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Four Challenges for Children Amid Our World’s Traumas

A Letter to Children by Gilbert W. Kliman, MD, HFI Board Chairman*
Saturday June 6, 2020

The Harlem Family Institute knows that recently there was a great day for space when Spacex launched two astronauts to the International Space Station from Florida, but it wasn’t such a good day for the Earth.

In fact, it was another bad day for all of us on the ground. That is the truth. Children, families, and whole populations in our own and many nations are facing four mental-health challenges. They are called crises because all are dangerous. All four crises require children to face very painful truths.

The latest of the crises is continuing clarity of evidence that black people are being killed by police. The whole world’s children see this painful truth for themselves. The truth is on modern videos made by witnesses to the murders. Protests and riots are happening as thousands of people see those videos and are outraged. After four hundred years have passed since the United States was founded with African American slaves as cruelly used helpers, the effects of that cruel history are still with us. Some estimates are that a black man in the United States has a one-in-one-thousand chance of being killed by a policeman, and that is a greater cause of death than many diseases. This injustice cannot be tolerated by white, black or any citizens, yet it keeps happening. That is the truth.

A second challenge is that millions of mostly older people they love are getting sick, and many are dying from a Covid-19 pandemic. Many of us know that the pandemic is a crisis that has been warned against for decades, but our current government was unprepared. It ignored the warnings, even used denial and avoidance of scientific truth. An awful mental-health aspect of the children’s need to cope is very hard on adults. That is the children must ultimately recognize that this pandemic crisis was foreseeable, preventable and that hundreds of thousands of deaths could have been reduced by honestly acting grownups. That painful recognition of adult shortcomings is required so we can prevent future pandemics. That is the truth.

The third mental-health challenge is that millions of previously employed people are suddenly unemployed. This crisis about money is because of the pandemic. As should have been expected and prepared for by the U.S. and other governments, many children whose caregivers lack money are hungry. They are at increased risk of malnutrition and are seeing their parents and caregivers depressed, irritable and helpless in the face of economic hardships. The U.S. and other governments have passed emergency laws to help the millions of suddenly unemployed. But the laws aren’t enough and often don’t even work to provide financial help to the unemployed. Lines for food distribution sometimes are miles long, filled with hungry people, many of them unable to feed their vulnerable children. That is the truth.

The fourth mental-health challenge is that preventable climate change threatens the lives of all future generations. Again, this dreadful stress was foreseeable, a preventable crisis. Damage to our planet and its many forms of life could have been reduced by honestly acting grownups. To help children with these enormous stressors, there is one necessary remedy without which little else will work. The remedy is that adult acceptance and advancement of scientific knowledge and honest adult leadership are required about both the pandemic and climate change. Adult honesty and facing facts will help children become more resilient and mentally healthier. That is the truth.

While the world’s politicians struggle to bring justice, food and economic stability to our nation — and while pandemic scientists search for better tests, treatments, cures and vaccines — parents, teachers and caregivers everywhere have the opportunity to improve their children’s knowledge and mental health. At the same time, our children deserve to know that their planet can probably be saved by listening to historians, honest leaders and climate scientists. Adults cannot seem to do this listening very well, especially at governmental levels. Children will have to grow up in a world whose races, resources, climate and all its living creatures have literally been threatened by the mistakes, ignorance, deliberate denials, greed, political motives and even selfish dishonesty of grownup leaders. That is the truth.

Unaccustomed as adults are in helping children face painful truths, we must do just that. With small children we can begin with pediatric doses of truth. We need the spread of truth from protests, government, school and family sources in order to inspire trust in children. Children will usually be frightened by protests. Usually and fortunately, most will have enough food and be the least physically sickened by the new virus. They will suffer mentally as they see hunger, violent protests, lose loved ones, often becoming orphaned and especially losing grandparents. Surviving grownups will have to help the children mourn while growing up. In some nations, children will grow up caring for bereaved younger siblings. That is not an easy psychological task. That is the truth.

Children are beginning to know that they will live through the epidemic and yet be living in a planet damaged by racism, dishonesty, injustices, food shortages, inequalities and climate change. We hope they rise to the challenge of becoming mentally active, curious, and educated. By mastering severe world-wide stresses, children can grow up to lead the world into political, scientific and medical progress. We will need their help as well as current adult world-wide cooperation to overcome our planet’s problems. That is the truth.

There are many other crises, injustices and challenges that adults aren’t solving or where they aren’t even listening to the victims. Children will have a hard job to make up for crises their parents couldn’t understand and solve. We at the Harlem Family Institute hope and try our hardest to help children do better. That is also the truth.

* Dr. Kliman received the American Psychoanalytic Association President’s 2020 Humanitarian Award for his lifetime psychoanalytic leadership in treating and advocating for underserved and traumatized children worldwide.

Studies of Treatment Effectiveness

Studies of Treatment Effectiveness: Comparing
Psychodynamic Therapies with CBT and Medication

Mark Winborn, PhD, NCPsyA

In recent years there has been a great deal of publicity and advertising regarding the benefits of medication and cognitive behavioral therapy (CBT) as cost effective approaches to treating emotional issues and various forms of mental disturbance. Additionally, sources that advocate for the use of “cost-effective” treatments often point to psychodynamic treatment as outdated, ineffectual and not cost-effective.

However, the information being disseminated to the public doesn’t accurately portray the effectiveness of either medication or CBT, nor does it accurately represent the available research on psychodynamic therapy as a robust, contemporary treatment that is both clinically effective and cost-effective. The psycho-pharmaceutical industry and insurance companies have vested monetary interest in misrepresenting the scientific findings for these various treatments. In this brief position paper, the available scientific literature for medication interventions, CBT, and psychodynamic psychotherapy will be contrasted and reviewed.

Large-Scale Studies of Treatment Effectiveness:
In a large-scale review of meta-analyses (a statistical method of combining multiple studies to create a larger subject pool) Shedler (2010) was able to compare the “effect size” of three broad kinds of treatments: (i) using only medication to treat depression, (ii) using CBT and other behavioral treatments, and (iii) using psychodynamic therapy to treat a range of symptoms. The comparison was made across dozens of studies and thousands of patients. An effect size represents a statistical method for comparing the results of studies that utilize different research designs and outcome evaluation tools. Typically, an effect size of .50 is good and an effect size of 1.0 is extremely good.

Treatment Outcomes                                                                                         Effect Size

  • Anti-Depressants (74 studies)                                                                         0.31
  • Cognitive Behavioral Therapy (33 studies)                                                    0.68
  • Psychodynamic Treatment – General Symptoms (12 studies)                    0.97
  • Psychodynamic Treatment – Personality Disorders (14 studies)                1.46
  • Psychodynamic Treatment – Complex Disorders (7 studies)                      1.80

An effect size of 0.31 for anti-depressants does demonstrate a statistically significant effect associated with anti-depressant medications. However, it also demonstrates that the effect of anti-depressants is actually much smaller than either CBT or psychodynamic psychotherapy. Similarly, the overall size of the treatment effect of psychodynamic psychotherapy is significantly larger than for either CBT or medication. In addition, the table above demonstrates that the treatment effect for psychodynamic psychotherapy is even larger when the patient population being studied has more severe psychological issues, such as a diagnosis of a personality or a complex disorder (i.e. a diagnosis involving several categories of disruption).

Treatment Effect after Treatment Concludes:
However, the effectiveness (and cost-effectiveness) of any treatment cannot be evaluated by the degree of change at the conclusion of the study. In CBT and and/or antidepressant treatment the treatment effect begins to decline almost immediately after the treatment is discontinued. Average time to relapse to pre-treatment level of functioning was 3.6 months and approximately 71% total relapse in a combination of CBT and medication (see Rush et. al. 2006).

In contrast, several studies demonstrate that the treatment effect of psychodynamic psychotherapy does not begin to diminish over time. In fact, it continues to grow stronger over time. In other words, psychodynamic therapy does more than provide short-term symptom relief – it also results in positive changes to the patient’s psychological structure. Growth in post-treatment effect is shown below:
                                                                                                         Effect Size
Post-Treatment Psychodynamic (9 months)                              1.51 – 2.21
(Depending upon diagnostic group – see Abbass et. al., 2006)

Clearly, the effect size for psychodynamic treatments across various patient population continues to increase at 9 months follow-up after treatment (showing an average increase in effect size of 0.65) rather than declining precipitously as it does with CBT and medication interventions. However, the treatment effect of psychodynamic treatment continues to grow long after treatment concludes:

  • Leischsenring (2013) demonstrated an increase of effect size from 1.03 at the conclusion of treatment to an effect size of 1.25 after 23 months.
  • A study by de Maat et. al. (2009) showed that the treatment effect of psychodynamic treatment had grown an additional 0.22 for mild to moderate symptom groups at 3.2 years. The same study demonstrated that the effect grew an additional 0.08 after 5 years for severe personality disorders.
  • Another study (Bateman & Fonagy, 2008) examined the effect of intensive psychodynamic treatment (partial hospitalization based) on a group of patients diagnosed with borderline personality disorder (a very difficult condition to treat). 18 months after the conclusion of treatment, 57% of those patients no longer met the criteria for borderline personality disorder that compares favorably to the control group for this study for whom 13% no longer met criteria for borderline personality when followed up at 18 months post-treatment. The control group received “treatment as normal” consisting of medication management and CBT. However, what is most astonishing is that when the participants in the study were followed up at 8 years post-treatment it was discovered that 87% of the psychodynamic treatment group no longer met the criteria for borderline personality, while the percentage of improvement for the control group remained unchanged at 13%.

Shedler’s findings are consistent with a more recent meta-analysis conducted by Town et. al. (2012) on randomized controlled trials of psychodynamic psychotherapy. Forty-six independent treatment samples totaling 1615 patients were included. The magnitude of change between pretreatment and posttreatment aggregated across all studies (46 treatment samples) for overall outcome was large (effect size 1.01), and further improvement (an additional effect increase of 0.18) was observed between posttreatment and an average follow-up of 12.8-months.

Again, these studies demonstrate that the positive effect of psychodynamic treatment consistently increases across time following the conclusion of treatment and that this effect is more pronounced as the severity and complexity of the patient’s symptoms increases. The increase of treatment effectiveness and the greatly diminished chance of relapse in comparison to CBT and medication needs to be taken into consideration when assessing cost-effectiveness of various treatments.

Looking further into CBT:
In several large-scale implementations of CBT as the treatment of choice in state sponsored programs in Scotland and Sweden there was no discernable beneficial effect over the long-term. A follow-up evaluation (see Durham et. al. 2005) of the participants in 10 large-scale studies of CBT conducted by the National Health Service of Scotland concluded: “The positive effects of CBT found in the original trials were eroded over longer time periods. No evidence was found for an association between more intensive therapy and more enduring effects of CBT. The cost-effectiveness analysis showed no advantages of CBT over non-CBT.”

Similarly, between 2008-2012 there was a countrywide implementation of CBT as the preferred psychological treatment in Sweden. The Swedish government invested more than a billion Swedish crowns (approximately $500 million US dollars) during the course of the implementation with 40,000 -50,000 individuals receiving CBT treatment in each year of the program. Karolinska Institut (a medical university) conducted an evaluation of the program in two studies. The final conclusion of the research team enlisted to evaluate the program was: “The widespread adoption of the [CBT] method has had no effect whatsoever on the outcome of people disabled by depression and anxiety,” (see Miller, 2012).

Session Frequency and Duration of Treatment:
Another criticism of psychodynamic therapies is the tendency for some therapies to take place at a frequency of greater than once per week and to have a longer duration. However, there is evidence for additional effectiveness in psychodynamic therapy when session frequency increases and the duration is longer. A study in Stockholm (Sandell et al., 2000) followed 400 patients over a three-year period. Two groups were treated in 3–4 times weekly psychoanalysis or 1–2 times weekly psychoanalytically oriented therapy. Although both groups improved significantly, treatment duration and session frequency were positively correlated with long-term clinical outcome.

In a review by Leischsenring (2004, 2008, 2013), there is evidence from randomized controlled treatment trials which supports the efficacy of both short-term (STPP) and long-term psychodynamic psychotherapy (LTPP) for specific mental disorders. However, in series of meta-analyses, LTPP was shown to be superior to shorter forms of psychotherapy, especially in complex mental disorders. Their data on dose-effect relations suggest that for many patients with complex mental disorders, including chronic mental disorders and personality disorders, short-term psychotherapy is not sufficient. The meta-analysis presented by Leischsenring supports long-term psychodynamic psychotherapy in these populations. In Leischsenring’s reviews he has found LTPP to have a 0.65 larger effect size than STPP.

This review supports psychodynamic therapy as an effective form of therapy that is actually more effective over the long term than either medication or CBT. Additionally, because the gains associated with psychodynamic psychotherapy are more stable, the likelihood of relapse is diminished and therefore it has significant additional cost savings over time than CBT and medication where the likelihood of relapse remains high.

Abbass, A. A., Hancock, J. T., Henderson, J., & Kisely, S. (2006). Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews, Issue 4, Article No. CD004687. doi:10.1002/14651858.CD004687.pub3.

Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, 165: 631–638.

de Maat, Sde Jonghe, FSchoevers, 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.

Durham, RC, Chambers, JA, Power, KG, Sharp, DM, et al. (2005). Long-term outcome of cognitive behaviour therapy clinical trials in central Scotland. Health Technology Assessment 9(42):1-174.

Leichsenring, F., Rabung, S., & Leibing, E. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: A meta-analysis. Archives of General Psychiatry, 61, 1208–1216

Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association, 300, 1551–1565.

Leischsenring, F., Abbass, A., Luyten, P., Hilsenroth, M. and Rabung, S. (2013) The Emerging Evidence for Long-Term Psychodynamic Therapy. Psychodynamic Psychiatry, 41: 361-384.

Miller, S. (2012, May 13). Revolution in Swedish mental health practice: The cognitive behavioral therapy monopoly gives way. Retrieved from

Rush, AJ, Trivedi, MH, and Wisniewski, SR. et al. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 163:1905–1917.

Sandell, R., Blomberg, J., Lazar, A., Carlsson, J., Broberg, J., & Schubert, J. (2000). Varieties of long-term outcome among patients in psychoanalysis and long-term psychotherapy: A review of findings in the Stockholm Outcome of Psychoanalysis and Psychotherapy Project (STOPP). International Journal of Psycho-Analysis, 81, 921–942.

Shedler, J. (2010) The Efficacy of Psychodynamic Psychotherapy, American Psychologist, Vol. 65, No. 2, 98–109.

Town, J., Diener, M., Abbass A., Leichsenring, F., Driessen, E., & Rabung S. (2012) A Meta-Analysis of Psychodynamic Psychotherapy Outcomes. Psychotherapy, Vol. 49, No. 3, 276-90.

Additional Bibliographies of Research on the Effectiveness of Psychoanalytic Therapies:

British Psychoanalytic Council –

American Psychoanalytic Association –