Psychotherapy

Lives Intersecting

Louis Breger

• Publisher: Routledge
• Year: 2017
• Topic: Psychology
• eBook ISBN:
  9781351495813
• Subtopic: History & Theory in Psychology
• Index: Psychology

In the best therapeutic tradition, Louis Breger describes contemporary theories and research in the field of analytic psychotherapy. Through the framework of his personal experiences as a scholar, researcher, and therapist, he focuses on his relationships with patients over the span of his fifty-year career. He records their reactions, in their own words, to their experience with psychotherapy many years after its conclusion. The author surveyed over thirty former patients to see if their progress, begun in therapy, had continued, expanded, or regressed. They were asked to highlight what they remembered as being most helpful, therapeutic, or curative in their treatment. The book is a unique long-term follow-up demonstrating the effectiveness of modern analytic psychotherapy. Breger primarily deals with the connections between therapist and patient. This is a professional memoir of the life of the psychotherapist dealing with trials as a young practitioner, lessons learned, and personal reflections on the choices, including mistakes, made along the way. Young therapists, and those who are in or considering psychotherapy, will find it helpful to have access to this self-reflective approach. Extracts from the patients are extensive and informative, giving the reader the opportunity to see therapy from their perspectives. The book also centers on the development of the therapist over his career span. Breger acknowledges that his understanding of patient care has improved over time in the eyes of his patients. In a larger sense, the book contains lessons for all psychotherapists. This is an important, unique, and innovative work. *Click here for an interview with the author. *Click here for an interview with the author on KQED's Forum with Michael Krasny

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Against Dogma

 

 

There are three forces, only three, on this earth that can overcome and capture once and for all the conscience of these feeble, undisciplined creatures, so as to give them happiness. These forces are miracle, mystery, and authority.

—Feodor Dostoevsky, The Brothers Karamazov

In his brilliant Grand Inquisitor episode in The Brothers Karamazov, Dostoevsky depicts the need many people have for powerful authorities and charismatic leaders, along with belief systems—religions, political ideologies—that offer answers and certainty; which prescribe a way of life in absolute terms. Societies do need leaders and belief systems, of course, but these may be flexible or rigid, adaptable or obdurate, democratic or authoritarian, benign or punitive. And, what is necessary in one sphere may be inappropriate in another. An army at war may require leaders whose decisions cannot be questioned, but the methods of a general or drill sergeant are ill-suited to the raising of children. So too with psychotherapy and the many ways that people seek help for their psychological distress. Therapeutic practice should be flexible, open-minded, and nondogmatic, but, all too often, the field has been dominated by powerful leaders and their orthodox doctrines.¹

You feel unhappy, sad, depressed, suicidal; overburdened with shame, self-loathing, or unfathomable guilt; little things frighten you to the point of phobic anxiety; you cannot seem to find a satisfying or loving relationship and each person you become involved with turns out to be a replica of the hostile, abusive, or sick man or woman you were with previously. You drown your sorrows in booze, drugs, or food, which then become problems themselves as you struggle with alcoholism, addiction, or obesity. You are stressed out, terrified, enraged, traumatized, out of control, feel too much or can’t feel anything. What is a troubled soul to do?

There are so many treatment options today that finding the right one may seem an overwhelming task. You can turn on the TV, and Dr. Phil will tell you what is wrong and what to do about it. Your physician or a psychiatrist can prescribe one of the many mood-altering drugs. You can go to alcoholics anonymous, or one of its many off shoots—narcotics anonymous, over eaters anonymous, gamblers anonymous, sex addicts anonymous—or enter rehab, to deal with your addiction. Exercise may help with disruptive emotional states; you can take up marathon running, biking, tennis, golf, or put in long hours at the gym. One can turn to pastoral counselors, spirituality, and religions of many kinds.² From the East come practices such as Buddhism and many forms of meditation, as well as Yoga, Karate, and Tai Chi, all of which may calm anxiety, put one in a peaceful state, or give meaning where confusion reigned.³ Or perhaps massage or Body Work is what is needed. Then there are marriage and couples therapists to help with troubled relationships, grief counselors to deal with painful losses, or, new on the scene, coaching. One can seek out friends for comfort, find shoulders to cry on. Or—and often as a last resort—you can see a shrink: try individual psychotherapy.

Again you are faced with myriad choices. What kind of therapist: psychiatrist, psychologist, social worker, marriage and family counselor? Freudian, Jungian, cognitive-behaviorist, existential-humanistic, eclectic, or some other? Since the 1960s the field has become crowded with such a range of practitioners that it is difficult to know what is best for your own situation. A brief course of cognitive-behavioral treatment to clear up symptoms or years of psychoanalysis? Perhaps, therapy is all a lot of bunk and your problems are due to faulty wiring of your brain, too much or not enough serotonin, and one of the new wonder drugs will clear things up.

There is a good deal of controversy over the effectiveness of psychiatric medications, which I will not review in detail here. While they seem essential in the treatment of a few conditions such as severe depression, bi-polar disorder, and certain anxiety states, there is also research that questions their effectiveness and suggests that at least some of their efficacy may be due to a placebo effect. Three recent books (Carlat 2010, Kirsch 2011, and Whitaker 2010) present strong criticisms of the ever growing use of such medications, largely due to the money and influence of drug companies. As one example, see Turner et al. (2008), who review seventy-four studies covering over 12,000 patients. They demonstrate how the FDA grossly inflates the positive effects of these drugs, claiming that over 90 percent of patients benefit when, in fact the number is about 50 percent, while simultaneously distorting or downplaying studies that show negative effects. In two highly critical articles, the distinguished physician Marcia Angell (2011, 2011a) lays out the arguments and evidence that demonstrates how psychiatric medications have been widely overused, largely due to the financing and influence of the pharmaceutical industry. She also points out the great expansion of psychiatric diagnoses, which then become the bases for increased drug use, especially troubling in children. For a balanced discussion, see Summers and Barber’s (2010) chapter on psychopharmacology. They point out that there is an increasing use of medication in combination with psychotherapy though there is little hard evidence for the effectiveness of this to date. George Atwood (2011) presents strong arguments and case material for the damaging effects of antipsychotic medications in the treatment of schizophrenia and trauma survivors. As we will see, several of my patients found antidepressants, in combination with psychotherapy, helpful, though the drugs had little to do with the major changes in their lives, relationships, and views of themselves.

Each of these many approaches can be dogmatic or not, demand exclusive adherence or be open to collaboration with others. Some AA groups think psychotherapy is incompatible with their twelve-step programs, while others recommend a combination of the two; some psychotherapists believe AA dilutes and interferes with therapy while others will not treat alcoholics or addicts unless they are simultaneously in a twelve-step program. All of these treatments have their values and limitations; they may be useful for particular problems or work best with certain individuals. I know people who have received help from almost all of the approaches mentioned above and certainly do not think that therapy is the best solution for everyone. The focus here, however, will be on what I know best from my own experience: individual analytic psychotherapy.

Psychotherapy and psychoanalysis are themselves split into many schools and factions, typically named after a founder—Freudian, Jungian, Kleinian, Kohutian—with their own theories, terminology, journals, training programs, rules, and techniques.⁴ And they each claim to be the best, a practice begun by Freud when he labeled psychoanalysis the “pure gold.” Schools of therapy can offer answers, certainty, solutions, which is what some people crave, especially in times of trouble. And there is much of value to be found in a number of these approaches, but only if their ideas are used as starting points, hypotheses, hunches to be pursued or abandoned depending on the response of the patient. Any therapy becomes compromised when it hardens into dogma, when the same methods and interpretations are applied to everyone, when one size fits all. The type of psychotherapy I practice is the result of a long process of development that has taken me through university departments, a medical-psychiatric training center, psychoanalytic institutes, and a variety of research and scholarly projects. This journey has led me, I like to believe, to an approach that is neither miraculous, mysterious, nor authoritarian. There is some difficulty in knowing what to call the kind of therapy I practice. “Psychoanalysis” has too many connections to the old Freudian version while “psychotherapy” may be too broad. So I will call what I do contemporary or modern analytic psychotherapy, or, to be brief, analytic psychotherapy. What it actually consists of will become apparent from the case descriptions themselves.

An analyst some fifteen years older than me once said that, when he was beginning his training at the Southern California Psychoanalytic Institute in the 1950s, he sought out one of the senior members and asked whom he should choose as his training analyst. He was told to just pick anyone from the list of analysts approved by the American Psychoanalytic Association, the person did not matter since the technique and analysis would be the same. Freud had counseled that psychoanalysts behave like surgeons and, if you are having your appendix removed, any competent physician will do; his or her personality need not be a factor.⁵ Contemporary analytic psychotherapy has come a long way from this idea now, and we currently talk about psychoanalysis as a “relational,” “interpersonal,” or “intersubjective” endeavor: a meeting of two people, each with their distinctive personalities and subjective worlds. Patients bring their history, symptoms, and life situation, and the therapist brings his or hers, including their specific training and clinical experiences. What transpires is a unique interaction of the two.

Over the course of fifty years I have evolved my own way of practicing analytic psychotherapy, and this book will illustrate what I have learned from my experience.⁶ Psychoanalytic case histories—which, from Freud on, have been the primary evidence for both theory and technique—are almost always written by the analyst. It is quite rare to ask patients for their version of what transpired. In other words, most psychoanalytic cases are discussed solely from the analyst’s point of view. As Stepansky puts it, “analysts have never incorporated patient reports into their comparative assessments of theory, technique and therapeutic efficacy” (2009, 163). Exceptions are Stoller (1973) and Yalom (1974) though the latter would not call himself a psychoanalyst. Te work that is closest to the present study is the volume edited by Schachter (2005) which reports seven cases that were treated by seven different psychoanalysts. Each case begins with a lengthy account written by the analyst and in four cases the patients, after reading their analysts’ accounts, wrote relatively brief versions of their experiences. Tus, that study differs in important ways from mine, which begins with the patients’ own accounts, with them reading my versions later. While the analyses described in the Schachter book are, in general, more formal—four or more times a week, lying on the couch—they are more contemporary and relational than classical Freudian, in my view. In addition, there are suggestions that, while a great deal of interpretive work went on, what was helpful were the same factors that my patients describe. One patient in the Schachter study reported, “I’d say my analyst values… insight or at least highlights it more in our work … than I do. To me what stands out most over the course of time are moments of mutual intense feeling, moments where we both had a good laugh about something that happened or something that one of us said” (90). Another patient commented, “You and your analyst become sort of like a real friend like I never had before” (123). And a third said, “The fact that he becomes an active participant in each session has been most effective in the parts of my life that have needed help the most” (144).

Psychotherapy outcome research frequently uses follow-up reports by patients, though these are often checklists and not the kind of long personal accounts presented here. Most analytic psychotherapists do not read the psychotherapy research literature and psychoanalysts have, until quite recently, rarely done research on the effectiveness and outcome of their methods, the one early exception being the Menninger Project, summarized by Wallerstein (1986), which, interestingly, found that “supportive psychotherapy” was superior to psychoanalysis. For a comprehensive review of psychotherapy research see Roth and Fonagy (1996) and Shedler (2010). Hans Strupp and his colleagues have done a great deal of excellent research in this area, clearly summarized in his article of 1996. Tere is beginning to be some acknowledgment among psychoanalysts of the need for evidence for the effectiveness of their methods, as reflected in the reviews provided by Shedler (2010), Summers and Barber (2010), and Curtis (2009). Of the various contemporary psychoanalytic schools, only the Control-Mastery approach was directly built from research findings (see Weiss 1993, and Silberschatz 2005).

While most previous work has been centered on analyst or therapist reports, I will turn this around and devote a great deal of attention to what my former patients have to say about their therapy. Among other things, I was curious to see how their lives had gone after the conclusion of our work together: whether the progress they made endured, regressed or expanded. I conducted an informal survey of over thirty of these patients, asking them to describe what they remembered as being most helpful/therapeutic/curative in our work together, adding that their answers could be as long or short as they wished, and assuring them that their identities would be disguised and confidentiality respected. I also asked them to report what was not helpful, what they remembered as nontherapeutic. The patient quotations used in this book are uncensored; I have edited out repetitions and extraneous material, changed some details to disguise patients’ identities, but included the essence of their comments, whether these were positive or negative.

The way I use the responses of my former patients parallels my collaborative approach to therapy. After I wrote up each individual account—my memories of what occurred and theirs—I sent this material back to them so they could modify, add, or change what was written. Chapter 3 will demonstrate how significant growth in our mutual understanding arose from these continuing dialogues. In addition, rather than my choosing their pseudonyms, I asked each person to choose their own.

A few cautions at the outset. The survey is not strictly speaking scientific. The patients who responded to my questions were those who valued their therapy, while the few who did not respond were more likely to include those who were dissatisfied. In addition, this entire group of respondents, with a few exceptions, was drawn from the last thirty years of my practice when I was more experienced, more confident, and less likely to be defensive. Certainly, in the beginning, I made more mistakes and had my share of therapeutic failures, and the fact that they appear here infrequently is, in part, a function of the selective nature of the sample and the time it was collected. The issue of therapist-patient match is also significant. Clearly, cases in which patients came to see me and stayed in treatment for a long time were ones where both of us felt there was a good match. While I have been open to seeing almost anyone who was willing to give therapy a try, some people, from early on, did not feel I was the right kind of therapist for them and dropped out. So my sample of largely successful cases is made up of those in which both of us were relatively comfortable working together.

While contemporary psychoanalysis stresses the relational, interpersonal, and intersubjective nature of the enterprise, studies of therapy are still almost all confined to reports in which the therapist describes the patient and says little or nothing about himself or herself. Another innovative aspect of the current study is my inclusion of autobiographical material so the reader can get a sense of what kind of a person I am and how this affected the therapy. Finally, it is worth noting that, since many of the patients who responded to my questionnaire were seen more than twenty years ago, they constitute a long term follow-up.⁷ Tis is very rare in the literature and will show how durable the effects of analytic psychotherapy can be.

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Early Psychoanalytic Cases

I don’t think I ever would have been sane enough to have children without the time I spent in analysis.

—Judith

I came to understand myself much better and accept me with all my foibles, quirks and faults. Not that I’m cured of them all, I just control them better and accept them as who I am without being so judgmental and hard on myself.

—Scott

I began doing psychotherapy in 1959 and, while a full-time professor for a number of years after that, continued to see patients, gradually increasing the number I worked with until I began formal psychoanalytic training some fifteen years later. In the earliest years, I was quite green and uncertain of what I was doing but, when I did see my first cases in full psychoanalysis, I already had a significant amount of clinical experience and felt more competent. But, let me go back to the beginning.

“Ralph” was a man I saw in 1959 when I was doing my predoctoral internship at The Langley Porter Institute in San Francisco. I was twenty-four years old and he was one of the first supervised cases assigned to me as part of my training. Being very inexperienced, my memory is that I was mostly silent—not knowing what else to do—and mainly listened as he described his difficulties as a first-year law student as well as his problems with various women he was involved with. I have very little memory of what else occurred in this therapy over fifty years ago. Ralph and I became friends some years later, and remain so to this day, and he has provided me with his version of what went on between us. He begins his account by describing his poor performance at law school and his troubles with a girlfriend. He felt he was about to have “a nervous breakdown” and came to Langley Porter where he was assigned to see me:

When I first met him, I was ambivalent about whether he could help me…he looked too youthful, he was about my age and looked very “square.” I thought that he was ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Prologue
• 1 Against Dogma
• 2 Early Psychoanalytic Cases
• 3 Continuing Dialogues
• 4 Psychoanalysis Old and New
• 5 Finding My Way
• 6 Learning the Ropes
• 7 Looking for the “Pure Gold”
• 8 Patients Speak
• 9 When I Didn’t Help
• 10 Endings
• 11 Summing Up
• Acknowledgments
• Notes
• Bibliography
• Index