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The Application of Psychodynamic Psychotherapy Within a Preexisting

Primary Care Assessment and Treatment Approach

Article  in  Psychoanalytic Psychology · April 2016

DOI: 10.1037/pap0000083

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 Psychoanalytic Psychology © 2016 American Psychological Association
2017, Vol. 34, No. 4, 499 –505 0736-9735/17/$12.00 http://dx.doi.org/10.1037/pap0000083

The Application of Psychodynamic Psychotherapy Within a Preexisting

Primary Care Assessment and Treatment Approach
Anthony F. Tasso, PhD, ABPP
Fairleigh Dickinson University

This article aims to demonstrate the utility of psychodynamic treatment approaches within primary care
medical settings. First, I provide an overview of the basic integrative care principles, followed by a
discussion of a widely used primary care assessment and intervention method (The 5 As: assess, advise,
agree, assist, and arrange). I then review specific psychoanalytic perspectives and techniques that are
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

effective in dealing with shorter term, circumscribed conditions. Next, I offer a discussion of the value
This document is copyrighted by the American Psychological Association or one of its allied publishers.

of a psychoanalytic framework within primary care settings, with a specific focus on the integration of
psychodynamic techniques within the 5As approach. This article concludes with a clinical vignette
demonstrating the applicability of psychodynamic techniques for a patient presenting in a medical setting.

Keywords: primary care, medical setting, integrative care, collaborative care, psychodynamic/
psychoanalytic

Medical ailments and psychological processes are inextricably
linked, with significant shared variance in etiological, physical,
and behavioral manifestations. Cardiac problems, behavioral
health struggles (e.g., smoking, appetitive and addictive control
problems), psychoneuroimmunological illnesses (e.g., autoim-
mune disorders), and “classic” psychological conditions (e.g., de-
pression, anxiety) present with oft-complex psychophysiological
constellations. Historical bifurcated distinctions between constitu-
tional and psychological determinants have now been relegated to
the realm of lore, with all but a marginalized handful of health care
professionals fully acknowledging the mutually facilitative pro-
cesses of somatic and psychological conditions.
Despite the professional and, indeed, growing public awareness
of the potentials of psychotherapeutic treatments for many health
conditions (Kendall-Tackett, 2009; Woltmann et al., 2012), along
with evidence suggesting the significant prevalence of primary
care patients presenting with concurrent mental health conditions
(Arbus et al., 2014; Azrin, 2014; Olfson, Kroenke, Wang, &
Blanco, 2014; Petterson, Miller, Payne-Murphy, & Phillips, 2014;
Stein et al., 2004), there is still a considerable absence of ill people
seeking mental health treatment. Many individuals instead opt to
seek “pure” medical-based assistance. Whether the reason for the
underutilization of psychological services is anchored in stigma,
lack of familiarity with the breadth of conditions amendable to
psychotherapy, compromised access to mental health services,
and/or greater familiarity with medical providers, what is unques-
tionable is that there is a large percentage of people who would
benefit from mental health services but are never seen by a
psychologist.
This article was published Online First April 14, 2016.
Correspondence concerning this article should be addressed to Anthony
F. Tasso, PhD, ABPP, Department of Psychology & Counseling, Fairleigh
Dickinson University, 285 Madison Avenue, Madison, NJ 07940. E-mail:
atasso@fdu.edu
499
Integrated primary care (IPC; also referred to as behavioral
health care or collaborative care)—the coalescence of mental
health and medical services, often consisting of cotreating patients,
in addition to collaborations with mental health practitioners lo-
cated in either a independent practice or medical setting— dem-
onstrates a successful bridge by which to overcome the formidable
gap in health care services. Behavioral health consultants (BHC)
differ from traditional psychotherapists, commonly referred to as
mental health specialty care therapists in the IPC literatures, in
several distinct ways. A BHC’s work can consist of seeing patients
in nontraditional settings, such as medical examining rooms, often
for only a brief session (10 min or less), and frequently with
time-limited treatment durations. A behavioral health consultant
may see dozens of patients in a single day (often in a triage
format), have less restrictive confidentiality parameters, be more
symptom specific in their interventional foci, and may coexamine/
treat with medical providers (for review, see Breen Ruddy, Borr-
ese, & Gunn, 2008). Behavioral health clinicians are not restricted
to offering treatment at medical sites, with a large number of such
psychotherapists working in collaboration with medical providers
and seeing patients in an independent practice setting. Although
the academic study of integrated primary care is only still in the
embryonic stages, the extant evidence is quite promising, with
research suggesting that IPC treatment outcomes are as good or
superior to specialty treatment in addressing certain mental health
issues (Bartels et al., 2004; Krahn et al., 2006) as well as being
cost-effective (Cummings, O’Donohue, & Cummings, 2009;
Domino et al., 2008; Katon, Roy-Byrne, Russo, & Cowley, 2002;
Woltmann et al., 2012).
Perhaps unsurprisingly, the main psychotherapeutic interven-
tional modalities in such environments are shorter term, solution-
focused approaches. Given the symptom-specific nature of IPC,
motivational interviewing, cognitive-behavioral approaches, and
related stress-reduction models have found a secure place within
this setting (Robinson & Reiter, 2007). Conspicuously absent from
much of the mainstream primary care literature are psychoanalytic
 500 TASSO
treatments. Although several psychodynamic clinicians have tested
the waters in this domain (see Balint & Shelton, 2002; Covino,
2008; Kent & Blumenfield, 2011; Lichtman, 2010; Mollen, 2001;
Moore, 2011; Stern, 1999; Wain & Gabriel, 2007 for work explor-
ing the psychodynamic conceptualizations and treatments of med-
ical conditions), a robust linkage has yet to be achieved. This may
not seem shocking, even to (or especially with) psychoanalysts
given the leaning toward longer term treatment coupled with the
emphasis on the clearly explicated therapeutic parameters of psy-
chodynamic psychotherapy and psychoanalysis proper. As such,
the paucity of scholarly work applying analytic interventions in
settings outside the traditional consulting room may perpetuate the
belief in both analytic and nonanalytic circles that such an ap-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
proach may not be a good fit within primary care.
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Davis (2009) made a strong case for the marriage between
psychoanalytic treatments and medical settings. Articulating the
benefits of psychodynamic therapists who consider such a profes-
sional expansion, Davis proposed that key factors for success
include clinicians’ prompt responsiveness to patients and physi-
cians, an appreciation of the value of “mere” symptom reduction,
and for psychoanalytic psychologists to be more inclusive in
treating the range of patients complete with various comorbid
pathologies. This last point is contrary the traditionally narrow
inclusion criteria by which to identify prospective patients deemed
to be analyzable, possessing the capacity for significant insight, or
willingness to commit to lengthier treatment durations.
Despite Davis’s (2009) excellent overview of the practicalities
of including psychodynamic treatments in integrated care work,
such partnerships have been slow to develop. As such, this article
further explores the applicability of psychodynamic treatment
techniques to primary care. First, I review a well-used primary care
assessment and intervention approach, followed by specific psy-
choanalytic views that are complementary to shorter term,
symptom-specific pathologies. Next, I integrate such concepts into
a regularly used primary care assessment and intervention para-
digm. This is followed by a discussion of the relevance and
usefulness of a psychoanalytic framework within primary care
settings. Specifically, this article aims to illustrate how a psy-
chodynamic assessment and case formulation has the potential for
significant understanding of the meaning of symptoms, thus pro-
viding an avenue for treating certain patients using a psychoana-
lytically oriented approach, a modality not commonly associated
with primary care work but capable of offering productive treat-
ment outcomes.
Primary Care Assessment and Intervention: The 5 As
One widely used assessment and intervention approach within
primary care is the 5 As, which stand for assess, advise, agree,
assist, and arrange (Whitlock, Orleans, Pender, & Allan, 2002; see
also Goldstein et al., 2004; Hunter, Goodie, Oordt, & Dobmeyer,
2009). Assessment involves a standard biopsychosocial intake and
functional assessment to determine the possible contributing and
sustaining psychological, biological, and environmental factors
associated with the patient’s current impairment(s). This is fol-
lowed by the advisement stage, which involves presenting the
patient with treatment options based on assessment data. Next is
agreement, which is when the patient and behavioral health con-
sultant concur about the recommended course of treatment. During
the assistance phase, the psychotherapist provides psychoeduca-
tional and interventional guidance aimed at addressing the pa-
tient’s presenting problem(s). Last, the arrangement phase ad-
dresses patient follow-up, including medical, nutritional, and/or
proceeding with open-ended “traditional” psychotherapeutic ser-
vices. Although additional integrated primary care models exist
(for review see Robinson & Reiter, 2007), I focus on the 5 As
interventional approach because of its acceptance within the IPC
field owing to its ability to meet the demanding, fluctuating needs
of this patient population, in addition to what I argue makes for a
complementary fit with psychodynamic therapy techniques.
How Can Psychoanalytic Tenets Fit Within the
5 As Model?
The BHC psychologist’s assessment provides the treating prac-
titioners (e.g., physicians, nurses, occupational and physical ther-
apists) with relevant patient-related information and details on
symptomatology (e.g., presenting complaint, physical conditions,
environmental stressors). Necessary assessment data include the
patient’s identified problem(s), duration of symptoms, self-
reported triggers, and functional impact (e.g., occupational, rela-
tional, familial). Key to a useful IPC assessment is its brevity and
relevance to the entire treatment team (Breen Ruddy et al., 2008).
With a depressed patient, for example, the BHC should inquire
about the severity of the depression, potential triggering events,
affective and vegetative factors, and the functional impact. On the
other hand, when assessing a patient who is in pain, the BHC will
determine the location, intensity, anteceding event(s), experience,
functional limitations, and whether or not the pain is chronic or
acute. Behavioral health consultants commonly agree on the in-
dispensability of meaningful assessment data for successful IPC
treatment (Hunter et al., 2009).
Assessment and conceptualization are central to psychoanalytic
treatments. The Psychodynamic Diagnostic Manual (PDM; Psy-
chodynamic Diagnostic Manual Taskforce, 2006) exemplifies the
emphasis on clinically useful patient formulations. Beyond the
taxonomic approach associated with medical practice of the Diag-
nostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 2013), the PDM provides conceptual in-
formation designed to directly impact a clinician’s ability to de-
velop a rich case formulation of the patient by incorporating the
characterological underpinnings of psychiatric conditions and their
subsequent treatment implications.
Comprehensive conceptualization is a cornerstone of brief psy-
chodynamic therapies, with analytic authors (e.g., Davanloo, 1992;
Malan, 2001; Mann, 1973; McWilliams, 1999; Sifneos, 1992)
proffering conceptualization factors anchored in analytic sophisti-
cation and designed to apprehend the idiography of a patient. Such
authors make use of a flexible outline to assess key patient char-
acteristics from which psychotherapy can commence. With con-
sidered procedural information highlighting the assessment of de-
velopmental themes, defenses, affect, relational patterns, as well as
aspects of an individual that are generally intractable (e.g., tem-
perament, certain neuropathologies), patient evaluations predi-
cated on analytic theories set the stage for treatment. Common to
these analytic views is the comprehensive and expeditious assess-
ment of the presenting complaint(s), developmental experience,
and identifying appropriate patients for short-term intensive treat-
 PSYCHODYNAMIC PRINCIPLES-PRIMARY CARE
ment. The assessment and interventional foundations of these
analytic practitioners will serve as the backdrop to the application
of psychodynamic treatment techniques in the primary care setting.
Integrative primary care and short-term analytic assessments are
grounded on the well-defined identification of the main problems.
An IPC assessment utilizes circumscribed inquiries and judicious
use of opened-end questions because of the time constraints
(Hunter et al., 2009). It is imperative that the BHC and the medical
treatment team have a comprehensive understanding of the dura-
tion, triggering event(s), frequency and intensity of problems,
associated factors (i.e., physical, emotional, behavioral, environ-
mental/social, cognitive), and functional impairments of the pre-
senting condition by the conclusion of the initial BHC meeting
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(Hunter et al., 2009).
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What Can an Intensive, Short-Term Structured
Psychodynamic Assessment Provide?
Short-term dynamic approaches are slightly different from psy-
choanalytic psychotherapies and psychoanalysis as they are less
open-ended and make use of more structured interviewing center-
ing on presenting complaints similar to commonly used behavioral
consultation approaches. Short-term analytic approaches therefore
emphasize focused, symptom-specific assessment interviews (see
Davanloo, 1992; Mann, 1973; Sifneos, 1992). The application of
analytic savviness allows for the use of verbalizations to move
beyond the inscrutable in order to access affect-laden material. For
example, the awareness that fluctuations in cadence, patient-
directed changes of the content being discussed in treatment, or
avoidance of particular themes or topics may be suggestive of
significant core conflicts. As such, the richness of analytic princi-
ples allows for the primary care consultant to use minimal surface
data to ascertain potent unconscious material to shape the psycho-
therapeutic and assist with supporting medical treatments.
Brief psychodynamic approaches provide a guidepost for deter-
mining whether patients are suitable for such intensive, circum-
scribed treatments. Sifneos (1992) and Davanloo (1992) list inclu-
sion criteria for patient selection in their respective (and somewhat
overlapping) time-limited approaches. Sifneos’ identifies patients’
ability to pithily and accurately describe their problem(s), report at
least one meaningful relationship during childhood, relate flexibly
with the clinician, demonstrate a modicum of psychological mind-
fulness, are intelligent, and motivated to change. Davanloo explic-
itly includes neurotic-level individuals with more obsessional and
panic-focused conditions, those who can tolerate loss, and being
able to proactively respond to first-session interpretations. I in-
clude these aforementioned criteria as they would be relevant to
those primary care patients who are able to benefit from analyti-
cally informed BHC approaches.
During an initial consultation, an analytic BHC can begin to
formulate a working hypothesis of narcissistic defenses with a
patient during an initial consultation who continuously focuses on
the failures of previous treatment teams to help him, while a
patient reporting diffuse somatic complaints without substantiating
location or severity may elicit a working hypothesis of passive
dependency with fantasies of others (possibly the psychotherapist)
rescuing him. But what if the patient is more hostilely dependent—
presenting as compliant, needy, and helpless, though undermining
treatment and staunchly stonewalling the supportive attempts at
501
intervention, thus attempting to render the BHC as ineffective? In
this case, a dynamic BHC can employ more testable hypotheses
via “standard” analytic techniques such as exploring transference
phenomena and examining experiences of vulnerability. Alterna-
tively, when warranted the BHC can him or herself “shift” to
longer term clinical work.
These nuanced, patient-specific assessments dynamics segue to
the advisement phase, which uses assessment data to present
treatment options to patients (Hunter et al., 2009). Common pri-
mary care advisements are deep breathing, relaxation, psychotro-
pics, sleep hygiene, and exercise. Such recommendations are cru-
cial and have the demonstrable ability to be effective in primary
care settings and for patients with medical and psychological
ailments. Though such aforementioned therapeutic interventions
are commonplace within primary care and other clinical settings,
they are not central to psychoanalysis. However, an analytically
oriented BHC can determine whether, for example, poor sleep or
a sedentary lifestyle partially accounts for a portion of the etio-
logical variance in a patient’s symptomatology, or if it appears to
be more related to underlying dynamics. If an analytic BHC
identifies that a patient’s unproductive sleep is resultant of poor
sleep hygiene, a brief, more behaviorally anchored intervention
may be employed. However, if such problematic sleep is deter-
mined to be secondary to entrenched marital discord, insight-
oriented BHC work would be applied in lieu of standard primary
care approaches.
Analytic approaches allow for the elucidation of patient-specific
dynamics and thus, potentially greater tailoring between patient
themes and recommended interventions. Primary care patients
regularly fail to adhere to treatment regimens, be they pharmaco-
logic, behavioral, or traditional mental health. Insight-oriented
BHCs are able to use the rich analytically derived data to deter-
mine the best possible interventions. An analytic BHC may assess
a patient presenting with cardiovascular disease and deem time
urgency and hostility as key characteristics, both with some link-
age to cardiac problems (Cole et al., 2001). The clinician may
determine that the salience of time-urgency warrants a circum-
scribed, pithy intervention such as hypnosis and, in certain cases,
consideration of a selective serotonin reuptake inhibitor. However,
a patient with cardiovascular disease assessed with depressive
symptomatology manifested as irritability may be more amenable
to brief, insight-oriented work. These aforementioned possible
advisement suggestions differ from nonanalytically assessed infer-
ences in that they aim to tailor interventions based on the patient’s
idiography rather than the commonly accepted algorithmic ap-
proach utilized in traditional IPC work. Specifically, while tradi-
tional BHCs will rely solely on symptomatology and then imple-
ment the appropriate algorithm with little (if any) consideration of
underlying dynamics, the analytic BHC is more apt to consider the
richness of the patient—fully acknowledging that there is indeed
more to the individual than a collection of symptoms.
The agreement phase, which presents the patient with possible
treatment recommendations, taps into a solid analytic strength.
This aspect to treatment consists of presenting the patient with the
best possible therapeutic recommendations. The analysis of the
therapeutic relationship and transference phenomena can be of
significant assistance. For example, an analytic therapist may
determine on the basis of the assessment process that a patient’s
depression is brief and situational, thus plausibly implementing
 502 TASSO
supportive therapeutic techniques. If, however, the dynamic case
formulation indicates that the depression is more idiomatic of a
harsh, self-critical, perfectionistic style suggestive of introjective
depression (See Blatt, 2004; Blatt, Zuroff, Hawley, & Auerbach,
2010), than more exploratory, insight-oriented approaches would
be recommended.
With primary care practitioners under incredible duress due to
extremely high patient caseloads, the patient– doctor relationship is
frequently ignored. Attention to the therapeutic alliance is a cor-
nerstone of all analytically informed interventions. Balint and
Shelton (2002) examine ways to establish a solid patient-centered
approach in medical settings. Treating the medically compromised
or those referred by primary care centers means treating individ-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
uals presenting with a host of comorbid (constitutional or psycho-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
genic) conditions, which often indicates that “treatment as usual”
is not plausible. As such, clinicians must balance a clear therapeu-
tic frame with flexibility within that frame. Owen and Hilsenroth
(2014) empirically demonstrate that psychodynamic clinicians
who are more flexible in the treatment process achieve better
treatment outcomes than therapists with more rigid therapeutic
parameters, suggesting better abilities to meet in-session patient
needs. This is key for the rapid, often unpredictable ebbs and flows
of treating primary care patients, whether in the medical treatment
center or in an independent practice setting. This, I believe, speaks
to the strength of psychodynamic clinicians working in such set-
tings based on the psychoanalytic ethos of treating people, even
when the therapy is symptom-specific.
The assistance phase, aimed at helping the patient overcome
practical and intrapsychic barriers to positive outcomes, is at the
heart of the interventional process and ripe for psychoanalytic
application. Common assistance by an BHC with a symptom-
specific focus aims to counter functional deficits. With anxious
individuals, for example, the careful aforementioned analytic as-
sessments can bestdetermine and implement a systematic,
symptom-specific and empirically supported analytic treatment
(e.g., Busch, Milrod, Singer, & Aronson, 2012), which provides
comprehensive treatment in a time-limited fashion. Analytic inter-
ventions offer the promise of, and demonstrated success in, pro-
viding comprehensive symptom reduction via accessing the
characterological-based underpinning of symptomatologies. An
analytically trained therapist can assess whether panic and anxiety
conditions, for example, co-occur with struggles with separation-
autonomy, guilt, anger, or sexual conflict (Busch et al., 2012),
parse depressive subtypes (Blatt, 2004; PDM, 2006), or implement
elements of mentalization-based treatment techniques with pa-
tients dealing with self-regulation difficulties or struggles within
intimate relationships (Bateman & Fonagy, 2006, 2012; Fonagy,
Gergely, Jurist, & Target, 2002). Such programmatic time-limited
analytic interventions allow for a systematic treatment in which
transference and other interpretations allow affect-rich childhood
experiences, memories, and meaningful parent(s)– child dynamics
germane to the specific type of conditions to be addressed. This is
similar to the evidence put forth by other brief, symptom-focused
analytic approaches (Davanloo, 1992; Mann, 1973; Sifneos, 1992).
Patients presenting in medical settings commonly have comor-
bid personality disorders, which makes psychoanalytic treatments
particularly valuable. Bravesmith (2004) provides rich case mate-
rial on treating a woman in a medical setting with borderline
pathology and describes the ways in which analytic interventions
proved to be particularly useful in addressing primitive defenses of
splitting, denial, and projection. Busch et al. (2012) leaned on the
empirical evidence highlighting the efficacy of psychoanalytically
based treatment in panic and other anxieties with comorbid Cluster
C personality disorders of dependent, avoidant, and obsessive–
compulsive personality pathologies.
Psychopharmacological interventions are regularly utilized
within primary care settings. Patients’ receptivity and adherence to
pharmacotherapy, either as the singular treatment or ancillary to
psychotherapeutic care, vary greatly. A thorough understanding of
therapist and patient character styles allows for potentially greater
medication compliance. Alfonso (2009) examined countertransfer-
ence phenomena such as an inability to tolerate patient distress and
subsequent feelings of professional inadequacy leading to over-
medicating, or, the conversely, undermedicating to psychologi-
cally distance one’s self from highly symptomatic patients. Al-
fonso also addressed the role of attachment theory vis-à-vis
medication maintenance and emphasizes the meaning of the nature
of the treatment to the patient and its relation to intervention
adherence.
Hypnotic interventions are particularly adept for the brief inter-
ventions in medical settings (see Moore & Tasso, 2008 for review
of hypnotic efficacy). Baker and Nash (2008) provided contem-
porary information on the application of psychodynamically in-
formed, problem-focused hypnoanalytic interventions with medi-
cal conditions, whereas Covino (2008) illuminated the overlapping
influences of affects-arousal-behavior-psychodynamic factors in a
host of medical conditions, which are incorporated into psychody-
namically informed hypnotic work.
The final stage, arrangement, has the goal of prescribing appro-
priate follow-up treatment for primary care patients, which in-
cludes scheduling a “check-up” appointment for a later date,
medication management, or making a recommendation for longer
term traditional mental health therapy. This is the phase in which
the BHC and medical treatment team determine if the current
course of treatment(s) is deemed to be working as well as the
necessary follow-ups for sustaining the treatment efficacy, or
addressing barriers to successful treatment. Here, through the
analysis of transference and resistance and awareness of core
characterological deficits the psychodynamic BHC can ascertain
possible reasons for unsuccessful treatments and therefore con-
sider the best courses of action by which to maximize treatment
success.
Confidentiality and carefully delineated therapeutic parameters
are the hallmark of psychodynamic psychotherapies and psycho-
analysis proper. Dynamically trained therapists, perhaps more than
therapists of other modalities, fully appreciate the necessity of
confidentiality, space, and timing of the clinical work, with strays
from such boundaries typically anathematic to analytic patient
work. This ethos stands in rather stark contrast from primary care
theories, which collectively extoll the putative merits of more
porous confidentiality boundaries as a means of fostering greater
communication of germane patient health-related information be-
tween practitioners (see Robinson & Reiter, 2007).
At first blush, the more open forms of communication within
IPC may seem transgressive of core analytic principles; however,
the two views are actually more complementary than contradic-
tory. Breen Ruddy et al. (2008) underscored that notion the BHC’s
communication with the treatment team does not consist of dis-
 PSYCHODYNAMIC PRINCIPLES-PRIMARY CARE
cussions of patients’ relational dynamics, core conflicts, or other
potentially sensitive information. In fact, traditional medical pro-
viders typically do not want such information but rather desire a
snapshot of relevant patient characteristics that impact the health
of the individual as well as the treatment. If, for example, it is
identified through the BHC psychotherapeutic work that a pa-
tient’s noncompliance with blood pressure medications is rooted in
transference-based dynamics, the information to be conveyed to
the medical team is that the noncompliance is due to the patient’s
personality style not because of the lack of comprehension of the
necessity of such medications. Furthermore, the clinician would
then instruct the medical team that this compliance problem would
be best to address with continued psychotherapy. As such, the core
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
conflictual dynamics of the patient would therefore remain be-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
tween the psychologist and patient.
Integrated primary care as a means of mental health treatment is
a different therapeutic approach from traditional psychotherapy
at-large, and especially psychodynamic therapies, given the for-
mer’s emphasis of symptom-reduction and brevity. Though IPC
has a demonstrated track-record of effectiveness (Bartels et al.,
2004; Krahn et al., 2006), such a psychotherapeutic approach has
its limitations. If following the assessment phase the BHC deems
the patient’s psychological needs cannot be met within the more
restrictive parameters of IPC, a recommendation for traditional,
longer term mental health treatment is made, which can be con-
ducted by an outside clinician or by the BHC themselves. This
process is aligned with the approach for both psychodynamic and
nonanalytic BHCs. The BHC, analytic or otherwise, should aim to
determine which patients are suitable to be treated within a pri-
mary care context and which would be best-served in a traditional
open-ended therapeutic context. For example, an BHC may deter-
mine that a patient’s presenting mental health concern of depres-
sion may actually be secondary to a narcissistic injury, or an
elevation in a patient’s anxiety may be resultant of a perceived
separation and that the patient may struggle with borderline fea-
tures— both of which may warrant a more open-ended, insight-
oriented psychotherapeutic approach. Such assessments and ad-
visements are common within primary care work.
Dynamically Informed Treatment With a Primary
Care Patient
Stacy was a 35-year old married mother of two who was
referred for outpatient mental health treatment by her primary care
medical team. A highly educated corporate professional, Stacy had
not worked since the birth of her first child four years prior. Stacy
had been experiencing considerable physical pain concurrent with
depression and anxiety for the past 2 years. Her physical symptoms
consisted of diffuse gastrointestinal (GI) distress and muscle pain.
Believing her dysphoria to be secondary to her physical ailments,
Stacy first sought relief via the medical route. At the completion of
comprehensive medical testing (much of which came back nega-
tive or inconclusive), a referral to a psychologist was made. Using
Davis’s (2009) emphasis on prompt responsiveness and encour-
agement of symptom relief in addition to some of the processes
previously documented (Tasso, 2014), I proceeded with psychody-
namically informed therapy using the 5 As as an overarching
procedural guidepost.
503
The assessment process consisted of reviewing Stacy’s medical
records before moving on to ascertain relevant data related to her
presenting physical and emotional symptoms. Additional informa-
tion gleaned included the quality of her current relationship (stable
marriage, though emotionally unavailable husband), successful
work history (though now several years removed), and commence-
ment of her physical and depressive symptoms (coinciding with
her maternity leave). The assessment process illuminated Stacy’s
modicum of insight, the flexibility with which she expressed
herself, and her tolerance for examining her current symptomatol-
ogy and relationship status. I advised (Stage 2) that we proceed
with twice weekly psychotherapy, with an emphasis on her historical
experiences and current symptoms, possible linkage between the two,
and functional impairment. I also informed Stacy that there would be
continued correspondence with her medical treatment team. She con-
ceded (agreement; Stage 3) with the caveat that we aim to terminate
therapy near the time of her return to work.
The assistance phase (Stage 4) consisted of a discussion regard-
ing the parameters of treatment as well as psychoeducation on the
inextricable mind-body relationship, aimed at disabusing any be-
lief that mental processes undergirding physical symptomatologies
and concomitant dysphoria are not as significant as “pure” bio-
medical processes. From here, we discussed her family of origin
and significant relationships. It emerged that her father was an
emotionally labile alcoholic, and her mother was a cold, unin-
volved parent who preferred peripheral parenting activities (e.g.,
household cleaning, community service) over attentiveness to her
children. Stacy’s struggles with control emerged early in the treat-
ment process. Psychotherapy illuminated her fear of not being in
control as a child due to her father’s explosiveness along with not
feeling safe or protected by her mother because of her overall
disengagement from the family. It became evident that Stacy
regularly dissociated painful experiences in concert with intellec-
tualization propensities aimed at addressing feelings of being
out-of-control. Specifically, we identified how Stacy immersed
herself in studies and extracurricular school-based events as a
means to control and avoid experiences of family distress. This
eventually manifested in obsessional tendencies, workaholism, and
a failure to identify and tolerate the range of affective experiences
due to the anticipation that her emotional needs would not be
managed by either parent. We explored how this theme was
recreated with her husband given his “hands-off” approach toward
the marital and familial unit. This propensity served her without
much distress until she transitioned from a 60⫹ hour work-week to
being a fulltime mother, at which time her apprehension and
difficulties with tolerating the emotionality of her children and of
herself expressed itself in physical symptoms, anxiety, and depres-
sion.
During treatment we focused on attending to Stacy’s here-and-
now feelings and intentions, with a particular goal of developing a
greater ability to identify when she is vulnerable to become anx-
ious, which was typically when she felt that her tasks at hand (e.g.,
child rearing, transitioning back to work) are not within her com-
plete control. This defense against feeling out of control also
emerged in the transference, with an example of Stacy attempting
to control the duration of psychotherapy (under the auspice of
needing to cease treatment prior to her return to work). After
carefully attending to my countertransference of the pull to engage
 504 TASSO
in power struggles with Stacy (commonly centering on topics such
as the relevance of talk therapy and wordsmithing when it came to
distinguishing feelings, such as “anxious” vs. “nervous,” “perfec-
tionism” vs. “efficiency”), we explored her here-and-now experi-
ence of psychotherapy, at which point she reported feeling dis-
tressed owning to not being “fully in charge” of directing the flow
of the sessions, despite her acknowledgment of my limited direc-
tion of content. Following such exploration, we were able to
address how her desire for control had elements of adaptability as
a child and, at times, an adult, though are the source of much of her
contemporary distress, with such discomfort accelerating due to
the unpredictability of returning to work.
With full permission, I had multiple correspondences with Sta-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
cy’s medical treatment team. The nature of my discussions were
This document is copyrighted by the American Psychological Association or one of its allied publishers.
circumscribed to the basics of Stacy’s symptomatology and func-
tionality—providing the relevant information on her conditions
though not conveying the patient’s early experiences with her
parents or the quality of her marriage. Specifically, I instructed the
medical providers that Stacy experienced a complicated transition
from the corporate world to motherhood, which likely accounted
for her psychophysiological symptoms. Furthermore, her immi-
nent return to the workforce now as a mother of two was adding to
her unrest. Dynamic information about her family of origin or
current marriage, though highly pertinent to her overall emotion-
ality, was not pertinent to her medical care and thus kept confi-
dential. The medical providers merely wanted to know that the
likely nature of her current struggles were identified and that the
treatment was moving in the right direction.
The psychotherapeutic process lasted a total of 21 sessions,
concluding with Stacy’s return to work. Closing arrangements
(Stage 5) consisted of reviewing our treatment goals and discuss-
ing follow-up planning. The clinical work targeted symptom relief
and the beginnings of insight into the genesis of her somatization
proclivities. This resulted in a substantial remission of her GI and
muscle issues, with reportedly less severe and less frequent flare-
ups. Stacy also reported less depressive symptoms and an aware-
ness of her leaning toward somatization based on early familial
experiences. She reported returning to work without much fanfare.
Stacy checked in with me monthly and followed-up for regular
check-ups with her physician.
Conclusion
This article aimed to demonstrate the complementary relation-
ship between psychoanalytic theories and specific treatments with
a well-used 5-step approach within primary care. Building on the
analytic primary care foundation set forth by Davis (2009) and
others (e.g., Mollen, 2001), this current article circumscribes an-
alytic thinking to the well-established procedural IPC process of
the 5 As. Imperative in primary care treatment is the modification
of the therapeutic frame. Solid boundaries are at the heart of
analytic practice. This may ostensibly appear as contradictory
given the inherent flexibility of primary care work. It is not. A
proactive expansion of such parameters, including (though not
limited to) location, time, and confidentiality is central to primary
care work and capable among psychodynamic therapies (see
Akhtar, 2011 for a comprehensive examination of altering psycho-
analytic practice approaches). With the empirically demonstrated
cost-effectiveness of brief psychodynamic treatment (Guthrie et
al., 1999), analytically trained clinicians willing to broaden their
therapeutic scope and to modify their settings and interventional
foci can likely find a comfortable fit as a behavioral health con-
sultant. A thorough assessment anchored in analytic sophistication
potentially sets the stage for the best tailored intervention to treat
the person rather than a collection of symptoms with boilerplate
protocols, making psychodynamic techniques highly worthy of
consideration within collaborative primary care settings.
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