Common Questions

Answers to the questions prospective patients ask most.

• What does treatment cost?

  The financial aspect of treatment really needs to be talked through in person. Though I still do accept some insurances, I am increasingly shifting my practice to a fee-for-service model. If your plan includes out-of-network benefits, your insurance may reimburse you for a meaningful portion of each session — I can provide the receipts (called superbills) you would submit, and this guide explains how that works. I know the cost of treatment is significant, but so too is its value. I offer consultations — at least two sessions within a week — as a chance to meet and get a feel for one another. And if we can't find a workable fee, I'll keep the cost of the consultation modest and gladly help with referrals to other clinicians. Call me — I'm happy to talk things through with you.

• How often would we meet?

  At least twice weekly, consistently over time. Meeting twice weekly is considered psychoanalytic psychotherapy, whereas meeting four or five times weekly is considered psychoanalysis. The difference is one of intensity and possibility. An analysis is a much fuller experience, but psychoanalytic psychotherapy is still experiential, richly meaningful, and very effective.

  An analysis doesn't always make sense and isn't always recommended. I tend to start with patients at a frequency of twice weekly and let things unfold for a number of months or even a year or more. Then, as we get a better sense for how well we work together and how your mind is structured, it may or may not make sense to consider converting to an analysis.

• Why not meet just once per week?

  Psychoanalytic work deals with the structure of your thoughts, not just their contents. When you talk in a session — even when you're describing people and events from another time and place — you're also conveying something else: information about how your mind is working right now, in the act of thinking and speaking. What reaches me is never the events themselves. The events you're describing have already been interpreted. What we need access to are those automatic processes of interpretation, not their products.

  That's the aim. The question of frequency is really a question about what makes that access possible, and there are three honest answers.

  The first is continuity. With a week between meetings, each session largely starts over. A thread that opened on Tuesday has gone cold by the following Tuesday, and you arrive with a week of accumulated life that seems to demand reporting. Much of the hour gets spent updating me. At higher frequency, the reporting function falls away — there's simply less to report — and what remains is your mind, working, in front of both of us.

  The second is momentum. The central activity of this work — loosening your control over your own mind and letting thoughts surface as they come — is genuinely difficult, and the difficulty doesn't yield to a single effort. The mind's ordinary management re-establishes itself quickly. With a week between sessions, each meeting spends much of itself climbing back to where the last one ended. Frequency isn't more of the same thing; it's what allows the process to build rather than perpetually restart.

  The third is evidence. If I'm going to say something to you about how your mind organizes experience, I need enough material to distinguish a real pattern from a coincidence. That standard is a matter of intellectual honesty: an interpretation offered on thin evidence isn't insight, it's speculation. Meeting more often produces the density of material that makes it possible for me to say things that are actually warranted — and for you to test them against your own experience rather than take them on authority.

  None of this means weekly therapy is empty. The implicit dimension of your speech is present in every session, at any frequency, and real work can be done with it. But frequency changes what's possible. At once per week, I can follow your patterns at a distance; I can rarely engage them as they're happening. And it's the engagement — catching the machinery in motion, not reviewing its output afterward — that produces change in how the mind itself works, rather than change in what you know about it.

  How often is enough? Enough that the work can build on itself rather than restart — for most people, that threshold is two or more meetings per week. Where it settles depends on what we're trying to reach, and it's something we work out together.

• This talk of patterns is hard to grasp. Can you say it another way?

  Try this. Imagine the mind as a projector. It doesn't just receive the world — it projects onto it, casting images assembled long ago: ideas about who you are, what others intend, what's possible for you, what's safe and what isn't. Most of the time you don't see the projector at work. You just see the picture and take it for the world itself.

  When the picture is accurate enough, life goes reasonably well. But when old footage keeps playing — when you find yourself in the same argument with different people, the same disappointment in different jobs, the same distance in different relationships — that's the projector running film you didn't choose and can't see. The "pattern" is simply the same scene appearing again and again, projected onto situations and people who didn't call for it.

  Most therapy works on the picture: what's on the screen, how you feel about it, what to do about it. This work is about the projector itself. In the analytic setting, the projection happens live — onto the treatment, onto me — where the two of us can finally watch it operate. And once you can see your mind projecting, rather than just seeing the projection, something fundamental shifts: the film loosens its grip, and the world gets to be newer than it was.

• This talk of patterns is abstract. Can you talk in terms of depression or anxiety?

  Yes. Most people who come to me would describe what they're facing as depression, or anxiety, or both — and this work helps with those. But there's a reason I tend to talk about patterns rather than leading with the diagnosis.

  When you actually sit, week after week, with someone who has been seriously depressed for a long time, the depression itself is often oddly quiet — not the thing that's most alive between us. David Taylor, describing the Tavistock Adult Depression Study, called this "the reticence of the depression." What tends to be more present is something more particular to the person: a punishing relationship with themselves, a private struggle they've never put into words, confusions that resist any tidy name, a way of clinging to or fending off the people they most need.

  So "depression" and "anxiety" are real and useful names — but they name the surface, the trouble you arrive with. The treatment reaches toward what's underneath and around them: the specific shape of one person's inner life. That's what "patterns" points to. The diagnosis is the door; the work is with the whole room behind it.

• What's up with the couch?

  The couch is a tool, not a requirement. Lying down, without me in your field of vision, makes it easier to do the central work of this kind of therapy: loosening your control over your own mind and letting thoughts surface as they come. Face to face, some part of you is always reading my reactions and adjusting to them — that's just how minds work in conversation. The couch quiets that channel, and what emerges tends to come more from you and less from the social situation.

  In practice, psychoanalytic psychotherapy is usually done sitting up, and the couch typically belongs to analysis proper. But there's no rule about it, and nothing happens before it makes sense to both of us.

• How long does treatment take?

  The treatment doesn't have a fixed endpoint. It tends to find its own natural conclusion — a point at which the work feels genuinely complete rather than arbitrarily stopped. For most people this takes years, not months. That's worth knowing going in: it's a significant commitment, and what it offers in return is change that lasts.

• Is there evidence that this kind of therapy works?

  Yes, in two senses — one from the research, and one that matters even more.

  The research first. What's generally found is that psychoanalytic treatment works: symptoms improve, and — distinctively — the improvements tend to continue growing after treatment ends. Where other therapies' gains often fade once sessions stop, this work sets something in motion that keeps developing on its own. That's what you'd expect from a treatment that changes how the mind works rather than just managing what it produces.

  See, for example, Leichsenring & Rabung's meta-analysis of long-term psychodynamic psychotherapy (JAMA, 2008), and the Tavistock Adult Depression Study (World Psychiatry, 2015), in which patients with treatment-resistant depression continued improving well after treatment ended.

  But perhaps more important for you as a patient is this: the nature of the work is such that the evidence of its effectiveness is produced in the therapy itself. By helping you see how your mind works, we generate real-time data — observations you can evaluate and test against your own experience, rather than take on faith. And as you do, something observable happens: the interactions between you and me, the patterns that tend to characterize them, begin to change. You don't have to trust a study to know whether the work is working. You watch it happen.

• How do I get started?

  It starts with a phone call — 619-887-4068. From there, if it feels right, we can arrange an initial consultation: at least two meetings within a week, as a chance to meet and get a feel for one another. There's no obligation beyond that. The only way to really know whether this kind of work is for you is to get a feel for it.