or pets interrupt.

Of course, emergencies and unforeseen events happen, but I’m not talking about those. I’m talking about recurring patterns. When intrusions are the norm, that is psychological information.

Some patients struggle to maintain boundaries with others. Some seem relatively unaware of their therapist’s boundaries. I’ve heard of patients bringing their phone and therapist into bed, or onto the toilet. (Therapists can also have boundary problems; I once heard of a therapist conducting sessions from her bed with her partner just out of camera view.)

Recurring intrusions into therapy sessions raise questions about how the patient experiences boundaries in their other relationships. Some people struggle to distinguish wanted from unwanted contact, both emotional and physical. Some have difficulty separating their own desires from those of others. Some don’t recognize when they are intruding on others. Online therapy doesn’t create these difficulties, but it can cast them in high relief in the therapy relationship.

Patients who permit ongoing intrusions may be communicating something crucial about how they experience self and others. This is something for therapist and patient to explore, not gloss over. Therapists must also recognize that recurring intrusions compromise the therapy frame and interfere with therapy.

The therapy frame is the “envelope” in which therapy occurs. Its elements include predictability, defined roles and responsibilities, the boundaries of the therapy relationship, and especially privacy.

The reasons for blurred boundaries can run deeper than meets the eye. Psychoanalyst Gillian Isaacs Russell makes this point:

“It is unreasonable to expect the patient to be able to provide a safe setting for themselves, if they have never had that basic experience of safety and cannot even imagine it. So many patients come into therapy having experienced early impingement.”1

In other words, the patient may not fully “know” that their mind or body belongs to them and that access to either occurs by invitation and consent. Likewise, they may not fully appreciate that others’ minds and bodies belong to the other person.

This kind of not knowing traces to the earliest years. It comes about when a parent treats a child as an extension of themselves, or denies them the privacy of their own mind or body. In some cases, a parent or caregiver inserts themselves relentlessly into the child’s experience. In others, a parent may be so emotionally needy that the child’s bids for separation and individuation are experienced as threats.

Such patients need the therapist’s help to know that safe boundaries are even possible and what it feels like to have them. This kind of embodied knowing does not come from explanations. It emerges from the lived experience of secure boundaries in the therapy relationship.

The challenge in psychotherapy is that difficulties around boundaries and privacy often play out in the background, in actions, not words. It would be a rare patient who could say in words, “We’re getting into uncomfortable topics and I’ve arranged interruptions so we don’t go too deep,” or “I never understood that I am entitled to have private thoughts and feelings or decide for myself what I choose to share.”

Here is a sampling of some things a therapist might say, at the right time and place, to help bring privacy and boundary concerns into the therapy relationship:

• “I notice that your husband (child, roommate, etc.) entered your room several times. It seems like it’s difficult to protect your privacy during our meetings.”

• “It’s not possible to discuss your experience more deeply when your dog jumps up on you each time an emotional topic comes up.”

• “I’m not comfortable having our therapy session while you are lying in bed without a shirt. I’d like to pause our session here and resume when you are fully dressed and sitting up.”

The therapist’s task is to help bring the boundary difficulties from the background into the foreground, where they can be acknowledged and discussed in words, not just lived out in actions. The shift from background to foreground is part of “making the unconscious conscious.”

The full conversation with video is embedded below. For those who want to jump to specific topics, I’ve also included chapter timestamps.

Listen or watch: Amazon Music · Apple Podcasts · iHeart · Pandora · Spotify · YouTube

Topics:

02:03 Beyond therapy brands
05:02 Change requires entering the unknown
07:17 Why doctors must unlearn
11:59 Training therapists the hard way
21:20 Dose matters and there are no shortcuts
33:25 Testing a therapy hypothesis
35:09 Case formulation in the real world
36:47 Transference is data
38:52 Symptoms as signals not enemies
39:46 What patients want from therapy
41:33 Evidence-based assumptions
43:23 The dangers of therapy-speak
44:18 The problem with saying “your feelings are valid”
46:25 From clichés to specifics
52:07 Confrontation without blame
56:51 Therapists as martyrs

If you enjoy listening to my podcast interviews, I’ve collected the best of the best in one place:

• My Favorite Podcast Conversations (Best Of)

Back to regular written content next week.

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• Therapy Influencers Sell Illusion, Not Insight (May 4, 2026)

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• That Was Then, This Is Now: An Introduction to Contemporary Psychodynamic Psychotherapy (Part 1) (March 30, 2026)

• Eavesdropping on a Psychotherapy Session (May 11, 2026)

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One principle is central:

The foundation of all effective psychotherapy is the relationship between clinician and client—and the clinician’s skill in using that relationship in the service of self-understanding and psychological change.

A hallmark of a skilled psychotherapist is the ability to navigate a meaningful therapy relationship with people who have serious difficulty creating and maintaining relationships. Skilled psychotherapists understand and expect that their clients’ dysfunctional relationship patterns will be recreated in the therapy relationship. These patterns become the focus of psychotherapy, not obstacles to it.

But you cannot brand or commodify a relationship.

There is no money or status in publicizing psychotherapy’s core principles. The incentive is to invent something new, brand it with an acronym, and promote it as a proprietary approach.

Time and again, the active ingredients are just a subset of time-honored principles of psychotherapy—repackaged in the “new” treatment in watered-down, often trivialized form.

The proliferation of acronym therapies and brands erodes psychotherapy knowledge and expertise. It deflects attention from core principles and time-honored wisdom accrued over generations and shifts the focus to gimmicky techniques and made-up terminology.

In some cases, purveyors of acronym therapies knowingly draw on established knowledge and fail to acknowledge it. In others, they are so disconnected from clinical traditions that they genuinely think they’ve made a new discovery. Either way, the incentive is to claim it as their own and portray it as new and proprietary.

The core skills of psychotherapy therefore recede into the background. What gets branded and promoted misses the essence of the work.

Related Essays

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Author’s note: I originally published this 10 months ago, just after launching this Substack. Many newer readers have not seen it, so I’m republishing it for the holiday weekend. New essay next week.

Psychotherapists have long observed that people repeat and relive painful experiences. Freud called it the “repetition compulsion.” Why do we do this? Here are six reasons.

1. To alleviate guilt

Some people feel guilty about success or pleasure, as if enjoyment were a transgression. They seek suffering to expiate guilt and appease their conscience. In some cases, pain and suffering become the “admission price” for whatever pleasure they allow themselves.

2. To gain a sense of control and mastery

The person attempts to gain a sense of control over painful or traumatic experiences they once endured helplessly. There is an underlying (unconscious) fantasy that they can undo a past hurt or right a past wrong by repeating it and getting it to come out differently. But in reality, they keep reliving the same pain.

3. Because suffering is home

When panicked horses are rescued from a burning stable, they often run right back in. The horses associate the stable with safety and security—it’s their home. Likewise, a child’s earliest attachments, however painful, are home. However neglectful or abusive, that was where they experienced whatever care and comfort they knew. In their search for comfort, they return to the same pain.

4. For secondary gain

Mental health symptoms often come with hidden benefits, known to clinicians as “secondary gain.” These may include attention, sympathy, release from responsibility, special treatment, even financial incentives (e.g., disability pay). Secondary gain can be a powerful incentive for continued suffering.

In psychotherapy, it’s useful to invite patients to consider the downside of getting well. The first response is often, “There is no downside, I’d do anything to get better.” But when the therapist creates space for deeper reflection—“Not so fast, let’s really think about this”—surprising answers can surface.

5. To punish others (passive-aggression)

The desire to punish someone can be more powerful than the desire to avoid pain. A person may sabotage their own prospects for success or happiness precisely because it’s what someone else wants for them (hence the expression, “cutting off your nose to spite your face”).

Mental health symptoms often cause pain and suffering for others. A depressed person may be too depressed to do their share of work, earn a living, keep commitments, have sex with their partner, and so on. There can be (often unconscious) sadistic pleasure in punishing others, especially when done without responsibility or consequences. After all, who would blame the victim?

6. To enhance self-esteem or feel superior

For some, self-worth—and even a sense of superiority—is rooted in self-deprivation and suffering. They seem organized around the belief: I’m better than you because I suffer more. The greater the hardship, the greater their feeling of moral superiority. Psychoanalysts call this moral masochism.

These are some reasons why we repeat painful experiences. Most of these patterns operate outside conscious awareness. We are often our own worst enemies without knowing why.

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It’s about competence: understanding how psychotherapy works and the conditions necessary for it to happen.

We maintain confidentiality not because it’s an ethics rule, but because no one is going to open up to us unless they know what’s said in therapy stays in therapy. Without confidentiality, the conditions necessary for psychotherapy do not exist.

We avoid dual relationships not because the rules say so, but because we understand that entangled roles impair our ability to think psychologically, recognize relational patterns, and respond effectively as psychotherapists.

We don’t promise cures, make exaggerated claims, or traffic in hype because psychotherapy can work only when our words actually mean something.

We’re transparent about our credentials and training because psychotherapy depends on trust. If we spin the truth, why would our patients believe anything else we say?

We maintain therapy boundaries because we understand the raw power of transference and countertransference—and because we know that the more secure the boundaries, the more patients can unclench and the deeper the work can go.

We don’t diagnose or give clinical advice outside a professional relationship because we know psychological understanding requires the kind of comprehensive, in-depth assessment that can happen only within a clinical context.

Most professional ethics is actually about basic competence. The rules are simply attempts to codify the minimal conditions that make psychotherapy possible.

Related Essays

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• Much of What Is Called Therapy Is Not Psychotherapy (February 23, 2026)

• What Is Therapy For? (April 20, 2026)

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Psychotherapy, at its best, creates a relationship where it becomes possible to tell secrets of the third kind.

For that to happen, privacy is non-negotiable. It creates a challenge for training: students rarely see experts at work. They lack models of what to say when.

There are videos of therapy sessions with volunteers, and textbook cases with made-up session transcripts. The problem is they suck. They don’t capture the feel of a real session.

The Paradox

The truest portrayals I’ve seen are sessions recreated with actors, or fiction written by therapists drawing on deep experience. To see the truth, we must rely on fiction.

What follows is a fictional psychotherapy session transcript. It shows what in-depth psychotherapy can look like.

It came about by accident. Like many therapists, I tried AI as my therapist to see what it could do. I tried several AI models, and all I can say is they were terrible. Spectacularly terrible. I tried to teach one to stop shutting down thoughts and feelings and steering toward the superficial. It couldn’t learn. In frustration, I told it that I would switch roles and show it.

While the AI failed as a therapist, it was surprisingly good at playing the patient. We conducted a “session” and when it ended, I realized I had created something that felt true.

It may help emerging therapists in the lifelong study of what to say, when to say it, and why. It may also help non-therapists understand what in-depth psychotherapy actually is.

Caveat: The “patient” responds well. AI is trained to align with the user: it will “benefit” from anything a user-playing-therapist says, no matter how unskilled. It cannot provide differential reinforcement.

The full session follows, with my moment-to-moment reflections.

Read more

“Everything good is costly, and the development of character is one of the most costly of all. It will cost you your innocence, your illusions, your certainty.”
—Sheldon Kopp

Therapy-influencer culture has a core message.

It can be stated simply:

• You are a victim and you are good.

• Someone else is to blame and they are bad.

It feels good because it sides with our defenses, not with the part of ourselves that strives for insight and self-awareness. In the long run, the message is profoundly self-destructive.

The Defenses at Work

The message bolsters two specific defenses:

1. Splitting

2. Projection

These are among the costliest of all defenses.

Splitting is a form of dissociation where we compartmentalize feelings, dividing self and others into binary categories of all-good and all-bad. It distorts our perception of reality, because human beings do not come in black-and-white categories. Humans are complex and contradictory and exist in shades of gray.

Once a person has compartmentalized and disavowed unwanted aspects of self—like anger, spite, aggression, hate, cruelty, and selfishness—they are projected onto others. This is called primitive projection. We then see ourselves as virtuous, innocent, blameless—the repository of good. We see the other as hateful and evil—the repository of bad.

The Cost

We call these defenses primitive or costly because they distort our self-perceptions and therefore our ability to function in the world. We cannot accurately recognize our internal states or see ourselves as we are. We see and believe our illusions.

This means we cannot learn from our experience, grow emotionally, connect authentically with others, or experience genuine intimacy.

Likewise, we cannot accurately perceive others’ internal states or see them as they are. Instead, we see our projections. And so we cannot function effectively in the interpersonal world or grow through our relationships.

Ultimately, we become prisoners of our own defenses.

These defenses are not just personally costly. They are also destructive to society. Because once we project badness, aggression, and hate onto others and come to see them as evil and dangerous, we feel justified in attacking them. We unleash our worst impulses.

But we don’t see it that way. We see ourselves as righteous and our cause just, even as we act in hateful and destructive ways.

This is the source of much conflict and polarization in the world.

Why It Works

The message is the core message of pop culture “therapy” influencers—the ones whose social media accounts attract millions of followers and whose books sell.

• You are a victim and you are good

• Someone else is to blame and they are bad

It speaks to real pain, and it feels so good in the moment. Who doesn’t want to believe they are in the right and someone else is in the wrong?

This is why it spreads.

The message provides an immediate sense of clarity and moral certainty. It delivers an instant high, and it is addictive.

But it is at cross purposes with genuine psychotherapy, which helps us know ourselves more fully, perceive others more accurately, and become more whole.

So we need to ask what we’re looking for:

The immediate high?

Or the honest emotional work that leads to long-term growth and change?

That is the choice.

Related Essays

• How to Choose a Psychotherapist: A Guide to Recognizing Competence (September 22, 2026)

• The Psychological Harm of Saying “My Truth” (October 20, 2025)

• Much of What Is Called Therapy Is Not Psychotherapy (February 23, 2026)

For paid subscribers

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More writing, interviews, and related work on my Linktree.

Psychology’s deepest insight is that we are not of one mind. We are of many minds. We have multiple, often contradictory feelings. We have layers of experience, conscious and unconscious. What’s on the surface is never the whole story.

So we have to ask: given multiple layers of experience, which part of the patient is the therapist “empathizing” with?

In practice, the answer is usually the same: the therapist “empathizes” with the patient’s hurt, needy parts. Then the therapist takes on the complementary role of comforting, nurturing, and caretaking.

The problem is that this excludes all the other parts of the patient that are also real: anger, envy, resentment, hate, spite, rivalry, destructiveness, aggression.

When the therapist doesn’t acknowledge these parts of the patient’s experience, the patient cannot acknowledge them either. The feelings go underground and the opportunities for self-awareness are lost. Therapist and patient collude with each other’s defenses, and each presents a false self. The acknowledged feelings become the acceptable version of the self while the rest is disowned.

What is not recognized cannot be worked with.

So we have to ask again: which part of the patient is the therapist empathizing with, and which parts are being erased?

What is called “empathy” can become a rationale for selectively attending to the feelings that are comfortable for the therapist, or that bolster the therapist’s self-image as caring and nurturing.

Genuine empathy is receptivity to the full range of a patient’s experience—not just the hurt parts that are easiest for therapists to identify with, but also their anger, envy, spite, and aggression.

Anything less is erasure, not empathy.

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“Therapy should never begin before the therapist knows what it is for or why it is being undertaken.”
—Otto Kernberg

The Problem

Knowing what therapy “is for” isn’t as simple as it sounds.

If you ask therapists the purpose of therapy with a particular patient or client, many will tell you a symptom or diagnosis (“depression”), or something about the patient’s history (“they were abused as a child”), or a desired life outcome (“they want to find a life partner”).

None of these things tell us what psychotherapy is for. They may tell us what the patient is unhappy about, but they don’t give therapy direction or purpose.

The Purpose of Psychotherapy

The purpose of psychotherapy is to help the patient change something about themselves.

More specifically, the purpose is to help the patient change something about themselves that:

1. is causing difficulties or limitations

2. they desire to change

3. psychotherapy can realistically help them change

In other words, the purpose is not “depression,” but understanding and helping to change something in the person’s psychology that makes them vulnerable to depression.

The purpose is not “childhood abuse,” but how their past affects them in the present and plays out in their lives in ways that cause difficulties.

It’s not “finding a life partner,” but understanding and helping to change something about themselves that is getting in the way of having the relationships they want.

In every case, the purpose is to change something about oneself.

That is the only thing psychotherapy can directly influence.

Treatment Purpose Comes from Case Formulation

The treatment purpose comes from a case formulation. A case formulation identifies the psychological processes that give rise to the person’s difficulties. It links surface problems to psychological processes that psychotherapy can help change. This is what gives psychotherapy direction and focus.

This is what is missing when the therapist and patient jump into “doing therapy” before they both understand and agree about what they are setting out to do together and why.

This is why treatments get stuck, reach an impasse, or lose direction.

“Therapy should never begin before the therapist knows what it is for or why it is being undertaken.”
—Otto Kernberg

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The Continuum

Otto Kernberg is arguably the most influential theorist on personality pathology. His work derives from object relations theory, which concerns how our experience of self and others is structured by past relationships. “Objects” in psychoanalytic theory are people, or mental representations of people. The term object is used in the sense of a person as the object of our interest, attention, or desire.

In Kernberg’s object relations model, pathological narcissism, malignant narcissism, and psychopathy form a continuum. The core consideration is the balance of love and hate. Here are my “CliffsNotes” on these concepts.

Pathological Narcissism

Pathological narcissism is based on the defense of splitting. The person identifies with idealized, all-good representations of self and others, imagining that they possess those qualities. Parts of self that would otherwise be experienced as weak, bad, or deficient are denied and projected onto others. In this way, the person maintains an idealized sense of self as good and superior, and a devalued view of others as bad and inferior.

This defensively distorted self-concept is called the pathological grandiose self.

Malignant Narcissism

Malignant narcissism is pathological narcissism suffused with hate and aggression. Others are not just seen as lesser, but treated in cruel, exploitative, and hateful ways—even as the person continues to see themselves in grandiose terms. Other defining features are antisocial behavior and a paranoid orientation—because the person experiences their projected aggression as coming from others.

Psychopathy

In psychopathy, the personality is fully dominated by hate and aggression. Other people are treated solely as objects to dominate, exploit, or toy with sadistically.

Love and Hate

Hate is the crucial variable: the more hate, the further a person moves along the continuum from narcissism to malignant narcissism to psychopathy.

Where there remains a capacity to love—a desire for attachment and connection—the person is on the narcissistic end of the continuum and treatment is possible.

Where hate and aggression predominate, the diagnosis is malignant narcissism. It may or may not be treatable, depending on the balance of love and hate.

Where there is hate and aggression without a capacity for love and connection, the diagnosis is psychopathy. True psychopathy is considered untreatable.

What Pop Psychology Gets Wrong

The abusive, exploitative, and predatory behavior that popular therapy culture attributes to narcissism has little to do with narcissism and everything to do with malignant narcissism and psychopathy. Understanding the distinction is crucial in both the therapy office and in public life.

Disclaimer: This summary is necessarily oversimplified. It’s meant to offer a point of entry to ideas that many therapists have not had access to. If it has sparked interest in learning more, that’s enough.

For a deeper dive, I recommend: Diamond D, Yeomans F, Stern B, & Kernberg, O. (2021). Treating Pathological Narcissism with Transference-Focused Psychotherapy. Guilford.

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I take no pleasure in being the messenger. It breaks my heart. But it would break my heart more to remain silent.

These are some factors contributing to the decline of psychotherapy:

1. Deep intrusion of health insurance agendas into psychotherapy practice and training.

2. Dramatic decline in reimbursement. In inflation-adjusted dollars, psychologists in managed care settings are paid 70% less than in the 1980s. The “best and brightest” predictably choose other careers.

3. Runaway proliferation of for-profit training programs with minimal admission and graduation standards.

4. Influx of practitioners into the therapy professions who lack adequate training or aptitude for the work.

5. Pharmaceutical marketing led the public to view emotional distress in medical rather than psychological terms.

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6. The pharmaceutical and health insurance industries steer people to primary care doctors (“talk to your doctor”), effectively making medication the first-line treatment for mental and emotional suffering.

7. Therapy researchers operate in academic silos and have little contact with practicing psychotherapists, producing research that does not address the needs of patients or clinicians.

8. Conflation of mental and emotional distress with DSM diagnostic categories by both health insurers and researchers.

9. Therapy “outcome” research focuses almost entirely on DSM symptoms, ignoring the goals and outcomes most desired by actual patients and therapists.

10. Rise of social media therapy influencers; public inability to distinguish legitimate expertise from self-promotion, popularity, and branding (see The Death of Expertise).

11. Intense politicization of the therapy professions; emergence of a training culture that rewards ideological conformity over clinical expertise.

12. Impact of tech companies, venture capital, and private equity. For example, online therapy platforms recruit inexperienced therapists and pay them like Uber drivers; their advertising deliberately erases distinctions in training and experience.

13. Low or no barriers to entry. The mental health “space” is low-hanging fruit for all manner of self-promoters, opportunists, profiteers, and scammers.

14. Clinical supervision is no longer a meaningful training relationship with a skilled teacher and mentor; clinics and agencies often reduce it to a mere administrative function.

15. Runaway bureaucratization. Inordinate time is spent on forms, paperwork, and documentation that does not benefit patients or develop therapists’ clinical skills.

16. In-depth personal psychotherapy is no longer treated as an essential part of psychotherapists’ training. This leads to didactic “skills training” instead of therapy of relationship and depth, with increased risk of acting out unresolved psychological conflicts on clients.

17. Increased focus in training programs on paint-by-numbers “manualized” therapies instead of mastering foundational psychological principles and core skills.

18. Endless proliferation of “new” therapy brands, models, acronyms, and certifications instead of an emphasis on cumulative knowledge. Virtually all of them repackage time-honored therapy principles, reinvented time and again by people who never learned them in the first place.

19. Significant gender imbalance in training programs, with resulting loss of intellectual diversity and balance in training culture.

20. Rampant denial of psychological complexity and the role of unconscious mental life; therapy increasingly addresses only the surface.

Taken together, these factors have transformed the psychotherapy professions. There is no shared definition of therapy, or what it means to be a therapist. There is no baseline for assessing professional competence.

This is not a complete accounting of what’s going wrong. What would you add?

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Index

This work is in seven parts. Here are links to each section.

Part 1: Roots of misunderstanding ◀
Part 2: Unconscious mental life
Part 3: The mind in conflict
Part 4: The past lives on in the present
Part 5: Transference
Part 6: Defense
Part 7: Psychological causation

Author’s Note

This seven-part piece is a jargon-free introduction to contemporary psychodynamic thought. It is intended for trainees and for clinicians trained in other therapy approaches. I wrote it because existing books did not meet my students’ needs. Many classic introductions to psychoanalytic therapy are dated; they describe the psychoanalytic thinking of decades past, not today.

Others contain too much jargon to be accessible, or assume prior knowledge that few contemporary readers possess. Still others have a partisan agenda, promoting one psychoanalytic school over others—but trainees are ill-served by treating them as pawns in internecine theoretical disputes. Finally, some otherwise excellent books assume an interested and sympathetic reader. That assumption is now unwarranted. Students today are exposed to considerable disinformation about psychoanalytic thought and often approach it with inaccurate and pejorative preconceptions.

The title is a double entendre. “That was then, this is now” alludes to a central aim of psychoanalytic therapy: to help free people from the bonds of past experience in order to live more fully and freely in the present. People tend to react to what was rather than what is, and psychoanalytic therapy aims to help with this. The title also alludes to sea changes in psychoanalytic thinking that have occurred over the past decades. For too many, the term psychoanalysis conjures up century-old stereotypes that bear little resemblance to what contemporary practitioners think and do.

This piece was originally intended as the beginning of a book. I may finish it one day, but the project is on the back burner. For now, this is it.

Roots of misunderstanding

Psychoanalytic psychotherapy may be the most misunderstood of all therapies. I teach a course in psychoanalytic therapy for clinical psychology doctoral students, many of whom would not be there if it were not required. I begin by asking the students to write down their beliefs about psychoanalytic therapy. Most express highly inaccurate preconceptions.

The preconceptions come not from first-hand encounters with psychoanalytic practitioners but from media depictions, from undergraduate psychology professors who refer to psychoanalysis in their courses but understand little about it, and from textbooks that present caricatures of psychoanalytic theories that were out of date half a century ago.

Some of the more memorable misconceptions are that psychoanalytic concepts apply only to the privileged or wealthy; that psychoanalytic concepts and treatments lack scientific support (for reviews of empirical evidence, see, e.g., Shedler, 2010; Leichsenring, et al. 2023); that psychoanalytic therapists “reduce everything” to sex and aggression; that they keep patients in lengthy treatments merely for their own financial gain; that psychoanalytic theories are sexist, racist, classist, ableist, etc. (insert your preferred condemnation); that Sigmund Freud, the founding father of psychoanalysis, was a cocaine addict who developed his theories under the influence; and that the terms “psychoanalytic” and “Freudian” are synonyms—as if theory and practice have been frozen in time and have not evolved since the horse and buggy era.

Most psychoanalytic therapists have no idea how to respond to the question (all too common at social gatherings), “Are you a ‘Freudian?’” The question has no meaningful answer, and I fear that any answer I give could lead only to misunderstanding. In a basic sense, all mental health professionals are “Freudian,” because so many of Freud’s concepts have simply been assimilated into the broader culture of therapy. They now seem so commonplace, commonsense, and taken-for-granted that people do not recognize they originated with Freud and were radical at the time.

For example, most people believe that trauma causes emotional and physical symptoms; that our care in the early years shapes our development; that people have competing and often contradictory motives; that sexual abuse of children occurs and can have disastrous consequences; that emotional difficulties can be treated by talking; that we sometimes find fault with others for the very things we do not wish to see in ourselves; that it is exploitive and destructive for therapists to have sexual relations with patients; and so on. These and many more ideas that are commonplace in the culture of psychotherapy are “Freudian.” In this sense, every contemporary psychotherapist is a (gasp) Freudian, like it or not. Even the practice of meeting with patients for regularly scheduled appointment hours originated with Freud.

In another sense, the question “Are you a Freudian?” is unanswerable because no contemporary psychoanalytic therapist is a “Freudian.” What I mean is that psychoanalytic thinking has evolved radically since Freud’s day—not that you would know this from reading psychology textbooks. In the past decades, there have been sea changes in theory and practice. The field has grown in diverse directions, far from Freud’s historical writings. In this sense, no one is a “Freudian.” Psychoanalysis is continually evolving new models and paradigms. The development of psychoanalytic knowledge did not end with Freud any more than physics ended with Newton, astronomy with Copernicus, or the development of the behavioral tradition in psychology ended with John Watson.

There are multiple schools of thought within psychoanalysis with different and sometimes bitterly divisive views and the notion someone could tell you “the” psychoanalytic view of something is quaint and naïve. There may be greater diversity of viewpoints within psychoanalysis than within any other school of psychotherapy, if only because psychoanalysis is the oldest of the therapy traditions. Asking a psychoanalytic therapist for “the” psychoanalytic perspective may be as meaningful as asking a philosophy professor “the” philosophical answer to a question. I imagine the poor professor could only shake her head in bemusement and wonder where to begin. So it is with psychoanalysis. Psychoanalysis is not one theory but a diverse collection of theories, each of which represents an attempt to shed light on one or another facet of human functioning.

What it isn’t

It may be easier to say what psychoanalysis is not than what it is.

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Index

This work is in seven parts. Here are links to each section.

Part 1: Roots of misunderstanding
Part 2: Unconscious mental life ◀
Part 3: The mind in conflict
Part 4: The past lives on in the present
Part 5: Transference
Part 6: Defense
Part 7: Psychological causation

Foundations

If psychoanalysis is not a theory about id, ego and superego, or about fixations, or about repressed memories, what is it about? The ideas I discuss here play a central role in the thinking of most psychoanalytic practitioners. These ideas are intertwined and overlapping; I present them separately only for didactic convenience.

Unconscious Mental Life

We do not fully know our own hearts and minds, and many important things take place outside awareness. This observation is no longer controversial to anyone, even the most hard-nosed empiricist. Research in cognitive science has shown repeatedly that much thinking and feeling goes on outside conscious awareness (e.g., Bargh & Barndollar, 1996; Kahneman, 2011; Nisbett & Wilson, 1977; Weinberger, 2019; Westen, 1998; Wilson, Lindsey, & Schooler, 2000).

Usually cognitive scientists do not use the word “unconscious” but refer instead to “implicit” mental processes, “procedural” memory, and so on. The terminology is not important. What matters is the concept—that crucial memory, perceptual, judgmental, affective, and motivational processes are not consciously accessible. Psychoanalytic discussions of unconscious mental life do, however, emphasize something that cognitive scientists tend not to emphasize: It is not just that we do not fully know our own minds, but there are things we seem not to want to know. There are things that are threatening or dissonant or make us feel vulnerable in some way, so we tend to look away.

I came across a poignant example early in my career. I was interviewing participants in a research project on personality development and my job was to learn as much as I could about each participant’s personal history. In general, these were easy interviews to conduct. Most people, with a little encouragement, enjoy talking about themselves to someone respectful, sympathetic, genuinely interested in what they have to say, and sworn to confidentiality. But one interview was puzzlingly tedious. Although the interviewee, whom I will call “Jill,” was attractive and intelligent, and although she seemed to answer all my questions cheerfully and cooperatively, I did not feel engaged at all. Slowly, I began to recognize that Jill’s answers to my questions amounted to a string of abstractions, clichés, and platitudes. I simply could not get a sense of Jill or the people important to her.

Our conversation went something like this:

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Index

This work is in seven parts. Here are links to each section.

Part 1: Roots of misunderstanding
Part 2: Unconscious mental life
Part 3: The mind in conflict ◀
Part 4: The past lives on in the present
Part 5: Transference
Part 6: Defense
Part 7: Psychological causation

The mind in conflict

Another central recognition is that humans can be of two (or more) minds about things. We can have loving feelings and hateful feelings toward the same person, we can desire something and also fear it, and we can desire things that are mutually contradictory. There is nothing mysterious in the recognition that people have complex and often contradictory feelings and motives. Poets, writers, and reflective people in general have always known this. Psychoanalysis has contributed a vocabulary with which to talk about inner contradiction, and techniques for working with contradictions in ways that can help alleviate suffering. To paraphrase F. Scott Fitzgerald, wisdom is the ability to hold two contradictory ideas in mind at the same time and still continue to function. Psychoanalytic psychotherapy seeks to cultivate this form of wisdom.

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Index

This work is in seven parts. Here are links to each section.

Part 1: Roots of misunderstanding
Part 2: Unconscious mental life
Part 3: The mind in conflict
Part 4: The past lives on in the present ◀
Part 5: Transference
Part 6: Defense
Part 7: Psychological causation

The past lives on in the present

Through our earliest experiences, we learn certain templates or scripts about how the world works (a cognitive therapist would call them schemas). We learn, for example, what to expect of others, how to behave in relationships, how to elicit caring and attention, how to act when someone is angry with us, how to express ourselves when we are angry, how to make people proud of us, what it feels like to succeed, what it feels like to fail, what it means to love, and on and on. We continue to apply these templates or scripts to new situations as we proceed through life, often when they no longer apply. Another way of saying this is that we view the present through the lens of past experience, and therefore tend to repeat and recreate aspects of the past. In the words of William Wordsworth, the child is father to the man.

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Index

This work is in seven parts. Here are links to each section.

Part 1: Roots of misunderstanding
Part 2: Unconscious mental life
Part 3: The mind in conflict
Part 4: The past lives on in the present
Part 5: Transference ◀
Part 6: Defense
Part 7: Psychological causation

A person starting therapy is entering an unfamiliar situation and a new relationship and necessarily applies his previously formed templates, scripts, or schemas to organize his perceptions of this new person—the therapist—and make sense of the new situation. There is no alternative other than to view this new relationship through the lens of past relationships; it is not a matter of choice. Thus, different patients show dazzlingly different reactions to the same therapist.

Read more

This work is in seven parts. Here are links to each section.

Part 1: Roots of misunderstanding
Part 2: Unconscious mental life
Part 3: The mind in conflict
Part 4: The past lives on in the present
Part 5: Transference
Part 6: Defense ◀
Part 7: Psychological causation

Defense

Once we recognize there are things we prefer not to know, we find ourselves thinking about how it is that we avoid knowing. Anything a person does that serves to distract his or her attention from something unsettling or dissonant can be said to serve a defensive function. There is nothing at all mysterious about defensive processes. Defense is as simple as not noticing something, not thinking about something, not putting two and two together, or simply distracting ourselves with something else. The psychoanalyst Herbert Schlesinger (2003) described defense in the context of systems theory. Systems (biological and psychological) regulate themselves to maintain equilibrium or homeostasis (for example, biological regulatory processes work to keep our body temperature near 98.6 degrees Fahrenheit despite large variations in outside temperature). When something is sufficiently dissonant with our habitual ways of thinking, feeling, and perceiving that it would disrupt psychological equilibrium, we tend to avoid, deny, disregard, minimize, or otherwise disavow it. Family systems therapists work to disrupt homeostatic processes that maintain dysfunctional family patterns, expecting that the system will reorganize in a more adaptive way. Analogously, psychoanalytic therapists work to disrupt homeostatic processes that maintain problems in living.

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Index

This work is in seven parts. Here are links to each section.

Part 1: Roots of misunderstanding
Part 2: Unconscious mental life
Part 3: The mind in conflict
Part 4: The past lives on in the present
Part 5: Transference
Part 6: Defense
Part 7: Psychological causation ◀

Psychological Causation

Psychological symptoms often seem senseless. They serve no apparent purpose and often feel alien to the person suffering from them. Many depressed patients have told me that feelings of despair and sadness come on “out of the blue.” Feelings of anxiety or even panic can also come on unpredictably. In fact, the DSM diagnostic criteria for panic disorder specify that the panic attacks come on “unexpectedly,” that is, with no apparent cause.

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1. Think of a time you were upset with your therapist. Did you tell them?

No: You are not working in depth.
Yes: You may be working in depth.

2. Did your therapist respond with non-defensive curiosity and genuine interest in hearing your thoughts and feelings about them?

No: You are not working in depth.
Yes: You may be working in depth.

If you did not tell your therapist that you were upset with them, here’s a chance at redemption:

3. Is your therapy relationship on a trajectory where you will be more likely to tell them in the future?

No: You are not working in depth.
Yes: You may be working in depth.

Why these specific questions?

Because we repeat relationship patterns throughout our lives. That is human nature. Our patterns can be as invisible to us as water to a fish.

Meaningful psychotherapy is a relationship. Problematic relationship patterns will be repeated in the therapy relationship too.

When you discuss and explore your patterns in real time, as they are lived out in the therapy relationship, you start to recognize and understand them. This is how you begin to free yourself from self-defeating patterns and create new ones.

What goes wrong in the therapy relationship is a window into what goes wrong in other relationships.

This is the path to self-knowledge and wholeness. This is what it means to work in depth.

Related Essays

• Getting Started in Psychotherapy: A Guide for Patients (and Their Therapists
  (September 3, 2025)

• When the Real Reason for Therapy Finally Surfaces
  (October 27, 2025)

• Therapists Say The Relationship Heals. Few Know What it Means
  (September 30, 2025)

More writing, interviews, and related work on my Linktree.