Mary Ellen Young
416 421 0121
My Approach to Therapy
Which Professional Do You Need?
How to Find the Right Professional For You
Regulation of Psychotherapy
Fees: $60 - $80
Education & Training
Fees: $60 - $80
Education & Training
There are two general approaches to psychotherapy:
I have been trained in the psychodynamic tradition, which has its roots in psychoanalysis and early childhood development. People often think that this involves blaming one's parents for one's problems. This is not the case. The focus is on how the child made sense of the world around him or her. While this world obviously includes parents, siblings and other relatives or family friends, it is the conclusions that the child draws about him or her self in relation to the world and other people that is formative and is the focus of therapy.
For example, a small boy may think that his mother, who is suffering from depression and is distracted or preoccupied, is not interested in him and conclude that he is not interesting. This is not the result of bad mothering. This "mom's-not-interested-so-I'm-not-interesting" is the sort of direct cause-and-effect thinking we see in small children. They draw all kinds of conclusions this way and, because they do a great deal of this before they can even talk, most of it never gets said out loud so it cannot be modified by any other reality.
The child never thinks to expound on these thoughts because he has simply observed the world and seen how it is. This knowledge is then stored with all the rest of the knowledge he is rapidly gaining about life and becomes part of the background of his world. Later these conclusions that were drawn so long ago become the assumptions on which the adult life is based, ie: "Since I'm not particularly interesting, no one is going to want to be my friend/lover/spouse." This person may be a loner, happier with his own company than in any gathering and may suffer from periodic depression.
Having said all that, therapy does not always begin with stories of the past. Some people have few memories of childhood, but they have vivid experiences in the present that they do not understand. Difficulties with intimate relationships, trouble at work, depression, anxiety, anger that seems out of proportion, general dissatisfaction with life – any of these may bring a person to therapy. We start with where you are at the moment.
The process of therapy is determined by you, the client. You decide how long the therapy will go on, what you would like to resolve, where you want to start and when you feel you have done what you need to do. I help you to uncover the hidden assumptions that are governing your feelings and actions. When these assumptions are made conscious, you have a wider range of choices about how you will respond to situations and people and what sort of life you will make for yourself.
Often clients begin to feel differently about themselves simply by talking to someone who is not judging or blaming them. This, in itself, can provide a freedom that allows people to express aspects of themselves that they have kept hidden for years. I become engrossed in your story, in what it is like to be you and then help you step back and see your life from a different perspective. This often opens up new possibilities for people.
The Centre for Training in Psychotherapy (CTP) has developed a program that requires intellectual development, clinical training and personal maturation. The minimum requirements to obtain a diploma at CTP are comparable to those for a Master's degree in psychology. The following summary of those requirements has been developed for professionals who may consider referring clients to CTP graduates.
Academic Program focuses on theoreticians and clinicians in the psychodynamic tradition as well as in the fields of psychiatry, psychology and neurobiology. Authors include: Meyers, Janet, Freud, Ferenczi, Jung, Heidegger, Klein, Guntrip, Winnicott, Bowlby, Sullivan, Mahler, Lachmann, Beebe, Kohut, Stolorow, Mitchell, Stern, Schore.
Training Psychotherapy Group engages the students from their emotional core. As a group activates powerful feelings, students come to understand the origins of such feelings and to see the ways in which they shape a person's responses to people and situations found in day-to-day life. Group work expands and deepens a therapist's ability to meet clients in individual therapy.
Personal Therapy is an ongoing requirement for participation in the program. Self-exploration enables students to absorb theoretical material at more than an intellectual level and prepares them to practice the quality of psychotherapy expected of CTP graduates.
Supervised Practice is begun after completion of 75% of the academic and experiential components of the program. Students must demonstrate an in-depth grasp of theoretical and clinical material, a steady progress in the development of self-understanding and good potential to work with clients.
Psychotherapist 1997 – present
Association work 2001 - present
Employment Consulting (Job Developer)
Environmental Consulting 1990 – 2002
Business development 1980 - 1990
Counselling 1972 - 1980
People often ask what the difference is between a psychologist, a psychiatrist, a psychotherapist and a psychoanalyst. The answer lies primarily in their respective trainings and orientations. This is the short answer:
A psychologist is trained academically. A psychologist obtains a doctorate (a Ph.D.) from a university in either clinical or experimental psychology. Clinical psychologists work with people; experimental psychologists do research. Psychologists are able to provide diagnoses and psychological assessments for various purposes and some clinical psychologists do psychotherapy.
Psychologist's are regulated in Ontario under the Regulated Health Professions Act and are members of the Ontario College1 of Psychologists. Their fees tend to range from $120 - $205 per hour and are covered by insurance companies, often up to an annual limit ranging from $300 - $3000.
A psychiatrist is a medical doctor who has specialized in the field of mental disturbances. They tend to look at the medical aspects of mental illness, prescribe medications and/or medical interventions and monitor the patient's progress. Some psychiatrists do psychotherapy but many do not.
Psychiatrists are regulated in Ontario under the Regulated Health Professions Act and are members of the Ontario College1 of Physicians and Surgeons. Their fees are covered by OHIP.
A psychotherapist is a person who works with people using a variety of techniques such as talk therapy, dream work, psychodrama, bodywork, art therapy and others.
There are two general categories of psychotherapy:
Until June 2007, psychotherapists were not regulated and anyone could practice regardless of their training. In the 1960s and 1970s, many psychotherapists were trained by experienced therapists studying under their tutelage. In the last 20 years, a number of training institutes have been established and grant diplomas to their graduates.
In June 2007, the Ontario legislature passed Bill 171 that regulated psychotherapists under the Regulated Health Professions Act and in the next three to four years, an Ontario College1 of Psychotherapists will be established, which will set standards for entry to the profession. For more information, see the page on Regulation in this website.
Fees for psychotherapists tend to range from $60 - $120 and are not currently covered by most insurance companies except as non-regulated practitioners. When the College1 is set up and psychotherapists are registered, insurance companies are more likely to cover their fees.
One exception to the lack of OHIP coverage is the General Practice Psychotherapist, a medical doctor practicing psychotherapy. These are members of the Ontario College1 of Physicians and Surgeons and the General Practice Psychotherapy Association. Psychoanalysts who are medical doctors are also covered by OHIP.
A psychoanalyst is a person who has been granted a diploma from one of the psychoanalytic institutes. These practitioners are trained to unearth unconscious thoughts and assumptions through specific techniques generally involving free association and dream work. An important component of psychoanalytic training is the training analysis, which raises awareness of the practitioner's own unconscious tendencies.
When a client undergoes psychoanalysis, s/he attends sessions four to five times per week, lies on a couch with the analyst out of sight (usually just behind and to the side of the couch) and speaks about dreams or thoughts without censoring. The analyst then interprets which is more or less translating the random thoughts or dream images into everyday feelings that are "hidden" in the discourse.
Psychoanalysts may be psychologists, psychiatrists, medical doctors or non-medical people who have gone for this type of training. Psychoanalysts are not regulated as such but individual members may belong to one of the regulatory Colleges, depending on their other qualifications. They tend to be members of specific associations such as the Toronto Society of Psychoanalysis. The psychoanalytic institutes have a variety of academic entry requirements ranging from a B.A. to a Ph.D. Many psychoanalysts do psychotherapy (that is, see clients less than four or five times per week and do not use the couch).
1 The term "College" here means a regulatory body, not an educational institution.
Websites can be very helpful. Using a search engine to find a website for a college or an association will help you find a practitioner. These sites generally have a section that identifies practitioners who have openings for new clients/patients.
Looking for a psychotherapist is currently more arduous and will be until the College is set up. By searching on ‘psychotherapy' and typing in the specific city in which you live, you will get a wide range of results that can be overwhelming. Do persist – it will be worth the search.
Qualifications to practice are set for psychologists, psychiatrists and psychoanalysts. As has been discussed above, the qualifications for practice for psychotherapists are not set in law or even in common practice (as they are for psychoanalysts). Therefore, in looking for a psychotherapist (even those who are medical doctors), it is important to know how they got their psychotherapy training.
Training in cognitive behavioral therapy is available through university programs in psychology. Training in psychodynamic therapy tended to be ad hoc until the 1980s. Prior to that people would perhaps get some training at an institute (such as one of the psychoanalytic institutes), read books written about theory and technique and train under the individual instruction of another practitioner. This was quite common practice in the 1960s and 1970s, primarily because so few psychotherapy training institutes existed and were specific to a particular form of psychotherapy (such as the Gestalt Institute). Some of the practitioners that came out of that tradition are extremely skilled and practice in a fine professional and thoroughly ethical manner.
In the 1980s, more training institutes and programs in psychodynamic therapy began to be established. These are generally private and grant diplomas. The key elements to good training are academic work, personal therapy and supervised practice.
The law governing the most health professionals in Ontario is the Regulated Health Professions Act, 1991. There are also profession-specific acts that govern each of the professions. Directions for finding the pertinent legislation are provided below.
The specific Acts that will govern the profession of psychotherapy are:
When a profession is regulated, a regulatory body, known as a college, is formed. The main purpose of the college is to ensure that its members have completed a proper training to practice, maintain their competency through continuing education, adhere to a code of ethics and conform to standards of practice. This is designed to protect the public from harm that may be caused by incompetent practitioners.
The college is run by a council that determines the requirements, standards and codes governing the profession and is responsible for its overall operation. Some members of the college council are appointed by the Lieutenant Governor in General and others are elected from the membership. A certain number of the appointees are members of the public who are there to protect the public interest.
The structure of the college is determined by the Regulated Health Professions Procedural Code. Each college has certain committees, such as a registration committee, a complaints committee, a discipline committee, etc.
Anyone who wants to practice as a psychotherapist will be required to register with the college. The college will set entry requirements, that is, each person applying for membership to the college will have to meet specific training/educational requirements that will be decided by the college council and will have to demonstrate their competency to practice. The college will also require each member to show evidence of participation in continuing education or training programs on a regular basis.
The mandate of the college is to protect the public from harm and all of its procedures and operations are focused on that goal. The college will have a website that will provide information for the public, including a section on finding a psychotherapist.
For further information on legislation, follow the instructions provided here:
Go to www.health.gov.on.ca
Go to www.health.gov.on.ca
What is it like?
Depression has been a topic of considerable concern for a number of years, not only because those who suffer from it suffer badly, but also because it has significant social and economic effects. In their 2006 book, Chronic Depression: Interpersonal Sources, Therapeutic Solutions, Petit and Joiner state that “In a recent large-scale study of medical outcomes, only heart disease was associated with more bed days, physical symptoms, and social and role impairment than depression.” (p. 23) Additionally, it was found that “…among primary care patients, those with clinical depression were twice as costly to treat as other patients.” (p. 24) Once the problem shows economic implications, everyone gets interested.
However, I became interested because of the persistent suffering of some of my clients and as I researched this subject more intensely, I found that there are different types of depression in people with different kinds of personalities. This has powerful implications for those seeking treatment and for those providing it.
The medical community, consisting of General Practitioners and Psychiatrists, tend to look at the pharmacological solutions to depression and, indeed this can be very helpful to many sufferers. In fact, there are some clients who are not amenable to psychotherapy without some form of medication as symptoms interfere with therapeutic intervention. Since I am psychoanalytically oriented in my approach to psychotherapy, I have focused on the writings of the psychoanalysts. One of the more interesting books that I found was Experiences of Depression, Theoretical, Clinical and Research Perspectives, by Sidney J. Blatt, psychologist, psychoanalyst and professor at Yale University.
According to Blatt, there are two types of depression with distinctive characteristics at their core:
The anaclitically depressed person tends to feel empty and sad because he feels that he is not lovable. The introjective feels guilty for not being good enough or not being perfect. Thus, depression is caused by a loss of self-esteem due to either unlovability or lack of self-worth.
In the psychoanalytic literature it is generally agreed that the roots of depression are found in some experience of early loss. This can take the form of the death of a parent, divorce when the child is young, a parent having to go to work and having little time for the children or the disappearance of some significant figure in the child’s life. It can also arise from the child abandoning his or her own strivings that are seen to be hurtful to a parent such as curbing growing independence and curiosity about the world because his absence is seen to leave mother lonely.
If loss occurs at a very early stage of the child’s life, say in the first year to 18 to 24 months, the result is more apt to be anaclitic depression. At this stage of life, a child’s self-esteem is based on being loved and being alone results in a loss of self-esteem (“If I am alone, it must be because no one loves me.”).
The adult with this sort of depression finds being alone intolerable and feels easily abandoned if, for instance, no one is available when s/he wants company. These people will enjoy activities such as smoking, drinking, eating and talking. They see relationship as the only real solution to the abiding feeling of emptiness that pervades their existence. If an anaclitically depressed adult is not involved in a romantic relationship, s/he longs desperately for one and will spend most of his/her free time looking for a lover or mate. Those who are in relationship find it difficult to be away from the loved one for any length of time. If the relationship breaks up, the anaclitically depressed person will focus on finding a new mate to the exclusion of virtually all other activity.
The introjectively depressed person, on the other hand, does not feel empty but is filled with self-hate. This person will be relentlessly self-critical, feeling as though s/he falls short in every endeavor. This person will hold unrealistically high standards for him or herself, then feel deficient if s/he fails to achieve them.
This sort of depression tends to arise from a family atmosphere in which one or both parents were critical of the person as a child. A 90% grade on a test will be met with a comment such as “Where did the other 10% go?” rather than praise for the achievement. The child ends up feeling that nothing is good enough but rather than become angry at the parent for being so demanding, the child will turn the anger inward and become angry at him or her self for not being able to do better. Turning anger toward the self enables the child to hold out the hope that if the problem is with him/her, s/he may be able to change it and thus win the love and admiration of the parent.
The parental response to the child may not be critical but the standard of achievement in the family may be extremely high (say a family filled with professional people such as lawyers or doctors) and the one child who is, say mechanically inclined, will feel like a failure by comparison. Criticism may never be spoken or even implied by other family members but the one who is ‘different’ may feel that it is inferred.
For both anaclitically and introjectively depressed people, anger is dangerous as it threatens the potential for a loving relationship with the parents. As they feel either unlovable or deficient, they dare not add their own anger to the mix and further risk an already tenuous relationship.
What do we do?
In this section, I call upon the wisdom of Blatt (2004) and McWilliams (1994). I have found their writings to be particularly helpful in learning more about how to conduct therapy with the clients described above. Blatt’s work has been particularly helpful in elucidating the nature of these sorts of clients and McWilliams presents a clear summary of both the nature of the clients and the therapeutic approaches that work well with them.
Anaclitically depressed clients are found to do better in a therapy that is interactive, in which the therapist engages the client, asks questions and discusses solutions to problems. Anaclitically depressed clients are particularly responsive to the relational aspects of the therapy. Because they most fear abandonment and loneliness, the consistency of the therapy and the fact that the therapist is always there helps them to develop the security that eventually encourages the growth of self-assertion.
Their defenses tend to be avoidant: missing sessions, being late, talking about anything but the main thing that is on their minds (I always begin to fall asleep in the session when this happens – I have also put my therapists to sleep with this tactic).
As the therapy moves along, the therapist needs to be ready to challenge the tendency toward dependency in the anaclitic client. This may arise if the client is asking for an increasing number of sessions. The therapist must be able to help the client distinguish between a felt need and an actual need. As McWilliams pointed out: there are times when the client needs to be fed and times when s/he needs to be asked why s/he has not learned to cook.
Therapeutic changes in the anaclitically depressed client will be seen in the types of relationships they develop and in the way they conduct themselves within those relationships. They may begin therapy with few friends who are rather self-centered and non-supportive. As the client changes, the friends and romantic interests become more responsive to the client and the client is able to feel truly enriched by them.
Introjective clients are more afraid of relationship because the more that another person means to them, the higher the risk of the client failing to live up to the standards that the client assumes the therapist would have for them. Therefore, the introjective client tends to respond more readily to psychoanalytically oriented therapy in which the emphasis is on interpretation. This focuses the client and therapist on the workings of the mind rather than the relationship between the two of them and provides the client with the time and space to determine whether the therapist is really reliable enough for the client to risk being truly seen. Introjective clients are unconsciously convinced that if the therapist really knew them, the therapist would discontinue the therapy.
Allowing the introjective client the time s/he needs to reveal him/her self to the therapist (i.e.: admit to faults, confess hostile feelings, etc) is paramount to the success of the therapy and takes a considerable length of time. It is the consistent presence of the non-judgmental therapist week after week that slowly convinces the introjective client that s/he is worth the investment of time and energy and is, therefore, a worthwhile person. They then are able to believe in, and even like, themselves.
In therapy, it is important to bring the unconscious convictions to light as they show up in the therapy. The client may begin talking about a relationship with a friend or lover and the client’s reluctance to show anger may become apparent, at which point it would be appropriate to talk about their conviction that anger would destroy the relationship. Discussions around the difference between irritation and fury could shed light on the fact that the client does not make much of a distinction between the two.
The client’s response to compliments is another rich topic for disclosing the fact that, because of their own low self-esteem, the admiration that comes from someone else is felt to be based on false assumptions the other person has about the client (i.e., that the client is worthwhile, talented, etc.).
Studies have shown (Blatt 2004) that both introjective and anaclitic clients do poorly in short-term therapy. The arbitrary termination after a specific number of weeks (not negotiated by the client but set by the therapist/clinic/insurance company) confirms the client’s unconscious conviction that s/he is not worth a significant investment of time and effort. As this conviction is not conscious, it will neither be articulated by the client nor interpreted by the therapist but will continue to operate underground, eroding the client’s sense of self-esteem.
A final note for psychotherapists: you will find common feelings toward your clients who are either anaclitic or introjective in their character structure. McWilliams refers to these people as narcissistic or depressive respectively. There is, of course the sense of caring and wishing to ease their suffering. With the anaclitic person, the therapist can find him or herself responding to the client’s sense of helplessness or dependency and actually believing it is real rather than looking at whether the client is, in fact, capable of more independent action than they think they are. If the client is relying on the therapist by continuing with two or three sessions a week when they could do very well with one, this may need to be brought to light. The client’s reluctance to assume greater responsibility in life may come into the discussion.
The most surprising and refreshing aspect of the countertransference that McWilliams discusses is the therapist’s tendency to feel utterly useless in working with the introjective/depressive type of client. This feeling is a signal that we are working with a particular type of person, not a reflection of our capability. It is, however, pervasive and powerful and requires good supervision (either peer or professional) to keep in perspective. I always think that if the client can live through the depression, I can live through feeling useless.
The list of references that follows may be of interest to psychotherapists who are working with depressed clients in their practices.
Psychoanalytic Case Formulation
Depression: Clinical, Experimental and Theoretical Aspects
Experiences of Depression
Psychoanalytic Concepts of Depression, Second Edition
The Psychoanalytic Theory of Neurosis
The First Year of Life
Depression – Comparative Studies of Normal, Neurotic and Psychotic Conditions
Essential Papers on Depression
Ideas in Psychoanalysis – Depression
Integration in Psychotherapy
Mindfulness-Based Cognitive Therapy or Depression
Chronic Depression: Interpersonal Sources, Therapeutic Solutions