Psychodynamic Treatment for Separation Anxiety in a Treatment Nonresponder

The Syndrome of Separation Anxiety

Patients with separation anxiety experience significant anxiety when anticipating or experiencing separation from important attachment figures. They worry excessively about losing important attachment figures or about harm befalling them. They may refuse or be highly reluctant to be alone or leave their home (agoraphobia). Somatic worries are frequent, particularly when separated or anticipating separation. Separation anxiety disorder in adults has high prevalence (6.6% lifetime prevalence in the National Comorbidity Survey Replication; Shear et al. 2006), and those with the disorder show greater disability, anxiety, and depression relative to other patients typically treated in anxiety disorder clinics (Silove et al. 2010).

The clinical syndrome of separation anxiety (SA), in which the symptoms are more severe and the impact more pervasive, is a common precursor to anxiety disorders (Manicavasagar et al. 2010; Kossowsky et al. 2013). SA is a risk factor for nonresponse to treatments for several anxiety and mood disorders (Aaronson et al. 2008; Benevuti et al. 2010; Coryell et al. 2012; Frank et al. 2000; Milrod et al. 2014). The adverse impact of SA suggests a need to develop treatments that can effectively target SA, with the idea that such interventions might be of benefit in the treatment of anxiety and depression (Milrod et al. 2014). Psychoanalytic treatments may be of value in addressing SA. The impact and ramifications of separation anxiety and ambivalent attachments have been a longstanding area of clinical interest for psychoanalysts (Pappenheim and Sweeney 1952; Bowlby 1960).

There is a substantial literature concerning the dynamics of separation and attachment (e.g., Bowlby 1973; Busch et al. 1991, 2012; Deutsch 1929; Shear et al. 1993; Main 2000; Milrod et al. 1997; Nolte et al. 2011; Shear 1996). Separation fears, complicated, ambivalent attachments, and associated unconscious conflicts have always been a central concern in the dynamics and treatment approach to panic disorder as operationalized in Panic-Focused Psychodynamic Psychotherapy/eXtended Range [PFPP/PFPP-XR] (Busch et al. 1991, 2012; Milrod et al. 1997). Patients with panic disorder commonly struggle with chronically problematic, dissatisfying relationships that they find difficult to change, because they fear that acknowledging or expressing their frustrations and rage could lead to the loss of these crucial attachment relationships. We believe that conflicts surrounding ambivalence are particularly severe in patients with significant SA, intensified by fears that the attachment figure is easily damaged, often resulting in quelling positive feelings and mutuality in close relationships. The inability to tolerate or acknowledge ambivalence or to effect meaningful change in disappointing relationships can exacerbate depressive symptoms (Rudden et al. 2003; Busch et al. 2004). Complicated attachment relationships and the associated ambivalence these patients experience may be replicated with therapists, and with doctors and caretakers more generally, often disrupting therapeutic efforts and leading to nonresponse. The prospect of increased autonomy can be experienced as threatening the relationship with needed others, potentially triggering an urge to flee the treatment, a form of negative therapeutic reaction (Freud 1923). Careful attention to close attachment relationships and the accompanying intrapsychic conflicts of patients with significant SA may therefore enhance treatment response. We hypothesize that PFPP-XR, like psychoanalysis and intensive psychodynamic psychotherapies, addresses problems that may otherwise lead patients not to respond to therapeutic efforts. In certain instances, as in some patients with severe SA, such interventions may need to be made quite early on to prevent a disruption in treatment. These psychoanalytically based approaches may also be of value for other health professionals working with such patients.

Separation Anxiety and Ambivalent Attachments

Patients with SA are beset with fears of losing a significant attachment figure, with whom there is typically a complicated ambivalent relationship (Bowlby 1973; Busch et al. 2012; Shear 1996). A core terror for patients with SA stems from a belief that by themselves they cannot function adequately. The danger perceived in separations or in being alone fuels worries that harm may befall themselves or others. Separation fears can present in the form of somatic symptoms symbolizing these dangers. Such symptoms can also be a defense against feelings and fantasies seen as threats to attachment relationships. Increasing personal autonomy, as we have mentioned, can be experienced as threatening to ambivalent attachment relationships and thus raise fears of losing someone who is depended on. These patients may unconsciously fear punishment or rejection for greater self-assertion and autonomy (Busch et al. 2012).

In the literature, the role of anxious parents in the development of separation anxiety has been emphasized (Milrod et al. 2014; Hudson and Rapee 2002; Last et al. 1987, 1991; Rosenbaum et al. 1988). In our clinical experience with SA patients (Busch et al. 2012), they commonly report that separation and autonomy were viewed by caregivers as dangerous or not acceptable. Age-appropriate separations, such as school attendance, sleepovers, or summer camp, were perceived as being discouraged, and the dangers of separation emphasized. Patients often report that their parents became angry or rejecting in response to their child’s growing autonomy, burdening efforts at independence with an emotionally complicated overlay. These patients also report believing that attachment figures were easily threatened or vulnerable, and that they therefore had to be careful about expressing their own needs, instead feeling the need to monitor their caregivers’ safety and moods. These patients internalized a view of separation or greater independence as dangerous or damaging to significant attachment figures. These feelings persist into adulthood or can be triggered again by stressors perceived as threatening to close relationships.

Patients with active separation anxiety and attachment fears commonly have difficulty tolerating and expressing anger (Bowlby 1973; Busch et al. 2012). Patients may fear that their anger will disrupt the relationship with close attachment figures by triggering rejection or damaging others. Worries about harm coming to significant attachment figures can be a displacement of fears of damaging them because of the rage they trigger. Fears of being assertive may lead to a submissive stance in attachment relationships that can exacerbate feelings of helplessness and anxiety. Conflicted anger and separation fears trigger defenses that diminish awareness of associated feelings and fantasies. Somatic symptoms, denial, or confusion can be unconscious means of avoiding awareness of frightening fantasies and memories of traumatic developmental experiences.

Our observations of adults with clinically significant SA suggest they experience intense anger and ambivalence that feels intolerable, and view positive attachment and love as almost obliterated in their fraught relationships with close attachment figures. Although conflicts surrounding anger, ambivalence, and attachment may be common across mood and anxiety disorder patients, we believe the degree of conflict and threatened disruption in relationships is particularly severe among those with SA, with significant consequences for their anxiety and interpersonal relationships. These patients believe they must accept chronically problematic and dissatisfying relationships. They imagine that acknowledging, much less expressing, any dissatisfaction would have catastrophic consequences, such as their unwittingly damaging others or disrupting relationships, leaving them terrifyingly alone. Anger at close attachments typically gets directed toward themselves, adding to depression and hopelessness. Blaming themselves, they believe they cannot expect better relationships because of their own personal inadequacies.

Therapeutic Approaches

Our research group developed a manualized treatment intervention that is psychoanalytic in nature yet syndrome-focused and time-limited, PFPP-XR (Busch et al. 2012). PFPP-XR has been studied in twice-weekly treatments conducted over 21 to 24 sessions. In a series of studies we have found that symptom focus and identifying and addressing intrapsychic conflicts, including those arising in the transference, are valuable strategies in reducing panic disorder symptoms (Milrod et al. 2000, 2001, 2007). In the PFPP-XR approach to SA, therapists work initially to clarify the specific content of feelings, fantasies, and perceived dangers surrounding separations. This consists of identifying and addressing core fantasies, including, but not exclusively, (1) imagined catastrophic dangers surrounding separation; (2) a sense of incompetence and helplessness in being or doing things (or even thinking) alone; (3) a belief that close relationships are fragile and can be easily disrupted; (4) a perception of others as fragile or easily damaged; and (5) a view of autonomy and anger as being dangerous or unacceptable.

Despite views of themselves as being inadequate or incompetent, SA patients typically have perceptions of themselves as capable and competent in certain areas. These areas of competence are often unacknowledged, due to overriding separation fears and the sense of threat that is created by feeling capable. Therapists help patients recognize alternative ways of evaluating themselves and others, such as viewing themselves as more competent and others as less fragile. This approach makes fears of separation and assertion more evident to the patient and, gradually, more ego-dystonic, which is a specific goal of PFPP-XR. Therapists can then examine with patients what contributes to their view of themselves as frighteningly incapable.

Interventions that help patients identify and tolerate their conflicted anger (and at times unconscious revenge fantasies) help diminish catastrophic fears of attachment relationships being disrupted. Greater acceptance and understanding of anger can also diminish guilt, thereby easing self-criticism and depression. Less conflicted and frightening experiences of anger contribute to patients’ becoming freer to be assertive in current attachment relationships. The increased capacity to express and negotiate needs can help them develop more satisfying interpersonal relationships. As patients become gradually less submissive, self-directed anger diminishes.

Genetic interpretations and the exploration of developmental factors can help patients understand the origins of their fears and ambivalent attachments. Identifying perceptions of caregivers that have contributed to separation fears helps clarify conflicted feelings and fantasies surrounding attachment. Reexperiencing these emotional conflicts in the transference can provide a salient opportunity for patients to identify and articulate threats they perceive in their attachment to the therapist. Because PFPP-XR is time-limited, patients can rapidly be engaged in addressing separation fears and angry feelings and fantasies involving the therapist, particularly as termination approaches.

Identifying patients’ defenses against awareness of ambivalent feelings and fantasies is essential to better access and identify unconscious conflicts. In addition to defenses commonly found in panic patients (Busch et al. 1995), including somatization, reaction formation, undoing and denial, several of our patients with severe separation anxiety reported experiencing a confusional state. Typically this confusion defended against frightening feelings, fantasies, and memories surrounding separation and anger. Bringing the patient to recognize these defenses is an important task of PFPP-XR, as the therapist works to translate these inchoate states to verbal expressions of feelings, fantasies, and a coherent view of self- and object representations. Avoidance of separations (or of situations that symbolize separation) can be used, as can somatic symptoms and confusional states, as a stepping-off point from which to explore unconscious conflicts and traumatic memories that play an organizing role in the patient’s symptoms.

To illustrate the dynamics and treatment approaches in PFPP-XR, we describe a patient with separation anxiety, major depression, and generalized anxiety disorder who was treated in a 21-session PFPP-XR psychoanalytic psychotherapy, as part of a clinical trial conducted by Weill Cornell Medical College for nonresponders with SA and anxiety disorders. We describe how PFPP-XR guides the interventions, aiding the analyst in rapidly identifying conflicts contributing to this patient’s severe separation anxiety. In addition, we illustrate how a brief treatment allows the analyst to rapidly and intensively address separation fears in the context of transference and extratransferential relationships.

Case Example

Mr. S., twenty-three years old, described a history of panic attacks, separation anxiety, and depression, and had failed to respond to three trials of antidepressant medications and three psychotherapies. The psychotherapies included one cognitive behavioral treatment and two referred to as counseling, each lasting at least ten weeks. Transcranial Magnetic Stimulation led to some improvement in his depression but did not affect his anxiety. He was diagnosed on the Anxiety Disorders Interview Schedule IV (ADIS-IV; DiNardo, Brown, and Barlow 1995), a semistructured interview that assesses the presence of DSM-IV Axis I disorders, as having generalized anxiety disorder, social phobia, and dysthymia, each with a severity level of 6/8 (very severe), and separation anxiety rated at 7/8 (extremely severe, causing near standstill). The ratings were obtained by a reliable independent rater.

Mr. S. had been diagnosed as an adult with attention deficit disorder and had occasionally been prescribed Ritalin.

The patient initially complained of being in a “fog” that interfered with moving “forward” in his life. He was also highly distressed by criticisms from his female boss and his girlfriend, Linda. Within the first several sessions, the therapist, realizing the level of threat this patient might experience in confronting someone close to him, identified a pattern in Mr. S.’s relationships with the two women. Mr. S. tolerated what he described as “abusive behavior,” including severe criticism, sometimes expressed in public to humiliate him, such as being called “lazy” and “stupid.” For instance, when Mr. S. said he might resign from work to attend law school, his boss responded, “Oh yeah, I wouldn’t have you as a lawyer because you wouldn’t show up for my case and I would go to jail.” For her part, Linda routinely criticized him for not keeping his apartment clean enough, for not making enough money to buy her things she wanted, and for not wanting to get married right away. He felt incapable of expressing anger effectively to get either of these women to stop complaining, as he feared disrupting or losing the relationships. To complicate matters, he was consumed with the fantasy that both of them were fragile, and that he needed to take care of them. His caretaking included feeling responsible for ensuring the happiness of Linda’s ten-year-old autistic son, Adam.

Given the intensity of his ambivalence and the degree to which it inhibited his expressing any disagreement in his relationships, the therapist thought it likely that this pattern had begun in his earliest relationships. On exploration, Mr. S. reported a similarly complicated ambivalent attachment to his mother, an immigrant from Nicaragua. He both “loved” and “despised” her, but was fearful that any expression of anger would disrupt their relationship and cause her to reject or punish him. He believed he needed to protect her because she was an immigrant, and he thought of her mostly as being alone in the world, viewing her husband, his own father, as “emotionally distant.” He described his childhood with her as traumatic, including frequent punishments that he viewed as unfair and abusive, such as being hit with a belt for minor infractions (e.g., talking too loudly), and significant neglect. His mother was unempathic, and her attention was divided among ten children. She was a fundamentalist Christian, and Mr. S. strongly disagreed with her ideas about how God rewards and punishes behavior, which he viewed as rigid and unthoughtful. For example, she told him if he did not fear God he would be punished and that giving to the church should come before meeting his own needs. Mr. S.’s father was a theologian from whom he developed an interest in philosophy, but the patient was angry at him for being passive in tolerating his wife’s punishment and neglect of the children.

Employing the PFPP-XR formulation for SA patients, the therapist wondered if Mr. S.’s “fog” was a way of avoiding painful feelings, fantasies, and memories. Mr. S. described the “fog” as a state of confusion that enveloped the traumatic memories of his childhood; he said he did not remember most of it, other than a pattern of punishment and neglect. In addition to what he viewed as his mother’s abuse, the painful episodes he did recall emphasized his feelings of inadequacy, and of being frightened and alone with a lack of empathy from others. When he was nine, Mr. S. was hit by a car, injuring his leg, though not severely, when hurrying to keep up with his siblings and his father. His father said, “Don’t you ever tell your mother about this!” and expressed little concern about his son’s injury, essentially blaming him for the accident. He recalled being teased and bullied from the age of nine until he was twelve, and was aware at the time that there was no one to protect him. When he was nineteen, he was alone in a room with his eleven-year-old brother when the brother died from cancer. He recalled little empathy from his parents, who were perhaps struggling with their own feelings about the loss. Since that time, Mr. S. had recurrent dreams in which he was searching for his brother. When the therapist asked if he was close to his brother, Mr. S. seemed disconnected from his feelings: “I don’t remember. It’s the fog.” Although Mr. S. had received treatment for ADD, over the course of his therapy he came to believe that it was his compelling, warded-off memories of punishment and neglect that disrupted his concentration, rather than an underlying neurobiological disorder. He also became aware that the fog enveloped his thinking whenever he contemplated making changes in his life, including his job or his relationship with Linda.

Given the degree to which Mr. S. felt threatened by expressing any anger, a core component of the PFPP-XR formulation, the therapist believed it had likely affected earlier significant relationships. Mr. S.’s struggle with anger and with communicating his concerns had undermined his three previous psychotherapies, all of which were ineffective. At no time did he communicate to any of his therapists that he was not feeling helped, as he worried about disrupting the relationship or hurting the therapist. He said he did not tell one therapist about anger he harbored toward others because she was “too nice.”

In early sessions, the therapist worked with the patient to clarify his separation fears. Mr. S. described his belief that he had to accept abuse from his girlfriend or she would leave him. He feared losing the relationship, as her physical presence relieved his overwhelming anxiety, and he felt at least somewhat loved, which he had rarely felt growing up.

When the therapist told Mr. S. that the initial session was over, he requested that in the future he be given a five-minute warning, because ending the session was so upsetting. The therapist said they should explore his concerns about leaving the session. Mr. S. replied that he needed to have time to get his feelings under control before he left the office. The therapist noted the importance of identifying and understanding these emotions, as the need to get them under control was likely related to the danger he experienced about saying good-bye.

The therapist further explored Mr. S.’s struggle with angry feelings, with the goal of easing the threat and conflict he experienced around anger, along with the tendency to defensively avoid such feelings. In the second session, Mr. S. described a pattern of his anger building up inside him whenever his girlfriend or boss criticized him, followed by a switch to feeling inept, sad, and submissive. The therapist noted how his anger seemed to morph into self-criticism and depression. Mr. S. replied that despite his anger, he needed to take care of the women so they would be nice to him. The therapist pointed out that this approach, which again demonstrated his intolerance of his anger, did not appear to be working.

Mr. S. then missed two appointments and was quite late to the next one, the third session with the therapist, claiming confusion about the time; his continuing the treatment appeared to be in doubt. In line with brief psychoanalytic psychotherapeutic approaches, the therapist presented an early formulation. He described how Mr. S.’s confronting his feelings in therapy and the possible impact of traumatic experiences on his emotions were leading to a surge in his “fog,” this time enveloping session times and attendance. Mr. S. feared his feelings would lead to disruption and loss in his relationships, causing him to accept behavior that he experienced as hurtful. He also believed that he needed to protect the women he felt close to, because they appeared vulnerable to him, despite their overt aggression toward him. In addition to causing these women to reject him, Mr. S. feared his rage might damage them. He felt guilty about being angry and directed this anger at himself, seeing himself as bad or inadequate, identifying with the aggressors’ view of him. For example, when Linda was angry at him for wanting to spend more time with his friends independently of her, he blamed himself for wanting to do things that hurt her. Thus, he believed that his emotional needs were unacceptable, and that he had to yield to the needs of others. In addition, when his fear of being angry and his fear of loss became more severe, he suddenly felt as if he were in a “fog,” in which he became confused about what he was experiencing, and his memory and concentration were disrupted. Fears of loss and the assertiveness involved in moving forward in his life, such as going to graduate school or breaking up with Linda (which carried with it a fantasy of becoming more autonomous and less childlike, but necessarily more alone), also triggered his experience of the fog.

After this session, in apparent response to the formulation of how the “fog” functioned to help him avoid painful feelings and traumatic memories in his life and in therapy, Mr. S.’s attendance at therapy sessions improved significantly. He began to talk more about his experiences of neglect and punishment growing up and how it affected his current fears and relationships. He described an image that had come to his mind of being “jammed inside a barrel” with his painful childhood memories. He felt that a lot of energy was trapped inside the barrel, and he was unable to escape, which caused depression, anxiety, and the fog. This image appeared to represent the sense of frustration and helplessness he experienced in response to his mother’s punishments and his feelings of isolation. Shortly after exploring the barrel fantasy, he was able to acknowledge being angry at the therapist for having difficulty setting a regular time for him, although he recognized he had contributed to this situation, as the times he was able to come had become more limited. Other patients had regular times, whereas he was at the whim of cancellations, he noted. He then reported he could not look at the therapist. When the therapist asked why, he said he did not want the therapist to hate him; he did not want to injure the therapist; and he did not want to start off on the wrong foot. The therapist interpreted that Mr. S. needed to defend against his angry feelings because he felt it would disrupt his relationship with the therapist. It was important for Mr. S. to be able to identify his feelings of anger and to express his frustration; this was the way out of the barrel. Therapist and patient returned to the image of being jammed in a barrel of childhood traumas several times in the course of the therapy.

In the context of easing the dangers of assertion and separation, the therapist began to gently confront Mr. S.’s view of himself as incapable of addressing his problems with others. Mr. S. presented himself as being helpless, and stated repeatedly that he needed the therapist to give him specific instructions to effectively deal with his symptoms and relationships. He expressed frustration that the therapist did not do this enough. Mr. S. said he had no idea how to manage his passivity, submissiveness, and anxiety in relationships, and complained that he had no role models for expressing himself in an assertive manner. The therapist told Mr. S. that he was experiencing the therapist as being neglectful, like his parents had been, and pointed out that Mr. S. was minimizing his own capacities. Mr. S., still frustrated, responded that the therapist’s response was like telling your child who needed help with math to go work on his homework.

On the day of session 5, Halloween, Mr. S. called to say that unless the therapist changed the time of their session that afternoon, his nephew would not be able to go trick-or-treating, as he was the only one available to accompany the boy. The therapist focused on (1) why Mr. S. felt the need to put the therapist in the position of depriving a child of trick-or-treating, transferring his sense of guilt and self-abnegation to the therapist, and (2) the responsibility Mr. S. felt in his relationships with others, treating his own needs, such as his current need for therapy, as secondary. For instance, Mr. S. did others’ work at his office while ignoring his own work, spent money on items for his girlfriend and family that he wanted to save for graduate school, and took care of his sister’s children when it led to his missing work. And now the same conflicts were being played out in his therapy. The dynamic aspects included the following: (1) Mr. S. felt he needed to care for others, whom he viewed as fragile; he systematically overemphasized others’ fragility. (2) He placed others’ needs ahead of his own as a way of maintaining close relationships, with the fantasy that this would ensure others’ love. (3) He took care of others’ needs to keep them from attacking him. (4) In accordance with his mother’s religious views, he thought of any needs of his own as being bad or selfish. When he became aware of any of his own needs, which tended to be shrouded in the “fog,” he felt intense guilt. (5) He had the fantasy of being a hero for being self-sacrificing. (6) He took care of others as a reaction formation, a way of magically undoing his rage and wish to harm them.

Employing this formulation of the patient’s conflicts in a series of interpretations, the therapist told Mr. S. that if he could not identify his own feelings and needs, he would not be able to negotiate his relationships with other people. In essence, he believed there was no possibility of getting his needs met by others. Mr. S., showing increased comfort with his feelings, acknowledged anger about being in this position, but he felt stuck with his anger. If he tried to express his wishes, he felt guilty. The therapist noted that he unconsciously arranged to be punished, as by having relationships with others who were critical if he asked for something. For example, when he attempted to communicate to his girlfriend that he wanted to spend more time with his friends, she attacked him harshly, calling him a jerk. Finding himself caught between others’ various demands, he would become confused about time and his awareness of his commitments, typically missing one of them, which inevitably made people angry at him. His conflict over whether to come to therapy or take his nephew trick-or-treating exemplified this pattern.

As Mr. S. began to recognize the sacrifices he made for people in his life, he became increasingly aware of how angry he was about yielding to others’ needs. He felt routinely taken advantage of; though he did not protest, he felt compelled to agree to do things against his wishes. In a pattern often seen in PFPP-XR, he began to make efforts to express his anger, which felt more possible following the exploration and detoxification of his angry feelings toward the therapist for not giving him consistent session times. He described a recent instance in which he told his supervisor at work that it was not acceptable to attack him personally, which had the unexpected effect of making her take him more seriously. He experienced a feeling of manliness and was surprised at how positively she responded. The therapist noted Mr. S.’s capacity to competently assert himself in this situation, which was at odds with his view of himself as helpless and ineffective.

But when he thought of expressing anger at his girlfriend, he suddenly felt weak, drained, feminized, and imprisoned, even before saying anything to her. His newfound assertiveness still did not feel safe in his most intimate relationship, and the therapist further explored Mr. S.’s feelings toward Linda. He was upset about her focus on his buying material things for her and frustrated that she used her son Adam to pressure him to stay in the relationship or to get what she wanted. She would routinely tell the boy that he had threatened to break up with her. “Say good-bye to Tom,” she would say; “You won’t be seeing him anymore.” At which Mr. S. would feel sad and guilty, feeling he could not live with himself if he hurt Adam.

In addition to exploring Mr. S.’s identification with Adam as being abandoned and rejected, the therapist asked if he had ever told Linda not to use Adam to manipulate him. Mr. S. asked the therapist whether he should tell her that. The therapist responded that it was important to look at how his guilt interfered with his taking simple, self-protective steps. His view of himself as ineffective was a way of protecting himself and others from his self-assertiveness. Without giving direct advice, the therapist suggested various ways he might assert his needs more effectively.

Mr. S. began to fluctuate between an increasing sense of safety, becoming able to confront Linda or more seriously consider ending his relationship with her, and a return to guilt and anxiety. In session 11, Mr. S. reported that he had told Linda he did not want to stay with her, but then felt bad and guilty. He anticipated that the therapist would be critical of him, as he expected to be punished for asserting himself. The therapist told him he was dealing from a position “out of the barrel” in confronting Linda, but then pulled back in due to guilt and expected the therapist to side with that view. Mr. S. then had a memory of his mother coming after him with a belt, which linked to the punishment he anticipated for asserting himself.

As Mr. S. struggled with the idea of breaking up with Linda, two different views of her emerged that he could not connect. He felt she was a caring, responsive person, but also hostile, difficult, and damaging. The therapist said that his conflicts and guilt interfered with keeping both perspectives in mind at the same time. He tended to see the negative side of others, but after expressing his own needs, he felt guilty and saw only the positive side. This confused him, triggering the “fog,” which interfered with making changes in his close relationships.

Employing the approach to defenses in PFPP-XR, therapist and patient continued to address the triggers of Mr. S.’s “fog” as a way to identify links to his conflicted relationships and the ongoing effects of past trauma. At work, for example, the fog, which contributed to Mr. S.’s making errors, was found to increase when he felt angry and then guilty toward his supervisor. He also became confused when he experienced ambivalent, conflicted feelings toward his mother, as he could not tolerate his ongoing, blinding rage at her neglect and punishments. Identifying the fog provided an opportunity to look at the feelings and conflicts that triggered it.

Beginning in session 13, Mr. S. reported a resurgence of feeling guilty, anxious, and stuck in the relationship with Linda, an apparent regression in the setting of anxiety triggered by his increasing assertiveness and serious consideration of leaving her. He had panic attacks and felt suffocated, intruded upon by both his mother and Linda. When he visited his mother, she pressured him to do chores around the house, even when he needed to leave for a scheduled appointment. He told his mother to leave him alone, but then felt guilty. He described his task as “overcoming a monster.” The therapist said that Mr. S. had difficulty accepting aspects of himself: his own needs, his wish not to be intruded upon, and his wish to assert himself and be more independent. He should not have to feel guilty and bad, and accept mistreatment by others; he could set limits with others. Mr. S. struggled to understand the meaning of the term “setting limits” in regard to Linda, yet another manifestation of the fog. When the therapist noted that he could tell Linda not to threaten him through Adam, or not to demand his presence all the time, he felt guilty and confused. The therapist pointed out that Mr. S.’s confusion clouded his effort to think, and also to assert himself. His fear of damaging others came to the fore: he said he worried it would hurt Linda if he asked for time for himself.

In session 15, consistent with the approach of PFPP-XR, the therapist reminded Mr. S. that the treatment was entering its last third, with seven sessions left. Mr. S. acknowledged this but quickly focused on the ongoing distress he was experiencing: he felt anxious, out of it, weakened at work, and sad about Linda. He felt intense discomfort in his body, which was shaking. Finding his mind blank about what to do, he had tried hugging himself, but it did not help. Seeing Mr. S. become so explosively anxious made the therapist anxious as well, and worried that time-limited therapy might be contraindicated for him given his chronic separation anxiety. However, the PFPP-XR manual was grounding for the therapist, and he continued to explore the patient’s separation distress and began to view this as an opportunity to explore Mr. S.’s separation anxiety in the context of termination.

Mr. S. arranged to go on a trip to take a break from the tensions he felt with Linda, not telling her he was going away. However, he clearly had mixed feelings about the trip, as she found out where he was from a post he wrote on Facebook. This represented a guilty compromise, as again he arranged his own punishment. She called him a liar for not telling her, and he felt depressed and emasculated. He wrote a breakup letter to her and then went into a “fog” and did not send it. The therapist suggested that the idea of breaking up with Linda triggered fears of being alone, fears of damaging her, and the fog. Mr. S. said he had again tried to hug himself for comfort, and saw himself as a beaten-up, limping, homeless child. The therapist suggested that the image was of him as a traumatized child, and the limping might be related to the car accident that he seemed to be thinking about lately, and that seemed to carry symbolic import in his struggle. Now, as in childhood, he felt unsafe, alone, and emasculated after trying to assert himself and fearful about the treatment ending.

Entering session 18, Mr. S. reported the persistence of his fears, panic-like states, and being unable to soothe himself. The therapist increased his focus on Mr. S.’s symptoms and conflicts in the context of termination, suggesting that these feelings were related in part to separation terror about losing the therapist. Mr. S. acknowledged worrying about this, saying he would like to arrange to start with a new therapist as soon as this treatment ended. He described how his body was shaking: he would go into a fetal position and start crying. He began writing about the experience and had dreams that recalled his being bullied as a child. The dreams were about a bigger kid he had known as a child at church. The bully made fun of how he dressed and beat him and his brothers up, calling them poor. The bully attacked Mr. S.’s younger brother (the one who later died of cancer) and locked him in a closet. Mr. S. recalled that his sister was raped by a former boyfriend. But if he had tried to stand up to these assaults, he would have ended up being hurt, he said. There was no one to turn to.

In session 19 Mr. S. reported that he emerged out of “the vulnerable place” in his body a couple of days after the last session. Although he did not discuss it at the time, subsequent exploration indicated that the previous session had helped him identify his terror of aloneness as it related to childhood experiences of being bullied, feelings of lack of protection and the deep disappointment of being unable to depend on his family, and fears about the treatment coming to an end. He continued to display his newfound comfort with expressing anger, complaining that the therapist said it was hard to believe he could not think of anything else when in the last session Mr. S. hesitated to further describe his childhood experiences of being bullied. He said it felt like “someone has a severe physical injury and the ambulance person says ‘How are you feeling?’” The therapist acknowledged that Mr. S. felt disregarded and not listened to. He told the patient it was a valid criticism: “What do you think I should have said?” Mr. S. suggested “Take your time.” He noted that the therapist had helped him develop strategies for moving forward, but he wanted to know how to handle the impact of his painful childhood memories, which would always be with him. The therapist continued to confront the patient’s feelings of helplessness, responding that now that Mr. S. could better articulate the impact of his traumatic upbringing on his current life, he could recognize that he was not in a helpless situation anymore, unlike when he was a child, when he felt as if he were stuck inside a barrel. In this way, he could better manage his anxiety and anger, and was in a position to organize his life in a way he might choose.

In session 20, following up on the patient’s concern about the ongoing impact of his toxic, traumatic relationship with his mother, the therapist asked in what ways Mr. S. felt his past still affected him. Mr. S. described instances in which he reacted to authorities in an impulsive manner, which he attributed to his anger at the authoritarianism of his parents and those who bullied him. For example, when he believed a policeman was bullying someone who was a member of a minority group, abusing his authority, he asked the policeman why he was doing that. His friend said he could end up arrested. The therapist said that Mr. S. either seemed unable to be assertive or would directly confront bullies in an impulsive way. He seemed to have only fight or yielding modes. Mr. S. noted that he only fought with strangers. The therapist responded that when he felt attached to someone, he was too worried about hurting them to fight because he was so scared of losing them, and then feeling abandoned and alone. The therapist suggested that it might be helpful to step back from impulsively attacking bullies, and to express his anger more effectively with those to whom he is attached. When Mr. S. asked “How do I do that?” the therapist replied that he had already demonstrated this capacity somewhat but did not seem comfortable acknowledging it. The therapist reminded him about the danger the patient felt in gaining autonomy, pointing out that Mr. S. feared asserting himself and being left alone at termination, worried that he would not be helped by others and frightened that he could not defend himself alone.

In the final session Mr. S. reported the fantasy of wanting to grab on to the therapist’s leg and not let go, yet laughed as he said it. He said he felt more mature and able to set limits, but he still had difficulty telling Linda he wanted to end the relationship. He compared changing his life to “leaving prison,” and noted that many prisoners have difficulty with this transition. He did not want to be uncomfortable and suffocated, but he was scared of being alone. The therapist noted that grabbing on to his leg sounded like what a child would do: Mr. S. equated separation with feeling unloved and being a helpless small child who needed to plead to get attention. Thus, the therapist continued to articulate the threat surrounding separation, linking it to the termination of treatment, and how this interfered with Mr. S.’s being able to address problems in relationships that would allow them to be mutually satisfying.

In this context, Mr. S. shifted back to Linda, saying it was hard to let her know he did not love her. The therapist responded that if he ended the relationship by saying he did not love her it would increase his pain and guilt. He suggested that Mr. S. should consider describing the problems that made him not want to move forward with Linda. Mr. S. continued to discuss his feelings about Linda; he accepted that they both were needy. They both did not get affection growing up and were emotionally starved, but the relationship did not work. The therapist said rather than seeing himself as needy, which seemed to make him feel helpless and desperate, he could acknowledge having needs, a concept that until recently had seemed alien to him. Mr. S. ended his treatment by reading a note he had written to the therapist that described how he had learned a lot in therapy about his patterns and accepted his emotions more. He recognized he could not take away the pain of others. “You need to feel something in your body for change to take place,” he wrote. Although the note was helpful in identifying the insight and changes Mr. S. experienced in therapy, it also avoided anxiety about feelings or thoughts that might emerge spontaneously at the end of treatment.

At termination Mr. S. was significantly improved, and he felt more capable of addressing problems in his life and moving forward. His ADIS-IV ratings (by a reliable independent rater) upon completion of the treatment were general anxiety disorder: 3.5/8, social phobia: 3.5/8, specific phobia: 3/8, dysthymia: 1/8, and separation anxiety: 3.5/8, all of which were no longer in the clinical range.

Discussion

Psychoanalytic theories and clinical experience have identified conflicts surrounding attachment and anger in relation to panic and separation anxiety. In PFPP-XR, we have highlighted these aspects in the psychoanalytic approach to anxiety disorders. Mr. S. had a severe form of separation anxiety associated with an ambivalence of such intensity that he believed no form of self-assertion or expression of needs would be safe, preempting any hope for a positive intimate relationship. The degree of threat involved in becoming close and exploring his feelings, fantasies, and memories also had the potential to disrupt the treatment, something that had had happened with Mr. S. in three previous psychotherapies, when he had not raised negative feelings with the therapist due to fears of being hurtful.

In this context a brief manualized psychodynamic psychotherapy would be seen as a risky intervention based on the expectation that a problem of this severity would require a long-term intensive treatment. However, several psychoanalysts and developers of brief psychoanalytic psychotherapies have argued that a brief psychodynamic treatment may be particularly helpful in addressing separation issues. In addition, a manualized psychodynamic psychotherapeutic treatment such as PFPP-XR articulates a set of core dynamics operative in specific anxiety disorders, as well as techniques for focusing on the symptoms and associated dynamics.

The PFPP-XR approach aided the therapist in rapidly tackling the problematic relationship patterns and conflicts surrounding Mr. S.’s separation anxiety. Fluency with this formulation allowed the therapist to quickly identify the patient’s pattern of submissive frustrating relationships, although the degree to which Mr. S. felt threatened by raising any concerns was unusually severe. Dynamics that contributed to these problematic relationships were quickly recognized, including Mr. S.’s fear that asserting his needs or expressing frustration would rapidly disrupt his attachment relationships, leaving him entirely and frighteningly alone. In addition, he believed that attachment figures in his life were vulnerable and easily damaged, and that he could destroy them by being assertive or angry. This led to his feeling terribly guilty about expressing his needs, frustration, or anger, and he anticipated punishment and rejection. Additionally, his sense of personal inadequacy led him to believe that he could not expect or did not deserve a mutually satisfying relationship, with a tendency to respond to others’ needs and wishes to the exclusion of his own. Inhibited anger at others often became self-directed, exacerbating his depression. These patterns in his relationships added to his state of anxious, ambivalent attachments and feelings of inadequacy, greatly diminishing his capacity to experience the positive aspects of attachments.

The therapist was prepared to articulate the defensive functions of the “fog” and Mr. S.’s somatic symptoms (including feelings of suffocation, weakness, shakiness, and a sense of intense discomfort in his body) that interfered with his access to feelings and thus his ability to work through painful memories and experiences. Rapid attention to the meaning of the patient’s experience of “fog” in the context of the transference became essential, as it threatened to bring the treatment to an end; in this context, Mr. S. became unable to recall session times. The therapist employed the early use of a formulation to help the patient recognize the conflicts he was struggling with and their impact on his relationships and the treatment. He interpreted that the fog was intensifying in reaction to Mr. S.’s directly addressing painful and mixed feelings and changes in his relationships, which he found frightening and overwhelming. This interpretation was a crucial turning point in the treatment, as it allowed Mr. S. to attend and participate in the therapy.

After this interpretive work, Mr. S. became able to contemplate breaking up with his girlfriend, though this was accompanied by intense fear of being completely alone and of seriously damaging his girlfriend and her son. For the remainder of the treatment, the patient explored the implications of breaking up. In this context the brevity of the treatment likely heightened the intensity of his anxiety, while presenting an opportunity to address this anxiety in the transference. He regressed into a panic-like, somatizing state but was still able to verbally explore the dangers he experienced in expressing his needs, including being abandoned and punished. While exploring his termination fears, the emergence of traumatic memories of being bullied and unsupported by his parents was followed by a reduction in his somatic symptoms. Only then was Mr. S. able to differentiate the relative safety of his current situation from the dangers he experienced as a child, which he could now appreciate were largely responsible for fueling his chronic anxiety.

Articulation of the transference, quite likely intensified by the time-limited treatment, aided in exploring his separation anxiety, his chronic difficulties with being assertive and expressing anger, and his fears of punishment in his relationship with the therapist. With the therapist’s guidance, Mr. S. used the therapeutic relationship as an opportunity to better understand, articulate, and test his fears of assertiveness and to realize that these would not necessarily be responded to with criticism, rejection, or punishment. The therapist responded positively to Mr. S.’s criticisms of him, including complaints about his being relatively nondirective. The therapist acknowledged that he understood that his interventions might feel problematic, and he encouraged the patient to further explore his responses. The experience of competent assertions with his therapist and outside the treatment setting eased Mr. S.’s feelings of inadequacy. In the last phase of therapy, the exploration of termination fears paralleled an investigation of his primary separation fears. Mr. S. feared being unable to manage on his own without the therapist, as growing up he had felt abandoned and unprotected by his parents when picked on by bullies. However, he also felt more hopeful that he could change his relationships from being bullied to allowing himself to feel more cared for and responded to.

In summary, the use of a manualized, time-limited psychoanalytic psychotherapy allowed for a rapid exploration and significant improvement of Mr. S.’s separation anxiety symptoms. This approach helped him engage in a treatment that he was on the verge of thwarting throughout the first several weeks of therapy. Approaches to this patient, derived in part from the manualized treatment, included (1) recognizing and addressing his problematic submissive patterns in relationships; (2) identifying his state of “fog” and confusion and his somatic symptoms as serving to defend him against intolerable and painful feelings and fantasies linked to unacceptable childhood trauma; (3) identifying and addressing separation fears; and (4) exploring conflicts in asserting himself, including with the therapist, connected with his fears that doing so would disrupt relationships or damage others, fueling his separation anxiety and guilt. Identifying these factors led to greater awareness and tolerance of his feelings and fantasies, improvement in his anxiety and depression such that he no longer met DSM criteria, and increased assertiveness. The outcome in this case indicates the need to further explore and study the use of time-limited manualized psychoanalytic psychotherapies.