"Psychotherapy Lives Intersecting" by Louis Breger is a thoughtful, well- documented, readable and informative book. The Author's informal jargon-free style and his personal reflections contribute to the pleasure of reading this thin volume. Dr. Breger's narrative and the anecdotal material are warm, sensitive and rich. Citing a large number of verbatim responses from patients, the Author presents his ideas about what "cures" in psychotherapy with clarity and conviction.
Dr. Breger reports on his 50-years of clinical experience as a psychotherapist and psychoanalyst. To appreciate and document a fuller understanding of the treatment process - and to follow-up on how these particular patients fared in the years following treatment, Dr. Breger sent his former patients questionnaires inquiring about the quality of their lives, and what they remembered about their therapy with him, and what was helpful or unhelpful in their past work together. Though it is not clear how many former patients he attempted to contact, 30+ patients responded. Many of the responses came from patients whom Dr Breger had seen several decades earlier (Ralph, a former patient was in treatment starting in 1959) - and some completed their therapy in the previous 10 years. Many of the responses were detailed and extensive narratives.
Dr. Breger's study is unique. There are very few long-term follow up investigations of psychotherapy efficacy that rely on the patient's experience of their treatment. Some clinician/researchers have expressed concern that such post-therapy contacts might be an unwelcomed intrusion into a former patient's privacy, or that it would undermine an individual's sense of autonomy, and that planned follow-up studies might dilute the experience of termination or saying "good-bye." However, Dr. Breger clearly felt that such follow-up would be informative and helpful. I agree.
The most prominent finding from this survey, is how positive these 30+ patients felt about their therapy. Quotes from grateful patients best capture the tone:
"I found my treatment with you revolutionary in terms of helping me create the life I had hoped for "Š ""I carry you around with me always" Š. "The work we did in 1980's saved my life "Š. " That [therapy] helped me enormously Š. and had a great impact on me, primarily in the role-model department"Š"I've made headway in working and living as a functional adult ." With rare exception, there is an outpouring of positive regards for Dr. Breger, and for the therapy he provided. Most of the respondents describe major changes in their lives and personalities as a result of their work with Dr. Breger.
Dr. Breger in his introduction makes it clear that the results of this follow up study emerge from a very skewed patient sample. He notes, "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 trying to define what specifically was helpful to these patients, almost uniformly they underscored their relationship with Dr. Breger and the meaningful engagement that unfolded. Isabella, saw Dr. B for four years, mainly three times a week. She notes the qualities that were most helpful in their work together were "acceptance", "unflappability" .." you did not seem to feel anxious",Š "generosity"Š"you understood my point of view"'Š "authenticity",Š "trust". Dr. B elaborates and states, " It is clear how vital it was that they [his patients] knew I genuinely liked them and, because of this, they could like themselves".
Some respondents mentioned the value of insight, understanding themselves more fully and a few noted the value of appreciating a more accepting life narrative - but these therapeutic ingredients seemed secondary to their overall growth.
Since the earliest years of psychoanalytic thinking, there has been an ongoing debate as to what within the therapeutic arena is therapeutic - the words or the music - the content of the dialogue between therapist and patent or the relationship between the two participants. Evolving from the early concepts that successful treatment was comparable to an archeological dig - uncovering forgotten or repressed childhood memories and fantasies and making the unconscious conscious - there has been a distinct shift to focusing on the dynamics of the relationship between therapist and patient and how this interplay both helps clarify the inner conflicts of the patient and contributes to the therapeutic thrust of the treatment. Relational schools of thought, clinicians advancing an inter-subjective frame and self-psychologists align themselves with this position and certainly Dr. Breger's work and survey are consonant with this perspective.
To underscore this evolutionary change, Dr.Breger includes descriptions of his patients who in previous therapy with classical Freudian analysts experienced their therapists as "cold", "aloof", "non-responsive", seemingly uncaring and who maintained rigid boundaries between themselves and their patients. Indeed, if a classical analyst developed some feelings about his analysand or had a dream involving his patient it was considered a significant flaw in the therapist and some self-correcting intervention was indicated.
These descriptions of "classical Freudians" though accurate, represent therapeutic practice and thinking from a past era. In the first ¦ of the twentieth century (presumably when many of the therapists who initially treated Dr. Breger's patients were in training), psychoanalytic thinking was highly influenced by an influx of European clinicians who like Freud felt it was necessary to prove that this new therapeutic field (Psychoanalysis) was a True Science. In this effort clear boundaries between the observer and the observed were felt to be essential. The physicist, the epidemiologist, and the chemist observe without passion and personal involvement (a myth) and so early analytic training emphasized positivism and skills (abstinence, anonymity, neutrality) that allowed the therapist to be a "blank screen" and to allow the patient to displace onto an uncontaminated field internal and infantile conflicts.
Dr. Breger and his patients document well the shift from this sterile position and an important evolution of psychoanalytic thinking.
To emphasize the importance of the interpersonal ingredient in effective therapy, Dr. Breger focuses on this specific therapeutic element. Other important components of the therapeutic process such as increased self-understanding, insight and self-analytic functioning are left in the shadows. Though I suspect these are important elements that were very much part of Dr. Breger's approach, the focus of Dr. Breger presentation may obscure the wider picture and other important contributing factors to what cures in psychotherapy and psychoanalysis.
I highly recommend this book for those who want to learn and think more about the therapeutic process.
Newell Fischer, MD: Psychiatrist on the clinical faculty of the University of Pennsylvania Medical School and Chairman of the Education Committee of the Psychoanalytic Center of Philadelphia