Dr. Kristevski Treatment Guide

The purpose of this page is to introduce new patients to my treatment model so they can gain an understanding of the type of treatment I do, what the therapy process looks like, and whether this treatment is the type of help they are seeking. In addition, I hope to clear up some common misconceptions about therapy, which are common due to the proliferation of online mental health content on social media. There are literally hundreds of forms of psychotherapy and each therapist also has their own unique style of conducting therapy. This situation creates a lot of confusion, both for new patients and therapists alike. I hope that I can clear up some of this confusion and set new patients up for a satisfying and successful treatment. This page may also serve as a treatment guide that patients may refer to when trying to understand a concept, how therapy actually works, or where they are at in their therapeutic process. I strongly recommend that new patients read this page in its entirety; however, if you can’t commit to do this, then only read the bulleted sections below to see if you are a good fit or not so good a fit for this treatment approach.

Overview of Psychoanalytic Therapy

I provide a type of psychotherapy called psychoanalytic or psychodynamic therapy. This is a form of therapy that’s over a century old and developed as a method of assessing and treating complex psychiatric symptoms and life difficulties. The overall goal of this therapy is to deepen the patient’s self-understanding and self-awareness so that they may live in a more flexible and authentic manner. Patients will gain a clearer perspective on their personality, life history, current and past difficulties, and relationships. People often don’t have a solid understanding of themselves, their motivations, their feelings, and how they hold themselves back by engaging in self-sabotaging or self-destructive behavior. People often live their lives as though they are asleep and will repeat self-defeating patterns in their relationships, career, parenting, personal pursuits, how they manage their physical health, etc. During treatment sessions the therapist will help the patient examine these aspects of their lives, so they can gain awareness of the factors that perpetuate their difficulties. This increased awareness helps patients observe their unhelpful patterns so they can pursue positive change. Not only do people engage in self-limiting behavior in their daily lives, they often unconsciously bring such behavior into the therapy session itself. For example, a patient could assume a quiet and passive role during a therapy session, waiting for the therapist to solve their difficulties, remove their emotional pain, or somehow “fix” them. Oftentimes, these individuals will also struggle with feelings of powerlessness and have difficulty asserting themselves in life. The therapy process may involve the therapist drawing the patient’s attention to such behavior, noting that it occurs both within therapy and also outside of therapy. The therapist could also investigate the origins of the patient’s difficulties with assertiveness, how it is impacting their life, or whether they feel it is a problem worth addressing in therapy at all. It should be kept in mind that therapy can and does address many other difficulties in addition to passive tendencies and feelings of powerlessness. The important thing to keep in mind is that increased self-awareness, deeper self-understanding, and active collaboration with the therapist must occur before patients can make meaningful change.

Psychoanalytic Therapy vs a “Quick Fix” Model of Therapy

People sometimes enter therapy with the hope or expectation that they can be healed of deep emotional pain or somehow “fixed” after they have described their difficulties to the therapist. Simply put: the patient tells the therapist the problem, and the therapist offers a solution. I have even found that some therapists believe in such a simple and direct treatment approach. However, in my 15 plus years as a mental health professional, I have never seen significant mental health symptoms or difficulties effectively treated by such quick fix approaches. New patients who are expecting a quick fix out of therapy will need to alter their view of what therapy is and how it works. Patients will need to exchange the notion of being quickly fixed for a more collaborative and challenging process. This process involves discussions that can be emotionally difficult and anxiety provoking. The therapist may not immediately understand the patient’s difficulties or how to best help them. It will take time for the therapist to gain a solid impression of who the patient is as an individual, and thus how to help them. I believe these ingredients are essential for effective psychotherapy. This collaborative process will be more challenging than a quick fix approach, but patients often find it highly rewarding, meaningful, and even transformative.

Starting Therapy

New patients often have many ideas and questions about how therapy will look. People have seen therapy sessions in movies and shows, spoken to friends and family who have shared their experiences in therapy, and watched mental health professionals discuss various topics on social media. People these days enter therapy with a truckload of preconceived ideas about the process. I find that these preconceived ideas make it difficult for new patients to begin engaging in the process of therapy. New patients often have a preset expectation for how early sessions should go and when their expectations aren’t met some of them even opt to stop treatment and/or switch to a new therapist. Thus, I will try to offer a brief picture of what new patients can expect when starting psychoanalytic therapy.

I will begin the process by asking what is bringing the patient into therapy. I will closely listen to the patient while trying to understand their motivations, life difficulties, personality, and how they relate to others. Early sessions are more like interviews during which I’m trying to get to know the patient and their difficulties. I will do more listening than talking, and the patient will do the majority of the talking. I will ask many questions about the patient’s difficulties, relationships, feelings, personal interests, fears, and goals. Patients are expected to collaborate in this process to the best of their ability by answering these questions and expressing how they truly feel. This will help me gradually get to know the person. There is no way for me to help patients if I don’t first get to know them in a thorough manner.

During this interviewing process I will not share very much about who I am or my personal life. New patients may be curious about me, which is perfectly normal and understandable. Patients ask me a variety of questions such as where I’m from, whether I’m married, my religious or political views, etc. I may answer some of these questions, but most questions I will not answer. Answering personal questions about myself could create a more casual and “chatty” treatment atmosphere, which will ultimately not serve the patient. It is important to keep the focus on the patient, the difficulties that brought them to treatment, and helping them explore their inner mental life. The relationship between the therapist and the patient is unique and unlike other relationships. The role of the therapist is to guide the treatment process while trying to gain a sense of who the patient really is, and the role of the patient is to explore their inner world while trying to get to the root of their difficulties. It is strictly a professional relationship with a therapeutic goal. Although I strive to treat my patients in a kind and friendly manner, I do not form actual friendships with my patients.

As the treatment progresses I will gain a better sense of the patient’s personality, how they relate to others, and what may be perpetuating their difficulties. I will pay close attention to the patient’s body language, thought process, how they express feelings, and how they interact with me. All of this will inform how I attempt to help the patient. I do not utilize a one-size-fits-all approach. In early sessions I may try several techniques or therapy approaches, based on the patient’s personality and difficulties. I will pay close attention to how the patient reacts and will tailor the treatment to their unique needs. Examples of potential techniques and approaches include: helping people make mental links so that they can better understand difficult experiences; identifying automatic/unconscious defense mechanisms (such as minimization, rationalization, projection, etc) which lead to unhealthy emotional suppression; becoming more aware of bodily reactions, stored-up tension, or the physical aspect of emotions, which helps correct mind-body disconnects; developing assertiveness and/or communication skills; confronting self-destructive and/or self-sabotaging tendencies, etc. These are only a few of many possible techniques/approaches. I do not know which approaches will be helpful for new patients until I try them during sessions.

Length, Frequency, and Treatment Considerations

I start treatment by working with new patients on a weekly basis. In rare circumstances I will see a patient several times per week if they are in great distress, experiencing a crisis, or simply desire a more intensive treatment approach. I will not see new patients less frequently than once per week. I find that this tends to be noticeably less effective than weekly sessions and the treatment doesn’t gain adequate momentum to be helpful for the patient. I recommend that new patients complete at least 12 treatment sessions (45 minutes to 1 hour each), which constitutes a short-term therapy. This number of sessions is usually enough for some meaningful therapeutic work to take place, such as: the therapist offering their assessment of the patient’s difficulties, trialing several techniques or therapeutic approaches and seeing the patient’s response, identifying defense mechanisms, etc. After 12 sessions, both patient and therapist should have a feel for whether this treatment approach has been helpful and a good fit for the patient. In my experience, it is highly unlikely to adequately address longstanding and significant mental health problems in less than 12 therapy sessions. Many patients decide to continue their treatment well beyond 12 sessions. Some patients even continue seeing me for years, constituting a long-term treatment, which is perfectly fine, especially for patients with difficult and/or traumatic histories. Most new patients prefer an open-ended treatment model in which the number of sessions or length of treatment is not specified in advance; however, sometimes new patients will request a briefer, time-limited approach (for example, only wanting 5 or even less sessions). This is a perfectly fine treatment option and is preferable to no treatment at all. I have specialty training in a brief form of therapy called Intensive Short-Term Dynamic Psychotherapy (ISTDP), which helps me conduct briefer treatments. ISTDP is an accelerated form of psychoanalytic psychotherapy designed to help patients quickly see their defenses, “inner blocks,” and the unconscious ways in which they may put up walls with others. This approach tends to be more direct, challenging, and anxiety-provoking than many other therapies, but it can be highly effective for motivated patients who want to overcome self-defeating behaviors and thoughts.

Format of Therapy Sessions

I will generally begin sessions by saying something like “we can begin wherever you’d like,” or “where should we start today?” I start sessions in this manner as I prefer to give patients the room to discuss their difficulties and significant life experiences in whatever manner they wish. Patients are also free to discuss their thoughts and feelings about the prior session, various events that have recently occurred in their lives, or even recent dreams. Patients are free to mention whatever feels important to them. Starting sessions in this manner helps me gain an impression of how the patient spontaneously communicates, expresses themselves, and thinks. From this starting point the conversation will naturally evolve and the work of therapy will begin taking place.

For many people, starting sessions in this manner is just fine and they are able to engage in the process; however, there are patients who experience significant anxiety and feelings of resistance at the start of therapy sessions. Oftentimes these individuals struggle with feelings of vulnerability and mistrust. They often struggle with obsessive forms of worrying and tense up when interacting with others. Another statement that I often hear from them is something like “I need to know what’s going to happen,” or “where is this going?” Unfortunately, there is no way to know in advance where the conversation will lead. Therapy is an organic, complex, back-and-forth dialogue. If it was somehow possible to map out the ending in advance, then it probably would not be helpful as it wouldn’t reveal anything new or fresh, which is ultimately what most new patients are hoping for and seeking.

For new patients who experience this type of difficulty, I may try to help them in several ways. First and foremost, I will not assume that I know the cause of their difficulty, but will help them explore the potential causes and meaning of this difficulty. Does this only occur in therapy with me, or does it also occur in other interactions? I may help them regulate their anxiety by bringing their attention to their bodily posture or breathing pattern. Or I could ask whether they are worried about potential thoughts that I’m having about them. At times, patients may need to be reminded of their current treatment goals or what brought them into therapy in the first place. Until significant progress has been made on these issues, it is never a bad idea for the patient to start a session by discussing where they are at with respect to these difficulties.

Sometimes patients really struggle to engage in treatment and will be completely silent, sleepy, or repeatedly answer my questions by saying “I don’t know.” In these situations I may decide to join the patient’s silence and also be silent myself. It can be necessary for the patient and therapist to tolerate silence as part of therapy as it helps one quiet down, look within, and learn to tolerate difficult emotional states. How I assist a patient who is experiencing such a dilemma will be unique in each case; however, there are several things that I will not do in such cases. I will not engage in casual conversation in an attempt to make the patient feel more comfortable. This is inappropriate in that it blurs the line between therapy and casual interaction, and robs the patient of an opportunity to overcome their anxiety and passivity, which is likely negatively impacting their life. Similarly, I will not attempt to make up for a patient’s succinctness by doing the majority of the talking during a session. Ultimately, I believe that new patients will need to learn to tolerate the anxiety of speaking at the start of sessions. This requires a willingness on the part of the patient to engage in a collaborative process. If a patient is unwilling or unable to collaborate in such a manner and is showing low motivation then I may need to discontinue the treatment and possibly refer them out; however, if a patient is struggling to collaborate but sees this as a problem they are trying to overcome (that is, showing high motivation), then I will continue working with them. Verbal communication is the main driver of the therapeutic process, especially in early sessions. New patients will need to accept and embrace this reality in order to engage with, and ultimately benefit from, this therapy.

Terminating Treatment

Some patients decide to stop the treatment well before 12 sessions. There can be many reasons for this: finances, job or family obligations, low motivation for treatment, feeling coerced into treatment by a friend or family member, dissatisfaction with a session, negative reactions to the therapist’s style, feeling as though they are not progressing, etc. If patients are considering stopping therapy for the above reasons, I recommend that they discuss this with me during a session so that it can be sorted-out, and, if possible, prevented. I am open to feedback and sometimes make mistakes which require critical self-assessment. However, I will not “push” a patient to continue therapy if they want or need to stop treatment.

Patients often ask when they should stop therapy. I have discovered there are no set rules for this and it ultimately comes down to the patient’s judgement. If the patient feels they have adequately addressed their difficulties, have significantly deepened their self-awareness, have noted improvements in their daily functioning, mood, career, and/or relationships, then there may be less of a need for therapy and it would make sense for them to stop. However, other patients prefer to continue treatment despite their improvements since they have ongoing treatment goals and deeper issues they would like to address. Regardless, I encourage my patients to process these issues with me during sessions, rather than abruptly terminating treatment. The urge to abruptly stop treatment before processing this decision with the therapist may represent a deeper and more unconscious conflict involving abandonment, a fear of closeness, a tendency to avoid conflict, etc. Processing such issues may be an important aspect of one’s therapy, but also of one’s personal development and emotional maturation.

Some patients will discontinue treatment after only several sessions due to dissatisfaction with either the therapy process itself, or my particular style of working with patients. Many of these patients opt to continue therapy with another therapist. While it is true that certain patients and certain therapists are just not a good fit for one another, I believe it is more often the case that these patients are avoiding addressing difficult feelings that have unexpectedly emerged in the therapy. These patients likely believe that they will find another therapist with whom such difficult feelings won’t emerge; however, a similar pattern will likely repeat with the new therapist. This is because the difficult feelings and avoidant tendencies that have emerged towards the therapist are likely rooted in the patient’s unconscious attachment history (that is, their relationship with parents or early parental figures). By finding a new therapist the patient is pulling out the weed, but the root is still intact and will grow back in the patient’s life. Psychoanalytic psychotherapy is a unique opportunity to directly address difficult feelings towards others (including the therapist), avoidant tendencies, and their unconscious attachment histories, with both early parental figures and also later romantic partners and friends/family. Working through such difficulties in treatment can be life changing.

Patients Who are Generally a Good Fit for this Treatment

• Individuals who would like to explore their difficulties, personality, and inner-life, in a new way
• Individuals who don’t expect an easy and quick fix
• People who are willing to discuss their difficulties and life experiences at length and in detail (that is, a willingness to talk more than the therapist)
• People who are willing to open up therapy sessions by discussing their difficulties, treatment goals, and/or other experiences which they find relevant to their treatment
• People who are open to the element of surprise or self-discovery (that is, open to the possibility that the therapist may notice something about their difficulties or personality that the patient was not aware of)
• Individuals who feel motivated to do at least 12 sessions on a weekly basis (that is, a short-term treatment, but patients are welcome to continue treatment after 12 sessions)

Patients Who May Not be a Good Fit for this Treatment

• Patients who are expecting or hoping for a quick fix
• Patients who are unwilling to discuss the difficulties that brought them into treatment at length, in detail, and during more than one session
• Individuals who are unwilling to open up sessions by discussing their difficulties, treatment goals, or other relevant experiences (that is, patients who are unwilling to take the lead in their therapy)
• Patients who are being coerced into therapy by a partner, family member, friend, or authority figure; therapy is doomed to fail if it is not driven by the will of the patient
• Patients who come to therapy specifically due to a work issue, requesting that the therapist complete FMLA or disability paperwork
• Individuals who believe they are not the problem but someone in their life is the problem; this is called externalizing and it is a barrier to engaging in therapy
• Individuals who believe they know themselves so well that the therapist won’t be able to tell them anything about themselves that they don’t already know (that is, people less open to the element of surprise or self-discovery)
• People who have a strong preconceived idea of how the therapy will go and/or how the therapist will work with them
• Individuals who have a strong need to know what will transpire during a current or future sessions (this is impossible to know, unless patients are doing a structured or protocol-based therapy in which the content of each session is predetermined, which is not the type of therapy I do)
• People who hold beliefs such as “talking won’t help” or “talking doesn’t help” (traditional forms of psychotherapy have been called “talk therapy” or “the talking cure”; without verbal communication most psychological therapies are impossible)
• People who will want me to play several different roles for them other than therapist, for example, writing work letters, completing legal paperwork, completing emotional support animal evaluations, etc
• Individuals with acute or severe mental health problems that require a higher level of care or more comprehensive care than individual therapy; for example, patients with recent suicide attempts or hospitalizations; severe postpartum depression; significant substance abuse; etc

Patients who fit one or more of these criteria may not be a good fit for the therapy I do. If I’m working with a new patient and I notice that they meet some of these criteria then I will likely bring it to their attention so that this issue may be addressed. Having a direct conversation regarding this is essential because if a new patient is operating under these assumptions, or experiencing these difficulties, then they may not be able to benefit from the type of therapy I do. Patients are also welcome to let me know if they feel they fit some of the above criteria. The sooner they let me know the better. If a new patient fits some of the above criteria but sees this as a problem that they would like to overcome as part of the treatment process, then I will continue working with them; however, if patients fit some of the above criteria and are not open to questioning or challenging these tendencies, then I believe they are not a good fit for psychoanalytic therapy and will need to find another therapist or form of treatment.

Types of Clientele and Mental Health Problems I Work with

I consider myself a generalist and work with a broad range of mental health problems including major depression, various forms of anxiety (for example, panic disorder, social anxiety), sleep problems, trauma, personality disorders, relationship issues, and family conflict. I have specialty training in psychological approaches for chronic pain and other health conditions. I mainly work with adults but I also regularly see teens. On rare occasions I will work with children, usually by providing neurofeedback for conditions such as ADHD or autism. I have a good deal of experience working with Veterans and active-duty service members. The therapies I provide include psychoanalytic psychotherapy, Intensive Short-Term Dynamic Psychotherapy (ISTDP), relaxation training (autogenic training, progressive muscle relaxation), biofeedback, and neurofeedback. Providing psychoanalytic psychotherapy is the main component of my practice. I currently do not provide couples counseling, marital therapy, or family therapy. While I have training in CBT and related therapies (for example, ACT, Prolonged Exposure, CBT for insomnia), I do not provide them in a formal, structured, manualized format; however, I do sometimes include elements of these therapies in my psychoanalytic work. I do not do EMDR or IFS. I do not perform emotional support animal (ESA) evaluations, nor do I provide ESA letters.

Cancellation and No-Show Fees

Patients need to provide 24 hours notice when cancelling therapy sessions. If patients don’t provide at least 24 hours notice then they will be charged a late fee of $175. As a courtesy, I will waive one late cancellation or no-show; however, any further late cancellations or no-shows will result in the fee, regardless of the reason for the missed visit. In other words, I do not distinguish between justified and unjustified late cancellations or no-shows. Patients are often late to cancel sessions due to unforeseen work issues, family obligations, traffic, or illness. I believe that these are all valid reasons for late cancellations and no-shows; however, if I were to stop charging late fees due to these valid reasons, then the loss of revenue to my business would be substantial and possibly unsustainable. Ultimately, if a patient schedules an appointment with me then I expect to be paid for the hour that was reserved. I don’t consider charging late cancellation or no-show fees to be an act of punishment; rather, it is a business policy that is shared by many other industries (for example, legal offices, hotels, air travel, etc).

Limitations of Therapy and Other Treatment Options

Every form of psychotherapy has its limitations. Even after a successful treatment, people will continue to have difficulties and challenges. Some degree of anxiety, relationship issues, and/or depressed mood (that is, feeling down), will eventually re-emerge. This is part of life. The mental health industry cannot end human suffering. I do not know in advance if the therapy I do will be beneficial for a new patient. This is why I recommend a trial of 5 to 12 sessions to help the patient get a basic feel for what psychoanalytic therapy is like and whether they feel it is for them. It may also be important for patients to consider whether they are in the good fit or not so good fit categories mentioned earlier in this page. Patients in the good fit category will likely benefit from psychoanalytic psychotherapy. Patients in the not so good fit category will likely have some struggles when starting this treatment. This is due to the increased guardedness, anxiety, and avoidant tendencies common in this group of patients. If these patients are highly motivated then I will try to help them overcome these inner blocks; however, if their motivation is too low then they will need to consider other treatment options.

Another treatment option is structured, protocol-based therapies which follow a set treatment guide. These treatments often, but not always, prescribe what will be addressed during session 1, 2, etc. Examples of such treatments include Exposure and Response Prevention (ERP) for OCD, Prolonged Exposure (PE) for PTSD, and Cognitive Behavioral Therapy for Insomnia (CBT-I). These therapies may offer reassurance for patients who feel a strong need to know what will happen next in the treatment. These therapies also have substantial research evidence. However, such treatments are also challenging and intensive in their own way. Another con of such treatments is that they neglect the exploration of the patient’s unconscious mind, which I often find to be a crucial aspect of psychotherapeutic work. Nonetheless, I will sometimes refer my patients to these therapies. Other treatment options include therapies and mind-body modalities which require less verbal communication from the patient, such as: Equine Therapy, meditation, yoga, relaxation exercises, biofeedback/neurofeedback, music therapy, art therapy, and sand therapy. Online videos, podcasts, and books from reputable mental health providers, clinics, or agencies, can be another helpful avenue. Traditional psychiatric medication management, as well as newer neurostimulation technologies such as Transcranial Magnetic Stimulation (TMS), are now widely available. Lastly, psychiatric treatment and/or psychotherapy cannot replace the need for regular sunlight, fresh air, sleep, hydration, proper nutrition, exercise, positive relationships, and a sense of meaning. In my opinion, people can be receiving the best psychiatric and psychotherapeutic care imaginable, but if they are not in touch with nature or taking care of their bodies, then these treatments will have a minuscule effect. I also feel that mental health care should not be used as a substitute for friends (for example, someone believing they don’t need friendships since they have their therapist), relationships, or spiritual/religious faith or practice.