It is one of the remarkable but also unsettling characteristics of psychodynamic psychotherapy that its course is not rigidly predetermined; this allows things to emerge in therapy that neither the therapist nor patient could have anticipated. What focus the work takes and what therapeutic approaches are most useful for each patient need to be found out along the way. This does not however mean it is impossible to give direction or that there is no structure to therapy. In this chapter, we aim to provide orientation to clinicians who are embarking on their first courses of therapy. We integrate theory and technique to offer a longitudinal perspective on how matters can play out over a course of therapy. Firstly, we discuss the formation of the therapeutic alliance and the development of a psychodynamic formulation. The central part of this chapter looks at the therapeutic relationship as a vehicle for change. Finally, we discuss the late phase of therapy and the dynamics of separation from the therapist, and how this can be both a challenging but productive period.