Panic-focused psychodynamic psychotherapy

1. Introduction

Version followed: panic-focused psychodynamic psychotherapy (PFPP) as specified in Milrod, Busch, Cooper & Shapiro, Manual of Panic-Focused Psychodynamic Psychotherapy (APPI, 1997) and delivered in the Cornell/Penn trials (Milrod et al. 2007; Milrod et al. 2016). That means 24 sessions, twice weekly, in three phases. Where the later Manual of Panic Focused Psychodynamic Psychotherapy – eXtended Range (PFPP-XR; Busch, Milrod, Singer & Aronson, Routledge 2012) differs, this guide says so. Neither manual's full text is drawn on here. Technique detail comes from the founders' own papers (mainly Busch, Milrod & Singer 1999), trial method sections and the 1997 manual's table of contents. [source: Busch, Milrod & Singer 1999; Milrod et al. 2016; APPI/Woodslane catalogue of the 1997 manual] [uncertain: chapter-level wording of both manuals]

PFPP is a time-limited psychoanalytic psychotherapy for panic disorder with or without agoraphobia. Its premise is that panic attacks are not "out of the blue." They carry psychological meaning. They are a compromise formation between unacceptable wishes (most often anger and wishes for independence or sexual excitement, set within fearful dependency on attachment figures) and the defences against those wishes. Panic is treated as "traumatic" anxiety, which floods in when signal anxiety and defences fail. Change is thought to come from three things. First, finding the circumstances and personal meaning of panic onset. Second, making the unconscious conflicts and fantasies behind the symptoms conscious and tolerable, especially as they appear in the transference. Third, working through separation and anger directly when therapy ends. There is no exposure and no homework. [source: Busch, Milrod & Singer 1999; Milrod et al. 2016; Psychiatric Times PFPP review]

PFPP-XR keeps the same three-phase model and applies it to other primary anxiety disorders (panic, GAD, social anxiety, PTSD). The original PFPP described here is the version tested for panic disorder. [source: Taylor & Francis / Routledge description of PFPP-XR] [uncertain: specific XR adaptations per disorder]

2. Framework

Format. Individual sessions of 45–50 minutes, twice weekly. The full course is 24 sessions over 12 weeks; trials allowed up to 14–16 weeks to fit in all sessions. Concurrent medication may continue. The manual gives no session-by-session protocol. It sets out the focus for each phase and expects the therapist to apply it flexibly. [source: Milrod et al. 2016; McCarthy et al. 2018; Routledge PFPP-XR description; IPI review]

Phase I — Treatment of acute panic (roughly sessions 1–8; boundaries are approximate) [uncertain: exact session ranges are not specified in the sources; the 1/3–1/3–1/3 split is inferred from the trials' "final third" termination rule]

Goals: panic relief and reduced agoraphobic avoidance.
Work:
- Detailed evaluation of the attacks.
- Exploring the circumstances, stressors and feelings around panic onset.
- Exploring the personal meanings of the symptoms and the content of episodes.
- Taking a developmental history (earlier panic, separations, self and object representations).
- First outlining the core conflicts: separation/independence, anger, sexual excitement.
In published vignettes, panic often remits within about 5–6 sessions once onset is linked to its emotional circumstances. [source: Busch, Milrod & Singer 1999; Psychiatric Times PFPP review]

Phase II — Treatment of panic vulnerability (middle third)

Goals:
- Change the core conflicts so the patient is less vulnerable to recurrence.
- Improve relationships.
- Reduce anxiety around anger, separation and sexuality.
Work:
- Identify the conflicts and defences (reaction formation, undoing, denial) in different contexts and in the transference.
- Repeat the interpretations across contexts (working through). [source: Busch, Milrod & Singer 1999; IPI review]

Phase III — Termination (final third, at least the last ~8 sessions)

Goals: the patient re-experiences separation, anger and autonomy conflicts with the therapist, puts feelings about the loss into words and gets better at managing separation and independence.
Expect panic or anxiety to return temporarily. This is material to work with, not failure. [source: Milrod et al. 2000 open trial; Milrod et al. 2016; McCarthy et al. 2018; Busch, Milrod & Singer 1999]

Moving between phases.

Into Phase II: the meaning of panic onset has been clarified and symptoms are easing. Phase II is a shift of emphasis, not a hard switch. Panic focus continues throughout.
Into Phase III: set by the calendar. In the trials, termination was addressed for at least the final third (about one month).
If panic is still active when termination begins, decode it within the termination work rather than extending treatment. [source: Milrod et al. 2016; Keefe et al. 2018] [synthesis: "shift of emphasis" framing and handling of persistent panic] [uncertain: the manuals' exact criteria for phase transitions]

Therapist qualifications in trials.

Trained psychodynamic clinicians: in 2007, psychiatrists or psychologists with psychoanalytic training. They took a 10–12-hour PFPP course plus a supervised pilot case, then had monthly group supervision.
Adherence was rated on the PFPP Adherence Rating Scale (7 items).
The authors say less experienced clinicians should use PFPP under supervision. [source: Milrod et al. 2007 via Focus reprint; Milrod et al. 2016; psychiatryonline PFPP-XR review]

3. Guiding principles

Panic has meaning. Treat every attack, symptom choice and avoidance as psychologically decodable. Never accept "it just happens" as the final word. [source: Busch, Milrod & Singer 1999; Milrod et al. 2016]
Keep the focus on panic. Link new material (dreams, slips, relationship events) back to the panic. Panic-focused interpretations predicted symptom improvement; interpretations of conflict without a panic link did not. [source: Busch, Milrod & Singer 1999; Keefe et al. 2018]
Onset is the doorway. Investigate the life events and feelings around the first attack and each later one. Patients usually report none at first; the stressor is there but defended against. [source: Busch, Milrod & Singer 1999]
Core conflicts are predictable but individual. Listen especially for separation/independence fears with fearful dependency, unacknowledged anger, sexual excitement, and guilt with self-punishment. Expect these themes, but confirm them in the patient's material before interpreting. [source: Busch, Milrod & Singer 1999; Milrod et al. 2016]
Defences hide anger. Watch for reaction formation (excessive niceness or caretaking), undoing and denial. These cover anger at loved ones and pull the patient toward more clinging. [source: Busch, Milrod & Singer 1999; Psychiatric Times PFPP review]
Active, not neutral-silent. Ask direct questions about panic, raise it when the patient does not, and pursue slips and throwaway remarks. Do not wait passively for material. [source: Busch, Milrod & Singer 1999]
Reassure without closing exploration. Calm the patient with a firm, sympathetic attitude and early understanding. Any reassurance should open inquiry, not end it. [source: Busch, Milrod & Singer 1999]
The transference is the main agent of change. Interpret how separation, anger and dependency feelings arise toward the therapist. Do this with tact, because an overly aggressive transference focus can feel intrusive. [source: Busch, Milrod & Singer 1999; Milrod et al. 2016]
Avoid "external distortions." Do not manipulate the patient's environment, give directive behavioural guidance or bring in family. Doing so blurs the transference and the patient's ownership of change. [source: Busch, Milrod & Singer 1999]
No homework, no exposure. Avoidance is decoded, not exposed. The trials described PFPP as one that "lacks homework and never undertakes exposure." [source: Milrod et al. 2016]
Use the time limit. The fixed ending is a therapeutic lever. It recreates separation, so it is handled actively, and early, in the final third. [source: Milrod et al. 2000; McCarthy et al. 2018]
Not a cookbook. Follow the phase focus, not a script. The therapist chooses timing and content from the patient's material. [source: Busch, Milrod & Singer 1999; IPI review]
Psychological-mindedness is not a prerequisite. Engage concrete, somatically focused patients by linking feelings to circumstances. Do not exclude them up front. [source: Busch, Milrod & Singer 1999; Psychiatric Times PFPP review]

4. Intervention inventory

PFPP uses standard psychoanalytic techniques (clarification, confrontation, interpretation, transference work, working through), each kept tied to the panic. The items below are the interventions the founders describe. All therapist wording is illustrative unless quoted with a citation. [source: Busch, Milrod & Singer 1999; Psychiatric Times PFPP review; 1997 manual ch. 3, 6, 7 titles]

4.1 Detailed panic evaluation (Phase I, sessions 1–3)

Purpose: map the attacks precisely so their triggers and meanings can emerge, and show the patient from the first session that panic is something you can examine together.
When: the opening sessions. Return to it whenever a new attack is reported.
Steps:
1. Ask for the most recent attack in detail: where, when, alone or with whom, what happened just before, and what the patient was doing, feeling and thinking.
2. Ask what fantasies or images came during the attack: what did they fear would happen?
3. Ask which symptom frightens them most (heart, breath, dizziness, losing control, fainting). The most feared symptom often points to the fantasy underneath.
4. Map avoidance: where the patient can no longer go, and with whom they feel safe.
5. If the patient does not bring up panic, raise it yourself.
Example language (illustrative): "Take me back to Tuesday's attack. Where were you, who was there, and what was going on in the hour before?" / "Of everything you felt, what scared you most?" / "When your heart raced, what did you picture happening?"
Watch for: vague, purely physical accounts. Gently ask for the interpersonal context. It's working when the patient starts adding details unprompted and wonders aloud what was going on.
[source: Busch, Milrod & Singer 1999; 1997 manual ch. 3 "Initial Evaluation and Early Sessions" (title only)]

4.2 Exploring the circumstances of panic onset

Purpose: find the stressors and emotional situation around the first attack and around periods when panic got worse, the entry point to the conflict.
When: Phase I. Revisit in Phase II whenever panic rises again.
Steps:
1. Date the first attack and reconstruct the life situation around it: losses, moves, promotions, new relationships, separations, illnesses, anniversaries, independence milestones (graduations, birthdays).
2. Ask how the patient felt about these events at the time, not just what happened.
3. When the patient says "nothing was going on," treat that as a sign the stressor was defended against. Keep exploring calmly.
4. Look for a shared feature across onset and later surges, such as a threatened attachment, a step toward autonomy, or a situation calling for anger or assertion.
5. Offer the link tentatively. For example, onset came soon after a promotion that required reprimanding staff.
Example language (illustrative): "You said the first attack came out of nowhere. What else was happening in your life that spring?" / "It's striking that the attacks started the month you were put in charge of firing people. What was that like for you?"
Watch for: stressors the patient minimises because they are "good" (acceptance to graduate school, a promotion). Independence can be the threat. It's working when the patient recognises the timing and some of the feeling connected to it.
[source: Busch, Milrod & Singer 1999; Psychiatric Times PFPP review (Mr B vignette)]

4.3 Exploring the personal meaning of symptoms and the content of episodes

Purpose: uncover the unconscious fantasies expressed in the specific symptoms. A fear of stroke or heart attack may encode a fear of being punished for rage. Being ill may encode a wish for closeness or care.
When: Phase I, then throughout.
Steps:
1. Take the patient's catastrophic idea seriously as a fantasy: "dying," "going crazy," "collapsing in public."
2. Ask for associations: what does being sick, helpless or rescued mean to them? Who comes to mind?
3. Ask what the panic achieves or brings about, such as someone staying home or someone having to look after them.
4. Link the symptom to the relationship and feeling it carries.
Example language: The authors tell a patient that the panic "has a meaning" [source: Busch, Milrod & Singer 1999]. Illustrative: "When you picture yourself collapsing, who is there with you?" / "Being ill has meant your sister calls every day. I wonder if part of you is afraid of losing that."
Watch for: too-early, all-knowing interpretations. Build the meaning together from the patient's own associations. It's working when the symptoms start to feel understandable to the patient and less alien and catastrophic.
[source: Busch, Milrod & Singer 1999; Milrod et al. 2016]

4.4 Developmental and relational history

Purpose: place current panic within earlier separations, the patient's attachment style and the patient's images of self and others. This forms the basis for the conflict formulation.
When: Phase I, woven into the panic inquiry rather than done as a separate history-taking session.
Steps:
1. Ask about earlier anxiety, including childhood separation anxiety, school refusal and fear of being alone.
2. Ask about childhood separations, illnesses and losses, and about each parent's way of handling anger, independence and illness.
3. Note recurring self-images (weak, sick, inadequate) and images of others (harsh, rejecting, fragile, self-absorbed).
4. Connect these to the current onset situation.
Example language (illustrative): "Were you an anxious child when you had to be away from home?" / "What happened in your family when someone got angry?"
Watch for: history-taking that drifts away from panic. Keep linking it back. It's working when the patient sees parallels between past and present without being told.
[source: Psychiatric Times PFPP review; Busch, Milrod & Singer 1999]

4.5 Calming engagement: reassurance that opens exploration

Purpose: reduce acute terror and build the alliance while turning the patient's attention toward psychological meaning.
When: the first sessions, after medical work-ups, during flare-ups.
Steps:
1. Adopt a firm, sympathetic stance. Acknowledge how frightening the attacks are.
2. Accept medical clearance and then use it as a bridge: if the body is fine, the fear itself needs understanding.
3. Offer an early piece of understanding, such as a link to onset, so the patient has some sense of control.
4. Stir curiosity by pointing to puzzles in their account.
Example language: "so we need to understand more about why you still have the fear" [source: Busch, Milrod & Singer 1999]. Illustrative: "Your cardiologist says your heart is healthy. That makes it even more important to figure out what the fear is about."
Watch for: blanket reassurance ("you're fine") that closes off inquiry, or repeated requests for reassurance. Explore those requests in turn (see 4.15). It's working when the patient comes in curious rather than only frightened.
[source: Busch, Milrod & Singer 1999]

4.6 Inviting free association and following slips

Purpose: get past conscious, somatic accounts to fantasies and feelings.
When: whenever the patient's account stalls at the bodily level, or a slip, dream or throwaway remark appears.
Steps:
1. Ask the patient to say whatever comes to mind about a symptom, image or situation, without censoring.
2. Notice slips of the tongue and passing remarks. Do not let the patient dismiss them.
3. Ask for associations to the slip and link them to the panic themes.
Example language: "Let your imagination go a little" [source: Busch, Milrod & Singer 1999]. Illustrative: "You just said 'going with you' instead of 'going without you.' What comes to mind?"
Watch for: the patient feeling caught out. Frame slips with curiosity, not as a gotcha. It's working when associations lead to feelings (anger, guilt, excitement) the patient hadn't put into words.
[source: Busch, Milrod & Singer 1999 (Mr A vignette)]

4.7 Clarification

Purpose: sharpen vague or contradictory material so the patient and therapist can both see its emotional shape.
When: throughout. This is the main tool of Phase I.
Steps:
1. Restate what the patient described and ask for specifics: "What exactly happened next?"
2. Draw out the feeling that went unnamed in the account.
3. Gather recurring elements across episodes into one observation.
Example language (illustrative): "So each attack this month came on a day you'd had words with your husband?" / "You described the meeting in detail but skipped over how you felt when he criticised you."
Watch for: over-questioning that turns into interrogation. It's working when the patient begins to clarify on their own.
[source: Psychiatric Times PFPP review (names clarification, confrontation, interpretation as core techniques)] [synthesis: specific steps]

4.8 Confrontation

Purpose: point out what the patient avoids, minimises or contradicts, especially anger and the dismissal of meaningful material.
When: once there is enough alliance, typically late Phase I onward. Use it when the patient denies an obvious feeling or brushes off a slip.
Steps:
1. Name the discrepancy plainly and without accusation, for example between angry content and a calm or cheerful description.
2. Ask the patient to stay with it rather than move on.
3. Follow with clarification or interpretation once the patient takes it in.
Example language (illustrative): "You're describing your boss humiliating you in front of everyone, and you're smiling. I wonder what happens to the anger." / "You laughed off that slip quickly. I'd like to look at it."
Watch for: confrontation felt as criticism. Pair it with empathy for why the feeling is dangerous. It's working when the patient acknowledges the feeling ("I suppose I was furious") without the panic escalating.
[source: Busch, Milrod & Singer 1999; Psychiatric Times PFPP review]

4.9 Interpreting separation and fearful dependency

Purpose: make conscious the conflict between needing an attachment figure for safety and wanting, or fearing, independence. Panic often follows real or threatened separations or steps toward autonomy.
When: Phase I in outline. Phase II in depth. Phase III in the transference.
Steps:
1. Identify the safe person or safe place, and when panic appears in relation to them.
2. Note steps toward autonomy that preceded attacks (moving out, a new job, a birthday milestone).
3. Interpret both sides: the wish to be independent, and the fear that independence will bring loss, abandonment or punishment.
4. Show how panic keeps the attachment in place, since helplessness brings the other person close.
Example language (illustrative): "The attacks began the week after you turned 18 and talked about moving out. It's as if the panic both marks the step and stops you taking it."
Watch for: the patient hearing that they are "too dependent." Frame dependency as an understandable solution to fear. It's working when the patient can feel both the wish for independence and the fear of it, and can make moves toward independence with less panic.
[source: Busch, Milrod & Singer 1999 (18th-birthday and brother vignettes); Milrod et al. 2016]

4.10 Interpreting anger: recognition, management, expression

Purpose: bring into awareness the anger at loved ones (often rage at feeling abandoned, controlled or humiliated) that the patient fears will destroy the relationship. Panic patients typically minimise anger at first, even though it is present at onset.
When: from late Phase I. A central focus in Phase II and Phase III.
Steps:
1. Look for anger-provoking events just before attacks, even when the patient reports only hurt, worry or nothing at all.
2. Clarify the provocation, then confront the missing anger (4.8).
3. Interpret the danger the patient feels in anger: that it will drive the person away, hurt them, or bring retaliation.
4. Link the anger to the panic: the attack replaces the angry feeling, or punishes the patient for it.
5. Over time, help the patient find ways to recognise and voice anger that do not threaten the attachment, without directing them to do so (see principle against directive guidance).
Example language (illustrative): "You felt dropped when she cancelled, and an hour later you couldn't breathe. I wonder if the anger was too dangerous to feel, so it came out as fear."
Watch for: a temporary rise in anxiety as anger surfaces, and guilt after acknowledging it. It's working when the patient can name anger at loved ones and the therapist with less fear, and becomes more assertive outside sessions. In the Mr B vignette, he set limits with his mother and managed staff better.
[source: Busch, Milrod & Singer 1999 (Mr D, Ms C); Psychiatric Times PFPP review; Milrod et al. 2016]

4.11 Interpreting sexual excitement, guilt and self-punishment

Purpose: address panic that is linked to forbidden excitement or to the need to atone. An attack can carry excitement in disguise or serve as a punishment that relieves guilt.
When: Phase I–II, when the material points there (the timing of attacks around sexual or romantic situations, or attacks after successes).
Steps:
1. Notice attacks that follow excitement, success, competition or pleasure.
2. Ask about the feelings in those moments, including the arousal and the guilt.
3. Interpret the guilt-and-punishment sequence: the attack "pays" for the wish.
4. Interpret any excitement contained in the panic state itself only when the patient's own material supports it.
Example language (illustrative): "The attacks seem to come just after things go well for you, as if something in you says you don't deserve it."
Watch for: shame. Pace sexual material carefully. Also watch for fear of punishment as the patient improves; the authors note that improvement itself can set this off. It's working when successes stop being followed by attacks.
[source: Busch, Milrod & Singer 1999; Milrod et al. 2016 ("panic as an expression of guilt"); Milrod et al. 2000]

4.12 Interpreting panic as a compromise formation

Purpose: bring the pieces together into one formulation the patient can use: the attack expresses a forbidden wish and also defends against it or punishes it. For example, helplessness brings care without the patient having to admit rage.
When: once onset, meaning and conflict material have come up (late Phase I through Phase II). Repeat in new contexts.
Steps:
1. Name the wish (to be free, to be angry, to be cared for, to be excited).
2. Name the fear (loss, retaliation, guilt).
3. Show how the panic serves both, and why it can feel like the least bad option compared with facing the conflict.
4. Check the patient's response and revise.
Example language (illustrative): "When you panic, your husband has to come home. You get him back without having to say how angry you are that he's never there. The attack does both jobs."
Watch for: intellectual agreement with no emotional shift. Return to the feeling in the moment. It's working when the patient starts to spot the pattern themselves before or during an attack.
[source: Busch, Milrod & Singer 1999; Psychiatric Times PFPP review]

4.13 Defence interpretation: reaction formation, undoing, denial

Purpose: show the patient how they keep anger out of awareness, which matters because those defences fail and panic breaks through.
When: Phase II mainly, after the patient can tolerate some awareness of anger.
Steps:
1. Reaction formation: point out excessive niceness, caretaking or accommodation toward someone who is frustrating them.
2. Undoing: point out how an angry thought or act is quickly followed by reparative gestures or retractions.
3. Denial: point out the insistence that a plainly upsetting event "didn't bother me."
4. Interpret what the defence protects against, for example fear of losing the person.
5. Link this to the panic: when the defence fails, panic takes its place.
Example language (illustrative): "Each time you mention being annoyed with your mother, you quickly add how much she does for you. As if the annoyance has to be cancelled straight away."
Watch for: the patient feeling their kindness is being attacked. Acknowledge that the caring is real and also has a protective job. It's working when the patient catches the defensive move themselves.
[source: Busch, Milrod & Singer 1999 (Ms C); Psychiatric Times PFPP review (Mr B); 1997 manual ch. 5 title]

4.14 Decoding agoraphobic avoidance (no exposure)

Purpose: treat avoidance and "safe person" dependence as meaningful rather than as behaviour to be extinguished. PFPP never assigns exposure.
When: Phase I onward, whenever avoidance comes up.
Steps:
1. Explore what is feared in each avoided place or situation, and what being accompanied provides.
2. Link avoidance to the same conflicts (separation, anger, autonomy). For example, being unable to go out alone keeps the partner close.
3. Do not prescribe exposure or behavioural tasks. If the patient chooses to venture out, explore the feelings and meanings this brings up.
Example language (illustrative): "What would it mean to be able to go to the city on your own? Who would that change things for?"
Watch for: pressure (from the therapist, family or the patient) to "just push through." Explore it rather than act on it. It's working when the patient spontaneously widens their range as the meaning becomes clear.
[source: Milrod et al. 2016 ("decoding symptoms and avoidance"); Busch, Milrod & Singer 1999 (expected reduction in agoraphobia)] [synthesis: steps 1–3 phrasing]

4.15 Transference interpretation

Purpose: work with separation, anger and dependency conflicts as they happen live with the therapist. The authors see this as the main route to change.
When: whenever transference shows clearly. Increasingly in Phase II and central in Phase III. Typical triggers: cancellations, holidays, lateness, gaps between sessions, the therapist's comments, requests for reassurance, and the approaching end.
Steps:
1. Notice reactions to the therapist: worry about the therapist's health or anger, excessive compliance, flare-ups around breaks, wishes to be rescued.
2. Ask directly about feelings toward the therapist, especially hard-to-say ones.
3. Link the reaction to the core conflict and to the panic: "the same thing happening here."
4. Pace this. Too aggressive a transference focus can feel intrusive and leave the patient feeling misunderstood.
Example language (illustrative): "You had an attack the night after I told you about my week away. I wonder if part of you was angry with me for leaving and that felt dangerous to notice." / "You've been worrying I'll be annoyed that you're doing better and won't need me."
Watch for: the patient relating to the therapist only as a "real" helper or doctor. Keep inviting the fantasy level. It's working when the patient can say angry or dependent feelings toward the therapist and the panic around breaks eases.
[source: Busch, Milrod & Singer 1999; Psychiatric Times PFPP review (Mr B termination); Milrod et al. 2016]

4.16 Working through

Purpose: make insight last by repeating the core interpretations across many contexts (work, partner, parents, therapist, dreams) until the pattern no longer runs automatically. The aim is to reduce vulnerability to relapse.
When: Phase II mainly, continuing into Phase III.
Steps:
1. Each time a new situation fits the formulation, point to the familiar pattern.
2. Help the patient notice small differences and new responses.
3. Track the moments when the conflict comes up without panic, as evidence of change.
Example language (illustrative): "Here it is again, this time with your sister: feeling left out, then the tight chest. What's different this time is that you noticed you were furious."
Watch for: repetition that becomes rote. Each repetition should be tied to fresh feeling. It's working when the patient generalises the insight to new situations without prompting.
[source: Busch, Milrod & Singer 1999; IPI review; 1997 manual ch. 6 title]

4.17 Termination work (Phase III)

Purpose: use the planned ending to re-create separation, abandonment and anger conflicts with the therapist, so the patient can put them into words rather than express them as symptoms.
When: at least the final third (about the last 8 sessions). Mention the end date from the start, and actively take it up from about session 16.
Steps:
1. Raise termination explicitly and repeatedly. Do not wait for the patient to raise it.
2. Ask about feelings and fantasies about ending: abandonment, anger at the therapist, guilt about leaving, fear the therapist will be hurt or angry.
3. Predict and normalise a temporary return of symptoms, then decode it as a response to the separation.
4. Link ending reactions to past separations and to the onset of panic.
5. Notice and interpret urges to leave early or to skip sessions.
6. Review what has been understood, framed as the patient's own capacity rather than the therapist's gift.
Example language (illustrative): "We have eight meetings left. What comes up when you think about our last session?" / "The attacks came back this week, just as we started talking about ending. Let's look at that together."
Watch for: pseudo-independence ("I'm fine, it doesn't matter"). Treat this as denial. It's working when the patient can feel sad or angry about ending and the returning symptoms fade within the phase.
[source: Milrod et al. 2000 (termination addressed for at least final eight sessions); Milrod et al. 2016; McCarthy et al. 2018; Busch, Milrod & Singer 1999; Psychiatric Times PFPP review]

4.18 Working with medication and other treatments in PFPP

Purpose: keep PFPP's interpretive frame when the patient is also on medication or has other care. Changes in medication can have transference meaning.
When: whenever medication is started, tapered or stopped, or other care is involved.
Steps:
1. Do not change ongoing medication because of PFPP. In the trials, patients on stable medication continued it.
2. Explore what the medication and the prescriber mean to the patient (a safety object, a carer).
3. If panic rises during a taper, explore separation feelings toward the drug or the prescriber before concluding it is only pharmacological. Coordinate with the prescriber; any taper decisions are theirs.
Example language (illustrative): "The attacks got worse the week your dose was reduced. Besides the medication itself, what has it been like to feel Dr X stepping back?"
Watch for: genuine withdrawal or medical causes. Those belong to the prescriber or physician. It's working when the patient can talk about attachment to the medication or prescriber.
[source: Busch, Milrod & Singer 1999 (taper vignette); IPI review; 1997 manual ch. 9 "Combining PFPP With Other Treatment Approaches" (title only)] [uncertain: the manual's specific guidance on combination]

5. Handling problems

The 1997 manual has a chapter titled "Approaches to Common Problems in the Treatment of Panic Patients" (ch. 8). It is not drawn on here. The guidance below draws on the founders' papers where tagged [source], and the rest is marked [synthesis].

Somatic focus or limited psychological-mindedness. The patient talks only about symptoms and doctors. Keep asking about the circumstances around each attack and link feelings to life events concretely and repeatedly. Do not wait for insight to arrive. The authors found psychological-mindedness did not predict outcome, and these patients often engage once feelings are tied to concrete situations. [source: Busch, Milrod & Singer 1999; Psychiatric Times PFPP review]
"Out of the blue" and minimised anger. Treat the denial as a defence (4.2, 4.13). Gather timing evidence across several attacks before you interpret. Confront gently and keep at it. [source: Busch, Milrod & Singer 1999]
Requests for medical reassurance or more tests. Make sure a proper medical evaluation has been done once. After that, acknowledge the clearance and turn to why the fear persists (4.5). Explore repeated reassurance-seeking as a need for a protective figure, including in the transference. [source: Busch, Milrod & Singer 1999] [synthesis: the transference framing of repeated requests]
Overwhelm or panic in session. Stay calm and firm. Help the patient notice what was being discussed or felt just before the surge. That moment is first-hand onset material. Do not switch to breathing or relaxation coaching; it moves into another model's methods, which the trials screened against. Use only ordinary calming presence. [source: Busch, Milrod & Singer 1999 (firm, sympathetic attitude); Milrod et al. 2016 (adherence to model)] [synthesis: in-session handling]
Patient wants techniques, homework or advice ("Just tell me what to do"). Acknowledge the wish. Explain that PFPP works by understanding what drives the attacks. Explore the request: who used to tell them what to do, and what it would mean to work it out themselves. Avoid directive guidance and environmental manipulation. [source: Busch, Milrod & Singer 1999 (avoid external distortions); Milrod et al. 2016 (no homework)] [synthesis: wording and exploration]
Family or partner pressure, or requests to bring a partner in. Do not involve family in sessions. Explore the patient's dependence on the partner and their feelings about the partner's pressure as session material. [source: Busch, Milrod & Singer 1999] [synthesis: handling]
Improvement followed by relapse or anxiety. Consider unconscious guilt or fear of punishment for getting better or more independent, and interpret it (4.11). [source: Busch, Milrod & Singer 1999 (Mr A)]
Ruptures from transference work. Too aggressive a transference focus can feel intrusive, and the patient may feel misunderstood. Acknowledge the misstep, go back to their experience and their panic, and bring the transference up again later with more evidence. Missed cues are a recognised therapist error; review session notes or recordings in supervision. [source: Busch, Milrod & Singer 1999] [synthesis: repair steps]
Patient relates to the therapist only as a real helper. Accept the real relationship, but keep inviting fantasies and feelings about the therapist, especially around breaks. [source: Busch, Milrod & Singer 1999]
Missed sessions or lateness (PFPP has no homework, so attendance and engagement are the adherence issue). Explore absences as possible enactments of separation or anger, especially near breaks and during Phase III. Raise them in the very next session and connect them to the themes already under discussion. [source: Busch, Milrod & Singer 1999 (wish to flee in termination)] [synthesis: general non-attendance handling]
Flight or symptom return at termination. Expect it. Raise ending early and often, and decode returning panic and urges to stop early as separation reactions (4.17). [source: Busch, Milrod & Singer 1999; Milrod et al. 2016; IPI review]
Requests to extend beyond 24 sessions. Keep the end date. The time limit is the tool that brings out separation conflict, so explore the request as part of the termination work. If clinically necessary after the ending (significant residual symptoms or comorbidity), plan further treatment as a separate, explicitly agreed step. [synthesis] [uncertain: the manuals' rule on extensions]
Stuck: little panic change by mid-treatment. Check you are making panic-focused interpretations. Mid-treatment interpretations without a panic link were not associated with improvement. Check the conflict formulation against the onset data and against any new material. Raise the stuck point in supervision. At the end, if there has been no response, offer an evidence-based alternative such as CBT with exposure, or a medication review. PFPP outcomes varied between trial sites. [source: Keefe et al. 2018; Milrod et al. 2016] [synthesis: switching guidance]
Panic remits but agoraphobic avoidance persists. Keep decoding the avoidance (4.14) within PFPP. Do not add exposure during PFPP, because that breaks the model. If avoidance remains significant after termination, consider a separate exposure-based treatment. [source: Milrod et al. 2016 (no exposure)] [synthesis: sequencing]
Medication changes during treatment. Coordinate with the prescriber, and explore separation meanings of tapers (4.18). Do not advise on dosing. [source: Busch, Milrod & Singer 1999]
Comorbid depression, suicidality or substance misuse (including benzodiazepine misuse). Carry out standard suicide and substance risk assessment at intake and whenever risk signs appear. PFPP is not a crisis intervention. If risk is significant, prioritise safety planning or a higher level of care, and resume PFPP only once the patient is stable. [synthesis]
Personality pathology. Preliminary data suggested patients with cluster C traits may do relatively well in PFPP. Dependent and avoidant features fit the separation focus. For severe personality pathology, a longer-term treatment (e.g., TFP) may suit better. [source: Psychiatric Times PFPP review] [synthesis: the severe-pathology recommendation] [uncertain]
Countertransference. Clinging, reassurance-seeking patients can provoke irritation, rescue fantasies or an urge to direct. Use these reactions as information about the patient's relationships, which often mirror the anger and dependency conflict. Bring them to supervision rather than act on them. [synthesis]
Non-anxiety targets in PFPP-XR (GAD, social anxiety, PTSD). Use the XR manual's adaptations. This guide does not cover them, and the XR applications beyond panic have not been tested in RCTs. [source: psychiatryonline PFPP-XR review] [uncertain]

Sources

Sources:

Books and papers cited (full texts not drawn on unless listed above):

Milrod, B., Busch, F., Cooper, A., & Shapiro, T. (1997). Manual of Panic-Focused Psychodynamic Psychotherapy. American Psychiatric Press.
Busch, F. N., Milrod, B. L., Singer, M. B., & Aronson, A. C. (2012). Manual of Panic Focused Psychodynamic Psychotherapy – eXtended Range. Routledge (Psychoanalytic Inquiry Book Series).
Busch, F. N., Milrod, B. L., & Singer, M. B. (1999). Theory and technique in psychodynamic treatment of panic disorder. Journal of Psychotherapy Practice and Research, 8(3), 234–242.
Milrod, B., et al. (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164, 265–272.
Milrod, B., et al. (2016). Psychotherapies for panic disorder: a tale of two sites. Journal of Clinical Psychiatry, 77(7), 927–935.
Keefe, J. R., et al. (2018/2019). Focus is key. Psychotherapy Research, 29(8), 1033–1044.
Busch, F. N., & Milrod, B. L. (2015). Psychodynamic treatment for separation anxiety in a treatment nonresponder. Journal of the American Psychoanalytic Association, 63(5).

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