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A good psychotherapist has empathy and critical acuity, with intelligence and a wish to help. Carl Rogers spoke of "non-possessive warmth" and "unconditional positive regard." That Louis Breger has all this, nuanced in his own way, is evident to his patients, and now to his readers. This follow-up survey is unique and valuable. Breger's prior writing includes books on personality, Dostoevsky, Freud. This compact (150 page) memoir melds subjective and objective skills that all therapists must learn. He provides rich dialogue from former patients who answered his request for feedback, in some cases after many years. Breger might be a playwright watching, directing and editing a drama about people he knew very well, people who--mostly--changed for the better as they worked together.
Psychoanalysis is notoriously under-researched, so this is a model, a breakthrough. Some analysts would be incapable of such research due to presumptive infallibility, learned in part from Freud himself, who deserves credit for inventing a new and constructive form of human relationship, what Otto Rank called "the analytic situation," others "the Jewish confessional." The chapter titles describe Breger's approach--"Against Dogma;" "Psychoanalysis Old and New;" "Learning the Ropes;" and "When I Didn't Help."
Of 11 chapters, four present patients, while the other seven contain Breger's reflections on psychoanalysis then and now, his own upbringing (his mother was severely depressed), his personal qualities and therapeutic style. He comfortably shares inner workings and reactions--thoughts and feelings--including a wish to help and the ability to own up to mistakes. In his mid-seventies and retired from fifty years of practice and teaching, Breger contacted many former patients, explaining his interest in follow-up and evaluation of the process. Some of the 28 respondents are themselves therapists. A few had kept in contact over the years, exchanging holiday cards, sending marriage or birth announcements; Breger and his wife went to some of their weddings. He is not a classical Freudian (but neither was Freud).
"Successful therapeutic outcomes depend more on the kind of person the therapist/analyst is than his or her theory-based technique. All the same, good theories can be very useful while bad theories make it difficult, though not impossible, for even the most skillful therapists to be of much help. To come at it a different way, much depends on the match--or mismatch--between therapist and patient." (p. 31) Patients' remarks, like those of "Andrew," a therapist himself, are often eloquent and revealing:
...my memories of this therapy don't refer to clinical methodology or skill. This may be, in part because the methodology, as I recall it, was so deeply embedded in the humanness of the interaction. .... What is clear to me is that Lou's approach reflected an unusual grasp of the sometimes evanescent distinction between being too distant and too intimate. Achieving this appropriate distance is, surely, a struggle engaged in by all serious, caring, responsible therapists, but it is a struggle, nonetheless. So, in my view, as a patient and a clinician, achieving this rightness of distance reflects a particular grace."
Andrew had two prior analyses, Freudian and Kleinian. Of that history Breger, his analyst for three years, four sessions weekly, said, "...a patient is plugged into a fixed slot, his individuality ignored. There was essentially no relationship with him as a unique person..." (34-35) Reflecting on three other patients with similar experience, Breger notes that, despite the importance of free association, they "did not feel free to talk about how their analysts affected them in the sessions." (45)
Recognizing that patients who liked him were more likely to respond, Breger sought, and found, a range success and failure. "Oliver" recalls confronting him on mistakes: a "nagging" tone of voice when saying he would be ready soon. Breger responded "you're right" and apologized. Later Breger acknowledges a homophobic response to Oliver's suggestion that the two share the couch. Such failures are mended for a net plus. Deborah, who saw him weekly for three years, had come to view a behavioral approach as more effective than talk therapy: "relying on someone else to listen to you and ask questions feels like it's creating an unhealthy dependence." (106) "Karl" wrote: "working from so-called attachment theory was all you continued to want to do to draw me closer for your needs...With each major failure on your part, I began to lose confidence that you new what you were doing." (107) Breger finds some interference in other cases from his own personal characteristics, e.g. over-controlled emotion, a vulnerability to guilt feelings and excessive responsibility (too quickly yielding to the pressure of suicide/self-injury threats), and a conflict between pride and modesty.
A flexible therapist--he saw couples and families, too--and an introspective man who overcame difficult relationship problems in his own life, Breger comes to this unusual task with balanced pride and humility. A careful writer with broad scholarly pursuits, grounded in good personal relationships and realistic ideals, he provides a guide and a mirror for new and experienced therapists, their teachers and their clients. His pioneering achievement is a gift and a challenge for all of us who care about psychotherapy.
© 2012 E. James Lieberman
E. James Lieberman, M.D., Clinical Professor of Psychiatry, Emeritus, George Washington University School of Medicine