TIFT #129: Can We Improve PDT?

Many of today’s treatment breakthroughs come from an increasingly intimate knowledge of biological processes. The theme of this post is that understanding mental processes can do the same for psychotherapy. Psychodynamic psychotherapy has evolved over more than a century into a broad and subtle therapy. It’s final targets are mental processes. If we understand those mental processes with more precision, can we improve upon what has been honed and refined by intuition, experience, and practice? I’ll propose that the answer is yes.

First let’s review three science-based updates that connect existing theories of psychotherapy with the infrastructure that belongs to all therapies. These are described in more detail in my recent article, “Psychotherapy integration from the bottom up: A unifying, science-based view of psychotherapy’s infrastructure (Smith 2025).

Update #1: Our basic mammalian mind is the source of the problems psychotherapy is designed to treat.

There is quite a bit here. We are too used to thinking of our mind as the reasoning one we live with every day. But that recent addition to the information processing capacity of the brain is more like what I would call a “fancy add-on” given to us by evolution because our survival depends on complex social interactions that are too complex for the basic mind to handle very effectively.

The basic mammalian mind, on the other hand, has worked very well for the survival of most species and is still the primary source of our emotions, motivation, and what LeDoux calls “survival circuits,” designed to identify threats and match them with protective responses. These are located mainly in subcortical brain structures such as the amygdala and that is where the ultimate changes in therapy need to take place.

In Freud’s day, irrationality was seen as a deviation from reason. A more modern version is that reason provides us with some checks and balances to help out when the survival-oriented mind’s problem solving is less than optimal. The purpose of psychotherapy is to help out when the conscious reasoning mind is having a hard time overcoming the emotional power of our mammalian survival instincts. From here on, for simplicity, I’ll call the nonconscious, nonverbal, basic mammalian mind our “inner mind.”

Update #2: Psychotherapy is a treatment designed to help people trade Entrenched Maladaptive Patterns (EMPs) for more satisfactory responses to the same or similar inputs.

Using modern brain science to look at how, outside of consciousness, our basic mammalian mind goes about keeping us safe, let’s zoom in on those survival circuits. They perform a special type of pattern matching. Predictive coding means comparing what is expected with what is actually coming in from internal and external environments. This is done repetitively, reducing the prediction error on multiple levels with each iteration to gain the greatest possible accuracy. Expectations are based on past experience or procedural learning. 

A universal description of what psychotherapy aims to change is the Entrenched Maladaptive Pattern (EMP). These are mainly solutions invented to deal with problems the basic mind considers life threatening. Once a match (or prediction) is made that a threat is imminent, then predictive coding accomplishes the next step, selecting a response. As psychotherapy seeks to help change EMPs, then given the same or similar circumstances, we want the client’s inner mind to select a more satisfactory pattern of response instead of the old, maladaptive one.

An important complication is entrenchment, that is, resistance to change. The same survival-oriented basic mammalian mind that is watching out for dangers in the environment is also vigilant for threats from within including the (therapeutic) loss of a cherished coping strategy. A part of this protectiveness is that old solutions become frozen in time, keeping the same perceptions and rules for life in place regardless of their costs and regardless of changing circumstances. Letting go of an existing EMP constitutes a threat in itself and can generate strenuous measures to keep it in place against the client’s conscious will. That’s why professional psychotherapy is needed for the many situations where self-help is not enough.

Let’s go one step deeper. What is it that tells a survival circuit what is dangerous and what protective strategy to implement? The most recognized and universal name for this programming is the schema. These are the units of procedural learning or nonconcious logic that perform the dual jobs of threat detection and response selection. Those schemas are precisely what we want to help our clients trade for better ones. Now let’s consider the tools we have for doing that.

Update #3: Three change processes and three clinical objectives are at the heart of all therapies and understanding them can sharpen any practice.

For some readers, this will be familiar. It turns out from today’s neurophysiology that there are just three mechanisms that, together, can explain what therapeutic words, nonverbal communication, and relationship actually do. Here they are:

1. New learning: This is the kind that starts with a conscious concept and then becomes internalized through practice. It is the learning that ultimately makes a newer, healthier response available for the inner mind to match up with the calculated needs of the situation.

2. Extinction: Here the cortex takes in learning that contradicts the calculations of the basic mammalian inner mind, for example that a once-dangerous situation is no longer so. The cortex then sends inhibitory signals to suppress the response pattern or EMP. A serious problem is that the basic mind is still registering a threat, which often leads to a reappearance of the old pattern. Thus, while beneficial, this change mechanism tends to be temporary and require periodic reinforcement. The clinical requirements are very similar to those for the next and last change mechanism with one difference. Repetition is a central aspect of extinction, but not memory reconsolidation.

3. Memory reconsolidation: For me this is the “Queen of change mechanisms” because lasting changes are actually made to the schemas so that threat recognition and/or response selection are no longer the same. These are the transformative changes that Castonguay and others have described clinically. If a more satisfactory response is available, then the schemas are changed so the new response is automatically chosen. Memory reconsolidation has essentially the same requirements as extinction, except that, as in the corrective emotional experience, only one or a few repetitions are all that are required. Now, let’s focus on how PDT fulfills the requirements for this change mechanism and consider where a clearer understanding of the why’s can lead to improvement.

Three clinical objectives

Here is where the science allows us to focus in closely on how our words, nonverbal communications, and relationship actually function. We are especially interested in transformative change, meaning the kind that happens rapidly and doesn’t require reinforcement to maintain. That means memory reconsolidation because it is the only known mechanism that can bring about that kind of change. Therefore, we’ll focus on that mechanism, but note that new learning is often necessary when the client doesn’t already have a good alternative available in their repertoire of automatic responses.

First Clinical Objective: Deepening the Emotional Experience

I’m borrowing the term “deepening the emotional experience” from Hanna Levenson (2025). A more in-depth version would be “neurally activating the old schema.” The difference is that activating the old schema takes place outside of consciousness in the basic mammalian inner mind and is detectible only by its visible and conscious results. What Dr. Levenson is talking about is a conscious experience of affect, which is indeed our best clinical indicator that the deep neural activation is taking place. It is the deep activation of neurons that opens the door to change in the schemas that are generating the EMP or maladaptive pattern. Thus, “deepening conscious emotion” tells us clinicians that something important is going on in the nonconcious inner mind. Specifically, outward indications of affect, especially involuntary bodily changes like tears or changes in breathing, are the best markers we have of activation of the inner mind. For that reason, it is no surprise to us that in-session emotion had been confirmed by research as one of the “common factors” that are mediators (not mechanisms) of success in therapy sessions.

How PDT activates maladaptive schemas

Thus, our first clinical objective is activating those inner, nonconscious schemas. How does PDT do that, and can we improve on it? The first way psychodynamic therapy activates maladaptive schemas is eliciting free associations. The basic mammalian inner mind is always trying to find a definitive solution to its problems, and, in doing so, it generates a lot of spontaneous thoughts related to whatever it hasn’t fully solved. The therapeutic relationship plays an important role by gently steering towards problem areas and showing an interest in areas of “conflict.” Intrapsychic conflict is a concept based on the idea of internal agencies in conflict with one another and is not accepted in behavioral circles. In order to avoid argument between orientations, an alternative is to note that “conflictual” issues involve a clash between incompatible goals of the inner mind, or times when the inner mind’s aims clash with reality. That is a more universal way to describe the same thing. Free association brings to the surface the inner mind’s struggles to find a solution where its repertoire of available responses does not include one that is definitive or comfortable.

The other main way that PDT fulfills this first clinical objective is the transference. Here, the inner mind begins to relate to the therapist as a figure from the past. I’m going to add that a more complete version is that the inner mind begins to see the therapist either as the problem or the solution and tends to see changing the therapist as the ultimate solution to the original problem. As the inner mind (or inner self) becomes more focused on a solution involving the therapist, the phenomenon of transference blossoms, and with it, a chance opens up to find a more definitive and satisfactory solution to the problem. That’s called resolving the transference. What happens underneath is that memory reconsolidation reconfigures the schemas so a new way of responding within relationships becomes internalized and the troublesome response is changed in an enduring way. 

Can we improve PDT here?

Yes, Intensive Short-Term Dynamic Psychotherapy (ISTDP) has already incorporated an improvement in efficiency by focusing on problem solving more than an unstructured unfolding and has also made use of time limitation to “turn on the heat” for resolution. What I would add here, is that the element that is probably the most activating for emotions is the prospect of eventual behavior change as experienced by the inner mind. The scary experience of having change on the near horizon activates not only the threat of losing a highly valued protection, but also the threat that the original dread might return. For our purposes, the therapeutic objective of bringing affect “into the room” amounts to the same thing as “deepening the emotional experience,” but ties it more closely to the change mechanism of memory reconsolidation, for which neural activation (of the old schemas) is requirement number one.

We gain another potential improvement by identifying the outwardly manifested affect with a nonconscious emotion precursor. Such proto-emotions are the inner mind’s way of signaling a potential danger and triggering a protective response. The derivatives of nonconscious emotional signaling are both automatic bodily affects and conscious feelings. These are what we observe in session. The ability to share with clients that the target maladaptive pattern is a response to something the inner mind “dreads” is invaluable. We can ask a client “What do you think it is your inner mind is dreading right now?” A spontaneous answer often comes out and can be extraordinarily enlightening and helpful as well as further activating the schemas in question.

One client grew up in an unsafe and chaotic family. She felt responsible for solving every problem because, if she didn’t, she would not be able to grow up and have the adult life she felt she deserved. As she grew, she became a consummate problem solver, but her EMP was overwhelming anxiety when there was the slightest possibility of failure.

To be discussed below, the other requirement for memory reconsolidation is delivering the good news to the subcortical inner mind that there is a better way to deal with the dreaded inner emotion. Before we get there, we need to consider that clients often need to make use of the mechanism of new learning to make such an improved response available for the inner mind’s automatic use.

Second Clinical Objective: Having a better response available

Psychodynamic therapy generally doesn’t address this issue but leaves it to the client to discover for themselves. The rationale is that telling clients what to do contaminates the transference and is infantilizing. Even when clients report practicing new behaviors, the standard approach is to analyze the motives behind the change. It is likely that many experienced therapists do recognize and subtly support clients’ practicing more adaptive behaviors as part of the “working through” that comes after insight generated change.

Especially when the dread is repetition of a traumatic experience, there may not be a need for a new pattern of response. The therapeutic change is for the threat detection schema no longer to predict danger, where at some earlier time it could not be avoided.

Can we improve PDT here?

Let’s think about the common problem of a client not being assertive when it would be appropriate. It is a response they may never have dared even to try. The prospect may have raised nothing but anxiety and dread. It would be a significant improvement for the therapist to collaborate with the client to develop a more adaptive response if there were not severely negative consequences. Many therapies do actively encourage learning and practicing not only new response patterns to specific situations, but general skills such as mindfulness and acceptance. In those, more behaviorally oriented therapies, a more supportive and active stance does not seem to spoil the results. Let’s consider the negative consequences predicted in PDT.

The most compelling objection might be that PDT focuses on bottom-up work with unconscious processes and that trying to fix problems from the top down by teaching different cognitions and behaviors does not get at the underlying problem. But that is not what I am suggesting at all. On the limitations of top-down therapy, I agree with PDT. However, I am looking at words, nonverbal communications, and relationship as content to be translated into the native nonverbal forms of the subcortical inner mind so as to deliver new ways of appraising inputs and generating responses. What is suggested here is not top-down therapy but a way of understanding and explaining how therapeutic interactions of all kinds affect nonconscious schemas through the three change mechanisms listed above.

To the original objections that “gratification” of wishes and active support will discourage transference, I can assure you from clinical experience that transference is a robust phenomenon and is highly resistant to suppression. As for the objection of infantilization, as parents know well, it all depends on the person’s capabilities. Yes, doing something for a person that they can do just as well for themselves can carry the message that we don’t believe in their agency and capability. On the other hand, expecting them to solve problems beyond their ability is equally destructive as it suppresses hope and the motivation to learn and grow.

The improvement I would suggest is working with the client in collaboration to support and foster new solutions and patterns as well as improved ways of understanding and experiencing life. It is true, this can lead to transference reactions, so being sensitive to those and ready to switch to a mode of exploration and metacommunication (talking about what is going on in the relationship) is important. Similarly, being too helpful, where the client can do what is needed on their own, can send the wrong kind of message and should be avoided. Harry Stack Sullivan described how therapists are inevitably drawn into the client’s drama as a participant and need to be ready at any time to exercise the prerogative to become observers. “Hmm.., I think there might be something going on here between us.”

This is where those “common factors” that add up to trust in the relationship and the process are of greatest importance. A well-tuned therapeutic relationship encourages and supports taking the emotional risks involved in trying and internalizing new ways of responding.

Third Clinical Objective: Delivering disconfirming information where it is needed.

The easy part is that the inner mind’s maladaptive schemas represent less than optimal understanding of the dangers of life. They may have been valuable and helpful under earlier circumstances, for example in the dangerous and chaotic family mentioned earlier. But now, using that example, the client’s feeling of having absolutely to solve every problem on her own is no longer adaptive. Due to the absolute nature of the inner mind’s requirement (dating from an earlier era in development) it brings with it unnecessary anxiety and immense stress. The problem, then, is how to show the inner mind that getting help is OK and that not solving every problem is part of life and can be coped with. The interpretations of PDT can and will help here to bring clarity to the client. But, as seen in PDT, it is how this is received outside of consciousness that most concerns us.

The tricky part is that the new, disconfirming information, with which the schemas need to be re-written, needs to be delivered in nonverbal form to brain structures that do not utilize the same kind of reasoning as consciousness. The inner mind is associative and metaphorical. It makes use of tone of voice as much as content. It is sensitive to metaphor and to the connotative meaning of words. Think of the difference between an advertisement, meant to reach the inner mind and an academic paper that purposely shuns any attempt to use emotional persuasion. The inner mind is the main seat of motivation and a primary source of decision making. Reasoning is a minor part of communication delivered to the inner mind, while nonverbal cues are what do the heavy lifting. It’s all about show, not tell. Instinctively, experienced PDT therapists learn to use emotional language and metaphor. They learn to use their own intuition to communicate nonverbally using connotation as well as the denotative meaning of words. Unfortunately, this tends to be taught by long experience and supervision but is not always a basic part of the curriculum. Here again, Levenson (2025) is one exception.

Can we improve PDT here?

Yes! It doesn’t mean interpretations should be delivered like a sales pitch, since humans are naturally wary of being influenced. When we focus on the clinical objective of delivering new, eye-opening information to the inner mind, it becomes immediately clear that we will need to tune in to the client’s nonverbal language and put ourselves “in the shoes” of the inner mind. When we listen to our own communications using our understanding of the client’s inner mind, often frozen at some earlier point in time, it comes naturally to speak in its terms. Think of how you would change your way of communicating with a younger relative. You would not be thinking about “technique,” but using your own empathy to know what to say next. Effective PDT therapists teach the importance of using the language of the inner mind in the form of metaphor and emotional words shaped to match the client’s own style of expression. That is where our own intuition is our best tool for knowing how to reach our client’s inner mind without being pushy or inauthentic.

Experience as communication

The greatest path to improving PDT is by assigning homework. I’m exaggerating here for dramatic effect. What I really mean is that the client’s own experience is the most compelling and effective kind of communication, going directly to the inner mind. My favorite example is the TV show, “What Not to Wear,” in which participants agree to wear clothing chosen by professionals, rather than what they are used to. What is striking is the depth of the emotional reactions participants experience when they consciously adopt what amounts to an unfamiliar behavior.

There is a paradox here. Clients have often had experiences that directly contradict their inner mind’s views of things. The inner mind has many ways of invalidating experience so as not to be influence by it. In the case of voluntary behavior change, though, conscious discussion before trying something new seems to allow bypassing these invalidating tricks. When the therapist is a collaborator and witness, the meaning of the new behavior is far more potent in carrying new information to the inner mind.

One place where this kind of experience is well described and documented is the work of the quite famous Boston Change Process Study Group (Stern, 2004). They call these “moments of meeting,” in which often unanticipated events within the therapeutic relationship have major impact. Similarly, Alexander and French’s “corrective emotional experience” is based on unexpected events in the relationship carrying new meaning to the inner mind.

We don’t need to wait for these moments to happen. We can encourage the client’s creativity to conjure up thoughts, words, and actions to carry new, disconfirming information to their own inner mind. Having consciously refined our understanding of how the inner mind is seeing things, we can work together to find ways to deliver a new message. It might be a phrase or mantra. It could be a laugh and a different attitude. It could be imagining responding differently. In essentially every case, the client’s own ways of communicating to their own inner mind will be superior to whatever we might suggest.

Conclusion

In closing, I do want to repeat that speaking only to the conscious self is top-down therapy and does not properly aim at the inner mind, where the relevant schemas are located. One of the beauties of PDT is that it recognizes how unconscious processes are primary and are the ones where we want to see change take place. Another of PDT’s advantages is the full recognition of the uniqueness of each client. Building on both of those, I believe that knowing about therapy’s infrastructure and focusing on the three clinical objectives, we can further improve on what is already a subtle and highly effective route to improving lives.

Jeffery Smith MD

Author of the upcoming book, "How Psychotherapy Works: Navigating the Therapeutic Space with Confidence”

References

Levenson, H. (2025). Brief dynamic therapy (3rd ed.). American Psychological Association.

Smith, J. (2025). Psychotherapy integration from the bottom up: A unifying, science-based view of psychotherapy’s infrastructure. Journal of Psychotherapy Integration. Online publication located at: https://dx.doi.org/10.1037/int0000371

Stern, D. N. (2004). The present moment in psychotherapy and everyday life. W. W. Norton & Company.