Chapter 1. Developing a Problem List
Publication: Problem-Focused Psychodynamic Psychotherapy
In this chapter I will describe how the therapist and patient create a list of problems to be pursued in problem-focused psychodynamic psychotherapy (PrFPP) and how this effort aids in establishing the psychotherapeutic process. The therapist helps the patient to clarify difficulties that have not been fully defined and to address barriers to recognizing problems (e.g., denial, shame). The therapist works with the patient to develop self-reflective capacities and understand that problems have meanings and functions. Specific problems then become a lens through which contributory dynamic factors are formulated and addressed. Rather than viewing a problem list as static, the therapist uses psychodynamic techniques to further elaborate and clarify the nature of specific problems over time, as well as identify previously unrecognized difficulties when they emerge in treatment. In addition to defining areas of focus for psychotherapeutic intervention, this process enables work on the therapeutic alliance by allowing therapist and patient to collaborate on the goals of treatment, including resolution of problems.
Identification of Problems
Understanding the Types of Problems
Problem areas can roughly be divided into symptoms/disorders, personality factors, behavioral issues, and relationship difficulties (Table 1–1). This categorization mirrors the series of focused psychodynamic psychotherapeutic approaches, including those for depression (Busch et al. 2016), anxiety (Busch et al. 2012), and PTSD (Busch et al., in press); personality pathology (Bateman and Fonagy 2016; Caligor et al. 2018; Yeomans et al. 2015); and behavioral change (Busch 2018). In general, psychodynamic treatment manuals have not targeted interpersonal difficulties (see Caligor et al. 2018 for an exception), although such difficulties have been addressed as they related to the dynamics of the central problem; relationship issues are an important focus of PrFPP.
Types of problems |
Symptoms |
Personality factors |
Relationship difficulties |
Behavioral issues |
Recognizing the problem as a psychological issue |
Defining the extent and impact of the problem |
Therapists and patients should consider each of these categories in elaborating a problem list, but because there can be significant overlap, the boundaries between these problem areas are fluid. For example, unassertiveness can be viewed as a combination of symptom, personality, behavioral, and relationship difficulties. Problem areas, however, do not have to be clearly categorized for the therapy to proceed effectively; the language and components of problems will be defined by the therapist and patient as they elaborate their understanding of and approaches to areas of difficulty. For some patients, it can be helpful for the therapist to develop a shorthand term that can be used to allude to specific problems, such as “your anxiety,” “your struggle with low self-esteem,” “your communication problems with your spouse,” or “your difficulty managing your temper.”
Clarifying the Nature of the Problem and Its Psychological Basis
Some problems are readily identified by patients, whereas others are not for a variety of reasons (Table 1–2). Some difficulties are experienced as a natural part of the patient’s self or life, or can occur reflexively, almost out of the patient’s awareness. In these instances, the therapist works with the patient to recognize the problems as such, indicating that something can be done to relieve or improve them. For other problems there is an active resistance to acknowledging them, consciously or unconsciously (see section “Barriers to Addressing Problems” below). In these cases, the therapist uses psychodynamic approaches to help the patient identify the difficulty and understand the source of the patient’s struggle. It is not unusual for problems to be unrecognized due to both a lack of recognition and an unconscious resistance.
Denial |
Guilt and shame |
Intrapsychic conflict and defense |
Examples |
Impulse-control problems |
Personality disorders |
Case Example
Ms. A, a 24-year-old woman, presented for treatment of severe anxiety. In the course of the evaluation, the patient alluded to struggles with motivation, but did not discuss them further. The therapist returned to this topic later in the interview:
THERAPIST: So tell me more about your problem with motivation.MS. A: I’m not sure if it’s relevant. I’m really here for my anxiety, but okay . . . I get very excited and involved in a project. Then as it’s nearing completion, I totally lose interest. Not just in that project; in all of my work. I just kind of stall out and don’t do anything sometimes for a couple months, until a new project comes along.THERAPIST: What causes you to lose interest?MS. A: I don’t know. I’ve never really thought about it. It goes all the way back to grade school. I’m like really moving along with something and then boom, no interest.THERAPIST: Well, I think there’s something important to understand about what triggers these episodes.MS. A: Why?THERAPIST: I think by understanding more about it we could help you to address the problem. And maybe it’s even related to your anxiety.MS. A: I’ve never really considered that anything could be done about it. I thought it’s just how I operate. That would be interesting to think about why it happens.
On the basis of this pattern, the therapist also considered and explored the possibility of attention-deficit disorder. Over time, it emerged that the patient associated effective motivation with aggression and was conflicted about it as well as anxious. She felt most threatened when a project was moving toward completion. Recognition of the emotional basis of this problem, once the problem was identified, aided in its relief over time, as well as provided additional information about what was making the patient anxious.
Other problems are not recognized as psychological or emotional difficulties because they are believed to be due to something wrong with the body. For instance, patients with panic disorder are often convinced that certain symptoms are of somatic origin and are surprised to learn after thorough evaluation that nothing is medically amiss. The therapist provides psychoeducation that, because a medical basis for these symptoms has been ruled out, the source is likely psychological and emotional, and patients would benefit from therapeutic work to identify these factors. Somatization often functions as a defense against conflicted feelings and fantasies through a displacement to the body.
Defining the Extent and Impact of the Problem
Problems may more readily emerge as the therapist explores the pattern of their occurrence and repercussions. For instance, a patient may report significant anxiety, but the extent and impact of the anxiety (e.g., phobias; inhibitions) on the patient’s life may not be evident. For example, a patient presenting with panic attacks (readily identified as such) became aware in the course of the initial psychiatric evaluation that she struggled with intense anxiety and unassertiveness in a number of areas of her life (at work, in close relationships):
Case Example
Ms. B, a 25-year-old nurse, experienced the onset of panic attacks a few days after a patient of hers died suddenly. She did not know the patient particularly well but viewed the death as “unfair,” because the patient was young and much improved. As the period preceding panic onset was explored, she described intense anxiety in two important areas of her life. She felt “underpaid and overworked” in her job and would become fearful and frustrated when feeling under pressure to fulfill her hospital duties, and highly anxious in her relationship with her “cold and callous” boyfriend.
THERAPIST: Tell me more about how you felt with your boyfriend.MS. B: It was like he gave 10% and I gave 110%. Every time I was with him, I would get really anxious.THERAPIST: This was before you had the panic attacks?MS. B: Yes.THERAPIST: What were you worried about?MS. B: I was frightened that he was going to break up with me. Looking back, I’m not sure why I stayed with him so long. I was so frustrated inside.THERAPIST: Did you say anything to him about your frustration?MS. B: I didn’t want to be a complainer. My dad always told me I was one, and I didn’t want my boyfriend to think of me in that way.THERAPIST: What did you think would happen if you did complain to your boyfriend?MS. B: I don’t know. That would be pretty scary. I would explode maybe. And I’m sure he would have gotten furious. Maybe the whole relationship would end. But I guess that happened anyway.
This early exploration demonstrated that Ms. B experienced significant anxiety in several areas of her life preceding the onset of panic. In addition, the evaluation revealed one of the dynamic factors in her anxiety: She had difficulty acknowledging her frustration, and when she expressed angry feelings, she would become frightened. She would tend to take back her angry comments. For example, after expressing vengeful fantasies toward her boyfriend, she said, “But I’m not a grudgeful person.” Her comments suggested that she feared her anger would disrupt her relationships, indicating separation fears common in panic patients (Busch et al. 2012). History taking further revealed many years of hypochondriacal symptoms and an anxious childhood with a temperamental father and fearful mother. As the evaluation proceeded, Ms. B acknowledged: “I guess I’m just an anxious person. I didn’t realize how much it affected my life.”
Case Example of an Initial Assessment in PrFPP
The following case provides an overview of identifying a problem list and obtaining information about contributors in the early phase of treatment.
Ms. C, a 46-year-old married woman working in public relations, presented with a primary complaint of anxious and depressed mood, including decreased motivation and interest, reduced appetite, and decreased concentration. She also described social anxiety, and fears of confrontation. The treating therapist concluded that she met criteria for generalized anxiety disorder along with some depressive symptoms and would benefit from a trial of escitalopram. On the baisis of the stressors described below, the therapist told her that psychological and emotional factors contributed to these symptoms and recommended weekly psychodynamic psychotherapy.
The therapist proceeded with exploring the onset of the depressive and anxious symptoms to identify contributors to these problems. Therapist and patient determined they occurred in the context of two stressors that had been developing over the preceding several months. One problem involved the patient’s daughter, Heather, the youngest of two children, who was in her senior year of high school and was applying for college. Ms. C reported that she and Heather had always been “very close,” and she was feeling upended by intense sadness about her daughter leaving home. In exploring the history of this problem, the therapist learned that the patient had significant difficulty with Heather’s aging over many years. She was very attached to the time period before Heather was 10, when Ms. C returned to work and felt sad about the loss of childhood activities they did together. Indeed, Heather never attended camp or sleepovers and spent much of her time, well into adolescence, at home rather than going out with friends. Ms. C’s older son, Brian, had a more typical level of involvement outside the home and spent much more time away from the family. He occasionally expressed frustration at the amount of time his mother spent with his sister and sometimes complained that Heather was her favorite.
Her relationship with Heather had intensified when Heather was age 5 during a period in which Ms. C’s husband, an entrepreneur, was working particularly hard and often not home at night. She described Jim at that time as not only very busy but increasingly irritable and critical as he became more successful in his work. Subsequently however, Jim suffered setbacks in his business. He worked very little at the time when Ms. C presented, although he was always considering new projects, and she earned the bulk of the family money at her public relations job.
The therapist began an initial exploration into the problems with her daughter:
MS. C: With her going off to college I feel so sad, and I’m worried it will get worse.THERAPIST: What do you anticipate it will feel like?MS. C: I’m worried about feeling lonely or empty. I mean Brian’s around, but Jim and I are pretty distant. I also regret not having a third child. Jim really objected, and I didn’t want to create trouble with him.THERAPIST: What problems would that have caused?MS. C: Well, he was really irritable at that time because he felt so stressed about his job. He would just end up attacking me, saying that neither of us had time for another kid, and why didn’t I focus on taking on more of the chores in the home first or go back to work? I’m fearful of confrontation and don’t push for what I want. So after he yelled at me, I just withdrew from the discussion. I essentially gave up.THERAPIST: What frightens you about confrontation?MS. C: I worry it’s going to create a rift. It’s certainly like that with my father. I get angry at his criticisms but I’m hesitant to say anything to him. And I guess it’s true about with my boss as well.THERAPIST: So maybe it’s a pattern?MS. C: Yeah, I guess I never really like confrontation.
As seen in this exchange, Ms. C’s problems with assertiveness began to emerge in the context of elaborating her separation fears from her daughter and became more apparent in exploring a second major source of distress, frustration with her work. The patient described a history of feeling unappreciated at her job at the PR firm. Although she did well and was considered highly successful by her peers, she believed she was underpaid, especially when she learned in recent months that others at her level received a higher salary. Nevertheless, she was fearful of addressing this problem with her boss, a man who had been an important mentor to her for many years. In spite of generally feeling unappreciated, she had always felt recognized by the boss as his “right hand woman” and had some satisfaction from this perception.
About two years prior to presentation, a younger man, Ajay, joined their group. The boss seemed quite taken by him and had been giving him increasing responsibility. Ms. C believed that he had limited talent for the job, and that her boss was blinded by his being a man, his youth, and his social skills. She felt frustrated and also became concerned that Ajay was being relatively well paid and might soon have a salary that approximated hers. She obsessed over whether to talk to her boss about the problem with her salary and the limitations of her coworker but was deeply hesitant to confront him. She believed that in spite of their long history of a good relationship, she could not predict how he might respond if she confronted him about these issues. She also feared that because she was a woman, her boss would react more negatively to her asking for a raise that he would a man. As her frustration persisted, she began to feel less enthusiastic about her work and put less effort into it.
In the context of exploring her problems at home and work, Ms. C reported long-standing feelings of inadequacy. She felt embarrassed about the college she had attended, believing that it was not prestigious and that her father was disappointed in her for going there. She believed that others would not respect her PR job because her firm was not as well known as some companies. She was anxious at social gatherings, fearing others would look down on her, and had few close friends. She also felt uncomfortable with her husband’s friends, believing them to be more high-powered and successful. These feelings combined with her sense of regret about certain decisions she made and with her fears about asserting herself. Finally, Ms. C experienced ongoing marital tensions and felt unable to communicate with her husband. Based on this information the therapist and patient identified an initial problem list (Table 1–3).
1. Anxious and depressive symptoms |
2. Intense sadness about her daughter going to college |
3. Difficulties with assertiveness |
4. Frustration with her work and boss |
5. Feelings of inadequacy and low self-esteem |
6. Social anxiety |
7. Marital tensions |
Additional aspects of how the therapist and patient addressed these problems will be described subsequently.
Barriers to Addressing Problems
As noted above, with many problems the patient may demonstrate an inability or aversion to acknowledging or designating them. Understanding these interfering factors is important for both identifying problems and areas of distress or intense negative feelings (see Table 1–2). Some of the more prevalent obstacles are denial, shame and guilt, and intrapsychic conflicts and defenses. Although these factors interfere with a range of problems, prominent examples include substance use and other impulse-control problems, about which the individual is often in denial or deeply ashamed; personality disorders, in which the patient views the issue as part of who he or she is; and some interpersonal problems, in which the patient does not want to recognize his or her own contribution to the difficulties. Cultural factors can also play a role, because some subgroups react to psychiatric problems with shame or denial. The therapist works with the patient to identify painful feelings and defenses (Freud 1936) that interfere with problem recognition.
Denial
Denial functions as a defense mechanism in which the individual repudiates or will not acknowledge the reality of his or her internal state (e.g., feelings or fantasies) or external reality (illness, climate change, the impact of COVID-19). Denial is a common reaction to painful aspects of reality and can be adaptive in coping with difficult circumstances. However, areas in which a patient rigidly holds on to magical thinking may create significant danger or damage. Denial is commonly associated with substance abuse problems but can be found with a broad range of difficulties. The therapist works to tactfully address the patient’s denial and identify what makes the problem painful or frightening to accept:
Case Example
THERAPIST: Tell me about your pattern of drinking.MR. D: I don’t really think there’s any particular trigger. Certain days I just start drinking. I could drink like 10 to 12 beers. But it’s not really a problem for me. I can handle that much.THERAPIST: Well, it seems like a lot. When did you last drink?MR. D: Two days ago.THERAPIST: So tell me about what happened that day.MR. D: I felt frustrated about my work. I got into a really bad mood and decided to just put it away for a while. When I got home, my girlfriend was like “What’s wrong?” I told her and she said: “Well, you can’t just not do the work.” I was furious. Of course I know that. I just kind of stomped off and started drinking.THERAPIST: That sounds like a very specific precipitant.MR. D: Yeah, it does. It usually doesn’t work like that.THERAPIST: Well, we should look at some other examples to see if that’s the case. Did you talk to her about your frustrations?MR. D: No . . . what’s the point? It doesn’t get anywhere.THERAPIST: We might want to explore other ways of dealing with these tensions with her.MR. D: Okay. But I don’t think the alcohol is a problem. Most days I don’t drink.THERAPIST: But when you do is it usually that many drinks?MR. D: Yeah, I guess so.THERAPIST: I think you might have trouble acknowledging your drinking is a problem.MR. D: Well, my Dad was an alcoholic. I don’t drink like he did.THERAPIST: Maybe that’s part of why it’s hard for you to acknowledge the problem, because you don’t want to be linked to him. I’m not saying you’re an alcoholic, but it sounds like you do have a problem with drinking,MR. D: Yeah, well if I do have an issue it’s nothing like he had.
The therapist may note to patients that denial is a common part of substance use problems and disorders and that being able to more consistently recognize and control the use of substances will be part of treatment.
Guilt and Shame
Guilt and shame are common symptoms but also can interfere with identification of other problems. Thus, patients may be embarrassed to reveal certain aspects of their difficulties, including thoughts, feelings, and experiences that they are ashamed of, behaviors that they are critical of, or traumatic events for which they partly blame themselves. The therapist works to identify the presence of shame and guilt as well as the way these feelings block identification of other problems. One example is obsessive-compulsive disorder, in which patients may feel ashamed about the degree of their symptoms, such as handwashing or checking, and tend to minimize or dismiss them. The therapist’s nonjudgmental stance aids in the emergence of various issues in the course of treatment. Therapists may reassure patients that their concerns or symptoms are common and explore what is making them anxious or guilty about revealing their difficulties.
If patients demur from revealing a problem (stating, for example, “I don’t feel comfortable discussing that”), the therapist can suggest that it would be helpful to explore their concerns and hopefully over time they can feel safe enough to describe them. Many patients take several sessions (or sometimes months) to reveal something that they feel particularly ashamed about, such as a history of abuse or troubling sexual fantasies. In other instances, patients are unconscious of what is causing guilt and shame, and therapists need to address the conflicts and defenses that are interfering with awareness of these feelings (see next section).
Ms. C made a reference to “sometimes having attitudes and behaviors that are like my father,” whom she was very critical of. The therapist made an effort to learn more about these:
THERAPIST: Can you tell more about these attitudes?MS. C (appearing uncomfortable): I don’t like to say too much about them.THERAPIST: I have some ideas about what might make that difficult for you, but can you describe what’s making you uncomfortable?MS. C: You know I feel very critical of him, so it’s kind of embarrassing that I behave like that. Like I’m so mad that he’s so controlling, but I can be like that too.THERAPIST: Well, it’s good you’re able to recognize that. It’s actually not an unusual pattern. Can you give an example?MS. C: Yes. If the family is doing an activity and I don’t want to do it, I just kind of pout. I’m obviously not having fun.THERAPIST: Is this like what your father does?MS. C: Well not exactly. He decides what he’s going to do, and he just does it no matter what anyone else says.THERAPIST: I see. So he won’t even try to participate.MS. C: Yes, but I still see myself as being similar. Even though it’s not quite the same. And I really don’t like to talk about it, although I know we probably should.THERAPIST: I suspect those difficulties have been hard to address because you keep them cordoned off even from yourself. If we learn more about them I think it will help you to manage these feelings and behaviors better. And we have to understand more about why you equate yourself to your father, when you at least have some perspective on your behavior.
Intrapsychic Conflict and Defense
Intrapsychic conflicts (Freud 1926/1959) and defenses (Freud 1936), while important to elaborate in any psychodynamic psychotherapy, represent other sources of difficulty in identifying problems. Patients may struggle, consciously or unconsciously, with accessing aggressive, dependent, or sexual wishes that trigger anxiety or guilt, which will be elucidated over the course of a successful treatment. For example, a patient’s conflict about aggressive feelings and fantasies, associated with fears of disrupting important relationships, can lead to minimizing tensions and submissive behavior with a par tner or spouse. Ms. C (see below), for example, took several sessions to acknowledge the extent of her problems with her husband, based in part on fears of her anger.
Problems in Which Barriers to Acknowledgment Are Common: Some Examples
Impulse-Control Problems
Problems controlling impulses can occur in a variety of forms, including temperamental outbursts, poor control of sexual urges, and various forms of addictive behavior (American Psychiatric Association 2013). Patients may deny these types of difficulties, which are sometimes brought to their attention by others. Alternatively, patients may experience painful feelings, such as guilt and shame, in the context of having thought about or acted on these impulses. For example, they may enact sexual behaviors in response to strong sexual urges or a wish for intimacy, but regret doing so with someone unlikely to be a long-term partner or outside their primary relationship. Or they may buy items when in debt, or excessively use drugs or alcohol, followed by intense self-criticism. More severe forms of these impulse-control disorders can require specialized treatment interventions, such as addiction specialists, rehab, or a form of anonymous meetings. Psychodynamic psychotherapeutic approaches targeting problems, however, can often be of value in modulating these difficult to control impulses, especially in less severe forms. Identifying the context, feelings, and fantasies along with contributory dynamics can provide additional tools in regulating these urges and behaviors. In addition to Mr. D whose case was described earlier, many examples of dealing with these problems will be described in this book.
Personality Problems
Personality problems are a source of persistent difficulty for many individuals that are important to define and address. Patients with personality disorders typically do not recognize these attitudes and behaviors as problems, seeing them as part of who they are, creating inherent barriers to acknowledging them. Additionally, patients can feel injured or threatened by designating a problem as part of their personality, and suggesting the patient has a personality disorder may exacerbate this reaction. Furthermore, patients can demonstrate certain features of a personality disorder (American Psychiatric Association 2013), but not others, or have issues or behaviors that meet some of the criteria for different personality disorders, complicating referencing a problem as a specific personality disorder. Therefore, with personality issues, the therapist should work to identify the specific characteristics as part of the problem list in ways that are acceptable and comprehensible for patients. For example, problems with assertiveness, difficulties controlling impulses, and being avoidant of others are terms that may help patients to define and acknowledge these issues.
Narcissistic traits represent a particularly sensitive area for patients, because they are likely to view pointing out these characteristics as attacks and be dismissive or angry in response. Such problems may be more acceptable when described as sensitivity to rejection or low self-esteem (see Chapter 7). Once these concepts are introduced, other narcissistic issues may, over time, be identified as reactions to these vulnerabilities. Thus, the therapist can suggest that a patient’s sense of certainty or pressure to be “special” may represent an attempt to compensate for feelings of inadequacy. One patient, for example, was outraged when a close friend told him he suffered from narcissistic personality disorder, and he demanded to know if the therapist corroborated this diagnosis. The therapist stated that rather than trying to determine whether someone met criteria for the disorder, he found it more useful to explore whether a patient suffered from self-esteem issues and problems associated with them, such as being very reactive to slights. The patient was willing to consider this sensitivity as one of his problems, as he often felt criticized by others, although he blamed it primarily on others’ lack of recognition of his talents.
Interpersonal Issues
In the case of interpersonal conflicts, patients may describe certain difficulties with others but not recognize the role they play. They may find it upsetting to consider their contribution, wanting to believe the fault lies entirely with the other person. In these instances, the therapist works to tactfully address patients’ difficulty identifying these problems, often involving recognizing parts of themselves or behaviors that are painful to acknowledge.
Ongoing Emergence and Clarification of Problems
In PrFPP problem lists are not considered to be static. As sessions proceed, there is both a clarification of problems already being explored and an identification of new problems. New problems can emerge through further exploration of the patient’s mental life and environment and identification of blocks that are inhibiting addressing problems (denial, guilt, intrapsychic conflicts, and defense) as described earlier. In the following example, the degree of Ms. C’s problems in the relationship with her husband emerged through additional exploration. It also became clear that she had been reluctant to discuss these difficulties.
In a subsequent session Ms. C began to talk about her marital problems in greater depth. It emerged that she was uncomfortable discussing her long-term frustrations with her husband. She described him as driven and perfectionistic, with a very clear idea about the right way to do things. He was often critical of Ms. C’s cooking, even though she was working more hours than he was. Although he had been irritable in the past from increased work, he was now frustrated about the setbacks in his entrepreneurial efforts. He would snap at her to “mind her own business” or “fuck off” if she tried to ask questions about his work ventures.
THERAPIST: So how are you affected by his temper?MS. C: I guess I get kind of quiet and I eventually apologize, even though I don’t think I should.THERAPIST: How do you end up doing that?MS. C: Well, the whole thing is really painful. In some ways it’s easier to talk about separating from my daughter.THERAPIST: This situation with your husband seems quite relevant to that. Because when your daughter is gone, you’re going to be alone a lot more with him. In fact, this may be significantly adding to your worries.MS. C: That makes sense. I mean I love him, but he can be very difficult. And often I just feel alone when I’m with him.
Other Early Therapeutic Interventions
In addition to identifying the nature of the patients’ problems, as discussed earlier in this chapter, other therapeutic tasks are important in paving the way for an effective treatment (Table 1–4). These include developing self-reflective skills; establishing meaning and symbolization; enhancing the therapeutic alliance; identifying relevant dynamics; recognizing and exploring the impact of cultural factors; and combining psychotherapy and medication. The ways in which PrFPP can be useful in enhancing these interventions are described.
Identifying problems |
Developing self-reflective skills |
Establishing that problems have meanings and functions |
Enhancing the therapeutic alliance |
Identifying relevant dynamics |
Recognizing and exploring the impact of cultural factors |
Combining psychotherapy and medication |
Developing Self-Reflective Skills
Assessing the nature of patients’ problems aids in the development of their self-reflective skills. The therapist encourages patients to attend to their own thoughts, feelings, and motivations and to explore triggers and contexts of the onset of problems and their persistence. The therapist helps patients recognize that emotions and contexts surrounding problems provide intervention points for addressing and relieving them. As they improve at these tasks, patients learn that problems are more discrete as opposed to an amorphous source of distress. They come to see problems as distinct rather than as an inherent part of themselves or caused by others, thereby creating the potential to relieve them. In addition, patients gain a better sense of control by identifying contributors and triggers of problems.
Establishing That Problems Have Meanings and Functions
In identifying and designating problems, the therapist communicates that they have particular meanings and functions for patients, which are often maladaptive. Thus, defining problems and early exploration of context and feelings are methods for establishing symbolization. For example, the therapist clarifies that somatic symptoms have a psychological and emotional basis, and therefore have a meaning for the patient. Focus on the body can represent poorly symbolized emotions, a defense against painful feelings and fantasies, or a symbolized representation of an intrapsychic conflict, often involving dependency or aggression. In designating the somatic states as a symptom, the therapist suggests that understanding their meanings and function will contribute to relief. The process of designating symptoms, behaviors, and relationship difficulties as meaningful problems is a core part of this therapy.
Enhancing the Therapeutic Alliance
Working to identify the nature of specific problems enhances the therapeutic alliance (Greenson 1965; Horvath et al. 2011), because the therapist directly addresses what is distressing the patient. In elaborating the context and history of problems, the alliance is further established as the patient begins to recognize the value of these interventions and collaborate with the therapist in this effort. The therapeutic relationship can be used as a model for working together and communicating with others in addressing problems. Interpretations of the transference (Cooper 1987) (see Chapter 2) help the patient understand various reactions to the therapist and become aware of inhibitions and conflicts that interfere with relationships. Disruptions in the relationship with the therapist are key moments to explore, as they can help identify areas of vulnerability that create difficulties in extratherapeutic relationships.
Recognizing Relevant Dynamics
Defining underlying dynamics that are contributory to various problems is a key aspect of this therapy. Often preliminary dynamic information can be identified in creating a problem list. In an early session, for example, a therapist may note that the patient tends to take back his or her comments or feel guilty after expressing anger. In the case of Ms. C, conflicts about angry feelings and fantasies toward others, in which she feared potential damage or disruption to relationships, began to emerge as a factor in several problem areas, including her avoidance of discussing difficulties with her husband. Over the course of the treatment the therapist explored this dynamic’s contribution to various symptoms (anxiety or panic, depression), personality difficulties (unassertiveness), relationship issues (failure to express needs and dissatisfaction in relationships), and behavioral problems (e.g., passive aggressive behaviors, as anger could not be expressed directly).
Recognizing and Exploring the Impact of Cultural Factors
Recognizing and exploring the impact of cultural factors is a key area of consideration in the identification and treatment of problems. Patients’ cultural backgrounds strongly influence both the nature and perception of their difficulties and what problems they feel safe or unsafe discussing. Some subcultures are more likely to experience certain forms of trauma, such as through the impact of institutionalized racism. Patients may not feel understood unless such factors are taken into account, interfering with the alliance and their comfort in revealing problems. Ms. B, for example, described the influence of her Catholic background on her perception of her revenge fantasies:
MS. B: I’m a Catholic, and I learned that if you try to hurt someone, you’re going to get it right back. You’ll be punished.THERAPIST: But you actually haven’t acted on these fantasies. Is thinking the same as doing?MS. B: Well no. But I believe I shouldn’t even be having these thoughts.THERAPIST: I think it’s important to explore these fears further and obviously your religion has a big impact on how you feel about these things.MS. B: Yeah, I thought these ideas didn’t affect me so much anymore, but maybe my schooling had more of an effect than I realize.
Combining PrFPP and Medication
Much has been written about combining medication with psychotherapy in the treatment of various symptoms and disorders. In PrFPP, medications are used as another method for relieving problems (Busch and Sandberg 2007). While recognizing anxious or depressive disorders as physiologically based and treatable with medication, this approach also views environmental and psychological factors as contributory and symptoms as having important meanings and functions. This model can be conceptualized with the metaphor of a river with physiological, environmental, and psychological/emotional tributaries flowing into it. Overflow of the river represents the anxious or depressive disorder. In any given instance, the degree of contribution of the different components (tributaries) varies. Therefore, addressing physiological, environmental, and psychological/emotional factors can aid in providing relief of symptoms and problems. Difficulties with medication will not be a focus of this book but may become an issue in treatments in which they are used. For example, patients may struggle with shame about needing medication or noncompliance. Psychodynamic understanding can often be of help in addressing issues that arise with medication.
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Problem-Focused Psychodynamic Psychotherapy
Pages: 1 - 16
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Published in print: 30 August 2021
Published online: 5 December 2024
© American Psychiatric Association Publishing
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