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

Episode Date: April 10, 2026

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. Link to blog Link to YouTube video

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 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 it out,

psychiatrypodcast.com, and we will start the episode down. All right, welcome back to the podcast. I'm joined with Frederick N. Bush of New York as 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, psychotheliorism. therapy, along with psychopharmacology. He's also a clinical professor of psychiatry at Cornell Medical College and a lecture at Columbia University. Welcome to the podcast. Thanks. Thanks so much for having me. 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. Bush's, one's a PhD, you're the psychiatrist, you're in New York, the other one's in Boston. And so today we're going to be talking about solution, focus, 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. Thanks. Yeah, yeah. And I guess problem focus, psychodynamic psychotherapy, I guess, solution focus 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 to keep up with all of them, but I'll try to differentiate this one. Yeah, so tell me about problem focused. Like, what does that mean for you? 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? stand from it, what is 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 kind of an open-ended exploration, whatever the person brings in. And in terms of this treatment, it's really to identify and designate a set of problems that you're working on and to keep those in mind, follow them along as you're proceeding with the treatment. So, for instance, let's say he has anxiety symptoms, depressive symptoms, you know, trouble controlling their temper, disruptions and relationships, you could say, okay, well, that's the set of problems and that's what we're going to track. And the idea is to build a psychodynamic formulation, which we can talk about around the different problems and use those to target interventions. So that keeps you on track

to sort of say, 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, dealing with these issues, you know, what's kind of what's working and not working. So it's a bare amount of difference from, you know, more traditional forms of psychodynamic psychotherapy. Okay, so I think this has been a really helpful kind of repetitive theme

that we've talked about. in this podcast of how do we find what is the main issue that they're coming in with, what is their goal. So how do you start to sort of pull that out from the first session? Well, really, you know, you can do what the usual evaluation. You know, tell me about what your problems are. And so somebody say, okay, well, I have anxiety, you know, and start to identify, circumstances and context, because that's part of the process, intensity, pervasiveness, about depressive symptoms, how severe, how disruptive are they, to get an idea up, because the way I look at problems is symptoms, behavioral issues. So those have to do with,

are there struggles with, on the one hand, inhibition, you know, difficulties with the On the other hand, you know, impulses, you know, all sorts of addictive, impulses, shopping, loss of temper, and then take a look at, yeah, what are the issues in their relationships. Do they have like some anxiety, panic, or some other issues, you know, do they have problems with regard to feeling dependent and frustrated in their relationships? or dissatisfy with their partners or, you know, with narcissistic issues, no one's good enough for them. So those are the kinds of things that as they come up, 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 going to work on your anxiety. We're going to work on your depressive symptoms. We're going to work on this issue in the relationship. We're going to work on your difficulties asserting yourself. And we'll kind of keep that in mind as the issues that we're working on going forward. And that's a sort of collaboratively built effort.

And then, you know, there are things that are going to emerge that are, you know, in the initial, don't come out initially because people may be anxious or embarrassed about them. So, you know, a problem list isn't, it's not like, oh, this is a static list and we're done. You know, we could kind of modify that as we go along. 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?

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, uh, and then relationship problems, which by the way, relationship problems is not always a focus of the psychodynamic treatment and the way it is in this treatment as his behavior. But nevertheless, you know, with regard to your question, And it's interesting because I found that a better thing with people is to talk to them about the problem, not as you have this personality disorder, but how does it manifest itself? You know, somebody has a thing that says, okay, you know, my wife told me I had narcissistic personality disorder. What do you think? You know, so I, and it's say like, well, that's, you know, 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, that people don't get you. They devalue you. You don't feel adequately recognized. So I'm going to, I'm going to, 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 language of that is more oriented towards the problem than the personality disorder itself. I think, I think, you know, I saw your talk with, you know,

freight yeoman's. And I think they say, Oh, yeah, borderline personality disorder. I think that's, he would say that they have that diagnosis. To me, that's not always as helpful as, 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?

Because, you know, a lot of personality issues, people are, you know, they're not aware of. There you go, syntonic. That's part of the nature of that. So you're looking for what they're coming in with, the problem, how that relates in different domains of their life. And you added in relationship issues at the end there, which is kind of like because maybe they're coming in

because of conflict between them and a particular person, right? And that's kind of another category. So tell me about that category, and you said it doesn't usually come up in psychodynamic thinking. Well, you know, 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 bad in 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, hey, here's the problem with difficulty that we're targeting, you have this issue with behavior,

and we're going to try to build a formulation and understand it and talk about interventions to change it. Similarly with relationships, I mean, you know, if you take one type of not uncommon case and think about, you know, formulation 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 they're worried about disrupting relationships as a threat to them.

So it's not uncommon for them to, due to these conflicts, have struggles communicating 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 going to create a problem, this is going to disrupt the relationship. So a lot of times it tends to be sort of an angry, dependent relationship, although the anger isn't being expressed directly. So I'm going to start saying, okay, well, let's look at that frustration you're experiencing in that relationship. And here that court 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 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 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 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 have been talking about disavowed anger, Dr. Lottel. 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. Yeah. So kind of the disavowal, So let's, yeah, 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 is there one that jumps out at you is kind of like this is something that you often see in New York in your practice? Well, in New York, I have to say you see everything, but if we're talking about, you know, the disavowed anger issue, which I think it's a very interesting one, you know, a common, that's a common issue, people who are, you know, inhibited about how they or don't feel, you know, safe expressing those feelings or consider that they, you know, would be dangerous and are, and are frustrated. 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. 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 and 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 can be denial. Like some people say, I don't have anger. You know, I've heard that of war or the reaction formation, trying to, you know, connect or take care of or of others. you know, those are, or even like expressing anger and taking it that, what we call undoing, like an angry statement, like, well, sometimes you're from panic patients. So, well, I hate my partner, but I really, I really love him, you know, just that there

indications that that's not safe for them. Yeah, okay. And so utilizing your approach, how do you start to help someone move? maybe from where they're disallowing, disavowing this kind of anger to bringing it more into their conscious awareness without a feeling of impending doom or high anxiety, right? Yeah, yeah. So one thing would be to help them, and this is a step in terms of this kind of approach, which is to develop an understanding of,

you know, context and feelings, you know, where do problems tend to occur? First, we identify the problem and then look at, you know, what are the situations that it happens in. So let's say, they say close attachment relationships like with their mother, with their wife. Right, right. So once we, you know, once we get that kind of idea, you know, one of the, one of the, one of the, one of the ideas here is to, we're working to build, but I'm now tending it to call a staging area. It's sort of, it's sort of more than observing ego. It's building a place to be able to step back from various problems, you know, anxiety states, traumatic states, depressive states. And, you know, I'll 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 building a way to step back from that. 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. I'd say, like, I have trouble asserting myself. And it turns out they may not have, you know, I have people like at work there 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. And one of the 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 my? So a lot of this stuff, these issues, they just, you know, they happen, you know, automatically. They're under the radar. People don't really explore them or identify them. So, you know, and what do you picture is the threat? Again, these, you know, they tend to happen, you know, so rapidly. And again, it said the question, is this unconscious or is it just not been identified? So for instance, one page, she said, well, you know, I'm worried if I bring this issue up with my, you know, wife, you know, let's say, oh, I'm frustrated about that she doesn't, you know, spend enough time with me, that she's going to get enraged and she's going to, she's going to get enraged and she's going to,

and she's going to, you know, withdraw for days. And, okay, well, let's take a look at that. Is that, is that of that, you know, what happens or what is that going to feel like? What does that remind you of? And then we might identify at that point, oh, well, what comes to mind is we, you know, kind of a 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, if I couldn't really, if I expressed any anger towards him where I was rebellious as an adolescent, you know, he would completely withdraw. He wouldn't talk to me for days.

So, you know, then we would take that and say, okay, you know, now we're starting to get a better idea of this conflict than this 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. Yeah, okay. So, like, let's go with this storyline.

Okay, so you have a parent that would maybe crumble if you were angry, maybe withdrawal, right? Or attack. Or attack. Fall apart, maybe attack. But how do you get from that to, like, change? Well, you know, the one would be to sort of say like, okay, well, let's see if you're, you know, are you under overestimating the danger in your current situation based on that? You know, in other words, that because you 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.

And it's understandable why this has felt, you know, very frightening to you. But let's understand, does it, you know, why do you feel the same thing is going to happen in the current circumstances so that you're, you're maybe overestimating the danger of your anger? we also would help it 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. Let's try this. I know. Let's try a role play if you, if your game, okay? I'll just walk into this scenario that we've co-created here.

So, 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. Well, yeah, I certainly, I understand that it is very, you know, frightening for you to be able to, you know, express your anger or choice about me.

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. Okay. Perfect. So, you know, I'm a psychiatry resident and my boss is a female and she wants me to help with accreditation. And for that, I have to do all of this paperwork and I just completely don't want to do it. but I'm not able to tell her that I'm not going to, that I don't want to do it. So it's like this has been on my mind for a month to tell her that I do, I want, she's asked me to help her, you know.

Oh, so she needs to do, it's not like something you have to do, it's something that she wants your out with? Yeah, yeah. It's probably her job to do this, to do the accreditation. You 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.

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

So what would have, so what? She'd feel like, oh, well, she's going to stop off. She's not going to talk to. I think she's, well, she's probably going to 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. Yeah. I mean, 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 taught 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'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. You know, it's like, it's like intellectually and cognitively I know that I know that something, like 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 I don't know, for a month, I've been still stewing about it, right? And so it's like there's, it feels very viscerally petrifying to tell her. Yes, yes. So I would say, you know, have one thing we could do is talk about like what you might say to her if you were to say something. you know, 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, are there other evidences that she's a person who's like that

that would stop off? I mean, how does she treat people? Does she, does she tend to be temperamental or irritable or? Not that I've necessarily seen. I haven't seen that temperamental or irritable side. And I think I've thought about this. What would I say? I've thought about this a lot. I think I've thought about saying like,

hey, I've thought about your request to help you with this accreditation and at this time that's not something I want to do because I feel like I'm pulled in a lot of directions right now and I think that 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,

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 end up not Telling her. Yeah. So what happens? Tell me about that moment. What happens that?

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

Maybe I'll just do it. Maybe I'll just help her. Maybe it would be better to help her. And then I sort of reverse myself right at the last second. And tell me a little bit about your other relationships. Do you have fears of expressing, have you noticed this with other relationships? Is this more predominantly with her? Do you find in other relationships that you're okay or safe to express these feelings?

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 it's, so it's like a love, there's a level of irrationality that I know I'm dealing with here. Right, right. Well, one thing we talked about, you know, your father's angry, yeah. I think it's more my mother, actually. I think that makes more sense to me. So tell me a little bit about that. because this doesn't this sounds a little bit different from what happened 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 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. Well, okay. Yeah, yeah. So that must, I mean, that's been a very tough thing to go through. Yeah. Oh, yeah. Yeah, I think it was, like,

I remember being like around six or seven at that time when she was going through it. And I remember, um, just kind of taking care of the house in the midst of her not taking care of the house, you know? And did you feel pressure to do that or feel if that was kind of your role or that you weren't feeling very supported? Or you just felt like, oh, this is what I have to do.

Yeah, I felt it was my role. I felt this is what I had to do. I felt sometimes happy doing it to kind of contribute. I felt like, yeah, I felt like I just had to kind of quietly help. Yeah, I mean, do you notice you tend to be kind of an over-responsible person? I mean, I know you're resident doctor. Are you? Yeah, yeah, yeah, yeah.

I mean, I think over-responsible or like over-going, going over-the-top. doing, you know, 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 do long phone calls off the hours of normal things. But I feel like with these clients, it's necessary to help them, you know. So I do feel like I go over and above. And what do you think will happen if you don't do that? If I don't do that? I mean, there's this one person that, like, I fear she might hurt herself in particular, yeah.

So I feel like, yeah, it's kind of like some added pressure. Right. Right. And does this kind of end up taking a lot of you tend to work extra hours and they're there late or preoccupied sometimes with people after work? Yeah, yeah, yeah, yeah. Yeah. And I think that that, it starts to wear on me, you know, after months and months and months of doing it.

But I feel like it's, 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. 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 these circumstances in terms of their development, and maybe we were overly focused on your father because you spoke about how scary or frightening he was, and particularly when you were an adolescent,

but it sounds like this kind of experience may be even more formative. And here we're looking at that this may lead at least to a couple different problems that not only have to do with your fear of, you know, kind of setting limits with, you know, female figure, 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 seems to create other problems for you, you know. I mean, I don't know. We need up to talk about that you get worn out or under strain because you feel like you can't set boundaries. And if you try to set boundaries, then that's something that can be deeply threatening to another person. So I think we need to explore this more with your mother because did you feel like, oh, were there fears like,

oh, she was going to die if you didn't do this? Or she, you know, she'd fall apart entirely. and maybe that's where the danger is. Not like, oh, she's going to stop off and be angry, but she is going to fall apart, collapse, and feel disappointed, as you were saying earlier. That feels relevant, yeah. There was a time where she did go into cardiac arrest at home,

and I was the only one there. I think it was seven. And I called 911 and ran over to the neighbors and got some help. But it was kind of haze. It's like my memory of it. It's kind of hazy almost, you know? It's like hard.

It's like I can remember parts of it very vividly. Like we had one of those old phones on the wall that the dial and my fingers, like it was almost hard to do that. I had to try 911 multiple times to get it. I knew it was 911. But, yeah, and then, you know, she did recover from that, but that was, like, incredibly frightening. Yeah, I mean, 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 That's a lot of responsibility for somebody to have had at that age. And, you know, 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, 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 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 a version of, you know, this person's going to collapse or be deeply disappointed to you in you. Yeah. You know, as I even talk about the, that cardiac arrest, the feeling that I get is kind of like this like nausea or like I feel like almost.

like kind of fuzzy my thoughts get a little bit more fuzzy and you know I've had all these dreams over the years I'm kind of 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 911 and then struggling to dial 911 initially that I you know I I felt like every second was going to be like I was going to kill my mother or something if I didn't dial it properly. Yeah, well, that's a very terrifying 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 terrifying experience that's been hard to talk about. And with the trauma of that nature, it's not unusual for people to, for that to kind of generalize

that people can feel like they're back in that traumatic situation and that if they, you know, art don't behave just right with this other person who needs something, that there's going to be some terrible disaster that happens. Yeah, I think with the father, the thought that comes is I never wanted to be angry like he was angry. But I'm, as I'm hearing you, as I'm kind of in this moment, I'm thinking like maybe, maybe, uh, I shouldn't be talking about this. Maybe it doesn't relate or something. Maybe I should, uh, maybe I should, uh, maybe, maybe I brought it up too early. Is that where you're saying? I brought it up too early? Or, oh, I'm doing something.

wrong. You did interbrot which up too early? My mom's, my mom, the phone calling. Oh, no, no, 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 didn't do something right, you know, within the that you still are carrying a heavy burden with that, that you, you know, that this is, you're still trouble, maybe feel you didn't, you know, do something, that you may have done something wrong.

So maybe I should have, maybe I should have brought it up earlier. I honestly didn't remember it until our conversation today though, but I guess I should have brought it up earlier in our sessions about this. I mean, I think I try not to think about it too much, you know. Like, I try to avoid thinking about it. Yeah, I mean, I would say, you know, it's not, it's understandable that you would avoid that. And from my standpoint, it's not a should or shouldn't. In fact, maybe that's something about 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. And, you know, we can explore further because there could be sorts of fears, you know, shame about these things or people can feel like this terrible sense of responsibility. And, 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 doing, you know, with this supervisor.

It's attending that you're feeling that. you know, you're kind of mapping this sort of life and death kind of threat onto that situation or experience that as, you know, the trauma that you had. 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 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 through my mind as we're talking here. It's like, oh, man, am I, like, too much for Frederick Bush? Yeah. You know, I mean, that's a painful feeling. Of course, you know, 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 travel, 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 put any of their needs into the picture that the other person's going to be troubled or could even put them at some kind of risk, and maybe that's started to fill out a picture or a formulation of understanding what you're dealing with, you know, that the over-responsibility is a threat on the one hand that you have to take

care of the person or they're going to fall apart or die, or that if you're, if you have your own needs, which you're saying, you know, that you're over, you're kind of, you're a psychiasia because you're overwhelmed, but maybe if you take care of your own needs, then you're burdening the, you know, the ending. And so you can't, you can't make a proper assessment of that, and that puts kind of a tremendous pressure on you. So I'm not burdening you too much, Dr. Bush. No, I mean, I think it's a very important. and valuable to be hearing about this. I mean, 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 kind of help to get you through this, you know, that, in other words, now we're getting a better idea why you're walking up to her and you can't say anything when it's so waited and maybe if you can see like, hey, it's safe to express your needs that it's okay, that that's, that's, that I want to hear about that, that that would help you to, to feel safer to, because 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. 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 feel myself.

I feel like kind of like a haziness. I feel like a disconnectedness or just a floaty, a little bit more floaty. And like I hear your words, but then I also. 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 that I fear that secretively, when you get out of this room, you're going to be like, that was a lot. Well, you know, I guess it's hard for you to believe about that 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 aren't 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 get the number right, you know, and it's often experienced in the body as well. And maybe that's a bodily threat you're getting when you're going up and trying to, you know, talk to the attending and you get this, I would pay attention. I'm wondering if you even get some of this bodily experience at that. time. And that's what I think that, you know, you may be feeling your back in this situation.

And one of the things that we let 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 telling the idea that you're not able to help work on this thing because you're overburdened. You know, so And I think also that you can see that I can stay with you through this, that I'm not burdened by it, even though it's hard for you to believe. I think I feel frustrated that my boss, you know, the program director, she wants me to do this at all. Like I feel like for some reason right now

Like 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 you want me to do this? Like I'm I wouldn't even know where to start you know paperwork It's like this is not something I know how to do

to do. Yeah. Well, I think, you know, in a certain sense, we could say, well, maybe, you know, that once we're talking about this trauma. Why isn't my neck so tight all of a sudden? Oh. Yeah. Yeah.

Yeah. Yeah. I mean, 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 of this out. But, you know, now this might have shifted to 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 that there's something scary to you about feeling that kind of anger? 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 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, calm frustration or, like, you know, having a voice or having boundaries. It was always just like zero to 100. And it's like I was so angry for my mom. I was just upset that that was something she had to go through, you know? And it was just kind of like, gosh, what is wrong with you? So I don't know. There's something about that that kind of resonates here.

But yeah, it's so interesting that my back just, I 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. You know, well, 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 jumping a little bit ahead. But I'm just putting out possibilities there. But 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 a burden and potentially dangerous or any expression of anger with 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 your needs because of this situation with your mother. So, I mean, that would be this kind of management of your anger is part of what gets kind of another problem we would look at, 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 afraid of being burdensome or expressing your own needs on the other. There's pretty loaded situation in there.

Yeah, it's like, the thing that comes to me right now is like, you know, 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 try to be honest with what's going through my mind.

I don't know whether that in particular is going through my mind right now. Maybe because it's like. but it's interesting that I feel this tightness in the midst of this. Yeah, I mean, maybe, you know, first of all, I think that's very good that you did, you know, bring this out. I mean, obviously, if they talk about,

look into 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 it seems to contain all of the issues that you're telling you,

are going to burden me, maybe you're bad, that you have to rush over, even though you can say anything about it. So, you know, maybe that's a sign, of, oh, maybe you felt more safety to actually raise something with me. Yeah. Yeah, it feels good. Thank you for, 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. Yeah, I mean, that's really 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, 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 these things can be expressed and you can feel safer and where we can understand, as we've done better, where these kind of problems come from. You know, 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 recommendation that you have on? 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, you know, with regard to, you know, 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, 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, let's say, like, hey, maybe we should think about, are you trying to avoid something here? And, you know, I mean, it's bad.

I think some people might you like, oh, okay, hey, I'm going to 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 actually need to get some work done, but I'm pushing to play these video games, is sometimes we can start to understand, well, are some of these issues coming to the four at that point? So it would be less a matter at this point if should or shouldn't, but I think we would want to understand more about, you know, like it represents for you.

And is it kind of 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? That's good. All right. Let's pause our roleplay. 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 over the course of multiple sessions, right?

Or even like six months of helping someone. But then how you addressed it, we should maybe comment on those things to kind of, because I think this was very practical, you know, and I think this kind of scenario, it shows a bunch of things all at once, right? So I appreciate you. Right. Yeah, I mean, I would say, you know, to put it in terms of, in terms of, you know, not to make it too schematic, but to think about it in terms of a grid that I would have in my mind, and in terms of the problem focus,

one is like kind of identifying problems as we go along. Okay, here's one of over-responsibility, here's one of conflicts about expressing anger, you know, fears of assertiveness, so that, you know, again, now usually if somebody's in the midst of telling me of trauma with their mother, oh, you know, here's, let's do it problemless.

I mean, obviously, we want to get into that point. The second is, you know, 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 identification of context, and in that emerged this very interesting thing, which you came up with somehow in the role play,

that we were kind of 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 were looking at the father's wages and the reactions to that,

although we think that's a piece, but maybe 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. And then a third step is trying to, working to connect the past experiences, whether adverse or traumatic, to help the person both understand,

and why they're struggling with these, why they're vulnerable to these types of problems and, you know, how they may directly connect, how they might lead them to overestimate the dangers currently, self and other representations. Again, I'm just going through the whole formulation list. Oh, I'm a, I'm a, I'm a, a burdensome person and the other person is vulnerable to that.

I'm an angry person and I may injure the other person or I'm a person with needs and the other person's going to be angry at me. Those are kind of three types of self and other representations that are going on. You know, a next step, you know, conflicts around. conflicts around anger and needs, right? Oh, my anger is going to be damaging and dangerous. And, you know, my needs are going to be burdensome and create a problem. So kind of highlighting those conflicts.

We'll skip over mentalization, which is another step, at least for right now, although I guess we could say, I don't want to throw in too many days, 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 because you feel like their reactions are going to either be irritable or, you know, burdened. So there's a certain kind of rigidity. That's another piece. So each of those are kind of, as I'm hearing it, I'm kind of building this grid.

And the interventions are targeted for these elements, 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 where it's coming from. You know, one thing about this is that, you know, when you have some different people who speak about, like, for instance, humans, we're, okay, we're focusing on the object relation. That's our central issue.

And this is like, oh, here's different, we're looking at these different elements. Because people are going to respond to or recognize different kinds of things. putting together a picture or what tell, oh, we're 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 worked. So there is that. But so those are the factors of I'm identifying and working to kind of put together what I call the formulation, which is or how, what are these different pieces.

And we could talk about, well, how many might identify them or challenge them or shift them. 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 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 the person you know, was actually feeling these different things that they were describing. Do you know what I mean? Well, you know, I mean, first of all, I thought it was, I mean, I'll be curious how people react to it. I thought it was pretty good.

And I kind of noticed, to me, you know, in terms of the role plays that I've seen you do, I felt you were very present and authentic, you know. I mean, sometimes it's harder than others, right? to be in this position. Yep. I thought it felt, it felt pretty authentic. Okay.

And to me... Okay. And then I guess the second thought would be... 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 roll play that into the scenario a little bit. So in this scenario, I was dissociating in the midst of, you know, the phone call scenario, right, during the cardiac arrest of the mother. And then, you know, this was like a life, this felt like a life for death situation. This is obviously the nitis of, you know, where a lot of the psychological stuff is because of the repetitive nightmares that are relating to, phones and such.

The transference that comes out is projected onto you, you know, and 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 fear of being burdensome from the mother, placing that onto you, right? with the shame and the kind of like the uh the traumatic some of the traumatic vibes there of nausea and and such and then the um yeah so 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? Yeah, you know, I mean, well, I want to go back to her prior question for a second. Okay. So I want to say, like, in terms, there's a couple things in terms of how I handled that. You know, first of all, you know, there are one thing with revisiting of 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, treatments that were the primary approaches that were like 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 in. We live the trauma and others that it's important to step back. I do this kind of foregrounding, backgrounding approach. In other words, I step into the trauma with the person,

and then I'm working on stepping back from it and helping them to understand, 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 I weren't trying to demonstrate a little bit more about how this therapy worked. I'm going to, yeah, I've stayed a little bit longer in that, in that place with you. But I feel that if you, sometimes if you stay in a trauma too much, you can over, you can

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, one of the things, I don't think I mentioned earlier, sort of say, like, kind of this, what's it, a 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. So the different currents are the struggles with anger, this traumatic event, the positive.

with the father, and we're identifying, you 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 that that thing were, it shifted to me, in other words, that it would safer there. Okay, well, yes, I think that can happen.

I think that's a pretty good outcome. You know, in other words, that you were able to express that, and that the anger came out not only with me, but towards the program director, you know, that showed like, oh, we hit something. We did, we did something. So I would say, you know, that it didn't come out at the, oh, you know, I was angry at my mom and dad, because they put me. 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 felt this way, that you felt similarly 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.

what it feels like with your program director. That's another step that we could work to build on. Yeah, I want to maybe like bold or like draw attention for the listeners that coming out of the dissociation, 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 coming out into the anger.

and the anger in the role play was towards the program director. Like, gosh, why did she give me this? It was also towards you, right? But in a very gentle way of like, I've been wanting to have a voice to changing the time of our sessions. But you could see all the fear that led to the, you know, this kind of interpersonal repetition that the patient was unable to ask you this before, right but now that they're coming out of the dissociation into the frustration it's like it gets

kind of associated from in the frustration to like this and you be welcoming you know welcoming the conversation welcoming the invitation your enthusiasm for the person to talk about this i think is is uh 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. Right, right. 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 an important, you know, mechanism for further change. You're testing out now with me whether these things are actually safe. Am I burdened? Am I angry? And, yeah, I thought that that was a very good sign.

in terms of the emergence of that. 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 seen from this roleplay? Because I think it, you know, the roleplay allows for people to kind of like grab onto something where it's not just purely theoretical, which is why I think it's so powerful. Any other threads that you've been thinking about or like ways of of thinking about this that relate to your model? Well, again, you know, I mean, sort of what I highlighted before,

how I'm 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 don't want to have, you, it's a semi-flexible, It's not, I don't mean 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, you know, talk to the program director.

And then partly you're kind of like, well, you know, this isn't doing anything and that we go back and we find out, let's re-look at the context. Let's re-look at what you're experiencing and open up another dynamic piece. So that's one element that I think is important to say that this is, even though, you know, we're part of the idea of this. And 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 done, and yet remaining open to here's a new or different dynamic.

here's an identification of a trauma that's even more powerfully relevant to the current struggle. I know 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 from a more trauma-focused, psychodynamic psychotherapy, what kind of things can we learn about your approach? 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? Yeah, and that was written with, you know, co-authors, Barbara Milrod, Corey Chen, who was actually, you know, working at the VA so that we did, you know, we did work, you know,

with therapists, with, you know, with veterans. So, you know, really was a severe, you know, trauma, there, and Marianne Singers, so just to mention them, because some of the books are single author on and some are with, you know, with co-authors. But, well, one of the elements is to link the current symptoms with past trauma.

So how are we, you know, that people are often not aware of the link of their current symptoms to pass trauma because there's a, you know, a dissociation that's taking place. Now, now you could say, well, that dissociation is just as a split that occurs at the traumatic event and we need to relink them. You could think of that as maybe Jeunet'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. So, but either way, you know, we're, we're trying to leak that. Now, if the person, so I'm going to say, 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, that's one of the elements that I'm trying to do. And 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. Because, again, that provides a basis for understanding that connection of your current experiences to trauma, part of building this framework to be able to step back. A second one that I tried to throw in there quickly was, was, you know, repeating of trauma.

So that's a big dynamic theory. So there's a couple key aspects of that. You know, one aspect is 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. So it's a form of that. So this person, he's experiencing, you know, what may be a tense situation.

It's a little bit tricky because she's the pause, but he's experiencing that connection as a recurrence of the trauma. But there's also ways in which people unconsciously repeat trauma, and that partly is there's some proneness to getting himself into situations or yourself into situations where they're overly burdened and feeling not responded to. And not intentionally, you know, partly because of the struggle around saying anything, but you'll see this like, you know, patient of mine said, oh, I can't believe my daughter, Mary, this narcissistic guy when she had this father. Well, you know, the idea is that

people can repeat these because they're trying to make them come out differently. They're trying to, you know, had a different outcome each time. So they inadvertently, through various means, repeat the trauma and trying to control it better. There's a, I have a bunch of us, so I don't know whether you want to stop or comment. But I want to put in another element, identification with the aggressor. So that's another, that's a common trauma-related defense.

So, yeah, I mean, the most common form of that is the bully who was bullied, you know. But many times this sort of identification with the father, with the father's aggression is a very complicated thing, because to the extent that there's fantasies of expressing anger, they may be like wanting to control or be hurtful. We didn't get to that quite yet, but that can create tremendous shame and guilt.

I mean, you could get the bully who was bullied. It may not be so terrible. conflicted. I mean, we see that too, right? But people with that, that it's all that 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 someone traumatized, they have fantasies that they want to hurt other people like they were hurt, that that can, that can create tremendous distress for them. Yeah. And I think sometimes 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, oh, absolutely. Or I even have had patients who, it's the, they become the perpetrator to themselves. So the, so they are, um, violating themselves sexually, for example, if they were, if they were, and so it's like they

become the perpetrator soon after even, you know, like soon after the trauma. Right, right. And that maybe if 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 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 origin of that. That's a very good point.

The repetition of the dynamic, I think, was very evident in this story. And by the way, guys, this is stuff I've seen. Like there's residents that I've known who have hidden from everyone. And maybe I was the first person that they told that they were having long conversations with patients, you know, off the books, right, as a way of trying to save these patients, right? You know, when you're, especially when you're young and you're in their first couple years of treating people or nurse practitioners have told me these stories as well. they end up having a really hard time containing the frame, the structure of the treatment. And then they have an even harder time pulling back the frame, the structure of the treatment. These are pretty common issues, I think, with a lot of professionals out there.

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 can be. from other issues, right? 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 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. Right, right. And generally, to be careful to empathize and not shame, but in that one, again, you know, 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, but 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 just sometimes they'd say, like, okay, well, why don't you wait? Let's try waiting 30 minutes before you place your bet or play your game or you shop or you go to have your, you've got to 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 relief here and there in a way that, you know, you might have been uncomfortable about taking any time for himself, right? Two very different dynamics. Right, right, right. And, yeah, there's some, many like variables on that you know it could be also sublimation of anger like i i was i was thinking maybe i was going to tell you that they were violent video games right right right it could

be you know i could say you know where can where can be anger is it something come up in a couple of your i guess that i watch you know where is where is anger it can be used in in positive ways or ways that are at least not, you know, not create trouble. I mean, obviously, if the violent one, it's complex in that regard, right? Because it's, but, but, yeah, that's, that is a possibility, right. Great. Well, I think we should probably be wrapping this up pretty soon. I do want to highlight you have some other books and people should check you out if this was interesting to them. Your website is Frederick N.bushmd.com, right? Mm-hmm.

Right. 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, psychodamic, 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 read it a lot of, you've rid it a lot in your career. It's impressive.

Yeah, I mean, thanks. I mean, again, you know, 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 found that sometimes you're writing these things down for both. therapist and actually could be helpful, which is not, again, not a typical psychotic psychotherapy kind of thing. So that one's a little bit, a little bit different, as is targeting changing behavior, 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. I noticed Howard Steele wrote a very nice thing on the cover. Are you friends with Howard Steele, or is he someone around there that you know? More kind of just, you know, colleagues or people that, you know,

where I work with them over the years, like editing papers or they'll, you know, write something for something I was doing. So, yeah. Great, great. if a patient's listening to this, you're licensed in New York, are you still accepting clients? Yeah, I mean, busy. That's a good side, right?

Right. But somebody could always call. Also, well, find someone who does work like this. Yeah, that's great. Yeah, well, this is wonderful. It's great to connect with you. It's great to do this fun role play and hear from you.

And if you're ever in Orlando, let me know and we'll get some food or something. Appreciate it. Right now, I would, I would like to be in Orlando right now. It's freezing. It's 60 degrees out. I got my heater on. Okay. Sounds great. That's good. How cold is it in New York right now? Well, right now it's finally gotten into the 30s, but it's been a very cold, snowy winter. Yeah, yeah. Maybe something will ease up soon.

That's fun. And you're doing some teaching for the Transters Focus Therapy group in Columbia, doing some stuff on trauma. Is that right? Well, I did a presentation for them in 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 Cornell, NYU, UPenn, and some teaching at the psychoanalytic institute. So different kind of different elements of this treatment. That's great. And like you prescribed too? Is that correct? Right. Yes. And that's some of the work I've done over time is about that sort of thinking about.

When do you choose to prescribe and when do you not choose to? Well, I mean, yes, but that is part of it. But I'm very interested in prescribing effects on the psychoanalytic, you know, what goes down dynamically because 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 analysis to do them that can be helped by that or help the therapeutic process or how the therapy, how it's like that an ania process can sometimes help with struggles with, you know, compliance, acting out around medication, you know, how people are affected by

side effects, you know, people struggle all the time with their doses, taking it, you know, what, you know, how, that's something that can be looked at in terms of, in terms of, you know, psychodynamically, it's sometimes helpful for that. 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, yeah, maybe we'll continue. to do the conversation in the future. That'd be great.

We'll leave it there for today. Okay, sounds great. Great speaking with you.