1. Is psychoanalytic psychotherapy right for me or my child?
Probably. Psychoanalytic psychotherapy addresses a wide range of difficulties occurring at any age. It is relevant to problems at work, at school, at home, in friendships. It addresses impulsive actions that cause trouble. It addresses severe inhibition and inability to take useful actions. It helps people who are overwhelmed by their feelings, and people who want to better connect with their feelings, so that they feel more creative and alive. In general, if you believe that behavior is meaningful and you are curious about yourself (or your child), you should call me.
2. Is psychoanalytic psychotherapy appropriate for children of divorce?
Children of divorce benefit from psychotherapy because it provides a neutral space, free from the loyalty conflicts children inevitably feel when parents are estranged. Sometimes, however, when parental conflict has escalated to legal battles over custody or the residential schedule, I recommend that parents first resolve their conflict and then pursue treatment for their child. Psychoanalytic psychotherapy for children requires a minimal amount of parental good will.
3. How often will we meet?
The frequency of meetings depends on your goals. As for any skill, the more you practice, the better you get. Three to six meetings a week builds momentum and continuity, and provides lots of time to practice new skills and perspectives. It also discourages the return of old habits. In the course of growth and change, the mind inevitably tries to snap back to the familiar, and frequent sessions keep it stretched. Frequent meetings also build trust. The more often people meet together, the more experience they share, and the more confident they become in each other’s dedication to the most important project in the patient’s life. Finally, frequent meetings make it easier to open up and explore feelings, knowing that you won’t be left for a long time to carry them alone. Simply said, higher frequency really makes a positive difference.
4. How long does psychotherapy last?
It depends. Because symptoms arise for different reasons and the same symptom can have different forces sustaining it, we can’t know at the outset how long therapy will take. Psychotherapy is best approached as an open-ended process, because important issues can hide behind time limits.
Psychotherapy with children, who still have so much of their personality development ahead, is usually shorter than with adults. While we still can’t predict a treatment’s length, parents and I can more precisely establish goals for a child’s treatment, so that we will know more clearly when it is time to plan an ending.
5. How do we afford the cost of treatment?
I will be glad to talk with you about my fees and your resources, and collaborate in making a realistic, long-term plan. Some people want to pay directly for their therapy, without using insurance. Others pay me and then get reimbursed from their insurance. Presently, I am in-network for Blue Cross Blue Shield of Vermont and in this case, will bill them directly. We can discuss the details of your situation.
6. Can treatment be coordinated with other providers?
Absolutely. With your permission, I will talk with your primary care physician and any other of your providers to be sure that we are all working together. For children, it is common to have a team that includes teachers, special educators and other therapists, the parents, and myself. In these situations, it is essential that the child knows we are a cohesive, integrated team and that the adults are in regular, effective communication with each other.
7. What about psychotropic medication?
I’m familiar with the controversy over psychotropic medication. I helped bring Robert Whitaker, award-winning author of Anatomy of an Epidemic to the Upper Valley to inform the community about the long-term outcomes of drugs. I am conservative about referring patients for a medication evaluation, and I want to evaluate, for as long as is prudent, how much change occurs through psychotherapy, as we work hard at this natural approach to mental growth. In rare situations, when a patient’s safety is in question or we need a second perspective, I refer to a psychiatrist. When people come to me already on medication, I recommend that we collaborate with the prescribing physician, keeping medication steady and adding psychotherapy. Sometimes, people want to stop their medication, and, once we’ve made sufficient progress in psychotherapy, we can work with the prescriber towards this goal.
8. What is the scientific evidence for the effectiveness of psychoanalytic psychotherapy?
Case Studies: The Original Evidence That Treatment Works
Scientific tools must match the research subject. Psychoanalysts, focused on understanding the richness and complexity of an individual mind, write case studies; these document the personality growth that accompanies psychoanalytic treatment.
Empirical Evidence for Adult Psychoanalytic Treatment
Despite an intractable myth to the contrary, there is good empirical evidence for the effectiveness of psychoanalytic treatment for adults. In 2008, the Journal of the American Medical Association published a meta-analysis of 23 studies of long-term psychodynamic psychotherapy for complex mental disorders, including eating disorders, chronic depression and/or anxiety, and long-standing interpersonal difficulties; 11 of these studies met the highest standards for empirical research, randomly assigning patients to treatments. The meta-analysis found that long-term psychodynamic psychotherapy patients did significantly better than those who had shorter-term treatments in overall outcome, target problems, and personality functioning.
Similarly, a meta-analysis published in 2009 in the Harvard Review of Psychiatryexamined 27 studies and found that long-term psychoanalytic treatment for adults with a range of diagnoses produced good overall results, with a strong effect for reducing symptoms and a moderately strong effect for personality change. Most important, both reviews identified a consistent trend for improvement to continue after analytic treatment has ended, a finding which does not occur with shorter-term treatments.
Consumer Satisfaction Surveys
In a 1995 Consumer Reports survey, readers reported more improvement from treatments lasting over 6 months than from shorter-term treatments. The readers also described more growth the longer they were in therapy.
Empirical Evidence For Child Psychoanalytic Treatment
For child psychoanalytic psychotherapy, the best scientific evidence comes from case studies and a chart review of over 700 cases seen at the Anna Freud Centre in London. In the chart review, over 80% of children who were anxious or depressed were symptom-free at the end of treatment. Children with conduct problems were less likely to respond well, but those who were younger and/or also anxious responded better. A long-term follow-up study of the children seen at the Anna Freud Centre found that a successful child therapy enhances resilience in adulthood. Those who had successfully completed treatment were functioning well at work, had at least one support person, and handled intimate relationships better than their untreated siblings. In general, children who were doing better at the beginning of therapy did better as adults. However, there was also a subgroup of very troubled children who, after a successful analytic treatment, did extremely well as adults.
In contrast to the adult psychotherapy research, large-scale controlled studies of child psychotherapy have focused on cognitive-behavioral therapy and parent training and have not examined the effectiveness of psychoanalytic treatments for children. However, we do have evidence from a small study that the findings in adult psychotherapy research—that analytic treatments promote growth that continues after therapy ends—also hold for children. Children with reading disabilities were assigned to once-weekly psychotherapy or to psychoanalytic treatment four times weekly. All treatments lasted 1.5 - 2 years, and all children had resumed normal rates of academic growth by the end of therapy. However, the rate of academic improvement continued to increase after therapy ended only for the children who had been seen four times weekly. In addition, those seen four times weekly were more creative and used humor as an appropriate coping strategy, experienced a broader range of feelings, functioned more autonomously, and had healthier relationships. As expected, the more these children put into psychotherapy, the better it worked.
1. For a summary of this evidence, see Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65 (2), 98-109.
2. Leichsenring, F. and Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association, 300(1), 1551-65.
3. De Maat, S., de Jonghe, F., Schoevers, R., & Dekker, J. (2009). The effectiveness of long-term psychoanalytic therapy: A systematic review of empirical studies. Harvard Review of Psychiatry, 17 (1), 1-23.
4. Does therapy help? Consumer Reports(1995), November, 734-739.
5. Target, M. & Fonagy, P. (1994). Efficacy of psychoanalysis for children with emotional disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 33(3), 361-371.
6. Fonagy, P., & Target, M. (1994). The efficacy of psychoanalysis for children with disruptive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 33(1), 45-55.
7. Schachter, A. and Target, M. (2009) The adult outcome of child psychoanalysis: The Anna Freud Centre Long-term Follow-up Study. In: Midgley, N., Anderson, J., Grainger, E., Nesic-Vuckovic, T., and Urwin, C., Eds. Child Psychotherapy and Research: New Approaches, Emerging Findings. London: Routledge, 144-156.
8. Heinicke, C. (1965). Frequency of psychotherapeutic session as a factor affecting the child’s developmental status. Psychoanalytic Study of the Child,20, 42-98.
9. Why choose psychoanalytic psychotherapy?
People make this choice for many different reasons. Some get temporary relief from other psychotherapies, but then recognize that deeper issues and personality traits continue to trouble them. Others find reassurance in the knowledge that their therapist will have had a long personal analysis, and will have worked hard on her own personal growth. Some people follow the recommendation of a trusted friend or colleague. Finally, some value self-knowledge above all other life-goals.
The decision to start psychotherapy, and the decision about what kind of psychotherapy to pursue, can profoundly influence the direction of your life. If, after consultation and evaluation, we decide to work together, we will have a general idea of the issues you or your child will be engaging in psychoanalytic work. Although we can never know the entire path of psychotherapy in advance, what I can promise is that I will dedicate my full attention, concern, intelligence, and creativity to you.