Problem-Focused Psychodynamic Psychotherapies

For many years, psychoanalytic theory and treatments were the primary approaches to care being taught and used in mental health training facilities for treatment of patients without psychosis. By the mid-1980s, however, psychoanalytic approaches were increasingly being marginalized as a form of treatment and a focus of training, for three reasons. The first key contributor was the relative absence of research on psychoanalytic treatments. Many psychoanalysts had a conviction about the treatment’s effectiveness (1), but a general belief was that psychoanalytic approaches could not be manualized and systematically studied. A second major problem was that psychoanalytic theories and treatments were considered difficult to learn, requiring extensive training. Psychoanalytic notions were often couched in complex or abstruse metapsychological terminology. A third issue was that the treatments, unlike medications and other psychotherapies, were not tailored to specific problems.

Around the same time, efforts began in earnest to manualize psychoanalytic psychotherapies focused on specific disorders, with goals of further clarifying these approaches and conducting systematic studies. In the late 1980s, our research group (Barbara Milrod, Arnold Cooper, Theodore Shapiro, and Katherine Shear) began to develop a psychodynamic formulation for panic disorder in order to identify the context and emotions surrounding the patient’s symptoms, as well as relevant internal representations of self and others, intrapsychic conflicts, and defenses. We used this formulation to develop a symptom-focused manual of psychodynamic psychotherapy for training and research.

There was a striking convergence of research and clinical data regarding psychodynamic contributors to panic disorder (2, 3). Studies indicated that individuals prone to developing panic disorder had early life temperamental or environmentally induced separation fears that led them to feel fearfully dependent on their caretakers (4). Many patients described histories of adverse developmental events or trauma and poor family management of anger and separation. It became clear clinically that these individuals had difficulties managing angry feelings and fantasies, which they unconsciously feared would damage or disrupt already insecurely attached relationships. Furthermore, these angry feelings were exacerbated by disappointment with perceived or actual unresponsive, critical or rejecting behavior by caretakers.

A series of clinical interviews and a review of life events literature (2) indicated that panic attacks were triggered in the context of perceived threats to attachment, such as a loss (either in reality or symbolically) or a movement toward increased autonomy (e.g., going to college, marriage, or having a child). In these circumstances, patients become fearful of abandonment and feel frightened and guilty that their anger will damage or destroy needed relationships. Defenses are triggered, including denial, reaction formation, and undoing (5), which attempt to modulate and control angry feelings and fantasies and increase affiliative efforts. For instance, in undoing, individuals take back thoughts or the expression of hostility (“I hate him, but I really love him”).

Despite these defenses, a vicious cycle is triggered, from fearful dependency to anger, then anxiety, further increasing fearful dependency and ultimately leading to panic attacks. The panic attack itself modulates the threat from anger through a defensive focus on the body (somatization). In addition, the individual appears to self and others as ill and nonthreatening, rather than as angry or damaging. At the same time, there is a hidden coercion of others in the intense pressure to obtain help (and reduce abandonment fears). Finally, the pain of the panic attack can serve a self-punitive function for guilty feelings about aggressive and dependent wishes.

Using this psychodynamic formulation, our group modified the traditional psychodynamic approach to focus on panic symptoms in a manual of panic-focused psychodynamic psychotherapy (PFPP) (4). In the initial phase of treatment, the therapist examines the context and emotions surrounding panic attacks and attempts to identify the meanings of symptoms (for instance, a patient’s unsteadiness may represent a fear of not being supported by close attachment figures). As therapy proceeds into the middle phase, the patient’s developmental history, self and other representations, conflicts and defenses, and mentalization skills (the capacity to understand one’s own mind and those of others) are explored in relation to how they contribute to panic episodes. The therapist works to detoxify abandonment fears and angry fantasies that the patient finds threatening, by understanding their origins and recognizing how the patient overestimates the threat from these thoughts and feelings. The therapy also addresses how these dynamics affect interpersonal relationships, in which patients are typically yielding, because they fear that being assertive may damage their relationships. As these fears are addressed, patients become more communicative about their needs, leading to increased satisfaction in their relationships.

In the last phase of treatment, termination, the therapist explores the patient’s reactions to ending treatment. As they emerge, anxious and angry feelings can be addressed directly with the therapist, referred to as the transference, which enables a consolidation of gains. Patients leave treatment with improved mentalization skills, helping them to identify contributory factors and address warning signs of panic recurrence. They are more aware and tolerant of dependent and angry feelings and fantasies.

This psychotherapy has been employed in studies as a 12-week, 24-session treatment and has been demonstrated to be efficacious in four controlled treatment trials (6–9). For example, Milrod et al. (7) studied patients with primary DSM-IV (10) panic disorder with and without agoraphobia and compared PFPP with a less active but efficacious psychotherapy for panic disorder, applied relaxation therapy (ART) (Cerny JA, Vermilyea J, Barlow DH, 1980, unpublished; available from the authors on request). Compared with ART, PFPP had a significantly higher response rate (73% versus 39%; p=0.016), as measured by a 40% reduction in the Panic Disorder Severity Scale (11) (p=0.002), and significantly improved psychosocial function, as measured by the Sheehan Disability Scale (12) (p=0.014). Gains were maintained at 6-month follow-up without intervening treatment. Milrod et al. (8) conducted a two-site (Weill Cornell Medical College and University of Pennsylvania) randomized controlled trial of 201 patients with primary DSM IV (10) panic disorder with and without agoraphobia, comparing PFPP, cognitive-behavioral therapy (CBT), and ART. At termination, there were different outcomes at the two sites: patients responded significantly better to PFPP and CBT compared with ART at the Cornell site, whereas at Penn there was no significant difference in response across treatments. Variations in supervision of ART and the novelty of PFPP for therapists at the Penn site were considered possible contributors to these differences. The overall response rates based on the PDSS were ART, 46%; CBT, 63%; and PFPP, 59%. Gains were maintained among responders at 12-month follow-up (13).

Alongside PFPP, several additional psychodynamic treatment manuals have been developed that focus on specific disorders (including personality disorders, which are not addressed in this article). A manual of psychodynamic treatment of depression identifies core dynamics surrounding vulnerability in self-esteem (14). Depressed patients also demonstrate conflicts regarding anger, often triggered by feeling rejected or criticized, leading to guilt and fears of damage; this anger is typically directed inward in the form of self-attacks. Given this psychodynamic overlap, addressing conflicts about anger typically helps with both anxious and depressive symptoms, as well as problems in interpersonal relationships. Notably, treating patients with PFPP has been found to reduce comorbid depressive symptoms, although this reduction did not reach significance (7).

A manual of trauma-focused psychodynamic psychotherapy (TFPP) (15) has shown promise in treatment of veterans with posttraumatic stress disorder. Psychoanalytic theory suggests that individuals unconsciously tend to repeat trauma, often attempting to master circumstances in which they feel helpless. Another central dynamic is identification with the aggressor, in which patients have fantasies of harming others as they have been harmed, frequently triggering intense guilt and self-punishment. Another recent manual focuses on using psychoanalytic treatments to accomplish behavioral change (16). This is anathema to traditional psychoanalytic approaches, which emphasize that efforts to change behavior may interfere with transference-focused psychotherapeutic strategies, rendering these interventions ineffective. But psychodynamic approaches are well suited for this purpose, given the exploration and addressing of multiple contributors to problematic behavior.

These approaches collectively can be referred to as problem-focused psychodynamic psychotherapies (PrFPP) (17). The therapist is more active and focused and provides more psychoeducation than traditional psychoanalytic treatments. These approaches can also be adapted as a more general form of treatment, because patients do not typically present with or experience a single disorder; core dynamics, trauma, and adverse developmental events are addressed as they contribute to various difficulties. These treatments can remain focused by developing a problem list and highlighting which problem is addressed in a particular session. Formulations are developed for each of the problems, which typically have some degree of overlap. Termination of these treatments differs from traditional psychodynamic psychotherapy in that an assessment can be performed to identify patients’ progress in achieving their goals. Nevertheless, the usual approaches to transference/countertransference and interpretation of conflicts and feelings in response to separation from the therapist are employed.

An advantage of these interventions is that they are designed for shorter-term treatments and are therefore more transportable to the public health sector. TFPP is being studied in treatment of veterans at the Veterans Affairs New York Harbor Healthcare System. In addition, the training of therapists in using these treatments is less extensive than that required by other types of psychoanalytic interventions. For example, therapists who have not received formal psychodynamic or psychoanalytic training have been able to function effectively as PFPP therapists. Psychodynamic interventions have been less commonly applied to the serious mentally ill population but may be useful tools for focusing on specific problems of these patients.

Evidence thus far indicates that intensive psychoanalytic approaches can be adapted as highly effective focused interventions for particular problems and disorders. By addressing underlying dynamics of these difficulties, these treatments may have a broad impact on various aspects of patients’ psychopathology and their lives and may relieve suffering over shorter periods. However, extensive research will be needed to identify which treatments work best for which problems. Such studies should involve problem-focused dynamic interventions to evaluate their effectiveness in the short and long term, in comparison with other evidence-based psychotherapies, including CBT and interpersonal psychotherapy. Multiple psychodynamic manuals now exist for proceeding with such research.