Accidental Blogger

An Interview With Psychotherapist Louis Breger, Author Of Psychotherapy: Lives Intersecting * - Part 1

by Norman Costa PhD

* Psychotherapy: Lives Intersecting, 2012, Transaction Publishers, New Brunswick, New Jersey

    Beatrice is a woman in her mid-thirties, and a smart, sharp attorney for a major law firm. She and three other women had been together in group therapy for two years. Each woman experienced severe childhood sexual abuse. In one very emotionally difficult session Bea put a question to her therapist. In tears, and with a voice of anger, pleading, and despair she asked, “What is the point of all this [experience of abuse]?” Her therapist, Francine, answered, “There is no point to it, except what you can give to it. And you have learned so much, and gained a compassion and a wisdom that few have. You can now tell the truth to people who need to know.”

    I was extremely fortunate to observe this group for a significant period of time, with the permission of all involved. I was doing research of my own on child sexual abuse. During the time I was observing I had regular individual therapy sessions with Francine. This is an absolute necessity, in my opinion, for anyone doing research on abuse from first-person accounts.

Louis Breger, author of Psychotherapy, Lives Intersecting

    While reading Louis Breger's new book, Psychotherapy: Lives Intersecting, I kept going back to that difficult session when Bea asked her question. Yes, her question moved me, deeply. Equally significant, for me, was Francine's response. Francine is a therapist that Breger describes as having 'the touch.' Others might refer to it as 'the gift.'

    My experience with Bea's group and with Francine in individual sessions, gave me a perspective on this book. In a way, Louis Breger, PhD is the complement to a patient like Bea. As a therapist, teacher, researcher, husband, and father he has learned many things and gained much wisdom in a 50 year career. In this professional memoir, he is passing it on, and telling the truth to people who need to know.

Who needs to know?

    Certainly, Psychotherapy: Lives Intersecting is a book for psychotherapists, counselors, and others in the helping professions in psychology, social work, and psychiatry. It is for students in mental health and related majors from upper-class students at the undergraduate level to Masters and Doctoral programs. Beyond the academic and training institutions, faculty, and students, this book belongs in the hands of all friends of psychotherapy, those considering therapy for themselves, and those who are trying to help family or friends make a decision about psychotherapy. Though a professional memoir covering professional subjects, it is still accessible to an educated and interested layperson.

    If the reader can set aside preconceptions of the usual and obligatory book-jacket blurbs, they will discover that Psychotherapy: Lives Intersecting IS unique in its field. As a professional memoir he discusses substantive matters like the history of psychoanalysis, and varied schools of thought and theories of personality. Breger is as clear as he can be in his criticism of methods of psychotherapy based upon a dominating guru, inflexible dogma, and cult-like followers. He is equally clear about what is most important to a successful therapeutic outcome for the patient – Hint: It may be a surprise for many. What makes this book stand apart from others in his field are two things: 

First, the reader is going to learn a great deal about the personal and professional development of Louis Breger. While it is not a tell-all book nor a standard autobiography, Breger gives us a good dose of self-reflection, self-revelation, and self-criticism. Would that more therapists did the same. Professionals and those in training can benefit enormously from his experiences.

Second, Breger's former patients contributed, substantively, to this book. His survey of former patients, some from 25 years earlier, amounted to a long-term follow-up of psychotherapy patients that is rare in the literature. The reader will hear from those who had a positive experience and some who did not. Such are the seeds of learning for all of us.

    I told you this book was unique. I will have more to say about Louis Breger and his latest book Psychotherapy: Lives Intersecting at various points in this interview. So, why don't we hear what he has to say.

The Interview

AGAINST DOGMA

Lou, thank you for doing this interview on the occasion of publishing your latest book, Psychotherapy: Lives Intersecting. I'm sure my readers will appreciate the time you are devoting to this.  

Not at all. I'm honored that you asked, and I'm happy to do this.

So why don't you tell us about how you came to the field of psychology, and started a career in the helping profession of psychotherapy? 

Like so many psychotherapists, I was drawn to the field by the craziness in my own family. By late childhood, I was aware that the family was “different” with a hypochondriacal mother and a father who was often out of work for reasons I couldn’t understand.  

As early as high school, I stumbled on Freud – I can’t remember which book – and it struck a chord. People’s symptoms had meaning, typically unconscious, that could be understood and treated. Eventually, it led me to graduate school in clinical psychology. As I later found out, a large number of therapists had depressed mothers. It's a bit of an oversimplification, but we were trying to cure them by curing our patients.

You write critically about various theories of personality, different schools of psychoanalysis, and professional factions. What are they and what led to your criticisms?

When I was a young professor at the University of Oregon, Behaviorism, and its leading proponent B. F. Skinner, was all the rage. It always seemed too simple minded to me, especially as applied to psychological disturbance and treatment. My colleague Jim McGaugh was a research psychologist in the areas of learning and memory. Jim and I co-authored an article, Critique and Reformulation of ‘Learning Theory’ Approaches to Psychotherapy and Neurosis in 1965. 

We exposed the sham science behind the claims of what was then called “Behavior Therapy.” It was my first major publication and was widely reprinted. This was my first exposé of the lack of real research evidence behind psychological theories and schools. 

A little later, I immersed myself in a critical review of what was then classical psychoanalytic theory, drawing on the work of Robert Holt, George Klein, and others. There was a parallel to my criticism of behavior therapy. In both cases ideas and methods were expounded as "scientific" when a careful review of the literature revealed that there was little or no basis in scientific research for such claims.

At this point in my career, I had become very critical of psychoanalytic theory. However, I still clung to my belief that the therapy was still the deepest and best, even though I had no first hand basis for this idea. This began to develop when I left Eugene,Oregon for The Langley Porter Institute at the UCSF Medical Center in San Francisco. There, in this full time clinical setting, I had much more exposure to patients and therapists of many persuasions.

Yet, the strong criticism in your book is not a total dismissal of some of these approaches in psychotherapy. At first blush it seems a bit odd, so tell us, please, why you just don't chuck them all into the waste bin?

Here's why. At Langley Porter, my colleagues and I set up a research program for brief psychotherapy. Any potential patient that came to the outpatient department could be seen immediately, but for a maximum of ten sessions. We did away with the cumbersome medical-psychological-social work screening that took so much time and was, we believed, fairly useless. We divided the treatments into Freudian, Jungian and Behavioral sections. Each section had a seminar, led by an expert in the respective orientation. Cases were presented – via tape recordings of the actual sessions – and discussed.  

There were several important findings of this research. Many patients were helped in as few as ten sessions. If their difficulties continued or were severe they were encouraged to seek additional treatment elsewhere. Of particular significance to me is that there didn’t seem to be major differences in outcomes among the three different sections – Freudian, Jungian, and Behavioral.  

The more important determinant of positive outcome for the patient was the personality of the therapist. Some of these therapists just seemed to have the touch and others not. I could see this first-hand in my supervision of them, and in their presentations in the seminars. A therapist whose orientation was Freudian, Jungian or even Behaviorist can be helpful if the therapist is a certain kind of person.  

Is there current research that would support your earlier findings?

Yes, Recent research has confirmed this position. Relationship traits and skills in the therapist like empathy, a caring attitude, and a good therapeutic alliance with the patient are central to positive outcomes in a variety of approaches.  

It's clear to me that this finding is a central thesis in your new book, “Psychotherapy: Lives Intersecting.”

Absolutely. But I should add that one’s theory is not irrelevant. One can do good psychotherapy with a bad theory, but one has to overcome it. You don't have to compensate if you start with a better theory. 

Regarding your thoughts on psychology as a science, I saw three things emerge in your book. First, you've already talked about theories of personality and psychotherapy that purport to be scientific when, in fact, there was no supporting research. The second thing is that you had done research in your career, and cite published studies and reviews of research in your new book. If you will allow me, for a moment, I'd like to suggest to faculty and students in psychology and the mental health field – at any level – that they check out your bibliography and citations. Third, you did new research in preparing material for this book. Please tell us about it.

Well, before the writing of this book, I had been engaged in two kinds of research during my career. There was empirical research, such as that on dreaming where we monitored sleep through the night. At different times we would wake students and record their dream reports.

Yes, that was your 1971 study “The Effect of Stress on Dreams”.

Right. And there was the research on brief psychotherapy that I already mentioned. Also, I wrote a number of scholarly research papers. For example, I wrote critical reviews of Behavior Therapy and Freudian theory.  

Speaking of a critical review of Freudian theory, I had the opportunity to read your biography of Freud, “Freud: Darkness in the Midst of Vision” published in 2000. Then there was your follow-up book in 2009 on Freud and Breuer, “A Dream of Undying Fame: How Freud Betrayed His Mentor and Invented Psychoanalysis.” I'm not an expert on Freud but I can say that for me there was much new learning and very satisfying assessments of Freud.

Thanks for mentioning them. I'm very proud of them because they represent my most significant scholarly work. 

Whether empirical or scholarly I think it important to take an open-minded, scientific point of view. Too often the fields of psychology and psychoanalysis have been divided into sects, centered around a leader – Freud, Jung, Adler, Klein, and Kohut, to name a few prominent characters. Students learn the ideas of their school to the neglect of others.  

In my view, almost all the well known psychologists have some ideas and methods of value. The task of the therapist is to seek out what works with a particular patient. The strategy should be to take ideas from different theories that fit the therapeutic setting. Let's not begin by forcing the patient into a theoretical mold.  

The therapist should act like a non-dogmatic scientist. Try out hypotheses and pay attention to the patient’s response. There is a long tradition of research on the effectiveness of psychotherapy. However, not enough attention has been focused on the effectiveness of therapists, themselves. They can remain immersed in their “school” or “movement” which they believe sufficient in providing what they need to know.  

This gets at an answer to your earlier question of why not throw bad theories in the trash. Almost all the approaches that have lasted over the years have some valuable components. Our task, as scientifically oriented psychotherapists, is to tease out what is of value and use it when it fits the particular patient.  

Now let me get back to the research for this new book. I think it's best to call it an informal survey of my patients whom I had seen over a period of several decades. I wanted to get their assessment of the effectiveness and outcomes of their therapy. The response sample is biased since patients who had a negative experience were less likely to respond – though I did have a few – but I was open to what they said and reported it fully in this book with no editorializing. 

Were there any surprises?

Yes. I was surprised by the results. Relationship factors in the skills and traits of the therapist were mentioned again and again as most important for the outcome of their therapy. Even more surprising was that insight into their unconscious, while on the list, was pretty far down in importance. I didn’t expect this. It shows the value of keeping an open mind. 

Great. We'll get into the replies from your patients a bit later. First, would you tell us something about psychodynamic therapy? What is it? How does it work?

The word “psychodynamic” has been around for many years. It's in vogue now as a general term for the host of approaches that began with Freud and that were elaborated upon by the Neo-Freudians. Today, the term “Psychodynamic Therapy” is used by many independent therapists that are not a member of any of the official clubs or schools. I think it is a good, broad term to characterize these modern analytic approaches. It differentiates them from approaches that stress medication only, or brief behavioral approaches that are done from manuals.

EARLY PSYCHOANALYTIC CASES

One of the powerful elements of your new book is that we learn a lot about you as a therapist. We get an inside view of the personal, academic, and clinical experiences that shaped your professional life. Tell us, please, about your early training and experience, and getting into formal psychoanalytical training.

I began training at an official psychoanalytic institute in Los Angeles about 16 years after I got my PhD. During those 16 years I was practicing psychotherapy on my own, doing research on dreams and brief psychotherapy, and writing three books. It was a relief to sit back and be a student again. Also, I needed therapy for myself – not because I had terrible symptoms, but because I remained a sort of workaholic, and an emotionally shut down guy. To others it wasn’t that apparent on the surface.  

Psychoanalytic training in those days was divided into three parts, training analysis, supervised cases, and seminars. Training analysis was the most important to me and I threw myself into in wholeheartedly. I went four and five times a week for over four years. I reported on my therapy and came to understand many of my dreams, transference reactions, and so on. I emerged much more comfortable with myself, and emotionally open with others.  

The supervision of cases, with one exception, was mainly a waste of time. The supervisors seemed bored and just applied standard formulas. 

The seminars were equally boring. We went over papers and books by Freud and his loyal followers, with little appreciation of the many contributions of those outside the Freudian fold. Orthodox psychoanalysis, as taught in such institutes, had much in common with religious or political cults, though it took me a while, post- graduation, to become fully aware of this. 

Early in your book you begin talking about yourself as a therapist. I love one of your self-revealing sentences. “In the earliest years, I was quite green and uncertain of what I was doing…”. I'm sure most readers can identify with this. It's encouraging to read it from someone who is looking back on a long and productive career. There is hope for us all. Now, please tell us how you progressed from there.

That remark was made about one of the first cases I saw on my pre-doctoral internship, though it could have applied, with a little modification, to the cases I saw during my psychoanalytic training. Not buying the standard psychoanalytic technique, I was more finding my own way and this certainly left me feeling like I was groping around in the dark.  

My strong anti-authoritarian streak certainly led me to listen closely to the patients. I didn't want to impose theory-based interpretations onto them. I wanted to work in a collaborative manner with my patient and co-construct (to use a bit of modern jargon) our understanding of what was going on.  

Over the years, I gained more and more confidence in what I was doing, though I never became one of those all-knowing authorities like so many in the field.   

Now, let's get to one of your cases in the book. It's the story of Gregor. I found it moving, disturbing, and very sad. I've known someone like this. An important aspect, for me, is your telling of the developing relationship of therapist and patient.

“Gregor” – his pseudonym taken from Franz Kafka – was one of my most disturbed patients, suffering from a combination of anorexia, bulimia (quite rare in a man in his late 20s) and compulsive exercise. He looked like a cross between a starving Jesus Christ and Leon Trotsky.  

He was enmeshed in a very destructive family. His father, an extremely narcissistic surgeon, spoke of him with undisguised disdain. His mother, who had had anorexia herself in the past, required him to shop and prepare all their food. Father prescribed a variety of drugs for both of them. Gregor was very intelligent, he had – in his own words – read all of Freud and Marx and had been doing well in graduate school in social science when he crashed into a near suicidal state.  

He came to me for “a real psychoanalysis”, lay on the couch and did his version of free association, which mainly consisted of accounts of what he had eaten, vomited, the consistency of his bowel movements, how twisted or bloated his stomach was, and the like. This was not easy to listen to hour after hour but it was clear to me that no one had ever taken a serious interest in him. So I paid close attention, offered few remarks, and I made no attempt to control him. Very gradually a trust developed and he revealed the complex belief system that lay behind his eating rituals.

The case ended tragically in a sort of combination accident-suicide-murder. He was laying in bed after one of his lengthy exercise routines, heavily sedated on one of the drugs supplied by his father, when he aspirated his own vomit and died. As in the case of Kafka’s Metamorphosis the family made every attempt to cover up his death: as in life, they acted as if he never existed. 

This is a very tragic and difficult case. My personal view is that you give to the reader something very important that is not easy to come by in other books on psychotherapy – your personal reaction to Gregor's life and death. Would you tell us something about this.

My own reaction to his death was a complex one. I was certainly sad at the wasted life of this intelligent young man. At the same time, his family situation was clearly impossible and he was adamant about not moving out on his own, believing he had to stay home to “protect his mother from his father.” I didn’t feel particularly guilty about his death, feeling that as long as he couldn’t get free of his family, little could be done. Still, one can never be sure: perhaps a therapist with a different personality or orientation could have done more for him.

CONTINUING DIALOGUES

The case of Emily is, I believe, very important. You wrote two articles – two versions – of Emily's story. What I saw in your telling of the story in this book was your ongoing professional transition from Freudian dogma and vocabulary, to ideas and words that were more reflective of what was really happening with the patient. I was wondering if you could talk about this case and the ongoing development of your ideas about psychotherapy, and your personal views as they affect the therapist-patient relationship.

I saw “Emily” towards the end of my training at the Psychoanalytic Institute and, while moving to freedom from the analytic strictures, I was not completely rid of them. This probably led me to focus more on interpretations, an understanding of her unconscious motives, the sexual activities in her life, and overlook what, after our later, continuing dialogue, was her mother’s gas-lighting of her, which I missed the first time around.  

In the book you talk about your own life and your views of 'traditional roles' for husband and wife, and how this influenced your interaction with the patient. 

My own involvement in a traditional marriage with children again led me to overlook something. What seemed like her marriage to a “nice guy” traditional husband was, in fact, as she put it, “a trap in a velvet cage of his design.” It was the broadening of my own views that let me see these troubling sides of her life that I had neglected or minimized during the first analysis. By her own account, she had a helpful experience, though it took her a very long time to make a commitment to her second husband, and I think if I had been more open in my thinking the first time I saw her, things would have gone faster. 

End of Part 1.

Louis Breger is Professor of Psychoanalytic Studies, Emeritus, California Institute of Technolgy. You can go to his website at http://www.louisbreger.com. You can email Lou at lbreger@comcast.net.

Please come back to Accidental Blogger on August 2, 2012 for Part 2 of my Interview with psychotherapist Louis Breger, author of Psychotherapy: Lives Intersecting.