This paper was co-authored by Merijn Merbis, Clinical Psychologist/Psychotherapist in The Netherlands.
Introduction
Patients seeking out psychotherapy often present with long-standing psychological problems that are deeply ingrained in their personality functioning, manifesting as pervasive intra- and interpersonal difficulties. Psychoanalytic theory provides a foundational framework for understanding these complexities, encompassing concepts such as unconscious mental life, personality dynamics, internalized relational patterns or object relations, and defense mechanisms. While not readily visible, these processes continuously operate in daily life and influence patients’ inner and outward behavior in as well as outside the therapy room. A key challenge in psychotherapy, therefore, is that these underlying and relatively unconscious processes – fundamentally linked to the patient’s distress – will inevitably unfold in the clinical encounter. To facilitate lasting change, these repetitions must be recognized, understood, and worked through within the therapeutic relationship. This is not at all an easy task and requires training programs to equip clinicians not only with technical skills but also with a solid, psychoanalytically informed understanding of their patients. In addition, trainees need to develop the capacity to tolerate uncertainty, reflect on their own (emotional) responses, and engage in the mutual process that psychotherapeutic treatment entails.
Contemporary professional training programs, however, largely prioritize skill acquisition and manualized interventions aimed at specific presenting symptoms (e.g., depression or anxiety), emphasizing action over reflection and the appearance of knowing over the reality of not knowing. Emphasis is placed on cognitive-behavioral models of symptomatology, while longstanding contributions from psychoanalytic theory continue to disappear from the curriculum. Diagnostic categories are linked to corresponding interventions, with little to no attention paid to developing a solid understanding of unconscious processes, personality organization, defense mechanisms, the idiosyncratic meaning of the presenting symptoms and transference-countertransference dynamics. The result is a lack of understanding, and an over-emphasis on acting – one acronym after another. Correspondingly, Gianotti (2022) writes: “My colleagues and I universally have found that this generation of practitioners seems to have varying degrees of difficulty grasping the ‘big picture’ of therapeutic complexity. That is, we have observed that newly trained clinicians often attempt a variety of techniques without necessarily knowing what impact these techniques will have on a patient or why they are choosing a particular intervention at any given point in time. We believe that this may be one of the unfortunate outcomes of graduate training that is too narrowly focused on mastering techniques rather than on having a solid grounding in case conceptualization”. Consequently, clinicians are trained to apply techniques rather than to engage in a mutual, at times potentially frustrating or unsettling process with their patients – a process Freud (1937) famously described as one of the “impossible professions, in which one can be sure beforehand of achieving unsatisfying results”. This emphasis on symptoms and corresponding interventions – without much attention to a psychoanalytically informed case conceptualization or formulation – creates a gap between training and clinical reality, leaving graduating clinicians ill-prepared to navigate the depths and complexities of daily psychotherapeutic practice.
While not advocating for a single and uniform theory or psychotherapeutic approach, this paper does argue that basic familiarity with psychoanalytic principles is essential for all clinicians, regardless of theoretical orientation. Neglecting the contributions from the psychoanalytic perspective not only compromises patient care but also limits clinicians’ professional development, denying them the structural understanding required to navigate the complexity of psychotherapy. This paper examines the gap between current psychotherapy training programs and practice, while arguing that integrating psychoanalytic principles in all psychotherapy training programs equips clinicians with the understanding and reflective stance necessary to engage with patients and promote lasting therapeutic change.
Rethinking Training: The Tree Metaphor
To conceptualize the complexity of human suffering and the structural elements missing from current symptom-focused models that dominate training programs, one can liken the patient to a tree. The leaves of the tree might represent the patient’s specific, readily visible symptoms (e.g., sadness, overthinking, anger), which are organized by the branches into broader diagnostic patterns (e.g., mood or anxiety disorders). The focus of manualized intervention is limited almost exclusively to treating these leaves and branches, with little attention paid to the rest of the tree. However, true psychological structure lies deeper: while the outer bark of the trunk might represent the more stable, conscious traits and coping styles, the inner growth rings and roots could be viewed as the more foundational, stable intra- and interpersonal patterns (e.g., personality organization, object relations, and defense mechanisms). These parts of the tree are not readily visible yet continue to influence the possibilities for growth and the overall health of the tree’s branches and leaves. The soil, lastly, represents the earliest experiences that might have nourished or restricted the subsequent development of the tree.
It is likely no coincidence that patients, especially those who have undergone multiple short-term or symptom-focused treatments and enter long-term psychotherapy, frequently state that they want to get to the root cause of their current issues. Of course, they want to experience an alleviation of their current symptoms. At the same time, their history of treatment often involves symptomatic complaints shifting over time – for example, moving from anxiety to depression – making their most prominent concern the prevention of recurrence or substitution of symptoms after treatment. These patients intuitively know or feel that something vital has been overlooked, yet do not always have a clear image of what that “something” is. If therapeutic attention is limited only to the manifest symptoms, something substantial about the patient remains unseen. Just as pruning the diseased leaves or branches of a tree without examining the trunk and roots leaves the underlying problem intact, focusing solely on alleviating symptoms rarely produces enduring change. What these patients need is for their clinicians to help them grasp something meaningful about themselves, their current symptoms, their personal history and its ties with the present, with the ultimate goal of achieving enduring improvements.
In working with complex psychopathology, an effective therapeutic stance requires the clinician to consider all abovementioned facets of the patients, all at once. It involves not only recognizing what is visible or known on the surface but also tracing how the relatively unconscious aspects of the patient’s inner world are organized and continue to operate. This approach demands a clinician trained in depth, not merely in technique.
The Training Gap
While symptom-focused, manualized techniques seem to depart from a top-down and knowing stance, clinicians need to be comfortable with the idea of not knowing. What is unconscious, cannot be readily identified and needs to be inferred from what is visible or noticeable. In order to do so, the clinician must – first and foremost – be prepared to tolerate extended periods of uncertainty, confusion and phases in the treatment during which nothing seems to make sense. However, to not remain lost, therapists must be trained in how to infer these unconscious processes - starting with the awareness of transference-countertransference dynamics. Patients tend to show rather than tell what is going on in their inner worlds, without them being readily aware of what it is they are revealing.
This bottom-up engagement stands in stark contrast to the top-down, prescriptive focus of much of current training, which emphasizes knowing what to do over curiosity and exploration. It fosters a therapeutic certainty that is ill-suited to the complexity of human suffering. The true task requires the therapist to maintain a theoretically grounded uncertainty that allows for genuine discovery rather than the mechanical application of pre-scripted steps. This essential shift from technique to structural understanding is precisely what current psychological education, dominated by symptom-focused protocols, is failing to deliver. The question, then, is how the field can reorganize its curriculum to teach this essential stance and the underlying theoretical knowledge needed to maintain it.
Case Example: Ms. B.
Before continuing, I would like to present the reader with a case example. Although the following case description is not based on a former or current patient, it is an example that is indicative of patients that therapists meet in psychotherapy. The case example will serve as a backdrop to not only illustrate the current training gap, but also to inform about the therapeutic task at hand and the ways in which training programs need to account for the work with patients like Ms. B.
It’s a gray, cold, and above all wet Monday morning in November. I glance at the clock in my office and realize that Mrs. B., a 34-year-old patient, is probably already sitting in the waiting room. I am the fifth psychologist she has seen in roughly ten years, and she has therefore already been through quite a number of treatments. These treatments each focused on more or less clearly defined complaints, such as panic attacks and severe agoraphobia, which temporarily improved with limited intervention. At the same time, she has been struggling for years with various other, less well-defined or clear problems—both in relation to herself and in her contact with others. These problems have been present since early adolescence and have clearly left their marks.
She never completed an education, despite being intellectually capable of doing so. Since the age of sixteen, she has worked in various jobs that—in her view—have always been beneath her level. She believes she has never truly been happy, and to say that she considers herself worthless would be an understatement. She has never been able to sustain a long-term romantic relationship, as these often turned from brief, intense infatuations into disappointment. Her days are now mostly empty, and she worries a lot about how to move forward with her life. On the rare occasions when her mood seems to lift and her trust begins to grow; she quickly undermines it again.
I feel a knot in my stomach, because I now find myself feeling almost as discouraged as she does. While she tends to feel that she constantly falls short, I mainly feel utterly inadequate in this treatment. She doesn’t hesitate to point out all the ways in which I fail her, either. Like her previous therapists, I cannot seem to give her what she needs. Yet she continues to show up for her appointments, and that alone has kept me from throwing in the towel. With some reluctance, I get up and prepare to bring Ms. B. in from the waiting room.
The Therapeutic Task
The challenge presented by Ms. B., and patients alike, illustrates the limitations of a prescriptive training model that privileges methodic action over understanding. Her history of temporary improvement followed by symptom substitution reveals that simply addressing the leaves (panic attacks and agoraphobia) and branches (anxiety disorders) has proven to be more or less futile in the long run. While her symptoms might have disappeared, she has continued to struggle with various intra- and interpersonal psychological difficulties (e.g., feelings of worthlessness, the inability to develop an enduring romantic relationship and difficulties in finding direction in her life). An approach based on knowing what intervention to apply next has, so far, only perpetuated the cycle of superficial symptomatic relief and subsequent disappointment. The effective therapeutic task, therefore, is not to mechanically prune the presenting symptoms, but to transition from certainty to curiosity. This requires the clinician to consciously embrace a non-judgmental and not-knowing stance, using Ms. B.’s manifest complaints and the emotional responses she elicits in the room as a compass. Her pattern of “undermining” her own growth, or her ability to make the therapist (and previous ones) feel “utterly incapable,” are not merely obstacles to be overcome; they are vital, live expressions of her underlying psychological structure, as well as her inner and relational conflicts – the rings and roots of the tree. To work effectively with this, the therapist must be grounded in theoretical knowledge – concepts like defense mechanisms such as projective identification, transference and enactments – that allows them to listen to the meaning of the emotional chaos without immediately having to fix it. This is the structural understanding, founded on the capacity to feel and think at the same time, that is at the heart of the psychotherapeutic endeavor.
Implications for Training
The gap between the complexity of clinical practice, as exemplified by patients like Ms. B., and the prescriptive simplicity of current curricula is not a minor oversight; it is a systemic failure that requires a fundamental overhaul of the current training climate. If one is to move past the superficial focus on the “leaves” and equip (new) clinicians with the capacity for structural understanding and the essential stance of grounded inquiry, training programs must be re-envisioned. In the following, some suggestions for re-envisionments are made, with reference to the case of Ms. B.
Reorienting the Curriculum
The Therapeutic Frame. For psychotherapy to be effective, therapists must maintain a stable therapeutic frame – a consistent and predictable set of conditions within which treatment occurs. These include clear agreements regarding session time and duration, setting, cancellations or missed appointments, and the respective roles and responsibilities of therapist and patient. Such stability provides the safety and continuity necessary for patients to explore their inner worlds freely, while enabling therapists to sustain their reflective function and therapeutic stance amidst the often-intense transference–countertransference dynamics that unfold in treatment (Mintz, 2025). Although breaches of the therapeutic frame are to be expected, the mere existence of said frame enables psychotherapists and patients alike to explore potential meaning(s) behind a breach of the frame. Even minor deviations from agreed boundaries, by the therapist as well as the patient, might hold significance and an entrance into the patient’s inner dynamics.
However, the importance of the therapeutic frame continues to be overlooked and, at times, actively undermined. Mintz (2025) even argues that the frame is under assault from “bureaucratic and market-driven impingements”. While these particular pressures are not necessarily the consequence of training programs, such programs frequently fail to adequately educate prospective psychotherapists about the components of the therapeutic frame and the critical necessity of maintaining its consistency throughout treatment.
The Therapist’s Stance. As mentioned earlier, current training programs all too often promote an exclusively top-down approach to psychotherapy, in which interventions – mapped directly onto DSM-5 classifications – are applied methodically and, at times, mechanically. While adherence to a manual can offer therapists a reassuring sense of control and certainty, such protocols might overlook the inherent complexity and unpredictability of the clinical encounter. In reality, therapists must often bear the strain of not (yet) knowing what to do or say next. Effective training should therefore prepare clinicians to tolerate this uncertainty while maintaining a grounded conviction that meaning can emerge from something seemingly meaningless.
Case Conceptualization. Effective psychotherapy requires clinicians to develop a case conceptualization that maps the multiple dimensions of a patient’s psychological functioning. Although this conceptualization is dynamic and continuously revised throughout treatment, it provides a critical framework from which therapy can proceed. Building an accurate and meaningful conceptualization demands familiarity with key domains such as personality organization, object relations, and defense mechanisms. For example, a patient with borderline-level organization, poorly integrated object relations, and predominantly primitive defenses will necessitate a very different therapeutic approach than a neurotically organized patient whose defenses are largely mature. Furthermore, this understanding guides the clinician in anticipating and navigating transference-countertransference dynamics that arise within the therapeutic relationship. Training programs should pay sufficient attention to educating therapists on developing a solid theoretical understanding of their patients, taking into account all “layers” - visible as well as less visible - of their psychological functioning.
Transference, Countertransference, and Enactments. A thorough understanding of transference and countertransference dynamics is central to effective psychotherapy. Transference refers to the ways in which patients project past relational patterns onto the therapist, often revealing unconscious expectations, fears, and desires. Countertransference, in turn, encompasses the therapist’s emotional responses to these projections, which can provide valuable information about the patient’s internal world when carefully monitored and reflected upon. Enactments occur when these dynamics are acted out within the therapy session, rather than discussed explicitly, potentially creating moments of misunderstanding or conflict. Training programs must equip clinicians with the skills to recognize and interpret these phenomena and use them constructively. By doing so, therapists can transform these complex relational processes into opportunities for insight and therapeutic progress.
Process-Oriented Consultation and Supervision. Instead of supervision and consultation that narrowly focus on which specific intervention to apply – often reduced to a three- or four-letter acronym – therapists must be encouraged to engage with the process of psychotherapy itself. This involves attending to and reflecting on their own emotional responses to the patient, using these reactions as a guide throughout the session. Doing so requires not only conceptual understanding but also sensitivity, discernment, and the ability to translate insight into a thoughtful and informed course of action.
The Integration of Psychoanalytic Principles Across Modalities. Although not all therapists practice from a (strictly) psychoanalytic orientation, training programs should aim to integrate the principles outlined above across therapeutic modalities. Even when therapists primarily use manualized approaches, factors such as personality structure, defense mechanisms, and transference-countertransference dynamics inevitably influence the therapeutic process. To effectively manage these phenomena, clinicians must be equipped with both conceptual understanding and practical strategies that allow them to recognize, reflect on, and respond to these underlying dynamics in the moment.
Concluding Comments: Lost in Technique, Seeking Understanding
Throughout this paper, I have highlighted the persistent gap between the complexity of clinical reality and the prescriptive simplicity of much current psychotherapy training. Patients such as Ms. B. remind us that therapy is rarely a linear application of techniques or a predictable process of symptom alleviation. Their struggles extend beyond what is visible in the “leaves” of presenting symptoms, reaching deep into the “roots” of personality structure, relational patterns, and unconscious dynamics. Effective psychotherapy, therefore, requires more than technical proficiency. It demands for clinicians to tolerate uncertainty, reflect on their own responses (in the room), and approach the therapeutic encounter with curiosity and a commitment to understanding the patient’s inner world.
Current training programs, dominated by manualized interventions and top-down, action-oriented approaches, risk producing clinicians who are adept at following protocols but ill-prepared to engage with these deeper processes. The challenge is not simply to teach more techniques, but to cultivate a reflective stance, grounded in theoretical knowledge, that allows clinicians to infer meaning from transference-countertransference patterns, enactments, and subtle expressions of psychological structure. Training that emphasizes the therapeutic frame, a theoretically informed not-knowing stance, case conceptualization or formulation, awareness of transference-countertransference dynamics, process-oriented supervision, and the integration of psychoanalytic principles across all treatment modalities equips therapists with the necessary knowledge and skills to work with complexity rather than against it.
Ultimately, bridging the gap between training and practice requires a fundamental reorientation of the educational paradigm – one that values the development of understanding over the application of technique, tolerates not-knowing as an essential part of clinical work, and encourages the therapist to engage in a mutual process of exploration with the patient. Only through such a transformation can training programs produce clinicians capable of seeing the whole tree, rather than merely pruning its leaves, and thereby foster psychotherapeutic work that is both meaningful and enduring - for patients, as well as their therapists.
References
Freud, S. (1937). Analysis terminable and interminable. The Journal of Psychoanalysis, 18, 373-405.
Gianotti, P. (2022). Embracing therapeutic complexity: A guidebook to integrating the essentials of psychodynamic principles across therapeutic disciplines. Routledge. https://doi.org/10.4324/9781003120278
Mintz, D. (2025). The Frame under Assault. Psychiatric News, 60(10), https://doi.org/10.1176/appi.pn.2025.10.10.24.
This was very insightful. Thank you so much for compiling it.
Reading Nancy Mc Williams Psychoanalytic Diagnosis I was shocked to realize that most of our patients 'had' obsessive compulsive personality's, and that she had a very clear idea about what was driving them, and how to help them on a deeper level then we were used to. I was also surprised to see that not all colleagues were as thrilled about this discovery as I was. :)