Front Matter

About the Author

Introduction

1 Developing a Problem List

2 Using Psychodynamic Techniques

3 Examining the Context, Emotions, and Developmental History Contributing to Problems

4 Developing a Psychodynamic Formulation

5 Addressing Problems: A Framework

6 Addressing the Role of Adverse and Traumatic Experiences in Problems

7 Addressing Personality Disorders

8 Integrating Dissociated Aspects of Self and Other Representations

9 Working Through

10 Managing Termination

Index

Dr. Busch is a clinical professor of psychiatry at Weill Cornell Medical College and a faculty member of the Columbia University Center for Psychoanalytic Training and Research. His writing and research have focused on the links between psychoanalysis and psychiatry, including psychodynamic approaches to specific disorders, psychoanalytic research, and psychoanalysis and medication. He has coauthored or authored numerous books on the psychoanalytic approaches to specific disorders, including Manual of Panic Focused Psychodynamic Psychotherapy, Manual of Panic Focused Psychodynamic Psychotherapy—eXtended Range, Psychodynamic Treatment of Depression (now in its second edition), Psychodynamic Approaches to the Adolescent With Panic Disorder, Psychodynamic Approaches to Behavioral Change, and Trauma-Focused Psychodynamic Psychotherapy (in press). Additionally, he is the coauthor of Psychotherapy and Medication: The Challenge of Integration. He has been involved in the development of and research on panic focused psychodynamic psychotherapy and more recently on psychodynamic treatment of PTSD.

For many years, and currently in many psychoanalytic institutes, psychoanalysts and psychodynamic psychotherapists have been taught to not be too active, to not focus on symptoms or specific problems, and to avoid psychoeducation. To do so, they’re counseled, would disrupt psychoanalytic techniques, including free association and development of the transference, and interfere with the effectiveness of the analytic approach. Over the years many clinicians, particularly those performing psychodynamic psychotherapy, have questioned these shibboleths and encouraged more active approaches in the treatment of patients. The development of symptom- or disorder-focused psychodynamic manuals (see, e.g., Bateman and Fonagy 2016; Busch et al. 2012; Busch et al. 2016; Caligor et al. 2018; Yeomans et al. 2015) provided a basis for the systematic articulation of alternative psychodynamic approaches that incorporated these elements, including more active interventions, a focus on symptoms and associated dynamics, and occasional (although not formal) psychoeducation. In addition, psychodynamic psychotherapeutic manuals required a clarification in terminology and techniques, to make them more user friendly and broadly comprehensible to students and those without psychoanalytic expertise.

I began to engage in the development of panic-focused psychodynamic psychotherapy (PFPP) in 1991 with my colleagues Drs. Barbara Milrod, Theodore Shapiro, and Arnold Cooper (Busch et al. 1991). After training other psychoanalysts in this form of psychotherapy, many of them reported that learning this treatment changed their usual practice. I realized that my own style had changed as well: I was more likely to provide information to patients about how the treatment worked, more focused on specific symptoms, and quicker to suggest a formulation regarding their problems. Although I had concerns about disrupting recommended analytic approaches, I found that patients responded positively to these interventions and rapidly gained an understanding of the process of therapy, how to observe their own intrapsychic states, and how to address symptoms and problems. Subsequent research studies confirmed the efficacy of PFPP for symptoms (Beutel et al. 2013; Milrod et al. 2007, 2016) but also suggested that the impact of focused therapies may be broader, affecting personality issues, behavioral problems, and relationship difficulties. Notably, a recent study (Keefe et al. 2019) found that the focus on specific symptoms and associated dynamics correlated with the effectiveness of treatment in relieving symptoms.

Since the publication of the PFPP manual and the subsequent more comprehensive PFPP, eXtended Range (PFPP-XR) (Busch et al. 2012), there has been extensive further development of symptom-focused psychodynamic psychotherapies (Busch et al., in press). These approaches provide core dynamic formulations for specific disorders along with modified psychodynamic techniques to address particular problems (Table 1). While several different types of disorders have been addressed (depression [Busch et al. 2016], panic/anxiety [Busch et al. 2012], PTSD [Busch et al., in press], personality disorders [Bateman and Fonagy 2016; Caligor et al. 2018; Yeomans et al. 2015], behavioral difficulties [Busch 2018]), there has not been a clear articulation of this overall treatment approach. This book presents such a focused psychodynamic psychotherapeutic approach that can be adapted for patients in general. Rather than one specific aspect of patients’ difficulties, problem-focused psychodynamic psychotherapy (PrFPP) focuses on a set of problems (e.g., symptoms, relationship issues, behavioral difficulties). The therapist works with the patient in identifying and addressing the overlapping and unique dynamics of the various problems. This more general approach makes it highly usable for both students and experienced clinicians in addressing a range of patients’ difficulties.

This treatment can be employed as a short-term or more extended intervention. Such an approach is of value in that many patients do not want to commit to a longer-term treatment and others lack access to interventions other than brief, focused treatments. With PrFPP, the therapist and patient can rapidly identify, engage, and address core problems and teach self-observational tools that patients can use after treatment.

The book describes how to make a problem list (e.g., symptoms, behavioral issues, relationship difficulties), in part by using psychodynamic exploratory techniques, and examines the context and emotions surrounding each issue. Working with a problem list helps the therapist to maintain a focus despite addressing various difficulties. These initial approaches aid in developing a psychodynamic formulation, providing a framework for identifying and addressing the dynamic contributors to the various problems. The working-through process demonstrates how specific dynamics emerge in different contexts and overlap in contributing to problems. For instance, conflicts about angry feelings viewed as potentially disruptive to close relationships can contribute to both panic symptoms and unassertiveness. These approaches speed the development of patients’ self-reflective capacities and the identification of their own dynamics, thus more rapidly addressing core difficulties. The work enables the continued use of modes of managing problems after the treatment is completed.

This book was completed just as the advent of COVID-19 and the subsequent upheaval that it created occurred. People were broadly affected in almost every aspect of their lives. Impacts included anxiety about the virus, isolation through quarantine, conflicts among those quarantined together, disruptions or loss of work, and social and political upheaval. In addition, there was a shift in how therapy was performed toward almost entirely remote work. PrFPP is particularly well suited to dealing with these difficulties, as problems can be addressed as they preceded, were affected by, or emerged with the impact of the virus.

As noted above, prior books on focused psychodynamic psychotherapies have been limited to addressing specific subpopulations rather than a treatment that can be used for most patients. After reading Problem-Focused Psychodynamic Psychotherapy, clinicians can consult texts on specific disorders for more details on treatments of these particular problems (Bateman and Fonagy 2016; Busch 2018; Busch et al. 2012, 2016, in press; Caligor et al. 2018; Yeomans et al. 2015). As with other books of this nature, there will be many case examples, and psychodynamic factors and techniques will be described in experience-near and relatively jargon-free terms.