Episode 264: Problem-Focused Psychodynamic Psychotherapy: Targeting Symptoms, Relationships, Trauma & Behavioral Change with Dr. Fredric N. Busch
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Introduction (01:34)
Puder:
Welcome back to the podcast. I'm joined by Fredric N. Busch of New York. He has an office in New York City. He is a psychiatrist, psychoanalyst, specializing in depression, panic disorder and other anxiety disorders, bipolar disorder. His approach includes psychodynamic psychotherapy, along with psychopharmacology. He's also a clinical professor of psychiatry at Cornell Medical College and a lecturer at Columbia University. Welcome to the podcast.
Busch:
Thanks. And thanks so much for having me.
Puder:
It's so good to have you and to meet you. And I think it's worth mentioning right at the beginning that there are two Dr. Busches. One is a PhD. You're the psychiatrist. You're in New York. The other one is in Boston. And so today we're going to be talking about solution-focused psychodynamic psychotherapy. We're going to be talking about a psychodynamic approach to trauma, panic disorder, or behavioral change.
What Is Problem-Focused Psychodynamic Psychotherapy? (02:40)
Busch:
Yes. And I guess problem-focused psychodynamic psychotherapy, I guess solution-focused therapy is actually a little bit of a different thing. Although, I mean, there's a lot of these acronyms out there, so it's hard to keep up with all of them, but I'll try to differentiate this one.
Puder:
Ye. So tell me about problem-focused. Like what does that mean for you?
Busch:
Well, you know, one of the issues is that sometimes hearing about people's prior therapies, or in the context of even supervising someone, I'll kind of say like, “Oh, what did you learn from your therapy? Or, what did you understand from it? What did you work on?” Or even to a supervisee, “What are you working on?” Sometimes there's a real lack of clarity in terms of what is the focus of the treatment and what they're trying to accomplish. And, although I'm a big proponent of psychodynamic psychotherapy, a lot of that is a kind of an open-ended exploration, whatever the person brings in. And in terms of this treatment it's really to identify and designate a set of problems that you're working on. And to keep those in mind, follow them along as you're proceeding with the treatment.
Busch:
So, for instance, let's say he has anxiety symptoms, depressive symptoms, trouble controlling their temper, disruptions in relationships. You could say, “Okay, well, that's the set of problems, and that's what we're going to track.” And the idea is to build a psychodynamic formulation, which we can talk about around the different problems, and use those to target interventions. So that keeps you on track to sort of say, “Wait, here's what we're working on. Here's what we've understood about it. Here's what's helping and not helping. Here's where we are in the context of the treatment dealing with these issues.” You know, what's kind of working and not working. So it's a bare amount of difference from, you know, more traditional forms of psychodynamic psychotherapy.
Identifying the Core Problems in the First Session (05:14)
Puder:
Okay. So I think this has been a really helpful, kind of repetitive theme that we've talked about in this podcast of how do we find what is the main issue that they're coming in with? What is their goal? So how do you start to sort of pull that out from the first session?
Busch:
Well, really, you know, what you can do is the usual evaluation. You know, “Tell me about what your problems are.” And so somebody's saying, “Okay, well, I have anxiety,” and start to identify circumstances and context because that's part of the process. Intensity, pervasiveness about depressive symptoms, how severe, how disruptive are they, to get an idea. Because the way I look at problems is symptoms, behavioral issues. So those have to do with, are there struggles with, on the one hand, inhibition, you know, difficulties with assertiveness. On the other hand, you know, impulses. You know, all sorts of addictive impulses, shopping, loss of temper… and then take a look at what are the issues in their relationships? Do they have some anxiety, panic, or some other issues? You know, do they have problems with regard to feeling dependent and frustrated in their relationships? Or dissatisfied with their partners or narcissistic issues?
Busch:
No one's good enough for them. So those are the kinds of things that as they come up, we will start to identify these problems. And one of the things that's kind of collaborative or helps to build an alliance is that there is a discussion about the problems. “Okay, so it sounds like here's what you're coming in for. You know, we're going to work on your anxiety. We're going to work on your depressive symptoms. We're going to work on this issue in the relationship. You're going to work on your difficulties asserting yourself.” And we'll kind of keep that in mind as the issues that we're working on going forward. And that's a sort of collaboratively built effort. And then, you know, there are things that are going to emerge that don't come out initially because people may be anxious or embarrassed about them. So, you know, it isn't, it's not like, “Oh, this is a static list and we're done.” We can modify that as we go along.
How Personality Styles Fit into the Psychodynamic Formulation (08:13)
Puder:
And then how does personality and your understanding of their personality fit into the formulation? So let's say they have a problem, like assertiveness, and then, for example, as you hear more about them, you realize the personality that goes with that is more of a dependent personality style. How does that link?
Busch:
Yes. So, you know, I do put personality issues as one of the four sets of problems and I talk about approaches to personality issues. So symptoms, behaviors, personality issues, and then relationship problems. Which, by the way, relationship problems is not always a focus of a psychodynamic treatment the way it is of this treatment, as is behavior. But nevertheless, with regard to your question, it's interesting because I found that a better thing with people is to let them talk about the problem. Not as, “You have this personality disorder, but how does it manifest itself?” You know, somebody comes in and says, “My wife told me I had narcissistic personality disorder. What do you think?” So I would say, “Well, I don't necessarily find that kind of label so particularly helpful, but let's talk about what issues you may have that you may feel that people don't get you.”
Busch:
“They devalue you. You don't feel adequately recognized.” Or dependency issues, “You don't feel able to manage on your own, or that you're able to function without someone else's support or you tend to avoid certain types of situations.” So that's, again, the language of that is more oriented towards the problem than the personality disorder itself. I saw your talk with Frank Yeomans [see episode 234], and I think they said, “Oh, you have borderline personality disorder.” I think that's, he was saying, that they have that diagnosis. To me that's not always as helpful as clarifying, “What does that mean? What types of symptoms that person has, and what's the language that they can understand and also tolerate.” Because a lot of personality issues, people are not aware of, they’re egosyntonic, that's part of the nature of that.
The Role of Relationship Problems in Psychodynamic Treatment (11:14)
Puder:
Okay. So you're looking for what they're coming in with, the problem, how that relates in different domains of their life. And you added in relationship issues at the end there. Which is kind of like, because maybe they're coming in because of conflict between them and a particular person. Right? And that's another category. So tell me about that category. And you said it doesn't usually come up in psychodynamic thinking.
Busch:
Well, yes. I would say that the way I would put it, and why I say it doesn't come up, is that it's [relational conflict] and behavior, which are two of the key components of this type of approach, don't tend to be targeted. The idea is that we're going to help you to understand what's going on inside, and that's going to help to make changes. Whereas, in this approach, it's sort of like, “Okay, here's the problem or difficulty that we're targeting. You have this issue with behavior, and we're going to try to build a formulation and understand it and talk about interventions to change it.” Similarly, with relationships, I mean, if you take one type of uncommon case and think about formulation, let's say, people with panic or anxiety disorder…part of our formulation, which we can talk about, is that they struggle with angry feelings of fantasies, and they're worried about disrupting relationships as a threat to them.
Busch:
So in that, it's not uncommon for them to, due to these conflicts, have struggles communicating their needs to a partner and that they can't bring up what they need because they fear, “This is only going to create a problem. This is going to disrupt the relationship.” So a lot of times it tends to be sort of an angry, dependent relationship, although the anger isn't being expressed directly. So I'm going to start, say, “Okay, well, let's look at that frustration you're experiencing in that relationship. And here, that core problem is that you're having trouble communicating your needs and wishes to the other person.” Now they say, “Okay, well, the other person's unresponsive, or they don't get it,” but in a certain way that hasn't been tested out. And, you know, I'm partly giving an example of how one dynamic issue may relate to a couple different problems, which is part of the approach here that dealing with certain kinds of dynamic issues can affect more than one problem.
Busch:
And there's an intersection that tends to occur, an influence on each other. I mean, let's say someone's fearful of anger. We have been talking about disavowed anger with Dr. Wachtel [see episodes 222 and 255]. Well, if you can help them to feel safer with their anger, and then they can express it in the relationship, and that can potentially lead to hopefully a positive outcome, helping them to feel safer with their anger, and hopefully change the relationship and feedback to help them to have more tolerance of those feelings.
Disavowed Anger: A Common Dynamic in Anxiety, Panic, and Relationships (14:58)
Puder:
Yeah, so kind of the disavowed. So let's pick a particular issue. Is there a particular issue that you find is very common that we could talk about today? And let's maybe try to go into a little bit more depth to make it more palpable or tangible or understandable. So is there one that jumps out at you as kind of something that you often see in New York in your practice?
Busch:
Well, in New York, I have to say, you see everything. But if we're talking about the disavowed anger issue, which I think it's a very interesting one, you know, that's a common issue—people who are inhibited or don't feel safe expressing those feelings or consider that they would be dangerous and are frustrated. And, and after all, I mean kind of the “proper,” so to speak, or “most effective” communication of anger is kind of a universal issue. I mean, it's not always clear how much we express it, how do we express it? But to the extent that you're frightened that any expression of anger is going to create a disruption in a relationship, then that's going to make it harder to be able to express it.
Busch:
So it tends to get suppressed. And then the defenses that often take place can be denial. Like, some people say, “I don't get it. I don't have anger.” You know, “Heard that before,” or the reaction formation, trying to connect or take care more of others, or even like expressing anger and taking it back. What we call “undoing” (Freud, 1936). Make an angry statement, like, “Well, sometimes you hear from panic patients, “I hate my partner, but I really love him.” You know, their indications that that's not safe for them.
Building a "Staging Area" to Step Back from Anxiety, Trauma, and Overwhelm (17:12)
Puder:
Okay. And so, utilizing your approach, how do you start to help someone move, maybe from where they're disallowing this kind of anger to bringing it more into their conscious awareness without a feeling of impending doom or high anxiety? Right?
Busch:
Yes. So one thing would be to help them, and this is a big step in terms of this kind of approach, which is to develop an understanding of context and feelings. Where do problems tend to occur? Firstly, identify the problem and then look at, so, “What are the situations that it happens in?”
Puder:
So let's say they say, “Close attachment relationships,” like with their mother, with their wife.
Busch:
Right. So once we get that kind of idea, one of the ideas here is to, we're working to build, but I'm now tending to call it a “staging area”. It's sort of, more than observing ego, it's building a place to be able to step back from various problems, anxiety states, traumatic states, depressive states, and I'll refer to symptoms and processes being kind of being caught in a whirlpool, and they're trying to find a way to build a way to step back from that. And if they're frightened of their anger, one of the things is, as we begin to identify the circumstances and triggers, they can start to recognize, “Okay, well this is when anger is scary to me.”
Busch:
“It's when I'm with close, intimate partners. Because they may not have known that I'd say, ‘Oh, I have trouble asserting myself.’” And it turns out they may not have, you know, I have people at work that assert themselves fine, but when they get home, you know, “Oh no, I can't. I can't do [it].” Okay, so what is it? Let's try, let's look at or understand what it is about that situation. Let's explore, and one of the issues is to have people begin to observe more what they're experiencing at those times. What are they struggling with? What comes to mind? So a lot of this stuff, these issues, they just happen automatically. They're under the radar. People don't really explore them or identify them. And what do [they] picture is the threat? Again, these tend to happen so rapidly.
Busch:
And again, it's a question, are they, is this unconscious or is it just not identified? So, for instance, one patient, you said, “Well, I'm worried if I bring this issue up with my wife, let's say, ‘Oh, I'm frustrated about that.’ She doesn't spend enough time with me that she's going to get enraged and she's going to withdraw for days.” Okay, well let's take a look at that. Is that what happens or what that is going to feel like? What does that remind you of? And then we might identify at that point, “What comes to mind?” is kind of a second step looking at, you know, developmental history.
Busch:
Where might these patterns have developed or emerged from? So,let's say, “Oh, yeah, you know, that's actually, that is reminiscent of my father. You know, in fact, I couldn't really, if I expressed any anger towards him, or I was rebellious as an adolescent, you know, he would, he would completely withdraw. He wouldn't talk to me for days.” So then we would take that and say, “Okay, now we're starting to get a better idea of this conflict and this struggle you're having, because we're finding out that there's this very deep threat that you anticipate from it, just from raising or discussing this particular issue. And we're having something about understanding of your past, of why you may be overestimating the danger that would happen at this point.”
Role Play: Helping a Psychiatry Resident Express Needs and Overcome Fear of Disappointing Others (22:10)
Puder:
Yes. Okay. So let's go with this kind of storyline. Okay. So you have, you have a parent that would maybe crumble if you were angry. Maybe withdraw. Right?
Busch:
Or attack.
Puder:
Or fall apart. Maybe attack. But how do you get from that to change?
Busch:
Well, one would be to sort of say, “Okay, well, let's see if you are overestimating the danger in your current situation based on that. You know, in other words, are the people in your current life, do they really follow that pattern? So, you had this, this was your experience, growing up; and it's understandable why this has felt very frightening to you. But, you know, understand, “Why do you feel the same thing is going to happen in the current circumstances so that you're maybe overestimating the danger of your anger?” We also would help to work to identify what exactly are the issues that they're feeling. And sometimes I'll even work with people to think about how they might talk to somebody about what's troubling them.
Puder:
Let's try this. Let's try role play. If you're game. I'll just walk into this scenario that we've co-created here. “So, Dr. Busch, I hear you. Does this person in my life, my spouse, react this way, like my childhood? No. And I know that cognitively. Right? But I still find myself not able to… just the thought of being angry or disappointing them is completely like I'm… it completely freezes me in that regard. You know? Like I never express my anger.”
Busch:
Well yes, I certainly understand that it is very frightening for you to be able to express your anger towards…. I mean, could you tell me a little bit about the specific situation that you're dealing with right now where you're feeling this way and you're having trouble saying something about it?
Puder:
“Okay, perfect. So, you know, I'm a psychiatry resident, and my boss is a female, and she wants me to help with accreditation. And for that I have to do all of this paperwork, and I just completely don't want to do it. But I don't have…. I'm not able to tell her that I'm not going to… that I don't want to do it. So, it's like, this has been on my mind for a month to tell her that I don’t want…. She's asked me to help her, you know?”
Busch:
Oh, so she needs to do…. It's not something you have to do. It's something that she wants your….
Puder:
“She wants my help with, yes. It's probably her job to do this, to do the accreditation. It's not a resident job, but she's asked me to help her. But I have been, for a month, it's been bothering me. I cannot tell her because I'm afraid I'm going to disappoint her.”
Busch:
Yes. So maybe you could tell me something about, have you thought about what you imagine would happen if you told her?
Puder:
“Yes. I really enjoy my relationship with her, and I feel like it would be irreparably damaged.”
Busch:
Yes. So what do you feel? Like, oh, she's going to stop…Oh, she's not going to talk to you. She's going to,
Puder:
“I think she's probably going to be polite. But then I think she's going to not give me the same care and attention and love that she has given me.”
Busch:
Yes. I mean, I guess we could look at why that feels so essential to you, that you're worried about losing that. And I know we've talked some about your experience growing up and that you felt this way with your father, and he would withdraw from you. So I'm wondering the possibility, I guess, you say you've thought about that, that maybe you're anticipating this danger with her, but maybe it won't occur in the same way that you,
Puder:
“You know, it's like intellectually and cognitively I know that something, I have some degree of insight that this may not be entirely true. Right? You know, or that she won't react this way. But for a month I've been still stewing about it. Right? And so it's like it feels very viscerally petrifying to tell her.”
Busch:
Yes. Yes. So I would say, one thing we could do is talk about what you might say to her if you were to say something. That is sometimes helpful because maybe you're having trouble if [it] just feels so dangerous. But if you actually consider doing it, and I guess I'm wondering, trying to get a sense of it, are there other evidences that she's a person who's like that? That would stop off? I mean, how does she treat people? Does she tend to be temperamental or irritable?
Puder:
“Not that I've necessarily seen. I haven't seen that temperamental or irritable side. And I think I've thought about this. What would I say? I've thought about this a lot. I think I've thought about saying, ‘Hey, I've thought about your request to help people with this accreditation, and at this time, that's not something I want to do because I feel like I'm pulled in a lot of directions right now, and I think that it would just be something that doesn't really excite me.’ But I feel like even knowing what I would say, or even knowing that she's not reacted like this, I feel completely like there's so many times where I've planned on telling her, and then I go up, and then I end up not telling her.”
Busch:
Yes. So what happens? Tell me about that moment. What happens then?
Puder:
“It's like we'll be passing in the hall, like during a clinic or something, and I'll have a moment where I could tell her, and, have tried to think it through, like, ‘Okay, I'm going to tell her.’ But then it's like, when it comes to the moment that it's like, ‘No, no, no, don't do it.’ It's like I feel like, ‘Oh, maybe I'll just do it. Maybe I'll just help her. Maybe it would be better to help her.’ And then I sort of reverse myself right at the last second.”
Busch:
And tell me a little bit about your other relationships. Do you have fears of expressing, have you noticed this with other relationships? Is this more predominantly with her? Do you find in other relationships that you're okay or safe to express these feelings?
Puder:
“I think I've definitely seen a trend. It's like the female boss that I have the issue with, more than the male boss. Sometimes in dating relationships as well. I'll have a hard time ending things when maybe I should end things because I don't want to disappoint them. Which is counterintuitive because I say to myself, ‘Well, it's not like, probably the best thing for them long term for me to stay in this relationship if I'm not wanting to be in the relationship.’ But yeah, it's like a love. There's a level of irrationality that I know I'm dealing with here.”
Busch:
Right. Well one thing we talked about, you know, your father's angry reaction.
Puder:
I think it's more my mother, actually.
Busch:
I think that makes…. Well, that’s interesting. Yeah. So tell me a little bit about that, because this doesn't, this sounds a little bit different from what happened.
Puder:
“She was very sick. I know she had cancer growing up and stuff, and she was often in her bed. And I just felt like I was kind of like a happy go lucky child to her that brought her some joy, and I felt like that was my role, and that was what was helpful for her during the sickness.”
Busch:
Wow. Okay. Yeah. Yeah. So that must, I mean, that must have been a very tough thing to go through.
Puder:
“Yes. Oh, yes. I think it was like, I remember being like around six or seven at that time when she was going through it. And I remember just kind of taking care of the house in the midst of her not taking care of the house, you know?”
Busch:
And did you feel pressured to do that or feel if you, that was kind of your role, or that you weren't feeling very supported, or you just felt like, “Oh, this is what I have to do?”
Puder:
“Yeah, I felt it was my role. I felt this is what I had to do. I felt sometimes happy doing it too, to kind of contribute. I felt like I just had to kind of quietly help.”
Busch:
I mean, do you notice, do you tend to be kind of an over responsible person? I mean, I know you're a resident doctor, are you?
Puder:
“Yes. Yes. I mean, I think over responsible or like over going over the top, doing like…. I have some patients that maybe they'll call during the week. I'll call them back and do like an extra phone session where it's, I know I'm not billing for that. I know it's probably…. I'm hesitant to even tell people that I'm doing these things, you know, because it's…. I know that there's probably ways that we're supposed to interact with patients, not to do long phone calls off the hours of normal things. But I feel like with these clients, it's necessary to help them, you know? And so I do feel like I go over, over and above.”
Busch:
And what do you think will happen if you don't do that?
Puder:
“If I don't do that, I mean, there's this one person that I fear she might hurt herself, in particular. Yeah. So I feel like it's kind of like some added pressure. Right?”
Busch:
Right. And does this kind of end up taking a lot of…. Do you tend to work extra hours and are there late or preoccupied sometimes with people after work?
Puder:
“Yeah. Yeah. And I think that it starts to wear on me, you know, after months and months and months of doing it. But I feel like… I also feel good sometimes doing it too. You know, like I feel a sense of my suffering is meaningful.”
Busch:
Yes. Yes. Well, I think, you know, one of the things is that maybe this issue with your mother may be more relevant to these circumstances in terms of their development. And maybe we were overly focused on your father because you spoke about how scary or frightening he was, and particularly when you were an adolescent. But it sounds like this kind of experience may be even more formative. And here, we're looking at that this may lead at least to a couple of different problems that not only have to do with your fear of setting limits with female figures, authority, but also, women in your life. But also the sense of over responsibility and this kind of pressure that you feel, and that seems to create other problems for you.
Busch:
You know? I mean, I don't know. We'd have to talk about, you get worn out or are under strain because you feel like you can't, you know, set boundaries. And if you try to set boundaries, then that's something that can be deeply threatening to another person. So I think we need to explore this more with your mother, because did you feel like, “Oh, were there fears?” Like, “Oh, she was going to die,” if you didn't do this. Or she'd fall apart entirely. And maybe that's where the danger is. Not like, “Oh, she's going to stomp off and be angry. But she's going to fall apart, collapse and feel disappointed,” as you were saying.
Puder:
“Earlier, that feels relevant. Yes. There was a time where she did go into cardiac arrest at home. And I was the only one there. I think it was seven.”
Busch:
Wow.
Puder:
“And I called, I called 911 and ran over to the neighbors and got some help. But it was kind of… it's like my memory of it, it was kind of hazy, almost. You know? It's hard. It's like I can remember parts of it very vividly. Like we had one of those old phones, on the wall, that the dial and my fingers…. It was almost hard to do. Like, I had to try 911 multiple times to get it. I knew it was 911. But yeah. And then, you know, she did recover from that, but that was incredibly frightening.”
Busch:
Yes. I mean it sounds terrifying and that sounds like that's a traumatic experience. And I guess one thing we have to think about was that's a lot of responsibility for somebody to have had at that age, you know? And, how were you in that position to be having to take care of things like that? And did you feel like literally if you didn't do something, she would die? And that trauma can very much get into one's mind and affect going forward. Where it may add to the sense of, “If I don't take care of this person, that's a catastrophe.” I mean, I'm sure you have this patient that you're worried about might hurt herself. And I haven't heard about that situation. But maybe that's a threat that maybe you also feel this powerful sense of responsibility is related to that traumatic experience, and that you are always the verge of, “Oh, this person's going to collapse or be deeply disappointed” in you.
Puder:
“Yes. You know, as I even talk about the cardiac arrest, the feeling that I get is kind of, it's like this, nausea, or like, I feel almost kind of fuzzy. My thoughts get a little bit more fuzzy. And, you know, I've had all these dreams over the years. I'm kind of associating these dreams of a phone where I'm trying to answer or call from a phone, but I can't get through. So I think there was something about having to dial 911 and then struggling to dial 911 initially, that I felt every second was going to be like I was going to kill my mother or something if I didn't dial it properly.”
Busch:
Yes. Well, that's a very terrifying place to be. And I guess I, I mean, it's interesting that this is coming out more now. Sometimes that happens. That it takes some time to reveal a trauma, partly because it is so scary. And again, maybe we emphasized your father because this was an even more terrifying experience that's been hard to talk about. And with the trauma of that nature, it's not unusual for people to kind of generalize that people can feel like they're back in that traumatic situation, and that if they don't behave just right with this other person who needs something that there's going to be some terrible disaster that happens.
Puder:
“Yes. I think with the father, the thought that comes is I never wanted to be angry like he was angry. But as I'm hearing you, as I'm kind of in this moment, I'm thinking, ‘Maybe I shouldn't be talking about this. Maybe it doesn't relate or something. Maybe I should…. Maybe I brought it up too early.’ Is that what you're saying? I brought it up too early?”
Busch:
Oh….
Puder:
“I'm doing something wrong?”
Busch:
You brought which up too early? The….
Puder:
“My mom's, my mom… the phone calling.”
Busch:
Oh, no, no. I meant to be saying the opposite. That maybe it was harder for you to bring up and maybe this thought that I was saying you didn't do something right, would indicate that you still are carrying a heavy burden with that. That this is, you're still [in] trouble. Maybe you feel you didn't do something. That you may have done something wrong.
Puder:
“So, maybe I should have brought it up earlier. I honestly didn't remember it until our conversation today, though. But I guess I should have brought it up earlier in our sessions. I mean, I think I try not to remember. I try not to think about it too much. You know, like I try to avoid thinking about it.”
Busch:
I would say it's understandable that you would avoid that. And, from my standpoint, it's not a “should” or “shouldn't.” In fact, maybe that's something about this responsibility that you feel you're supposed to do something for someone. And you feel that way with me. Like, maybe you did the wrong thing. But I would guess that the reason you haven't brought it up is because it's so terrifying. And there can, we can, we will explore further. Because, there could be sorts of fears, you know, shame about these things. Or people can feel like this terrible sense of responsibility. And, sometimes they even do something where they kind of put themselves, or feel like they're back in the traumatic situation. You know, they'll read circumstances where it's not really a terribly big problem, as kind of a life and death situation. And maybe that's something about what you're doing with this supervisor, is attending that you're feeling that you're mapping this sort of life and death threat onto that situation, or experiencing that as the trauma that you had.
Puder:
“You know, as I'm hearing you, I can't help but think, I feel bad that I have to even labor you with this. I know that it's your job to listen to people, but I can't imagine having to listen to people’s stuff all day. And I think I just hate to put too much on you and wear you down, or burden you. And so, for some reason, that's what's coming through my mind as we're talking here. It's like, ‘Oh, man, am I too much for Frederick?’”
Busch:
You know, I mean, that's a painful feeling. And of course, you know, this is what you're supposed to be doing here, talking to me about these problems. But I think it kind of fills out a little bit more, this picture of this impact of trauma. Because a lot of times kids taking care of parents that are ill do feel a sense of being that they could be a burden because the parent is ill and they put any of their needs into the picture that the other person's going to be troubled or could even put them at some kind of risk. And maybe that's started to fill out a picture or a formulation of understanding what you're dealing with. You know, that the over responsibility is a threat on the one hand that you have to take care of the person, or they're going to fall apart or die. Or that if you have your own needs, which you're saying that you're a psychiatric resident, you're overwhelmed. But maybe if you take care of your own needs, then you're burdening the attending. And so you can't make a proper assessment of that. And that puts a tremendous pressure on you.
Puder:
So I'm not burdening you too much, Dr. Busch?
Busch:
No. I think it's very important and valuable to be hearing about this. I mean, it's a very painful story, but that's not it. It's not burdening me to hear about it. And, you know, this is another way that we can try to help to get you through this. That, in other words, now we're getting a better idea of why you are walking up to her and you can't say anything when it's so weighted. And maybe if you can see like, hey, it's safe to express your needs, that it's okay, that's what I want to hear about that would help you to feel safer too. Because this has been so deeply buried that you don't even think about that. You just suppress your own needs.
Puder:
“I don't know why when I think about this stuff, I feel so nauseous, and I feel it's almost like I don't feel myself. I feel kind of like a haziness. I feel like a disconnectedness or just a little bit more floaty. And like I hear your words, but I also fear that you're saying this because you're trained to say this. Because I'm trained to say this, so I know kind of what we're supposed to be saying, but I fear that secretly, when you get out of this room, you're going to be like, ‘That was a lot.’”
Busch:
Well, I guess it's hard for you to believe that you're not going to be burdensome. But it sounds like that's even more evidence about how directly this is connected to the traumatic experience and that these aren't unusual reactions to trauma. Haziness, disconnect, kind of unclear memories of certain things, and other parts with very clear memories like trying to get the number right. You know, it's often experienced in the body, as well. And maybe that's a bodily threat you're getting when you're going up and trying to talk to the attending and you get this, I would pay attention. I'm wondering if you even get some of this bodily experience at that time. And that's what I think, that you may be feeling you're back in this situation. And one of the things that we want to do is to help build a narrative and have you be able to step back from that to realize, hey, this is just you telling your attending that you are not able to help work on this thing because you're overburdened.
Busch:
So I think also that you can see that I can stay with you through this. That I'm not burdened by it. Even though it's hard for you to believe.
Puder:
“I think I feel frustrated that my boss, the program director, wants me to do this at all. Like, I feel like for some reason right now, I don't know if this is something that feels a little bit new. Like, there's almost like a tightness in my chest. How this is your job. This is not my job. Why do you want me to do this? I wouldn't even know where to start…you know…paperwork. This is not something I know how to do.”
Busch:
Yes. Well, I think, you know, in a certain sense, we could say, maybe, that once we're talking about this trauma that….
Puder:
“My neck is tight all of a sudden.”
Busch:
It's an important kind of shift that's taken place. Maybe something about talking about your mother's experiences helped your anger to come out and realize that maybe the program director's kind of taking advantage of you, or she's not recognizing how this would be a struggle for you, and that you're actually angry about that. And again, you know, things are happening rapidly, so we kind of need to sort more of this out. But, you know, now this might have shifted to anger coming up, but not being safe for you. Maybe, it’s not safe because you connected with your father's rages, or, it's not safe because you're actually expressing your own need instead of taking care of someone else. But it's important for us to stay more in touch with this angry feeling and help that to emerge. Right now, I would say this bodily reaction is that there's something scary to you about feeling that kind of anger.
Puder:
“I think… two thoughts. One is my back. So all of a sudden it is really tight. The second thought is I think I feel some knowledge that I don't know if this was modeled well for me. Like with my dad. He would just go from zero to a hundred. Right? There was no calm frustration or having a voice or having boundaries. There was always just just zero to a hundred. And I was so angry for my mom. I was just upset that that was something she had to go through. You know? And it was just kind of like, ‘Gosh, what is wrong with you?’ So, I don't know. There's something about that that kind of resonates here. But yeah, it's so interesting that my back just…. I was feeling dizzy, but now I'm not. I'm feeling just tightness and it's more like just a lot of discomfort.”
Busch:
Yes. Well, there may be kind of one set of reactions around this trauma with your mother and another set of bodily reactions with your father. I mean, sometimes tightness can be because you're feeling activated in some kind of angry way, and it's not safe. I mean, again, that's jumping a little bit ahead. But I'm just putting out possibilities there. But what you, I think what we're kind of saying is that anger, if I'm hearing it right, either wasn't expressed at all and expressing any kind of need was seen as a burden and potentially dangerous or any expression of anger was something completely out of control and dangerous. And so, I would agree that you didn't have modeling, you didn't learn about how to be safe and express anger back and forth. It was either in this very damaging, hurtful way that your father expressed it, or this feeling of completely needing to withhold any expression of anger or your needs because of the situation with your mother.
Busch:
So that would be, this management of your anger is part of what gets another problem we would look at and again, it connects in, because that's a couple reasons why now we start to see more and more how loaded this situation is. Right? You're angry on the one end, and that's dangerous. Or you're afraid of being burdensome or expressing your own needs on the other. There's a pretty loaded situation in there.
Puder:
“Yes. The thing that comes to me right now is I've been wanting to start maybe half an hour later than we have, because I have to rush so hard to get out of the office, and it's so hard to get over here. And I've been wanting to ask you if you had that half an hour leniency, but I also didn't want to inconvenience you, but somehow that's what's jumping into my mind right now, that it's been hard to even ask you that. But I feel like I want to try to be honest with what's going through my mind. I don't know why that, in particular, is going through my mind right now. Maybe because it's interesting that I feel this tightness in the midst of this.”
Busch:
First of all, I think that's very good that you did bring this up. I mean, obviously we look into what we might do about the time and see if we can negotiate a time that's more comfortable for you. But the fact that you were now able to tell me this, even though you feel some discomfort, maybe that shows we got through a little bit of a block here. Because this seems to contain all of the issues that you're telling… you're going to burden me. Maybe you're mad that you have to rush over even though you hadn't said anything about it. So, you know, maybe that's a sign of maybe you felt you were more safe to actually raise something with me.
Puder:
“Yeah. Yeah. It feels good. Thank you. I'm surprised. Because I feel like there's part of me that thought if I were to bring this up, you would just be like, ‘You're ungrateful for the time that I've set aside, and this is a big inconvenience to me.’ And that's kind of what I thought you were going to say. So thank you for being open to exploring that.”
Busch:
Yes. I mean, that's already kind of seeing on the one hand worries about burdening me, and on the other hand, that I'm going to get mad. That's already sounding like your situation with your mother and father growing up. And part of what we hope you'd be able to experience is something different here, where these things can be expressed and you can feel safer. And that we can understand, as we've done better, where these kind of problems come from.
Puder:
“Yes. Do you think, when I think between sessions, when I start to think about these things, because they're distressing, I try to avoid thinking about them? And I either try to avoid it by playing video games or different things. Do you think I should avoid thinking about it? Or what should I do, between sessions, if I have thoughts? What's the best sort of…what recommendation do you have?”
Busch:
Well, part of what we're trying to do in this kind of therapy is have people be able to think more about these things. You know, with regard to kind of keeping an eye on their thoughts or seeing where it goes. I mean, I don't think, it's like you have to think about them all the time. So it's one thing if you, video games are a form of intermittent relief, but if you're playing video games for hours each day, that's creating even more stress for you, getting your work done. You know, then I'm like, “Hey, maybe we should think about if you’re trying to avoid something here” And, I mean, some people might be like, “Oh, okay. Hey, I'm going to stay away from those video games.”
Busch:
But then they don't. And what I usually do is I have them kind of think about what's going on at that point. You know, “Why am I? I actually need to get some work done, but I'm pushing to play these video games.” Because sometimes we can start to understand, well, are some of these issues coming to the forefront at that point? So it would be less a matter at this point of should or shouldn't. But I think we would understand more about what it represents for you; and is it something that you have control over as a relief, or is it something you feel compelled to do to get away from the problems that you struggle with inside?
Puder:
That's good. All right. Let's pause our role play. That was great. So you could see, I mean, this is obviously a lot faster than probably most therapies would go. I think you were commenting on that intermittently as well. But I think that for the listener, now we should try to sort of talk about what was going on in your mind at different points. You know, what kind of things you felt like came up. That would be some things that would normally come up, maybe over the course of multiple sessions. Right? Or even like six months of helping someone. And then, how you addressed it. We should maybe comment on those things too. Because I think this was very practical and I think this kind of scenario shows a bunch of things all at once. Right? So I appreciate it.
Debrief of the Role Play: Key Elements of the Psychodynamic Formulation (01:00:31)
Busch:
Right. Yes. I mean, I would say, to put it in terms of, not to make it too schematic, but to think about it in terms of a grid that I would have in my mind. In terms of the problem, one—focus—is identifying problems as we go along. Okay, here's one of over responsibility. Here's one of conflicts about expressing anger. Fears of assertiveness. So that, usually if somebody's in the midst of telling me that trauma with their mother, oh, you know, here's it is. Let's do it…a problem list. I mean, obviously we want to get into that. The second is– but for our purposes, I was doing a little bit more of that kind of problem identification–
Busch:
“Oh, let's look at this. Here's what we need to work on.” A second, is the identification of context. And in that emerge, this very interesting thing, which you came up with somehow in the role play that we were kind of trying to identify and looking specifically at that context of where this was happening, we kind of found out that we were paying attention to maybe not the most immediate issue, and maybe that's why it wasn't changing. We were looking at the father's rages and the reactions to that, although we think that's a piece, but maybe what emerged was this sense of burdening, creating trouble for the other person, over responsibility, that kind of led to the memories of the mother. And, then a third step is working to connect the past experiences whether adverse or traumatic to help the person both understand why they're struggling with these, why they're vulnerable to these types of problems.
Busch:
And you know how they may directly connect, how they might lead them to overestimate the dangers currently—self and other representations. Again, I'm just going through the whole formulation list. “Oh, I'm a burdensome person and the other person is vulnerable.” To that, “I'm an angry person and I may injure the other person,” or “I'm a person with needs and the other person's going to be angry at me.” Those are kind of three types of self and other representations that are going on and next step, conflicts around anger and needs. “Oh, my anger is going to be damaging and dangerous.” And, “My needs are going to be burdensome and create a problem.” So kind of highlighting those conflicts.
Busch:
We'll skip over mentalization, which is another step, at least for right now. Although we can, I guess we could say…I don't want to throw in too many things and I'm trying to go….that, it's hard to believe that the other person isn't going to react. There's a rigidity around mentalization being able to think about the mind of the other. Because you feel like their reactions are going to either be irritable or burdened. So there's a certain kind of rigidity. That's another piece. So each of those are kind of, as I'm hearing it, I'm kind of building this grid. And the interventions are targeted for these elements and trying to put together a formulation of story or narrative that involves those that can help the person to understand or identify the problem and where it's coming from.
Busch:
One thing about this is that when you have some, different people seek out, like for instance, Yeomans’, we're, “Okay, we're focusing on the object relation. That's our central issue.” And this is like, “Oh, here's different…we're looking at these different elements.” Because people are going to respond to or recognize different kinds of things, or putting together a picture, or the interpersonal cycle. Well, there is an interpersonal cycle here, and we could probably get to that because what's happening is that he's not bringing up his needs and so the other person isn't responding, so then he gets more taken advantage of and more mad and more concerned about being. So there is that, but those are the factors that I'm identifying and working to kind of put together what I call the formulation. Which are, what are these different pieces? And we could talk about how we might identify them or challenge them or shift them.
Puder:
I'm curious. Okay, so I think my problem with role playing and being the person maybe on the other side, sometimes is that it's different when you're in session and the person is actually feeling the thing maybe more viscerally than I was feeling, like I'm describing the thing. But maybe I'm not completely embodying the emotions. Maybe I'm not completely embodying what it would be like to dissociate in the midst of a trauma. Do you think you would react differently in a real session if the person was actually feeling these different things that they were describing? Do you know what I mean?
Busch:
Well, first of all, I'll be curious how people react to it. I thought it was pretty good. And I kind of noticed, in terms of the role plays that I've seen you do, I felt you were very present and authentic. You know, sometimes it's harder than others. Right? To be in this position. I thought it felt pretty authentic.
Puder:
Okay. And then, I guess the second thought would be, so one thing that I've noticed when I'm working with someone in the midst of trauma is, let's say there's the disavowed anger, they may feel it towards me before they feel it in the actual trauma. Right? So I was trying to role play that into the scenario a little bit. So, in the scenario, I was dissociating in the midst of the phone call scenario. Right? During the cardiac arrest of the mother, and then this was a life… or this felt like a life or death situation. This is obviously the nidus of where a lot of the psychological stuff is because of the repetitive nightmares that are relating to phones and such. The transference that comes out is projected onto you, and that this would be too much for you [see episodes 29, 41, 171, 234, 239, and 254].
Puder:
That this would be like, so I'm now taking that fear of being burdensome from the mother, placing that onto you. Right? With the shame and some of the traumatic vibes there of nausea and such. So I'm curious what you thought of that shift. If you've seen that in your own sessions where it's the dissociation, the trauma, and then there's some…the shame becomes more about what's going on in the session. Right?
Busch:
Yes. I want to go back to your prior question for a second. So I want to say, there's a couple things in terms of how I handled that. First of all, one thing with revisiting of traumas, how much do you stay in the trauma? How much do you step back from it? And there are treatments that were the primary approaches that were kind of processing therapy. We go through the trauma, at least we identify trauma. It may not even be the most central one. And how much do you step back? And there are different theories about that. Some say you have to really kind of stay and relive the trauma and others that you have to…that it's important to step back.
Busch:
I do this kind of foregrounding, backgrounding approach. In other words, I step into the trauma with the person, and then I'm working on stepping back from it and helping them to understand [how to] build this staging area. And that's partly what I was trying to do with you. I might have, if it worked, if I weren't trying to demonstrate a little bit more about how this therapy worked, I might've stayed a little bit longer in that place with you. But I feel that if you, sometimes if you stay in the trauma too much, you can re-traumatize. You have to be careful with that. And I feel like you're trying to help the person build a place outside of the trauma that they can go to, and that they can step back.
Busch:
Again, one of the things I don't think I mentioned earlier, they're in the whirlpool, and when they're caught in the whirlpool, they're overwhelmed and not able to think about things. And then I talk about currents in the whirlpool. So the different currents are the struggles with anger, this traumatic event, the problems with the father, and we're identifying, we can try to get you out of the whirlpool and then look at how it's affecting you. Okay. To go to your second question, I think that that thing where it shifted to me, in other words, that it would be safer there. I think that can happen. I think that's a pretty good outcome.
Busch:
In other words, that you were able to express that. And that the anger came out not only with me, but towards the program director. You know that showed, “Oh, we hit something. We did something.” So I would say that it didn't come out as, “Oh, I was angry at my mom and dad because they put me in this position. They didn't recognize what kind of position I was in.” You know, that's an interpretation we might make if we did another role play. Next time, we say, ”Oh, it occurs to me that you felt this way. That you felt similarly in that situation. That you were burdened and given things to do, put in positions you shouldn't have been. And that's what it feels like with your program director.” That's another step that we could work to build on.
Puder:
Yes. I want to maybe bold, or draw attention for the listeners, that coming out of the dissociation, the dissociation is embodied often by this kind of lightheadedness, disconnection, nausea coming out of that into a tightness type of thing, is coming out into the anger. And the anger in the role play was towards the program director. Like, “Gosh, why did she give me this?” It was also towards you. Right? But in a very gentle way of like, “I've been wanting to have a voice to change the time of our sessions,” and you could see all the fear that led to this kind of interpersonal repetition that the patient was unable to ask you this before. Right? But now that they're coming out of the dissociation into the frustration, it gets kind of associated from in the frustration to this [situation]. And you would be welcoming the conversation. Welcoming the invitation. Your enthusiasm for the person to talk about this, I think, is paramount to them to starting to practice this thing of having a voice. Right? They're going to practice in session with you. They're going to practice before maybe they practice with the program director.
Busch:
Right. Right. And, you know, it's a little bit different from maybe some old models of like, “Oh yes, tell me about…. Oh, tell me about that.” It is encouraging them, or, “Oh, this is positive that you're expressing this and that.” That feedback that, “Oh, okay, well here's a breakthrough. Something's loosened up. Now you're able to do this. And in fact, if we're able to work on this here, that's an important mechanism for further change. You're testing out now, with me, whether these things are actually safe. Am I burdened? Am I angry?” And yes, I mean, I thought that that was a very good sign in terms of the emergence of that.
Puder:
Yes. Really good. This is enjoyable. It's really good. Yes. I think, yes, as we kind of talk about this, were there any other threads that you wanted to make sure we kind of understood or were seeing from this role play? Because I think role play allows for people to kind of grab onto something where it's not just purely theoretical, which is why I think it's so powerful. Any other threads that you've been thinking about or ways of thinking about this that relate to your model?
Busch:
Well, again, what I highlighted before, how I am going through, which was a little bit more rapid than usual, identifying these different elements and how that helped us. But also that you don't want to have…. It's a semi-flexible system. It's not, “Here's a rigid structure.” So one of the things, we needed to be open, like, “Oh, we got this. I have a formulation that you are… this is your anger, your fear of asserting yourself is related to the anger that your father expressed. And that's too dangerous. So therefore, you can't talk to the program director.” And then, partly, you're kind of like, “Well, you know, this isn't doing anything.”
Busch:
And that we go back and we find out, let's re-look at the context. Let's re-look at what you're experiencing and open up another dynamic piece. So that's one element that I think is important to say, that this is, even though we're part of the idea of this…and I was trying to demonstrate that. I was trying to demonstrate, “Hey, we're keeping the problem in mind.” I would come back to that. “Oh, and so this is what's interfering with talking with your program director.” That's a little bit different from how psychodynamic psychotherapy is usually done, and yet remaining open to here's a new or different dynamic. Here's an identification of a trauma that's even more powerfully relevant to the current struggle.
Puder:
I know you, you wrote a book called Trauma-Focused Psychodynamic Psychotherapy (Busch et al., 2021). I was trying to see how you would interweave your approaches. I'm curious, from a more trauma-focused psychodynamic psychotherapy, what kind of things can we learn about your approach or about the approach to trauma from this role play? What were you doing? What were you thinking through in terms of this?
Trauma-Focused Psychodynamic Psychotherapy Insights from the Role Play (01:17:54)
Busch:
Yes. And that was written with my coauthors, Barbara Milrod, Meriamne Singer, Cory Chen, who was actually working at the VA [Veterans Affairs]. We did work with therapists, with veterans. So, you know, really some severe trauma there. So just to mention them, because some of the books are the single author and some are with coauthors. But well, one of the elements is to link the current symptoms with past trauma. So people are often not aware of the link of their current symptoms to past trauma because there's a, you know, a dissociation that's taking place now, now you could say, well, that dissociation is just a split that occurs at the traumatic event.
Busch:
But they are, and we need to relink them. That's, you could think of that as maybe Janet’s theory of dissociation (van der Hart & Horst, 1989), or you could say, “Okay, well that dissociation is because it's too painful to make a connection.” Right? You know, Freud's theory, essentially. So, but either way, we're trying to lead that. So I'm kind of saying, “Oh, this feels like that.” If they're having trouble, if they still deny it, you know, then maybe it shows even more of the defensive aspect. So that's one of the elements that I'm trying to do. And, in this instance, there was a very strong fit, which isn't unusual with the traumatic event as it emerges, because again, that provides a basis for understanding that connection of your current experiences to trauma. Part of building this framework, to be able to step back.
Busch:
A second one that I tried to throw in there quickly, was repeating of trauma. So that's a big dynamic [systems] theory. So there's a couple key aspects of that. You know, one aspect is that you're seeing the current event as the traumatic event, you're misinterpreting. Okay. You know, it's sort of like the guy that comes back from the war and he hears the loud noise and, “Oh, no! It's an explosion!” So it's a form of that. So he's experiencing, you know, what may be a tense situation. It is a little bit tricky because she's the boss, but he is experiencing that connection as a recurrence of the trauma. But there's also ways in which people unconsciously repeat trauma.
Busch:
And that's partly, there's some proneness to getting himself into situations or yourself into situations where they're overly burdened and feeling not responded to. And, not intentionally, you know, partly because of the struggle around saying anything, but you'll see this. Like a patient of mine said, “Oh, I can't believe my daughter married the narcissistic guy when she had this father.” Well, you know, the idea is that people can repeat these [patterns] because they're trying to make them come out differently. They're trying to have a different outcome each time. So they inadvertently, through various means, repeat the trauma trying to control it better. I have a bunch more, so I don't know whether you want to stop or comment, but I want to put in another element identification with the aggressor.
Busch:
So that's another. That's a common trauma-related defense. So, yes, I mean, the most common form of that is the bully who was bullied. But many times, this sort of identification with the father, with the father's aggression, is a very complicated thing because, to the extent that there's fantasies of expressing anger, they might be to control or be hurtful. We didn't get to that quite yet. But that can create tremendous shame and guilt. I mean, you could get the bully who was bullied, who may not be so terribly conflicted. I mean, we see that too, right? But people with that, that it only creates a fear for them in terms of expressing it, but also that…if somebody is traumatized and they have fantasies that they want to hurt other people like they were hurt, that can create tremendous distress for them.
Puder:
And also, I think sometimes it's not like they're actually bullying people. It's just the fantasy of bullying people.
Busch:
Yes. Oh, absolutely.
Puder:
Or, I even have had patients who they become the perpetrator to themselves. So they are violating themselves sexually, for example. And so it's like they become the perpetrator soon after, even soon after the trauma.
Busch:
Right, right. And that maybe if this person were… say if they were compelling themselves to work extremely hard as a way to try to sort of… that could be seen in that form, that now they're the one, you know, who's forcing them, uncaring, to be overly responsible. But they're the origin of that. That's a very good point.
Puder:
The repetition of the dynamic, I think, was very evident of this story. And by the way, guys, this is stuff I've seen. There [are] residents that I've known who have hidden from everyone and maybe I was the first person that they told that they were having long conversations with patients, you know, off the books. Right? As a way of trying to save these patients. Right? They get, you know, when you're especially young and you're in your first couple of years of treating people, or nurse practitioners have told me these stories, as well. They end up having a really hard time containing the frame, the structure of the treatment. And then they have an even harder time pulling back the frame, the structure of the treatment. These are pretty common issues I think with a lot of providers. Right?
Busch:
Exactly. And people who do what we do, where you take care of people, but you know, the extent to which you feel compelled to do it, that can be from other issues. Right?
Puder:
So, I appreciated that you didn't shame that piece and you didn't even shame the video game playing. Right? Which is a behavior that maybe this person felt a little bit of guilt, guilty pleasure of sorts. There're some people who, you know, who maybe take enjoying anything as feeling guilty. Right? Enjoying anything for themself feels kind of like shame, shame inducing or guilt inducing. And so….
Busch:
Right, right. And generally, trying to be careful to empathize and not shame. But in that one, again, differentiating what may be a compulsion. Which is a whole other problem and reaction to trauma. And that's another thing that we talked about, this kind of behavioral change approach where I try to have people step back, or even sometimes I'd say, “Okay, well why don't you wait. Let's try waiting 30 minutes before you place your bet, or play your game, or you shop, or you grab the beer and let's see what's going on in your mind at that point.” So it was, in that sense, in that case, important to differentiate, was this a compulsive issue that the person was using to avoid traumatic experience, or was he just, is this something that he was just using for relief here and there, in a way that he might've been uncomfortable about taking any time for himself. Right? The two very different dynamics.
Dr. Busch’s Books and Clinical Approach (01:27:34)
Puder:
Right. There's so many variables on that. It could also be a sublimation of anger, like I was thinking maybe I was going to tell you that they were violent video games. Right?
Busch:
Right, right. It could be because we say, “Where can the anger come from?” It’s something that has come up in a couple of your podcasts that I watched. You know, where is anger? It can be used in positive ways or ways that are at least not to create trouble. I mean, obviously if the violent one, it's complex in that regard. Right? Because it's a possibility. Right?
Puder:
Great. Well, I think we should probably be wrapping this up pretty soon. I do want to highlight, you have some other books and people should check you out if this was interesting to them. Your website is fredricnbuschmd.com. Right?
Busch:
Right.
Puder:
We'll put that in the show notes, and it has a nice link to all your books, some of which are Skills Training in Psychodynamic Psychotherapy: A Problem-Focused Approach (Busch, 2025), probably highlighting a lot of the things that we talked about, but in a more detailed way. And then Psychodynamic Approaches to Behavioral Change, Psychodynamic Treatment for Depression (Busch, 2018). You've written a lot. You've written a lot in your career. It's impressive.
Busch:
Yes. Thanks. The skills training is the latest one. It's sort of the idea, this idea of psychodynamic skills, people learning these capacities to self identify context to challenge self and other representations that are negative. And I've found that sometimes writing these things down for both therapists and patients could be helpful. Which is not, again, not a typical psychodynamic psychotherapy kind of thing. So that one's a little bit different, as is targeting changing behavior, which actually includes looking for alternative behaviors and thinking about those. Not like, “Oh, I advise you to do this, but let's talk about what you might do.”
Puder:
I noticed Howard Steele [see episode 213]wrote a very nice thing on the cover. Are you friends with Howard Steele or is he more just a colleague or person that you know?
Busch:
Well, I worked with him over the years, like editing papers or he’ll write something for something I was doing. So yes.
Puder:
Great. Great. If you're a patient listening to this…. You're licensed in New York. Are you still accepting clients?
Busch:
Yes. I mean, busy, but….
Puder:
That's a good sign. Right?
Busch:
Right. But somebody could always call and we could also find someone who does work like this.
Puder:
That's great. Yes. Well, this is wonderful. It's great to connect with you. It's great to do this fun role play and hear from you. And if you're ever in Orlando, let me know and we'll get some food or something.
Busch:
I appreciate it. I would like to be in Orlando right now.
Puder:
It's freezing. It's 60 degrees out. I got my heater on.
Busch:
Oh no. Okay. Sounds great.
Puder:
Oh, that's good. How, how cold is it in New York right now?
Busch:
Well, right now it's finally gotten into the thirties, but it's been a very cold, snowy winter. So yeah. Maybe, something will ease up soon.
Puder:
That's fun. And you're doing some teaching for the transference focused therapy group in Columbia, doing some stuff on trauma, is that right?
Busch:
I did a presentation for them at Trauma-Focused Therapy. I do a bunch of teaching at various levels, you know, and taught this, targeted for residency, residents at a couple different places. At Cornell, NYU, UPenn, and some teaching at the [New York] Psychoanalytic Institute. So different kinds of different elements of this treatment.
Puder:
That's great. And you prescribe too, is that correct?
Busch:
Right. Yes. And that's some of the work I've done over time is about that sort of thinking about….
Puder:
When do you choose to prescribe and when do you not choose to?
Busch:
Well, yes. That is part of it, but I'm very interested in prescribing effects on the psychoanalytic. What goes on dynamically, because that can have a lot of changes like reduce super ego or better affect regulation. Things that people think like, “Oh, you might need analysis to do them. That can be helped by that or help the therapeutic process.” Or how the psychodynamic process can sometimes help with struggles with compliance, acting out around medication. You know, how people are affected by side effects. People struggle all the time with their doses, taking it. You know, that's something that can be looked at in terms of psychodynamically, is sometimes helpful for that.
Puder:
That's great. Well, it's great to connect with you and great to start to understand your approach to psychiatry, psychotherapy. And maybe we will continue the conversation in the future.
Busch:
That'd be great.
Puder:
And we'll leave it there for today.
Busch:
Okay, sounds great. Great speaking with you.
Puder:
Alright, we will.
Books by Dr. Fredric Busch
Skills Training in Psychodynamic Psychotherapy: A Problem-Focused Approach
Psychodynamic Approaches to the Adolescent with Panic Disorder
Mentalization: Theoretical Considerations, Research Findings, and Clinical Implications
Trauma Focused Psychodynamic Psychotherapy: A Step-by-Step Treatment Manual
References
Busch, F. N. (2018). Psychodynamic approaches to behavioral change. American Psychiatric Association Publishing.https://books.google.com/books?id=5P1dDwAAQBAJ
Busch, F. N. (2025). Skills training in psychodynamic psychotherapy: A problem-focused approach. Guilford Press.https://www.guilford.com/books/Skills-Training-in-Psychodynamic-Psychotherapy/Fredric-Busch/9781462558858
Busch, F. N., Milrod, B. L., Chen, C. K., & Singer, M. B. (2021). Trauma-focused psychodynamic psychotherapy: A step-by-step treatment manual. Oxford University Press. https://doi.org/10.1093/med/9780197574355.001.0001
Freud, A. (1936). The ego and the mechanisms of defence. Hogarth Press.
https://openlibrary.org/books/OL6365497M/The_ego_and_the_mechanisms_of_defence
van der Hart, O., & Horst, R. (1989). The dissociation theory of Pierre Janet. Journal of Traumatic Stress, 2(4), 397–412.https://doi.org/10.1007/BF00974598