People often recognize that certain behaviors, or avoidance of certain actions, are causing difficulties, yet still find themselves repeating the behaviors. They may be aware that they drink too much, repeatedly lose their temper, take on more responsibility than they can manage, or avoid confronting an unfair boss. Understanding the sources of these behaviors is useful, but insight by itself does not necessarily lead to change.
Psychoanalytic approaches have traditionally eschewed targeting behavioral changes, believing that such efforts do not address the core issues that contribute to problems. Problem-focused psychodynamic psychotherapy (PrFPP) (Busch, 2022) works to identify specific problems, explore the psychological factors that contribute to them, and help patients develop more adaptive ways of responding to their relationships and environment. Such efforts include identifying the context and emotions, early experiences, representations of self and others, and intrapsychic conflicts to address and change problematic inhibitions and behaviors (Busch, 2018; Busch, 2025).
Identifying Problematic Inhibitions or Behaviors
PrFPP identifies behaviors as problematic when they cause recurrent difficulties for the patient and the patient seems unable to shift or change them. Patients may describe certain behaviors as problematic, but they may not recognize others (such as drinking or overwork), sometimes due to painful feelings or internal conflicts these behaviors manage. PrFPP can be useful in helping patients acknowledge and address these problems.
Identifying and Addressing Factors That Make Behavior Difficult to Change
Several factors can contribute to persistent problematic behaviors. These inhibitions or actions may, for example, temporarily reduce anxiety, protect self-esteem, diminish intrapsychic and interpersonal conflict, express anger indirectly, or avoid painful feelings. An individual who chronically agrees to unreasonable requests, for example, may want to become more assertive but experience guilt when considering such a response, or anticipate criticism and/or rejection.
Using PrFPP, the therapist addresses factors that interfere with changing these behaviors (Busch, 2018; Busch, 2022). Therapist and patient work to understand what triggers the inhibition or behavior, what feelings accompany it, what is accomplished emotionally, and what the patient fears might happen if it changed. A psychodynamic framework for behavioral change includes identifying and addressing a series of contributors: the situations and emotions surrounding the behavior; childhood experiences that helped shape it; recurring negative expectations of oneself and others; conflicts and coping strategies that make change difficult; and limitations in understanding one’s own or other people’s motives. The therapist and patient identify alternative behaviors and examine the feelings and expectations that arise when the patient imagines trying or actually attempts them.
Transference and Countertransference Factors
Psychodynamic approaches add another layer of value in accomplishing behavioral change by considering transference and countertransference factors that can interfere with such efforts. For example, patients may rebel against efforts to help them shift behaviors, experiencing the therapist as an authority attempting to compel change, despite having consciously agreed to such efforts. Additionally, the patient can feel guilty or fearful about such changes, creating resistance to the therapy. The therapist works to identify and ease such conflicts. Patients may also wish to please therapists by making changes, leading to guilt or feelings of being a “bad patient” when they have difficulty accomplishing them. Finally, the patient can become dependent on the therapist, requesting recurrent help with decision making rather than pursuing autonomy.
Therapists should also be alert to countertransference factors that might disrupt efforts at behavioral change. For example, therapists might develop a sense of certainty about how patients should behave. The therapist may believe he has better judgment than the patient regarding particular actions, but he should consider that he is only hearing the patient’s perspective and focus on developing the patient’s autonomy. For instance, a patient may report that her boss is behaving in a hostile or judgmental manner when in reality the boss is appropriately pressing the patient to complete essential tasks. Suggesting that the patient confront her boss or leave her job may reinforce problematic patterns without adequately addressing her underlying narcissistic sensitivity. Therapists should also be aware of frustration or disappointment about a patient’s difficulty changing. Such attitudes may be inadvertently communicated to the patient, potentially triggering feelings of inadequacy or of being a “bad patient.” Additionally, therapists should be alert to getting into power struggles, pressing patients to make changes or overriding patients’ concerns about suggested behaviors.
A Collaborative Approach to Behavioral Change
This approach reduces the risk of conflicts between therapist and patient regarding behavioral change by highlighting collaborative aspects of the process (Busch, 2018). They work together in identifying problems and their contributors. When considering alternative behaviors, the therapist can discuss how they cannot be certain of the best action in a given situation and some experimentation will be needed. Therapists can encourage patients to raise concerns about behavioral suggestions.
Experimenting with New Behaviors
Considering and trying new behaviors is useful in finding more adaptive ways of coping. For example, the therapist can discuss with the patient ways in which she might express her feelings directly when such a possibility frightens her. She can imagine what she anticipates the other person’s response will be. If the patient has difficulty trying these behaviors, these efforts help identify the psychological obstacles to change. A patient who plans to ask for a raise may suddenly feel ashamed, greedy, frightened, or convinced that the boss will become hostile. Those reactions provide important information about the meanings attached to assertiveness.
Homework, a nonstandard approach for psychodynamic psychotherapy, can also be valuable. Patients may use a diary to keep track of situations that trigger behaviors, note what they were feeling just beforehand, or delay an impulsive action long enough to observe what is driving it. Such strategies are often found to increase psychodynamic understanding as the patient gains insight into thoughts, feelings and fantasies that trigger various difficulties.
A Brief Clinical Example
A retired woman in her 60s presented for treatment when she became depressed after taking on major responsibilities in a family business and entered PrFPP. She felt trapped by the workload and resentful toward a relative who expected her to handle many administrative tasks. Yet she felt unable to reduce her responsibilities or challenge the arrangement.
In therapy, it became clear that she associated disengaging from responsibilities with being “lazy” and “selfish.” In exploring the origins of her difficulties, therapist and patient learned that during her adolescence, when her mother became seriously ill, she had been expected to assume substantial household duties. When she protested, she felt criticized by her father and experienced guilt. Years later, she still expected other people to condemn her if she felt overwhelmed and refused a task. Therapist and patient were able to identify feelings of anger about these demands, which triggered further guilt and shame.
Her therapist helped her connect these earlier experiences with her current situation and recognize how guilt about anger made it difficult to assert herself. She began speaking more directly with family members about how she felt overwhelmed by these tasks. Some were far more understanding than she had expected. Eventually, these changes enabled her to step away from the business, and her depressive symptoms substantially improved. She also became more alert to taking on unnecessary obligations in other areas of her life.
Insight and Change Can Work Together
Psychodynamic therapists do not have to choose between understanding behavior and changing it. In PrFPP, the two processes often strengthen each other. Identifying factors that contribute to a behavior can determine interventions that better enable change to occur. Trying a new behavior, in turn, can expose fears, guilt, assumptions, and conflicts that were previously difficult to access, enabling further work on those issues.