A litigator we'll call Dana (a composite of several people we've worked with, details changed) came to her first consultation with a question she'd clearly been mulling over for months: "Did CBT not work, or did I just do it wrong?"
She'd done twelve sessions of cognitive behavioral therapy (CBT) for the dread that started every Sunday around 4pm. She did every worksheet, logged every anxious thought, and by the end, the Sunday dread had genuinely eased.
Eight months later, it was back, except now it showed up as her phone face-up at every dinner, a short fuse with her partner over nothing, and a 2am habit of rereading emails she'd already sent.
Her CBT did exactly what it was designed to do, and she didn't do it wrong either. What she was running into is the real question underneath "psychodynamic therapy vs. CBT," which is less about which approach is better in general and more about what kind of problems you're actually dealing with.
Two Ends of the Therapy Spectrum
When people ask us how we work, we've found it's actually helpful to start by describing the opposite, just as a frame of reference, because there's a really wide range of therapy approaches out there.
On one end of the spectrum, you have the shorter-term, structured therapies, and CBT is the best known of these. Sessions usually open with an agenda that you and your therapist stick to pretty closely. You'll likely fill out worksheets in session and have homework in between, and the work focuses on identifying specific symptoms and targeting them with coping strategies, restructuring thought patterns, and behavior changes. The hope is that within a relatively short, defined stretch of time, you're done with therapy and on your way.
There are amazing clinicians who do this kind of work, and if that's the approach you're looking for, you'll probably be well served by someone who practices CBT, ACT, or EMDR.
On the other end, you have long-term, depth-oriented approaches like psychodynamic therapy, which is where we are at Helm Psychology. There's no set agenda or manual. We follow whatever you bring into the session that day, and over time, we look at what's happening underneath the surface of things: the beliefs, the early relationships, and the old rules that keep shaping how you react under pressure.
Here's what that difference looks like with the same person in the therapy space:
In a CBT session, Dana might set the agenda ("Sunday dread"), identify the automatic thought ("If I'm not ready for Monday, everyone will see I'm not that competent"), test the evidence for it, and leave with a thought record to fill out before next week.
In a psychodynamic session, she might start by talking about a deposition that went sideways, and then her therapist might notice out loud that she's apologized twice for being three minutes late. Then they get curious together about whose disappointment she's always bracing for, and where she first learned that being "on" at all times was the price of being okay.
Both kinds of therapy are useful, but they're aimed at different layers of the same problem.
What the Research Says About Psychodynamic Therapy vs. CBT
You've probably heard that CBT is "the evidence-based one." That reputation has a lot to do with how much easier it is to run studies on a structured, time-limited treatment, and the actual findings tell a more even story.
However, a 2017 meta-analysis in the American Journal of Psychiatry (Steinert et al.) compared psychodynamic therapy with other established treatments, CBT included, across 23 randomized controlled trials, and found it was just as effective.
And in a widely cited review in American Psychologist, Jonathan Shedler (2010) found that the benefits of psychodynamic therapy don't just hold up after treatment ends; they tend to keep growing.
That second finding speaks directly to Dana's situation. When change happens at the level of the underlying pattern, it doesn't need constant maintenance through worksheets and techniques, because the thing that kept generating the symptom has actually shifted.
Signs That Psychodynamic Therapy Might Be the Better Fit for You
Most of the people we work with are high achievers: physicians, executives, founders, attorneys, and people in finance. And most of them have been doers and fixers for as long as they can remember, which, of course, has served them incredibly well. It's a big part of how they got through medical school, made partner, or got the company funded.
But that fixing instinct tends to get generalized to everything, including therapy, and it's part of why structured approaches can sometimes hit a ceiling for these groups.
Here are a few signs that might be happening for you:
You did the program well, and the problem just moved. Like Dana, you followed through on everything, the symptom eased, and then something that felt suspiciously similar showed up somewhere else in your life. When a problem keeps changing shape, it usually means that there are patterns underneath it with roots undergirding things at a deeper level.
You can explain your patterns perfectly, but they haven't really changed. You might know exactly why you overwork, or walk a friend through your relationship with your father like a case summary, and still find yourself doing the same things anyway. Understanding something intellectually and having it change how you respond in the moment are two very different things, and psychodynamic work centers around noticing that gap as the means for shifting things over time.
It shows up most with the people closest to you. Many high achievers are assertive and clear at work but end up shrinking themselves, snapping, or shutting down with their partner, their kids, or their parents. Those patterns are relational, and they're hard to fix with a worksheet, because they tend to show up in real time, including in the therapy room with your therapist.
You've already tried the quick fixes. We often say this on consultation calls: for people this capable, if there were a fast, easy solution, they'd probably have found it already. The fact that you're still looking is useful information in itself.
And to be honest about the experience of it: setting the problem-solving urge aside can feel really uncomfortable and unfamiliar at first, especially if fixing things is what you're best at. But what we tend to find is that it leads to more meaningful and more lasting change over time than coming at things with the same problem-solving hammer that hasn't held up so far.
If any of these sound familiar, you might also recognize yourself in our writing on high-functioning anxiety, perfectionism, and people-pleasing.
One Thing to Try Before You Choose a Therapy Approach
Before you decide between psychodynamic therapy and CBT, write down the last two times you "solved" the thing that's bothering you, and then write down what came back afterward, even if it looked different on the surface.
If it genuinely stayed solved, a structured, skills-based approach may be all you need.
But if something came back in a new form, that's usually a sign there's a deeper pattern worth understanding, and it's exactly the kind of thing worth bringing to a first conversation with a psychodynamic therapist.
If you'd like to talk it through with us, Dr. Annia Raja and Dr. Chaim Rochester offer online psychodynamic therapy across California, Texas, Virginia, and 40+ other states. You can request a free 15-minute consultation and bring your notes with you.
FAQs
Is CBT more evidence-based than psychodynamic therapy?
No. CBT has more studies behind it, largely because structured, time-limited treatments are easier to research, but more studies isn't the same as better results. A 2017 meta-analysis in the American Journal of Psychiatry found psychodynamic therapy just as effective as other established treatments, including CBT, and Jonathan Shedler's 2010 review in American Psychologist found that the benefits of psychodynamic therapy tend to keep growing after treatment ends. Both approaches are evidence-based; they just work on different layers of a problem.
Which is better for anxiety, CBT or psychodynamic therapy?
Research supports both for anxiety. CBT tends to focus on reducing anxious thoughts and behaviors directly, while psychodynamic therapy looks at what the anxiety is protecting you from and why it keeps coming back. If your anxiety keeps returning in new forms, or it's tangled up with perfectionism, overworking, or people-pleasing, psychodynamic therapy is often a better fit.
Is psychodynamic therapy effective for depression?
Yes. Psychodynamic therapy has solid research support for depression, and its effects often continue after therapy ends. It's especially helpful when depression is connected to long-standing patterns, like feeling worthwhile only when you're achieving, or feeling flat and disconnected even when your life looks great on paper.
How long does psychodynamic therapy take compared with CBT?
CBT is usually short-term, often somewhere around 8 to 20 sessions with a defined end point. Psychodynamic therapy is open-ended and often lasts a year or more, because the goal is to change the patterns underneath the symptoms, and that does take time. Many people notice meaningful shifts well before then, though.
Is psychodynamic therapy just talking about your childhood?
No. We talk about past, present, and future, and everything in between: what's happening at work and in your relationships right now, what comes up in the room with us, where you want your life to go, and the earlier experiences that help make sense of all of it. They're all connected, so we follow whatever feels most alive for you that day.
Why do high achievers often choose psychodynamic therapy over CBT?
Physicians, executives, founders, attorneys, and other high achievers tend to be natural doers and fixers, and for many of them, CBT can turn into yet another program to complete well. If there were a quick fix for what they're struggling with, they'd likely have found it already. Psychodynamic therapy asks them to set that problem-solving urge aside and get curious about what's underneath, which can feel uncomfortable at first, but tends to lead to more meaningful and lasting change.