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Psychiatric News Special Report: Psychodynamic Approaches to Behavioral Change · The Medical Mind

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  you
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  and I'm out.
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  Welcome to the Psychiatric News Special Report podcast, a monthly podcast from Psychiatric News produced for the APA Medical Minds channel.
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  I'm Dr.
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  Adrian Preda, Editor-in-Chief of Psychiatric News and Professor of Clinical Psychiatry and Human Behavior at University of California Irvine School of Medicine.
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  Each month we sit down with the author or authors of our special report to discuss key issues at the intersection of mental health, psychiatric clinical care,
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  research and advocacy.
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  Today, I'm delighted to welcome Dr.
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  Frederick Bush, the clinical professor of psychiatry at Cornell University and faculty at Columbia University Center for Psychoanalytical Training and Research.
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  Who is joining us as we are taking a deep dive into a topic that might surprise some of you, psychodynamic approaches to behavioral change.
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  When you think of psychodynamic therapy or psychoanalysis, you might imagine long-term
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  in-depth exploration, and primarily at insight into the unconscious.
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  And while that's certainly a core component, Dr.
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  Bush, my guest today, discusses a different perspective on how these powerful approaches can be adapted in research to directly target problematic behaviors.
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  So, to get us started, Dr.
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  Bush, why are psychodynamic approaches traditionally seen as focusing on deep insight rather than direct behavioral modification?
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  now considered particularly valuable for behavioral change.
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  Well, the focus of typical or traditional psychodynamic treatments has been on insight and they have tended to be longer term treatments.
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  Occasionally people have tried to develop uh more of a uh focused uh type of approach uh dealing with a particular problem, but those have actually been uncommon.
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  So in general, people tend to think of it as longer term and for
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  quite some time in sight or even the therapeutic relationship was felt to be the main determinant of change.
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  However, in many instances, change was very slow or change wouldn't affect behavior.
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  Right, so I remember my residency training and meeting with my psychoanalysis supervisor.
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  I did not undergo psychoanalytical training, so let me say that first.
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  But I remember that during our supervision sessions, the point was that you shouldn't focus on behavior, I would be told, because behavior change was in kind of a band-aid type
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  of an approach that would in fact cover or disguise the real problem.
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  Right, right.
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  That was seen as not addressing the underlying structure of the neurosis that you were just dealing with the surface manifestation of the problem and that, you know, a change in
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  behavior would just lead to a different kind of problem as long as the neurosis wasn't dealt with.
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  And it was also viewed that focusing on behavior would disrupt
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  the transference, is an important tool of psychoanalytic therapy.
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  And my claim is that you can both uh address underlying structure of neurosis by uh addressing behaviors or focusing on them.
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  And that to the extent that it affects the transference, that's something that you can work with.
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  I see.
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  And how is that then different than the more traditional behavioral therapy approaches?
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  Well, in terms of the psychodynamic therapy, it does look at several factors that aren't typically looked at, you know, in those uh types of approaches, including things that may
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  be out of the person's awareness.
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  And that's exploring, you know, what are the psychological and situational triggers.
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  Um, what are the underlying developmental factors that may be affecting a particular behavior?
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  What are the conflicts and defenses that contribute to behavior, the self and other representations?
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  Um, so looks at the various, what we call psychodynamic factors and how they contribute and addresses those.
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  And those are not commonly.
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  addressed in other types of psychotherapy.
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  To make sure that I understand this correctly, in other words, what's different about the psychodynamically informed approach to changing behaviors versus just the typical
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  behavioral therapy is that the context matters, right?
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  And then in addition to that, the context is not about what's just happening in the given situation, but also the developmental context, which in turn will inform not only how the
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  behavior could be changed, but what the behavior is about.
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  Right, right.
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  And that includes as well how one's expectations of self and others that affects behaviors such as someone might have trouble being assertive in a particular context because they
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  anticipate negative responses from others or they see themselves as undeserving of being assertive or they may have kind of psychic
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  interpsychic conflicts about that, know, fears about their anger that interferes with their being assertive because they somehow associate being assertive with being angry.
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  So these kinds of aspects are affecting their behaviors in that particular context, but the patient doesn't tend to be aware of those and sometimes isn't even aware of the
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  triggers of the behavior.
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  Yes.
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  So let's actually with that, let's get into the practical side.
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  um So how do psychodynamic therapists work with patients to achieve these behavioral changes?
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  In your article, you actually discuss in a very sort of systematic way the stages of a psychodynamic informed approach to behavioral change.
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  What are these stages?
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  think from the standpoint of this kind of approach, the initial step is to identify the problematic behaviors and in a certain sense that may seem, well, that's self-evident, but
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  in fact, patients don't always have uh a clear idea of what particular problems they are or even that a behavior is problematic and that could be partly that they
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  defend against that knowledge or they don't have a realization of the difficulties that it's causing.
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  So psychodynamic approaches in and of themselves as a start to this framework can help to identify, for instance, patients may deny drinking behavior or acting out, you know, or
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  you mentioned the patient who had overwork as a way to try to to deal with his
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  know, but didn't realize that that actually created problems for both his health and his family.
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  point that you are making, Dr.
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  Bush, is that the therapist has a more active role in actually identifying the problematic behavior, which is different than the traditional psychoanalytical approach where the
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  behavior would not be actually put directly under the microscope.
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  Yes, that's correct.
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  And to uh then agree with the patient about that behavior being a problem and then work to uh consider changes in that behavior in a collaborative approach to understand that the
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  therapist can't know for certain what's the best.
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  shift in behavior that might take place, but that clearly this is causing difficulties for the patient.
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  And then the next step would be to look at the contexts and emotions that tend to trigger the behavior.
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  And that involves the analyst taking a history of the times the behavior occurs and what's going on at that time, getting
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  precise details, what the patient is feeling, and also to help to teach the patient the skills to do that so that they can begin to identify together what kinds of contexts and
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  emotions trigger that problematic behavior.
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  Right, and you are making the important point there that in therapy you are going to also explore the meaning of the behavior, which is a significant point of difference compared
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  to the typical behavioral therapy approaches.
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  Right, right, that the behaviors typically have particular functions for patients like one patient who would act out sexually after he experienced situations in which he felt uh
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  attacked or criticized by others and uh had conflicts with his wife and that this kind of acting out uh
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  you know, led him to try to, it was an attempt to try to relieve those feelings he was experiencing and hadn't recognized that or made that connection.
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  Yeah, yeah.
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  And then the other point that you are making in the article is in addition to the context and in addition to identifying the meaningful connotations of the behavior, what's
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  different about the psychodynamic approach to behavioral changes is that you're also going to explore, to understand to what extent the behavior is maybe an echo, a reiteration of
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  problems that occurred earlier in development.
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  Yes, yes.
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  And the example that I give in the article is a woman who was drawn into a family business that actually was very disruptive to her life.
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  um And, you know, she hadn't been able to even consider finding a way to get out of the business or maybe that the business could be sold because she felt that
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  it was necessary for her to do this and that this turned out to be related to a history in which her mother suffered from cancer when she was an adolescent.
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  And she was expected to take a lot of responsibility in the home and to the extent that she tried to do more activities with her friends or get away from these activities that
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  she was viewed very harshly or negatively by her father.
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  and that she had internalized these kinds of experiences.
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  Well, so there is so much in there, Dr.
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  Bois, let's maybe unpack that a bit, right?
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  And I think that the example that you use in your article is great.
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  that was a middle-aged woman, right, that you described.
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  And basically the problem that she was facing from a behavioral perspective is that she was caught right into this family business that she couldn't say no to, right?
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  And she would end up overworked with significant feelings of anxiety and depression.
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  Is that a fair summary of the presenting problem?
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  Yes, that's absolutely correct.
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  So then from the psychodynamic informed behavioral therapy perspective, how was the formulation that you had for that case different than the formulation of a traditional
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  psychodynamic oriental therapist?
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  I think that from the standpoint of that, another therapist may have come up with a formulation that involved those elements, but in this case, the formulation was
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  specifically uh surrounding the behavior and looking to change the behavior, that the agreement with the patient was that her being trapped in this uh
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  business, family business was upending her life.
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  She wasn't able to enjoy the things that she had previously enjoyed.
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  And that that was causing her anxiety and depression so that we were trying to understand how she might change this behavior, including even looking into the possibility that she
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  could have less responsibilities in the family business or get out of it entirely, that she didn't feel she was allowed to do that.
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  Great.
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  And was it of relevance how that behavior actually was enacted in her relationship with the therapist?
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  It did become uh relevant ultimately, you know, with the therapist because to some extent, you know, she did feel some kind of, you know, to make changes, which sometimes happens
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  with patients.
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  I felt like, the therapist wanted her to make a change or she was struggling to make a change and that that was something that could be looked into.
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  Again, that somehow she wasn't meeting her responsibilities with the therapist, like she wasn't meeting them with her as an adolescent or with regard to the family business.
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  uh This was part of what led her to overly drive herself to work.
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  And she could understand in the context of the transference that in fact, the therapist who didn't have a judgment of her put pressure on her.
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  to solve the problem that was simply working with her to try to help ease her difficulties.
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  So that's great, right?
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  Because transference and quantum transference are not typically ah informative in any way to a behavioral therapist, right?
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  That's not something that even
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  not typically and you know I mean obviously with behavioral therapists who are in practice they may have more open-ended models and you know that they use in their own clinical work
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  but they're not you know typically part of their uh you know structures of their treatment or manuals and my sense was that any therapist would benefit
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  knowing from these transference counter transference issues in trying to change behavior that patients may struggle with the therapist because they want to hold on to the behavior
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  because the behavior performs certain adaptive functions or helps them to push away certain kinds of issues, you know, that they may feel a need to please the therapist that
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  may create problems for them if they're having trouble.
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  you know, changing the behavior or that they may start to become dependent.
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  They may want the therapist to start telling them what to do.
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  And those are all transferences that could be looked at in a psychodynamic therapy.
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  I'm confident that they occur in other therapies, but I don't think that they're typically recognized and addressed.
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  And that's such an important point that you are making that by reorganizing actually the transference and the counter transference, that's just more information.
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  And the information in turn can be used to further uh help the patient and support them through their behavioral changes.
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  Right, right.
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  with this patient that, you know, both that she struggled with this pressure to perform and even that if she experienced frustration uh with the process of therapy, that that
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  would be a conflict that could be looked at because she feared expressing her anger.
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  That was part of her intrasychic conflicts.
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  And that's in fact part of why she couldn't address the problems that she felt with being having overwork because she was worried that it would come across as angry or damaging,
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  particularly with a co-worker she had.
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  was a cousin who put a lot of pressure on her and acted like she was her boss, even though she wasn't.
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  uh But the patient struggled to address that problem, even though this cousin uh was uh
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  you know, making her do a lot of the uh legwork uh and oh that the cousin was doing were taking a leadership role that wasn't even appropriate for her.
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  Yes.
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  So let's take a step back.
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  I'm also curious about sort of the general format of the therapy here.
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  So short-term, long-term therapy.
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  Well, you know, this approach is actually, you know, could be used in terms of a longer term approach for patients who have prolonged issues that they're struggling with.
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  But it's typically, you know, used as a shorter term approach in terms of focusing on a particular change, or it can even be adapted into
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  a clinic setting or even uh a single uh therapeutic session, maybe in an urgent care setting, trying to address a particular behavior or to make a change and understand some
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  of the factors that may be contributing to it.
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  So that makes this kind of therapy more exportable than the typical psychodynamic.
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  therapies.
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  that and also, you know, the, you know, it's presented in a very clear user friendly language.
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  We have a lot of times the, you know, psychoanalytic work can be presented in very kind of abstruse terms or, or, or complicated terminology.
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  And it's, it's difficult for people to both understand and use in it.
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  particularly as a short-term intervention.
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  So first meeting with a patient, what do you tell them?
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  Well, the first meeting with the patient would include, you know, an assessment.
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  mean, you sometimes I would say that the overall approach is a problem focused approach.
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  you know, that we're trying to identify the series of the problems that they struggle with.
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  And that would include, you know, symptoms, relationship difficulties and behavioral
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  problems.
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  So we work to identify those issues.
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  And then I would talk with the patient about that there can be various psychological contributors to these problems that occur from their past, from how they view themselves
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  and others, and from uh things they may struggle with inside.
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  that to understand those can help to
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  make changes and relieve those problems.
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  So in the example that we talked about, there was already evidence that the patient was overworking, was caught in this work and that that was leading to anxiety and depression
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  and that we should try to understand what was making it hard for her to consider removing herself from that.
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  So it seems like you are going to be a much more involved, psychoeducationally oriented and collaborative therapist, as opposed to the more traditional approach of the therapist
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  would be much more hands off and uh much less directive.
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  Right, right.
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  mean, in that regard, you know, there is, there's not formal psychoeducation, but it's the kind of teaching a patient how to think about their problems and how to think about their
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  minds to understand that behaviors have certain, you know, triggers and functions to understand that they're
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  representations of themselves and others, their expectations can contribute to these problems that they can struggle around certain feelings like, you know, anger and have
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  conflicts about expressing that or may have gaps in their mentalization capacity, their capacity to think about other people's minds.
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  So those are, one of the things is to help get the patient curious and interested.
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  to understand how these problems work because we're trying to help teach them skills that they can continue to use following treatment, that they can continue to work on their
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  issues by themselves.
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  And these skills would include these understandings.
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  So let's say, you know, a patient has, you know, recurrence of a problem, problematic behavior or a symptom such as panic.
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  They can stop and think about, what's going on right now?
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  You know, a patient who had temper tantrums, who those had an irritability that had ease significantly, but then
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  you know, started to occur again, had, you know, a recurrence of that.
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  um And then at that point, could think about, what had happened just now, realizing that he had been under certain pressures that he hadn't recognized that were beginning to
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  trigger off this problem again.
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  um You mentioned about being directive.
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  I think in that sense, there's still the element of working with the patient.
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  In other words, I'd say like, you're to change this behavior.
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  There still remains the component of the, we're not advising the patient, we're collaborating with them and helping to make those decisions.
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  So still try to steer away from being directive per se.
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  But there is, I would say it's more guidance.
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  Yeah, that makes sense.
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  So it's always difficult actually to look at the evidence basis of psychotherapy.
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  Psychotherapy research is so complicated by many different variables and difficult to put aside confounders.
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  But I'm curious, are there any studies looking at more behaviorally focused psychodynamic approaches compared with both just behavioral therapies and then just with more like pure
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  psychodynamic approaches?
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  I mean, there's really not a lot of studies of that.
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  mean, there are approaches that are been developed or suggested by, you know, Summers and Barbara have worked in this area or Levinson with the time-limited dynamic psychotherapy.
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  But there have not been real studies in part because there, you know, uh people haven't focused on
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  research and behavioral change in psychodynamic treatments.
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  There are studies such as the Clark and in Levy study part of the Kermberg group on border lines that do show uh changes in behavior and border lines through psychodynamic uh
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  treatments, but those behaviors are not the focus.
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  There are studies on focused psychodynamic psychotherapies, including one that I worked on the development uh
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  panic-focused psychodynamic psychotherapy that's demonstrated efficacy that uses a similar type of framework but does that for a panic disorder and that has demonstrated efficacy
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  focusing on a particular problem uh in a way of understanding and addressing psychodynamic factors.
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  Dr.
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  Bush, thank you so much for this insightful discussion on psychodynamic approaches to behavioral change.
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  It's clear that these methods offer a profound and effective pathway to addressing complex behavioral issues.
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  Well, thank you and thank you for having me.
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  And thank you all for listening to the Psychiatric News Special Report podcast.
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  You can read the full Psychiatric News Special Report at psychnews.org.
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  We've posted a link to the article in the episode description.
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  It helps others offer these important conversations.
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  Until then, stay informed, stay compassionate, and take care.