Problem-Focused Psychodynamic Psychotherapy: Targeting Symptoms, Relationships, Trauma & Behavioral Change with Dr. Fredric N. Busch

In this episode, Dr. David Puder sits down with Dr. Fredric N. Busch, psychiatrist, psychoanalyst, and clinical professor at Cornell and Columbia, to explore Problem-Focused Psychodynamic Psychotherapy, which is a practical, targeted approach that integrates psychodynamic principles with clear symptom relief, relationship repair, trauma processing, and behavioral change. Dr. Busch explains how to identify core problems in the very first session, build a focused psychodynamic formulation, and track progress on symptoms like anxiety, depression, panic disorder, disavowed anger, and over-responsibility rooted in trauma. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-264-problem-focused-psychodynamic-psychotherapy-targeting-symptoms-relationships-trauma-amp-behavioral-change-with-dr-fredric-n-busch Link to YouTube video https://youtu.be/4H_Y810KXtw

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:13David Puder?

  Welcome back to the podcast. Before we start, I'm going to give a short plug for the psychotherapy cohorts that I lead. They're yearly cohorts. They start again in September, and we are open for admissions. You can go to psychiatrypodcast.com, go to the top tab that says cohort, apply. In these cohorts, we go through psychodynamic psychotherapy, transference, countertransference, and we do a deep dive in reflective function, looking at our own reflective function, thinking about how we reflect about difficult patients, how we reflect about countertransference. You may have remembered that I often talk about reflective function and the power of the therapist effect. We know that it's about 70.5% of what accounts for therapist effectiveness. And so, we want to grow in

• 0:58David Puder?

  our reflectiveness and see this as a lifelong journey. And in these cohorts, it is really helpful, too, because sometimes you'll bring up some story of a deep reflection on a patient, and one of the other group members will have their own reflectiveness. And maybe it's something that's disavowed in you as you have kind of gone through this story, and they're feeling something that you can't feel yourself. So, there's something wonderful about the cohorts. These are great for those who may be a little bit isolated in their practice, maybe a little bit burned out, wanting to grow, wanting to dive deeper into topics like transference, countertransference, wanting their own personal growth, and continued aspirations towards being a high reflective function therapist. So, hope you consider that. Check

• 1:43David Puder?

  it out, psychiatrypodcast.com. And we will start the episode now.

• 1:50David Puder?

  All right, welcome back to the podcast. I'm joined with Frederick N. Bush of New York, 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.

• 2:23Speaker 01

  Thanks. Thanks so much for having me.

• 2:26David Puder?

  It's so good to have you and to meet you. And I think it's worth mentioning right at the beginning is that there are two Dr. Bushes. One's a PhD. You're the psychiatrist. You're in New York. The other one's in Boston. 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. Yeah, so welcome to the podcast.

• 2:53Speaker 01

  Thanks. Yeah, yeah. And I guess problem-focused psychodynamic psychotherapy, I guess, solution-focused therapy is, you know, actually a little bit different thing, although, I mean, there's a lot of these acronyms out there. So it's hard. It's hard to keep up with all of them, but I'll try to differentiate this one.

• 3:13David Puder?

  Yeah. So tell me, tell me about problem-focused. Like, what does that mean for you?

• 3:19Speaker 01

  Well, you know, one of the issues is that, you know, sometimes in hearing about people's prior therapies, or in the context of even supervising someone, I'll kind of say like, oh, what did you, you know, 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 to have an open-ended exploration, whatever the person brings in. And in terms

• 4:04Speaker 01

  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. So for instance, let's say he has anxiety symptoms, depressive symptoms, you know, trouble controlling their temper.

• 4:33Speaker 01

  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 psycho dynamic 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 like, 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 that dealing with these issues, you know, what's kind of what's working and not working. So it's

• 5:16Speaker 01

  it's a bare amount of difference from, you know, more traditional forms of psycho dynamic psychotherapy.

• 5:24David Puder?

  Okay, so I think this is a, 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?

• 5:42Speaker 01

  Well, really, you know, you can do like the usual evaluation, you know, tell me about what your your problems are. And so somebody say, okay, well, I have anxiety, you know, and start to identify you know, 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 up? Because the way I look at problems is, you know, symptoms, behavioral issues. So those are have to do with,

• 6:25Speaker 01

  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, you know, what are the issues in their relationships? Do they have like some anxiety, panic, or some other?

• 6:51Speaker 01

  Issues, you know, they have problems with regard to feeling dependent and frustrated in their relationships, or, you know, dissatisfied with their partners, or, you know, narcissistic issues, no one's good enough for them. So those are, those are the kinds of things that as they come up, you know, we'll start to identify these problems. And one of the things that's, you know, kind of collaborative or helps to build an alliance is that there is a discussion about the problems. Okay, okay, so it sounds like here's what you're coming in for. You know, we're gonna, we're gonna work on your anxiety, we're gonna work

• 7:34Speaker 01

  on your depressive symptoms, we're gonna work on this issue in the relationship, we're gonna 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, that's a sort of collaboratively built effort. And then, you know, there are things that are going to emerge that are, you know, in the initial, don't come out initially because people may be anxious or embarrassed about them. So, you know, it, you, a problem list isn't, it's not like, oh, this is a static list and we're done. Yeah, we could kind of, kind of modify that as we, as we go along.

• 8:19David Puder?

  And then how does like personality and your understanding of their personality fit into the formulation? So you have like, let's say they have a problem, like assertiveness. And then, for example, you know, as you kind of hear more about them, you realize like the personality that goes with that is more of a dependent personality, you know, style. Like, how does that kind of link?

• 8:44Speaker 01

  Yeah. So, you know, I do put, I put personality issues as one of the, kind of the four sets of problems. And I talk about, you know, approaches to personality issues. So symptoms, behaviors, you know, personality issues, and then relationship problems, which by the way, relationship problems is not always a focus of the psychodynamic treatment and the way it is of this treatment as is behavior. But nevertheless, you know, with regard to your question, it's interesting because.

• 9:20Speaker 01

  I found that a better thing with people is to talk to them about the problem, not as you have a this personality disorder, but how does it manifest itself? You know, somebody says, okay, you know, my wife told me I had narcissistic personality disorder. What, what do you think? Yeah. So I, it'd say like, um, well, that's, you know, I'm, I don't necessarily find that kind of label so particularly helpful, but let's talk about what issues you may have that you, you may feel, you know,

• 10:01Speaker 01

  that people don't get you, they're, they devalue you, you don't feel adequately recognized. So I'm gonna, I'm gonna, or dependency issues, you know, that you don't feel able to manage on your own or that you're able to function without someone else's support or, you know, or you tend to avoid, you know, or avoid certain types of situations. So that's again, the, the language of that is more oriented towards the problem than the personality disorder itself. I, I think, I think, uh, yeah, I saw your talk with, um,

• 10:43Speaker 01

  you know, Frank Yeomans, and I think they say, oh yeah, borderline personality disorder. I think that's, that he was saying that they had that diagnosis. To me, that's not always as helpful as, you know, you know, clarify what does that mean? What types of symptoms that person has and what's the language that they can understand? And also tolerate, uh, because, you know, a lot of personality issues, people are, you know, they're not aware of, they're egotatic, that's part of the, the nature of that.

• 11:19David Puder?

  So you're looking, you're looking for what, 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 kind of another category. So tell me about that category. And you said it doesn't usually come up in psychodynamic thinking.

• 11:43Speaker 01

  Well, you know, yeah, I would say that what, the way I would put it, that's why I say it doesn't come up, but it's not that and behavior, which are two of the key components of this type of approach are not, 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, 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.

• 12:26Speaker 01

  Similarly with relationships. I mean, you know, if you take one type of not uncommon case and, and to think about, you know, formulation of that, 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 and fantasies and, and they're worried about disrupting relationships as a threat to them. So in that it's not uncommon for them to, due to these conflicts, have struggles communicating

• 13:05Speaker 01

  their needs to a partner and that they can't, they can't, you know, bring up what they need because they fear, okay, this is only, this is going to create a problem. This is going to disrupt the relationship. So a lot of times it's, it tends to be of a sort of an angry dependent relationship, although the anger isn't being expressed directly. So. I'm gonna start say, okay, well, let's 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. The other you say, okay, well, the other person's

• 13:50Speaker 01

  I'm responsive or they don't get it. But in a certain way, that hasn't been tested out. And, you know, that sort of diet, it's I'm partly giving you an example of how, you know, 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. And there's, there's, you know, an intersection that tends to occur and influence on each other. I mean, let's say someone's fearful of anger that you had, you know, we're have been talking about

• 14:31Speaker 01

  this about anger, Dr. Watteau. 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, not always helping them to feel safer with their anger and hopefully change the relationship and feedback, help them to have more tolerance of those feelings.

• 15:02David Puder?

  Yeah. So kind of the disavowed. So let's, yeah, let's, 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 kind of maybe try to go into a little bit more depth to make it more. Kind of palpable or tangible or understandable. So what is there one that jumps out at you as kind of like this is something that you often see in New York in your practice?

• 15:32Speaker 01

  Well, in New York, I have to say you see everything, but if we're, if we're talking about, you know, the disavow anger issue, which I, I think it's a very interesting one, you know, a comment that's a common issue, people who are, you know, inhibited about how they are, don't feel, you know, safe expressing those feelings or consider that they, you know, would be dangerous and are, and are frustrated. And, and after all, I mean, you know, kind of the proper, so to speak, or most effective communication of anger is kind of a universal issue.

• 16:14Speaker 01

  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, you know, create a disruption in a relationship, then that's going to make it harder to be able to express it. So it tends to get suppressed. And then the defenses that often take place could be denial, like some people say, I don't get it, I don't have anger. Uh, you know, I've heard, you know, that of or, or the reaction formation, trying to, you know, connect or take care or of others.

• 16:57Speaker 01

  Um, uh, you know, those are, uh, or, or even like expressing anger and take it, taking it that what we call undoing, like an angry statement, like, well, sometimes you're from panic patient. So, well, I hate my partner, but I really, I really love him, you know, uh, it's just that they're indications that that's not safe for them.

• 17:19David Puder?

  Yeah, okay. And so you utilizing your approach, how do you start to help someone move maybe from uh, where they're disallowing, disavowing this kind of anger to bringing it more into their conscious awareness without a feeling of?

• 17:39David Puder?

  Impending doom or high anxiety, right?

• 17:43Speaker 01

  Yeah, yeah. So one thing would be to help them, and this is, this is a big step in terms of this kind of approach, which is to, to develop an understanding of, you know, who contexts and feelings, you know, where do problems tend to occur? Firstly, identify the problem and then look at, you know, what are the situations that it happens in?

• 18:12David Puder?

  So let's say, they say close attachment relationships, like with their mother, with their wife.

• 18:20Speaker 01

  Right, right. So that once we, you know, once we get that kind of idea, you know, one of the, one of the ideas here is to, we're working to build, but I'm now tending to call a staging area. It's sort of, it's sort of more than observing ego. It's, it's building a place to be able to step back from various problems, you know, anxiety states, traumatic states, depressive states, and you all refer to symptoms and positives being kind of, you know, being caught in a whirlpool and they're trying to find a way to, we're, we're building a way to step back from that.

• 19:01Speaker 01

  And if they're, 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, this is when anger is scary to me. It's when I'm with close intimate partners, because they may not have known that. It's like, oh, I have trouble asserting myself. And it turns out, they may not have, you know, I have people like at work, they're assert themselves fine, but when you get home, you know, oh no, I can't, I can't do. Okay. So what is it? Let's try, let's look at or understand, you know, what it is about that situation. Let's explore to, and, and one of the.

• 19:45Speaker 01

  Issues is to have people begin to observe more what they're experiencing at those times. You know, what are, what are they struggling with? What comes to mind? So a lot of this stuff, it, these issues, they just, you know, they happen, you know, automatically. They're, they're under the radar. People don't really explore them or identify them. So, you know, uh, and, and what, what, what do you picture is the threat? Uh, again, these, you know, they, they tend to happen, you know, so rapidly. And again, it's a question, are they, is this unconscious? Or is it just not been identified?

• 20:30Speaker 01

  So for, for instance, one, one patient, she said, well, you know, um, I'm worried if I bring this issue up with my, uh, you know, wife, you know, uh, let's say, oh, frustrated about that she doesn't, you know, spend enough time with me, uh, that she's gonna, she's gonna get enraged and she's gonna, and she's gonna, you know, withdraw for days. And, okay, well, uh, let's, let's take a look at that. Is that, is that, if that, you know, what happens? Or what is that gonna feel like? What does that remind you of? Um, and then we might identify at that point, oh, well, what comes to mind?

• 21:13Speaker 01

  As we, you know, kind of the second step is looking at, you know, developmental history? And what, where, where might these patterns have developed or emerged from? So, you know, I'd say, oh, yeah, you know, that's, actually, that is reminiscent of my father. You know, that 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, you know, then we would take that and say, okay, um, you know, now we're starting to get a better idea.

• 21:54Speaker 01

  Of this conflict and the struggle you're having because we're finding out that, you know, 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.

• 22:22David Puder?

  Hmm. Yeah. Okay. So like, let's go with, let's go with this, uh, this storyline. Okay. So you have, you have a parent that would maybe, maybe crumble if you were angry, maybe withdrawal, right?

• 22:38Speaker 01

  Or, or attack.

• 22:39David Puder?

  Fall apart, maybe attack.

• 22:43David Puder?

  But how do you get from that to like, change?

• 22:47Speaker 01

  Well, you know, the one, the one would be to sort of say like, okay, well, let's see if you're, you know, are you, you know, under, overestimating the danger in your current situation based on that. Um, you know, in other words, that because you are, are the people in your current life, do they really follow that pattern? So, you know, you had this, this was your experience, you know, growing up, uh, and it's understandable why this has felt, you know, very frightening to you. But, but understand, does it, you know, why do you feel the same thing is going to happen in the current circumstance?

• 23:31Speaker 01

  So that you're, you're maybe overestimating the danger of your anger. Um, we also would help to work to identify, you know, 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, um, which, yeah.

• 23:56David Puder?

  Let's, let's try this. Let's, I know. Let's try a role play. If, if you, uh, if you're game, okay? Well, I'll just, I'll just walk into this scenario that we've, that we've co-created here. So.

• 24:09David Puder?

  Dr. Bush, I mean, I hear you that, you know, does this person in my life, my spouse, do they react this way like my childhood? No. And I know that cognitively, right? But I still find myself not able to, like, just the thought of being angry or disappointing them is completely like, it's like, it completely freezes me in that regard, you know, like, and I, I never express my anger.

• 24:47Speaker 01

  Well, yeah, I certainly, I understand that it is very frightening for you to be able to, you know, express your anger twice. 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?

• 25:14David 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, 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 gonna, 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 do, I want, she's asked me to help her, you know?

• 25:48Speaker 01

  Oh, so she's had, she needs to do, it's not like something you have to do, it's something that she wants your-

• 25:55David Puder?

  She wants my help?

• 25:57Speaker 01

  Yeah, yeah. It's probably her job to do this, to do the accreditation, you

• 26:01David Puder?

  know, 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.

• 26:13Speaker 01

  Yeah. So maybe you could tell me something about, like, have you thought about, like, what you imagine would happen if you told her what would, you know, what's that?

• 26:28David Puder?

  Yeah, you know, I really enjoy my relationship with her and I feel like I would be irreparably damaged.

• 26:37Speaker 01

  Yeah. So what uh so what would have so what she feel like, oh, well, she's gonna stop off. She's not gonna talk to you. She's gonna.

• 26:46David Puder?

  I think she's well, she's probably gonna be polite, you know, like, but then I think she's going to, you know, not give me the same care and attention and, you know, love that she has given me.

• 27:01Speaker 01

  Yeah, I mean, um, I guess we could look at, you know, why that feels so essential to you, you know, that you're worried about losing that. And I know we've talked some about, you know, your experience growing up and that you felt this way with your father and he would, you know, withdraw from you. So I'm wondering the possibility, I guess you use a you've thought about that, that maybe you're anticipating this danger with her, but that maybe it won't occur in the same way that you, you know, it would.

• 27:39David Puder?

  You know, it's like, it's like intellectually and cognitively, I know that that I I know that something like I have inside, I have some degree of insight that this may not be entirely true, right? You know, like, or that she won't react this way, but

• 27:59David Puder?

  I don't know, for a month, I've been still stowing stewing about it, right? And so it's it's like there's um,

• 28:07David Puder?

  it feels very viscerally petrifying to tell her.

• 28:13Speaker 01

  Yes, yes. So I I would say, you know, have I one thing we could do is talk about like what you might say to her if you were to say something, you know, that that is sometimes helpful because, you know, maybe you're having trouble if 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 that would stop off? I mean, how does she treat people? Does she does she tend to be temperamental or irritable or?

• 28:56David Puder?

  Um, not that I've necessarily seen. Um, I haven't seen that temperamental or irritable side. And I think I've, I've thought about this. What would I say? I've thought about this a lot. I think I've thought about saying like, hey, I've thought about, you know, your request to help you with this accreditation. And at this time, that's not something I want to do. Cause I feel like I'm, I'm pulled in a lot of directions right now. And I think that would, 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,

• 29:40David Puder?

  I feel completely like I, it's like, there's so many times where I've planned on telling her. And then I go up and then I, I end up not telling her.

• 29:52Speaker 01

  Yeah. So what happens? Tell me about that moment. What, what happens then?

• 29:58David Puder?

  It's like, it's like we'll be passing to the hall, like during a clinic or something. And I'll have a moment where I could tell her and all like, have tried to think through like, okay, I'm going to tell her. But then it's like, when it comes to the, the moment that it's like, no, no, no, don't do it. It's like, I, I feel like, oh, ah, 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.

• 30:28Speaker 01

  And tell me a little bit about your other relationships. Do you have, you know, 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?

• 30:51David Puder?

  I think um.

• 30:54David 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 like 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 so it's like a love. There's a level of irrationality that I know. I'm dealing with here.

• 31:34Speaker 01

  Right, right. Well, one thing we talked about, you know, your father's.

• 31:40David Puder?

  I think it's more my mother, actually. I think that makes more sense to me.

• 31:44Speaker 01

  So tell me a little bit about that. This doesn't, this sounds a little bit different from what happened.

• 31:53David Puder?

  She was very sick. She, you know, she had cancer growing up and stuff and she was often in her bed. And um. I just felt like any.

• 32:07David Puder?

  Any uh 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.

• 32:20Speaker 01

  Well, okay, yeah, yeah. So that must, I mean, that's been a very. Tough thing to to go through.

• 32:29David Puder?

  Yeah. Oh, yeah. Yeah, I think I think it was like I remember being like around six or seven at that that time when she was going through it. And I remember um. Just kind of taking care of the house in the midst of her not taking care of the house, you know?

• 32:48Speaker 01

  And did you feel pressured to to do that or feel if you that that was kind of your role or that you weren't. Feeling very supported or you just felt like, oh, this is what I this is what I have to do?

• 33:05David Puder?

  Yeah, I felt I felt it was my role. I felt this is what I had to do. I felt I felt sometimes happy doing it. To to kind of contribute. I felt like. Yeah, I felt like I just had to kind of quietly help.

• 33:24Speaker 01

  Yeah, I mean, have you noticed you tend to be kind of an over responsible person? I mean, I know you're resident doctor. Are you?

• 33:35David Puder?

  Yeah, yeah, yeah, yeah. I mean, I think, I think over responsible or like over going over the top, doing, you know, like, like I have some patients that maybe, you know, they'll call during the week, you know, I'll like call them back and do like an extra phone session where it's like, 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 like, I know that there's probably ways that we're supposed to interact with patients, not, not do long phone calls off, off the hours of normal things.

• 34:16David Puder?

  But I feel like with these, with these clients, it's necessary to help them, you know? So I do feel like I go over, over and above.

• 34:25Speaker 01

  And what do you think will happen if you're, if you don't do that?

• 34:31David Puder?

  If I don't do that? Uh, I mean, there's this one person that like, I fear she might hurt herself.

• 34:42David Puder?

  In particular, yeah, so I feel like, yeah, it's kind of like, um, some added pressure. Right?

• 34:52Speaker 01

  Right, and, and does this kind of end up taking a lot of, do you tend to work extra hours and you're there late or preoccupied sometimes with people after work?

• 35:05David Puder?

  Yeah, yeah, yeah, yeah, yeah. Yeah, and I think, I think that that, um, it starts to wear on me, you know, after months and months and months of doing it. But I, I feel like it's, um, I also get, I also feel good sometimes doing it too. You know, like I feel like a sense of like, my suffering is meaningful.

• 35:28Speaker 01

  Yeah, yeah. Well, I think, you know, one of the things is that, you know, maybe that this issue with your mother may be more relevant to the 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, you know, kind of setting limits with, you

• 36:12Speaker 01

  know, female figures, you know, authority, but also, or women in your life, you know, but also this sense of over responsibility and this kind of pressure that you feel. And that's, that seems to create other problems for you, you know? I mean, I don't know, we have to talk about you get worn out or under strain because you feel like you can't, you have 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, we need to explore this more with your mother.

• 36:55Speaker 01

  Because did you feel like, oh, were there fears like, oh, she wasn't, she was gonna die if you didn't do this? Or she, you know, she fall apart entirely? And maybe that's, that's where the danger is, not like, oh, she's gonna stop off and be angry, you know, that, but she is gonna

• 37:17David Puder?

  Yeah.

• 37:17Speaker 01

  fall apart, collapse and feel disappointed, as you were saying.

• 37:22David Puder?

  That feels, that feels relevant. Yeah. There was, um, there was a, a time where she, um, she did go into cardiac arrest at home. And I was the only one there. I think it was seven. And I called, I called 911.

• 37:43David Puder?

  And ran over to the neighbors and got some help, but it was uh kind of hey, it's like my memory of it is kind of hazy almost, you know, it's like hard. It's it's like, uh, like I can remember parts of it very vividly.

• 37:59David Puder?

  Like we had one of those old phones with on the wall that the dial and my fingers like it was almost hard to do. I like I had to try nine one one multiple times to get it. I knew it was nine one one.

• 38:12David Puder?

  But yeah, and then, you know, she did recover from that, but that was like incredibly frightening.

• 38:21Speaker 01

  Yeah, I mean, it it sounds terrifying and that, you know, that sounds like that's traumatic. Experience and you know, 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 you know, how were you, 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, you know, that trauma can very much, you know,

• 39:01Speaker 01

  get into one's mind and effect going forward where, you know, 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 you have this patient that you're worried about. You know, might hurt herself and I'm not, I don't, I haven't heard about that situation, but maybe, maybe that's a threat that maybe you're also, you know, feel this powerful sense of responsibility is related to that traumatic experience and that you're always on the verge of, you know, that was this person's gonna collapse or be deeply disappointed to you in you.

• 39:45David Puder?

  Yeah. You know, as I even talk about the um that cardiac arrest, the feeling that I get is kind of like this like nausea. Or like I feel like almost um like kind of fuzzy, my thoughts get a little bit more fuzzy. And, you know, I've had all these dreams over the years.

• 40:10David Puder?

  I'm kind of like associating to like these dreams of like a phone where I'm like trying to answer or call from a phone, but I can't get through. So I think, I think there was something about like having to dial nine one one and then struggling to dial nine one one initially that I, you know, I felt like every, every second was going to be like I was going to kill my mother or something if I, if I didn't dial it properly.

• 40:37Speaker 01

  Yeah, well, that's, that's very terrifying, you know, place to be. And I guess, I mean, it's interesting that this is coming out more now. Sometimes, you know, that happens that it takes some time to, you know, reveal a trauma, partly because it is so scary. And again, maybe you either overemphasized your father because this was an even more, you know, terrifying experience that's been hard to, to talk about. And with the trauma

• 41:15Speaker 01

  of that nature, it's not unusual for people to, for that to kind of, to generalize that people can feel like they're back in that traumatic situation and that if they, you know, are, don't behave just right with this other person who needs something, that there's going to be some terrible disaster that happens.

• 41:44David Puder?

  Yeah, I, I think with the father, the thought that comes is I never wanted to be angry like he was angry. But I'm, as, as I'm hearing you, as I'm kind of in this moment, I'm thinking like, maybe. Maybe I shouldn't be talking about this. Maybe it doesn't relate or something.

• 42:15David Puder?

  Maybe I should, uh, maybe, maybe I brought it up too early. Is that what you're saying? I brought it up too early? Or I'm doing something wrong?

• 42:26Speaker 01

  You did interpret which up too early?

• 42:31David Puder?

  My mom's, my mom, the phone calling.

• 42:34Speaker 01

  Oh, no, no, I'm, I'm kind of, I meant to be saying the opposite, that maybe it was harder for you to bring up. And, you know, maybe this thought like that I was saying, you did, didn't do something right. You know, uh, would indicate that you, you still, you still are carrying a heavy burden with that, that you, you know, that this is, you're still trouble. Maybe you feel you didn't, you do something that you may have done something wrong.

• 43:10David Puder?

  So like, maybe I should have, maybe I should have brought it up earlier. I, I honestly didn't remember it until our conversation today though. But I, I, if I, I guess I should have brought it up earlier in our sessions that, that about this. I mean, I think, I, I try not to remember, I try not to think about it too much, you know? Like I try to avoid thinking about it.

• 43:33Speaker 01

  Yeah. I mean, I, I would say, you know, it's not, it's understandable that you would avoid that. And I, from my standpoint, it's not a should or shouldn't. In fact, maybe that's something about like, this responsibility that you feel you're supposed to do something for someone and you, you feel that way with me. Like, oh, maybe you did the wrong thing. But I would guess, you know, that from, that the reason you haven't brought it up is because it's so terrifying. Uh, and, you know, there can, we can, we'll explore further because there could be sorts of fears, you know, shame about these things, or people can feel like.

• 44:17Speaker 01

  This terrible sense of responsibility and you know, 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 kind of circumstances where it's not really a terribly big problem is kind of a life and death situation. And maybe that's something about what you're you're doing, you know, with this, you know, supervisor is attending that you're feeling that you're kind of mapping this sort of

• 44:57Speaker 01

  life and death kind of threat onto that situation or experience that as you know, the trauma that you had.

• 45:06David Puder?

  You know, as we're, as I'm hearing you, I can't help but think like, I feel bad that I have to even labor you with this kind of, you know, 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, you know, and wear you down or like it burden you. And so for some reason, that's what's going to going through my mind as we're talking here. It's like, oh, man, am I like too much for Frederick Bush?

• 45:43Speaker 01

  Yeah, I, you know, I mean, I, I, that's a painful feeling. Of course, you know, this is, this is what you're supposed to be doing here is talking to me about these problems. But I think it kind of fills out a little bit more, you know, this picture of this impact of trauma, because a lot of times kids taking care of parents that are ill, you know, do feel a sense of, you know, being that they could be a burden because the parent is ill and they they put any of their needs into the picture.

• 46:27Speaker 01

  Picture that the other person's gonna be troubled or could even put them at some kind of risk. And and maybe that's started to fill out a picture, you know, or a formulation of understanding what you're dealing with. You know, that the over responsibility is a threat on the one hand, they have to take care of the person or they're gonna fall apart or die. Or that if you're, if you have your own needs, which you're saying, you know, that you're over, you're kind of, you're a psychiatrist.

• 47:05Speaker 01

  Cause that you're, you're overwhelmed, but maybe if you take care of your own needs, then you're burdening the, you know, the attending. And so you can't, you can't, you can't make a proper assessment of that. And that puts kind of a tremendous pressure on you.

• 47:27David Puder?

  So I'm not, I'm not burdening you too much, Dr. Bush?

• 47:30Speaker 01

  No, I, I mean, I, I think it's a very important and valuable to be hearing about this. I mean, it's a, it's a very, it's a very painful story, but that's not, 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, you know, that, that. In other words, now we're getting a better idea of why you're 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.

• 48:14Speaker 01

  That that's, that's, that I want to hear about that, that that would help you to, to feel safer too. Cause I, I don't even, I think you, because this has been so deeply buried, that you, you don't even think about that. You just suppress your own needs.

• 48:35David Puder?

  I, I don't know why, when I think about this stuff, I feel so nauseous and I feel it's almost like, like, it's like, I don't, I don't feel myself. I feel like, kind of like a haziness, I feel.

• 48:53David Puder?

  Like a disconnectedness.

• 48:57David Puder?

  Or just a floaty, a little bit more floaty. And like, I hear, I hear your words, but then I also like fear like that you're saying this because you're trained to say this, like because I'm trained to say this. So I know kind of what we're supposed to be saying, but then I, I fear that secretly,

• 49:18David Puder?

  when you get out of this room, you're going to be like, that was a lot.

• 49:23Speaker 01

  Well, you know, I guess it's hard for you to believe about that you're, you're not going to be burdensome, but it sounds like that's even more evidence about how directly this is, you know, connected to the traumatic experience and that these are unusual reactions to trauma, you know, haziness, disconnect, you know, kind of unclear memories of certain things and other parts, you know, very clear memories, like trying to, trying to get the,

• 50:03Speaker 01

  the number right, you know, and, and it's often experienced in the body as well. And maybe, maybe that's a bodily threat you're getting when you're going up and trying to, you know, talk to the attending and you get this. I, I would pay attention. I'm wondering if you even get some of this bodily experiences at that time. And that's what I think that, you know, 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 like, hey, this is, this is just you

• 50:49Speaker 01

  telling the attending that you're not able to help work on this thing because you're overburdened. You know, so, and I, and I think also that you can see that I can, that I can stay with you through this, that, that I'm, that I'm not burdened by it, even though you, it's hard for you to believe.

• 51:13David Puder?

  I think I I feel frustrated that my my boss, you know, this the program director, she she wants me to do this at all. Like, I feel like, for some reason, right now, like, and I I don't know if like, this is something that feels a little bit new, like, there's like, almost like a tightness in my chest, like, what, this is your job? Like, this is not my job. Like, why do why do you want me to do this? Like, I'm I wouldn't even know where to start, you know? Paperwork, I it's like, this is not something I know how to do.

• 51:57Speaker 01

  Yeah, well, I I think, you know, in in a certain sense, we could say, well, maybe, you know, that once we're talking about this trauma.

• 52:06David Puder?

  Why is my neck so tight all of a sudden? Oh, yeah.

• 52:10Speaker 01

  Yeah, yeah, I mean, I it's, I mean, it's an important kind of shift that's taken place, maybe something about, you know, talking about your mother's experiences helped your anger to come out and realize that maybe the program director is 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

• 52:52Speaker 01

  anger coming out, but not being safe for you. Maybe it's not safe because you connect it with your father's rages, or, you know, it's not safe because you're actually expressing your own need, instead of taking care of someone else. But, you know, it's important for us to stay more in touch with this angry feeling and help you that to emerge. You know, right now, I would say this bodily reaction is that there's something scary to you about feeling that kind of anger.

• 53:32David Puder?

  I think, I think two thoughts. One is my back is all of a sudden really tight. The second thought is like, I think, like, I feel some

• 53:43David Puder?

  knowledge that, I don't know if this was modeled well for me, you know, like with my dad, he would just go from zero to 100, right? There was no like

• 53:52David Puder?

  calm frustration or like, you know, having a voice or having boundaries. There was always just like, just zero to 100 and

• 54:05David Puder?

  I, it's like, I was so angry for, or just for my mom, I was just upset that that was something she had to go through, you know?

• 54:17David Puder?

  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 mean, I was feeling dizzy, but now I'm not, I'm like feeling just tightness. And like, it's more like just a lot of discomfort.

• 54:35Speaker 01

  You know, well, there, there may be kind of one set of reactions around, you know, this trauma with your mother and another set of bodily reactions with your father. I mean, sometimes, you know, tightness can be because you're feeling activated in some kind of angry way and it's not safe. I mean, again, that's, 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 you, I'm hearing it right, either wasn't expressed at all and expressing any kind of need was seen as

• 55:19Speaker 01

  a burden and potentially dangerous, or any expression of anger was something completely out of control and dangerous. And so, you know, I would agree that that's, 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, you know, 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.

• 55:59Speaker 01

  So I, I mean, that would be this kind of management of your anger is part of what gets we kind of another column we would look at and, and again, connects in because that's a couple of reasons why now, you know, now we start to see more and more how loaded this situation is, right? You're angry on the one hand, and that's dangerous, or you're gonna, you're afraid of being burdensome or expressing your own needs on the other. There's a pretty loaded situation in there.

• 56:37David Puder?

  Hmm. Yeah, it's like, the thing that comes to me right now is like, you know, I've, I've been wanting to start maybe like a half an hour later than we have because I have to rush so, 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 like what's jumping into my mind right now, like that it's been hard to even ask you that. But I feel like I want to, I want to like, try to be honest with what's going through my mind. I don't know why that, that

• 57:17David Puder?

  in particular is going through my mind right now. Maybe because it's, it's like, but it's interesting that I feel this tightness in the midst of this.

• 57:29Speaker 01

  Yeah, I mean, maybe, you know, first of all, I think that's very good that you did, you know, bring this up. I mean, obviously, if they talk about looking to what we might do about the time and see if we can negotiate a time that's more, you know, 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 the block here, you know, that you're, because this seems to. Contain all of the issues that you're telling you are going to burden me.

• 58:10Speaker 01

  Maybe you're bad that you have to rush over, even though you hadn't said anything about it. So, you know, maybe that's, that's a sign of, oh, maybe you, maybe you felt you more safety to actually raise something with me.

• 58:27David Puder?

  Yeah.

• 58:30David Puder?

  Yeah, it feels good. Thank you for, I, I'm surprised because I feel like there's part of me that like, 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.

• 58:57Speaker 01

  Yeah, I mean, that's already kind of seeing like on the one hand worries about burning me and on the other hand, then I'm going to get mad, you know, so ready, that's already sounding like, you know, your situations with your mother and father growing up and part of what we hope you'd be able to experience in something different here where, where these things can be expressed and you can feel safer and that where we can understand is we've done better, you know, where these kind of problems come from.

• 59:38David Puder?

  You know, I think, I think one of my, like, between sessions, when I start to think about these things, because they're distressing, I start, I like, try to avoid thinking about them. And I either try to avoid it by like, playing video games or different things, you know. Do you think I should avoid thinking about it? Or what should I do like between sessions if I have thoughts? Like, how do I, what's the best sort of?

• 1:00:07David Puder?

  Recommendation that you have on.

• 1:00:10Speaker 01

  Well, you know, part of what we're trying to do in this kind of therapy is have people be able to think more about these things, um, you know, with regard to, you know, kind of 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 is a kind of a form of intermittent relief, but if you're feeling video, 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

• 1:00:53Speaker 01

  let's say like, hey, maybe we should think about is, are you trying to avoid something here? And, you know, um, you know, I mean, it's bad. Like some people might be like, oh, okay. Hey, I'm gonna stay away from those video games, but then they don't. And what I usually do is I have them kind of, you know, think about what's going on at that point, you know, why am I, I, I, I actually need to get some work done, but I'm, I'm pushing to play these video games is sometimes we can start to understand, well, are some of these issues coming to the fore at that point?

• 1:01:35Speaker 01

  So it will be less a matter at this point of should or shouldn't. But I think we would unders- want to understand more about, you know, what it represents for you. And is it kind of a, something that you have control over as a relief? Or is it something you feel impelled to do to get away from the problems that you struggle with inside?

• 1:01:59David Puder?

  It's good.

• 1:02:01David Puder?

  All right, let's, let's pause our, 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. What kind of things you felt like came up? That would be some things that would normally come up, maybe, you know, over the course of multiple sessions, right? Or even like six months of helping someone. And then, but then how you addressed it, you know, we should, we should maybe comment on those things to kind of.

• 1:02:42David Puder?

  Cause I think, I think this was very practical, you know, and I think this, this kind of scenario. It shows a bunch of things all at once, right? So I appreciate you.

• 1:02:53Speaker 01

  Right, yeah, I mean, I, I would say, you know, to put it in terms of, in terms of, you know, not to make it too, too schematic, but to, to think about it in terms of a grid that I would have in my mind. Would, in terms of the problem focus, what is, what is like kind of identifying problems as we go along? Okay, here's, you know, here's one of over responsibility. Here's one of conflicts about expressing anger, you know, fears of assertiveness. So that, you know, again, they'll usually, if somebody's in the midst of telling me of the trauma with their mother.

• 1:03:37Speaker 01

  Oh, you know, here's, let's, let's do a problem list, you know, I mean, obviously you want to get into that. Boy, the second is, you know, but, but for our purposes, I was doing a little bit more of that. Kind of problem identification, oh, let's look at this, here's what we need to work on. A second is the con identification of contexts. And in that emerged this very interesting thing, which you came up with somehow.

• 1:04:10Speaker 01

  And the role play that we were kinda, in 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're looking at the father's wages and the reactions to that, although we think that's a piece, but maybe that what emerged was this sense of burning, that creating trouble for the other person over responsibility that kind of led to the memories of the mother.

• 1:04:49Speaker 01

  And then a third step is trying to, 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, and you know, how they may, how they may directly connect, how they might lead them to overestimate the dangers currently, self and other representations.

• 1:05:26Speaker 01

  Again, I'm just going through the whole formulation list. Oh, I'm, I'm, 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 gonna be angry at me. Those are kind of three types of self and other representations that are going on, you know, a next step, you know, conflicts around, conflicts around anger and, and needs, right? Oh, my anger is gonna be damaging and dangerous, and, you know, my needs are.

• 1:06:15Speaker 01

  Are going to be burdensome and create a problem. So kind of highlighting those conflicts. I will, we'll skip over mentalization, which is another step, at least for, for right now, although we can, I guess we could say, as I don't want to, I don't want to throw in too many days. I'm trying to go to, which is that, you know, 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. Cause you feel like their reactions are going to either be irritable or, you know, burdened. So there's, there's a certain kind of rigidity that that's another piece.

• 1:06:56Speaker 01

  So each of those are kind of, as I'm, as I'm hearing it, I'm kind of building this grid. And, and the interventions are, are kind of, are targeted for these elements, you know, 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, and where it's, you know, where it's coming from. You know what? One thing about this is that you, you get, when you have

• 1:07:35Speaker 01

  some different people who seek out, like for instance, humans, where, okay, we're focusing on the object relation. That's our, 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. We're putting together a picture or what tell, oh, we're good at the interpersonal cycle. Well, there is an interpersonal cycle here and we could probably, 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 bad and more concerned about being

• 1:08:20Speaker 01

  hurt. So there is that, but, but so that those are, those are the factors of identifying and working to kind of put together what I call, you know, the formulation, which are how, what are these different pieces? And we could talk about, well, how we might, um, I, you know, identify them or, or challenge them or shift them.

• 1:08:47David Puder?

  What, um, I'm curious, like, okay, so I think my problem with role playing and being the person maybe on the other side sometimes is that, you know, it's different when you're in session and the person is actually feeling the thing, maybe more viscerally than I was feeling, you know, 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, if the person, you know, was actually feeling these different things that they were describing? Do you know what I mean?

• 1:09:28Speaker 01

  Well, you know, I mean, first of all, I, I thought it was, I, I mean, I'll, I'll be curious how people react to it. I thought it was pretty good and I, I kind of noticed to me, you know, in terms of the role plays that I've seen you do, I, I felt you were very present and authentic, you know? I mean, sometimes it's harder than others, right? To be in this position.

• 1:09:51David Puder?

  Yeah.

• 1:09:52Speaker 01

  I thought it, but it felt, it felt pretty authentic.

• 1:09:56David Puder?

  Okay.

• 1:09:57Speaker 01

  And, um, uh, to, to me.

• 1:09:59David Puder?

  Okay. And then I guess the second thought would be, yeah, okay. So one thing that I've noticed when I'm working with someone in the midst of trauma is like, let's say there's the disavowed anger, they may feel it towards me before they feel it towards in the actual trauma. Right? So I was trying to, I was trying to role play that into the scenario a little bit like, so in the scenario that I was dissociating in the midst of, you know, the phone call scenario, right?

• 1:10:33David Puder?

  During the cardiac arrest of the mother. And then, um, you know, this was like a life, this felt like a life or death situation. This is obviously the nidus of, you know, where a lot of the psychological stuff is because of the repetitive nightmares that are relating to phones and such. The, the, the transference that, that comes out is projected onto you, you know? And that, that you would kind of like, that this would be too much for you, that this would be like, so I'm now taking the, that kind of like, um, fear of being burdensome from the mother, placing that onto you, right?

• 1:11:18David Puder?

  Uh, with the shame and the, the kind of like, the, uh, the traumatic, some of the traumatic vibes there of nausea and such. And then the, um, yeah, so I'm, I'm curious what you thought of that shift, if you've seen that in your own sessions where it's like, the dissociation, the trauma, and then there's some, the shame becomes more about what's going on in the session, right?

• 1:11:51Speaker 01

  Yeah, you know, I, I mean, well, I want to, I want to go back to her prior question for a second.

• 1:11:57David Puder?

  Okay.

• 1:11:58Speaker 01

  So what is it like in terms, there's a couple of things in, in terms of how I handled that, you know? First of all, you know, there are, one thing with revisiting a trauma is how much do you, how much do you stay in the trauma? How much do you step back from it? And there are of course, you know, treatments that were the primary approaches that were, were like, you know, kind of processing therapy. We go through the trauma, or at least the identified trauma, and 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 have to stay and relive the trauma and others.

• 1:12:42Speaker 01

  That you have to, that it's important to step back. I do this kind of foregrounding, backgrounding approach. In other words, I, I step into the trauma with the person. And then I'm working on stepping back from it and helping them to understand, like I say, building this staging area. And that's a little bit, that's partly what I was trying to do with you. I might have, if it weren't, if I weren't trying to demonstrate a little bit more about how this therapy worked, I might have, yeah, I would have stayed a little bit longer in that, in that

• 1:13:23Speaker 01

  place with you. But I feel that if you, sometimes if you stay in a trauma too much, you can over, you can traumatize, re-traumatize. You have to be careful with that. And I feel like you're trying to help the person, you know, build a place outside of the trauma that they can go to and that they can step back. Again, you know, one of the things, I, something I mentioned earlier, sort of say like, kind of this, what's it, the whirlpool? And 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 talked about like currents into the whirlpool.

• 1:14:07Speaker 01

  So the different currents are the struggles with anger, this traumatic of bad, the problems with the father, the, and, and we're identifying, you try to, 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 mean, I think, I think that, that, that, that they were, it shifted to, to me, in other words, that it was safer there. Okay, well, yes, I think, I think that can happen. I think that's a pretty good outcome. You know, in other words, that there was, that we were, that, that was, that you were able to express that and that the anger came out not only with me, but towards the.

• 1:14:52Speaker 01

  Program Director, you know, that showed like, oh, we hit something. We did, we did something. So I would say, you know, that it, that it didn't come out at the, oh, you know, 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 were doing it, if we did another role play. Next time, oh, it occurs to me that you were, that you, you felt this way, that you felt similarly

• 1:15:30Speaker 01

  in, in that, in that situation, that you were, 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, with your program director. That's another step that we could work to, to build on.

• 1:15:49David Puder?

  Yeah, I want to maybe like bold or like draw attention for the, for the listeners that coming out of the dissociation, the, you know, dissociation is embodied often by this kind of like lightheadedness, disconnection, nausea, coming out of that into a tightness type of thing is, 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, I've been wanting to have a voice to changing the time of our sessions, but you could see all the fear that led to the, you know,

• 1:16:32David Puder?

  this kind of interpersonal repetition that the, um, the patient was unable to ask you this before, right? But now that they're coming out of the dissociation into the frustration, it's like, it gets kind of associated from in the frustration to like this and you be welcoming, you know, welcoming the, the conversation, welcoming the invitation, your enthusiasm for the person to talk about this, I think, is, is paramount to, to them, to the 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.

• 1:17:15Speaker 01

  Oh, right, right. And, and you know, that's, and it's a little bit different from maybe some old models of like, oh, yeah, tell me about, oh, tell me about that. Is it kind of encouraging them or, oh, this is positive that you're expressing this. And that, you know, that feedback that, 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, that's an important, you know, mechanism for further change. You're, you could, you're testing out now with me

• 1:17:54Speaker 01

  whether these things are actually safe. Am I burdened? Am I, I mean, angry? And yeah, I mean, I thought, I thought that that was a very good sign in terms of the emergence of that.

• 1:18:09David Puder?

  Hmm. Yeah. This is enjoyable. It's really good. Yeah. I think as we kind of talk about this, was there any other threads that you wanted to make sure we kind of like understood or were seeing from this role play? Because I think, you know, the role play allows for people to kind of like grab on to 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 like ways of thinking about this that relate to your model?

• 1:18:42Speaker 01

  Well, again, you know, I, I mean, sort of what I, I highlighted before how I'm, I'm, you know, going through, which was a little bit more rapid than usual, identifying these different elements and how, you know, that helped us. And also that you, you don't want to have you, it's, it's a, it's a semi-

• 1:19:06Speaker 01

  Flexible system. It's not, I don't need like, here's a rigid structure. So one of the things we needed to be open like, oh, we got this. I got, I have a formulation that you're, this is your anger, your fear of asserting yourself is related to your, the anger that your father expressed, and that's too dangerous. So therefore you can't, uh, you know, talk to the program director. And then partly we're, you're kind of like, mm, well, you know, this is, this isn't doing anything. And that we go back and we find

• 1:19:44Speaker 01

  out, let's relook at the context. Let's relook at what you're experiencing and open up another dynamic piece. So that's, that's one element that I, I think is important to say that this is, even though, you know, we're part of the idea of this. And I, I was trying to demonstrate that. I was trying to demonstrate like, 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

• 1:20:24Speaker 01

  done. And yet remaining open to here's a new or different dynamic. Here's an identification of a trauma that's even more, you know, powerfully relevant to the current struggle.

• 1:20:38David Puder?

  I, I know you, you wrote a book called Trauma-Focused Psychodynamic Psychotherapy. I was trying to kind of like, see how you would interweave your approaches. I'm curious, like, what, what from a, 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? Like, what were you doing? What were you thinking through in terms of this?

• 1:21:07Speaker 01

  Um, yeah, and that was written with, you know, co-authors Barbara Milrow, Corey Chen, who was actually, you know, working at, at the VA so that we did, you know, we did work, you know, with therapists with, you know, with veterans. So, you know, it was really severe, you know, trauma there. And Mary Ann, they sing, or so just, just to mention them because some of the books are single author on and some are with, you know, with co-authors. But, um, well, one of the elements is to link the current symptoms with past trauma.

• 1:21:51Speaker 01

  So how are we, you know, that there, what 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 is a split that occurs at the traumatic event and we, we need to re-link them. You could think of that as maybe Genet's theory of dissociation, or you could say like, okay, well, that dissociation is because it's too painful to make a connection, right? You know, Freud's theory essentially.

• 1:22:32Speaker 01

  So, but either way, uh, you know, we're, we're trying to link that. Now, if the per, the person, so I'm gonna say like, oh, this feels like that. If they're, if they're having trouble, if they still deny it, you know, then maybe it shows even more of the defensive aspect. So that, but that's one of the elements that I'm trying to do. And in this instance, you know, there was a very strong fit, which isn't, you know, isn't unusual with the traumatic event as it emerges. Uh, because again, that provides a basis for understanding that

• 1:23:11Speaker 01

  connection of your current experiences, uh, to trauma, part of building this framework to be able to step back. A second one that I tried to throw in there quickly was, uh, was, um, uh, you know, repeating of trauma. So that's a big.

• 1:23:32Speaker 01

  Dynamic theory. So the there's, there's a couple key aspects of that, you know, one aspect is that you're, that you're seeing the current event as a, as a, 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. Uh, so it's a, it's a form of that. So this person, he's experiencing, you know, what may be a tense situation is a little bit tricky because she's the boss, uh, but he's experiencing the, uh, you know, that, that connection as, as a recurrence of the trauma. But there's

• 1:24:17Speaker 01

  also ways in which people unconsciously repeat trauma. And that partly is, is there's some proneness to getting himself into situations or years, uh, into situations where they're overly burdened and feeling not responded to. And it not, it not intentionally, you know, partly because of the struggle around saying anything, but you'll see this like, you know, patient mind said, oh, I can't believe my daughter married this narcissistic guy when, when she had this father. Well, you know, the idea is that people repeat,

• 1:25:02Speaker 01

  can repeat these because they're trying to make them come out differently. They're trying to, uh, you know, had a different outcome each time. So they, they inadvertently through various means, repeat the trauma and trying to control it better. Um, there's a, I have a bunch where, so I don't know whether you want to stop or comment, but I do, I want to put in another element, identification with the aggressor. Um, so that's another, that's a, that's a, a common. Trauma related defense. So yeah, I mean, the most common form of that is the bully who was bullied,

• 1:25:45Speaker 01

  you know, but, but many times this sort of identification with the, 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 may be like trying to control or be hurtful. We didn't, we didn't get to that quite yet, but that can create tremendous shame and guilt. I mean, you could get the bully who, who was bullied, they may not be so terribly conflicted. I mean, we see that too, right?

• 1:26:26Speaker 01

  But, but people with that, that it's only creates a fear for them in terms of expressing it, but also that there's a, you know, that they see it. And this is if somebody traumatized and they have fantasies that they want to hurt other people like they were hurt, that, that can, that can create tremendous distress for them.

• 1:26:51David Puder?

  Yeah. And, and also, and I think sometimes it, it's not like they're actually bullying people. It's just the fantasy of bullying people or it's like the, it's like.

• 1:27:01Speaker 01

  Yes. Oh, absolutely.

• 1:27:04David Puder?

  Or I, I even have had patients who, um, it's the, they be, they become the perpetrator to themself. So the, so they are violating themself sexually, for example. If they were, if they were, um, and so it's like they become. The perpetrator soon after even, you know, like soon after the trauma.

• 1:27:38Speaker 01

  Right, right. And that maybe with this person, we were saying like, if they were compelling themselves to, you know, work extremely hard as a way to try to, you know, sort of, that, that could be, that could be seen in that form, that now they're the one, you know, who's forcing them uncaringly to be overly responsible. But they're the, they're the origin of that. That's, that's a very good point.

• 1:28:13David Puder?

  The, the repetition of, of the, of the dynamic, I think was very evident in this story. And by the way, guys, this is, this is stuff I've seen. Like there's residents that I've known who have hidden from everyone, you know, and maybe I was the first person that they told that they were having long conversations with the parents, patients, you know, off, off the books, right? As a way of trying to save these patients, right? They get, you know, when you're, especially when you're young and you're, you're in their 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, the frame, the, the, the structure of the

• 1:28:57David Puder?

  treatment. And then they have an even harder time pulling back the, the frame, the structure of the treatment. These are, these are pretty common issues, I think, with a lot of professionals.

• 1:29:07Speaker 01

  Exactly. And people who do what we do, you know, where you take care of people, but, you know, the extent to which you feel, you know, compelled to do it, you know, that, that can be from other, other issues, right?

• 1:29:22David Puder?

  And I appreciated that you didn't shame that piece, you know, and I was actually, It's like you didn't even shame the video game playing, right? Which is, which is a behavior that maybe this person felt a little bit of like guilt, guilty pleasure of sorts, you know? There's some people, you know, who like maybe enjoying anything feels guilty, right? Enjoying anything for themselves feels like a kind of like shame, shame inducing or guilt inducing.

• 1:29:53Speaker 01

  Right, right. And generally trying to be careful to empathize and not shame. But in that one, again, you have differentiating, you know, what may be, what may be a compulsion, you know, which is a whole other problem and reaction to trauma. And that's another thing, what we talked about, this kind of behavioral change approach. You know, with that, where I try to have people kind of step back or even I sometimes I'd say, like, okay, well, why don't you wait, let's try waiting 30 minutes before you place your bet

• 1:30:31Speaker 01

  or play your game or you shop or you go to have your, you gotta grab the beer and let's, 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, this is something that he was just using for, you know, relief here and there in a way that, you know, he might've been uncomfortable about taking any time for himself, right? Two very different dynamics.

• 1:31:11David Puder?

  Right, right, right, right. It's, and yeah, there's so many like.

• 1:31:18David Puder?

  Variables on that, you know, it could be also sublimation of anger. Like I was, I was thinking, maybe I was going to tell you that they were violent video games. Right?

• 1:31:27Speaker 01

  Right, right. It could be, you know, I could say, you know, where can, where can the anger? Is it something come up in a couple of your, like I said, I watch, you know, where do you, where is, where is anger? It can be used in, in positive ways or ways that are at least not, you know, not, not create trouble. I mean, obviously if the violent one is, it's complex in that regard, right? Cause it's, uh, but, but, um, yeah, that's, that is a possibility. Right?

• 1:32:00David 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, if this was interesting to them. Your website is fredericknbushmd.com, right?

• 1:32:17Speaker 01

  Mm hmm. Right?

• 1:32:18David Puder?

  We'll put that in the show notes and it has a nice link to all your books, some of which are like skills training, psychodynamic psychotherapy, problem focused approach, probably highlighting a lot of the things that we talked about, but in a more detailed, detailed way. And then psychodynamic approaches to behavioral change, psychodynamic treatment for depression. You've written a lot of, you've written a lot in your career. It's impressive.

• 1:32:42Speaker 01

  Yeah. I mean, thanks. I mean, get, you know, the, the, the skills training is the latest one. It's sort of the idea, this idea of psychodynamic skills, you know, people learning these capacities to self-observe, identify context, to challenge self and other representations that are negative. You know, and I've found that sometimes you're writing these things down for both therapists and actually it could be helpful, which is not, again, not a typical psychodynamic psychotherapy kind of thing. So that one's a little bit, a little bit different as is targeting changing behavior,

• 1:33:27Speaker 01

  which is 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.

• 1:33:42David Puder?

  I noticed Howard Steele wrote a very nice thing on your, on the cover. Are you friends with Howard Steele or is he someone around there that you know?

• 1:33:51Speaker 01

  More kind of just colleagues or people that, you know, okay, where I worked with them over the years, like editing papers or they'll, you know, write something for something I was doing. So, yeah.

• 1:34:08David Puder?

  Great, great. If a patient's listening to this, you're licensed in New York. Are you still accepting clients or are you?

• 1:34:15Speaker 01

  Uh, yeah, I mean, busy.

• 1:34:19David Puder?

  That's, that's a good sign, right?

• 1:34:21Speaker 01

  Right. But so we could always call. I could also find someone who, you know, does work like this. So.

• 1:34:30David Puder?

  Yeah, that's great. Yeah. Well, this is wonderful. It's great to connect with you. It's great to, to, to do this fun role play and, and hear from you. And if you're ever in Orlando, let me know and we'll get some food or something.

• 1:34:44Speaker 01

  Appreciate it. Right now I would, I would like to be in Orlando right now.

• 1:34:47David Puder?

  It's, it's a, it's, it's freezing. It's 60 degrees out. I got my heater on.

• 1:34:54Speaker 01

  Sounds great. Yeah.

• 1:34:58David Puder?

  That's good. How, how cold is it in New York right now? It's like 30?

• 1:35:01Speaker 01

  Well, right now it's finally gotten into the 30s, but it's been a very cold, snowy winter. So, uh, yeah.

• 1:35:10David Puder?

  Yeah.

• 1:35:11Speaker 01

  It's, uh, maybe we'll, maybe something will ease up soon. So.

• 1:35:17David Puder?

  That's fun. And you're, you're doing some teaching on, for the Transfers Focus Therapy Group in Columbia, doing some stuff on trauma. Is that right?

• 1:35:23Speaker 01

  Well, I did, I did a presentation to, for them and trauma focused therapy. I do a bunch of teaching at various levels, you know, and this is targeted for, you know, residency, treat residents at a couple different places at, at Cornell, NYU, um, UPenn, uh, and, and some teaching at the Psychoanalytic Institute. So different, kind of different elements of this treatment.

• 1:35:58David Puder?

  That's great. And, and like you prescribe too, is that correct?

• 1:36:04Speaker 01

  Right, yes. And that's some of the work I've done over time is about that sort of thinking about.

• 1:36:12David Puder?

  When do you choose to prescribe and when do you not choose to?

• 1:36:15Speaker 01

  Well, the, the, I mean, yes, but, but that's, that is part of it. But I'm, I'm very interested in prescribing effects on the psychoanalytic, uh, you know, what's go, the set, what goes dynamically? Cause that they can have a lot of changes like, you know, reduce super ego or better affect regulation, things that people think like, oh, you need, like need analysis to do them. That can be helped by that or help the therapeutic process or how the ther, how psychodynamic process can sometimes help with struggles with, you know, compliance, acting out around medication,

• 1:36:58Speaker 01

  you know, how people are affected by side effects, you know, people struggle all the time with their, their doses, taking it, you know, what, you know, how that, that's something that can be looked at in, in terms of, um, in terms of, you know, psychodynamically, sometimes, it's sometimes helpful for that.

• 1:37:20David Puder?

  That's great. Well, it's great to connect with you and great to, you know, start to understand your approach to psychiatry, psychotherapy. And, uh, yeah, well, maybe we'll continue the conversation in the future.

• 1:37:34Speaker 01

  That'd be great.

• 1:37:35David Puder?

  We'll leave it there for today.

• 1:37:37Speaker 01

  Okay. Sounds great. And great, great speaking with you.