Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Tuesday, July 03, 2012
Book Review: Psychotherapy Lives Intersecting
There's a bit of a formula to writing a book review, and here, I'm planning to break from that formula. I recently had the pleasure of reading Louis Breger's new book, Psychotherapy Lives Intersecting and I'd like to tell you how I felt, and what things I thought about, while I was reading it. The book is about psychoanalysis, so instead of reviewing, I'll be free associating. You'll bear with me on this? I did have a positive transference to Dr. Breger
Okay, so Louis Breger is a psychologist in California. He's not just a psychologist, he's also a psychoanalyst, at Caltech, no less. Caltech has psychoanalysts? I thought Caltech had math geniuses and computer geeks. I thought this because my brother went to Caltech, and one of my good friends from high school also went there. My brother has written such books as Computer-Aided Financial Analysis, and my friend is a physicist in a linear accelerator (SLAC, to be precise). Neither has ever mentioned a word about Oedipal complexes, ids, egos, pleasure principles, or psychoanalytic anything. Okay, so apparently there is a psychoanalyst at Caltech.
In the introduction, Dr. Breger starts by talking about how Marsha Angell says anti-depressants don't work. My feelings? Annoyed. Then he mentions that they've helped some of his patients, he's neither for or against them. I kept reading.
The premise of the book is that after decades as a psychotherapist, Dr. Breger contacted his former patients and asked them to fill out a questionnaire. He wanted to get their feedback on their psychotherapy. If you know me at all, you know this is an exercise I'd find very cool. Who writes to their patients 30 years after the end of psychotherapy and asks What did this mean to you? What a great idea, it inspired my admiration, and the positive transference began.
It seems that most of Dr. Breger's patients are in multiple times a week therapy for years. Okay, that's what analysis is, but who can afford that? My feeling: a little jealous. Maybe it's something I would have wanted to check out, but with my medical school debts, then childcare/tuition/etc, it wasn't an option back then. And now-- still too expensive, terribly time consuming, and hard to rationalize putting this degree of resources into something for the sake of intellectual curiosity. It's a mixed kind of envy, however-- one psychiatrist I know spent 11 years in analysis conducted at 6:15 every morning, and as someone who is not a 'morning person' such an endeavor would be unthinkable.
Many, if not most, of Breger's patients are psychotherapists themselves (or in training), and many had been in therapy before and had experienced unsatisfying, if not traumatizing, relationships with therapists who sounded to be rigidly engaged in a therapeutic stance that lacked empathy, warmth, and any degree of kindness or humanity. Dr. Breger broke that mold and his patients seemed to all comment on his kindness, attention, non-judgmental stance, and that he cared about them. These were the qualities they found healing, and few seemed to mention great insights or spectacular interpretations. He brought one patient cookies. My thoughts: What a nice guy. I think I'd like talking to him. And if not, I do love cookies. It presents therapy as a corrective healing response, often good for those who've had critical and damaging childhood relationships.
After a bit, it felt repetitive: the patients said the same things--- they all thanked him, they all appreciated him, they all contrasted him to the prior therapists who were personally related to the devil. He has no patients that didn't like him? That weren't full of gratitude? Even wonderful psychotherapists aren't wonderful for everyone, there's some chemistry there, and there are some very particular patients out there who manage to find fault with everyone. I went through a brief phase of feeling annoyed with Dr. Breger. Is he a narcissist? Why write about all the kudos? Ah, but he redeemed himself later in the book-- he tells us he only wrote to his long-term patients where psychotherapy seemed helpful, that he didn't want to trouble people who would be distressed by the request or communication, and he mentions that some people left therapy early on, and one even got better with medications and didn't want psychotherapy. So it's not a research study in the double-blind, placebo-controlled, all results are fair game for publication, type of project. Knowing that such patients existed and were acknowledged as such, in reasonably respectful terms, left it more realistic and honest. I liked the book again.
There were some intensely personal moments. The author talks about his own childhood, including his insecurities, his mother's mental illness which included hospitalizations and repeated suicide attempts, and his father's fatal heart attack. His grandmother also suffered from depression and had a lost a child, one his mother was born to replace. I enjoyed getting to know him and his family.
At one point, Breger talks about allowing patients to call him while he was sick in the Intensive Care Unit. While I might like to feed my patients cookies, and I certainly try to be responsive and available, this was a degree of availability and patient-first mind set that made me uncomfortable. For my own sense of sanity and boundaries, I'd like to think that if I'm ever so unfortunate as to be in an ICU, that I could simply be sick, fight for my life, and be 100% patient, without having to remain as anyone's doctor, at least until I was healed enough to be released from the hospital. While it's nice to be able to reassure patients, it seems that having a colleague cover should be enough, and I never want to be this indispensable.
Dr. Breger is a psychoanalyst-- a training analyst at that-- and this shows in the way he looks at problems as the result of childhood (or at least long-ago) events. There's little room in his paradigm that allows for genetics or biology, or illness. He's not shy, however, about discussing his disdain for psychoanalytic practice-- for it's abstinence, rigidity, coldness, and adherence to a theory that leaves little room for individual differences. The theory, he asserts, can be practiced in such a way that it is thrust upon patients, and if they don't buy the interpretation, they are "resistant." He seems to have found a way to draw out positive and helpful aspects of psychoanalysis while abandoning the parts that make it impersonal, rigid, and even mean.
After the therapy is completed, the doctor-patient relationship is left to the patient. In some cases, Breger becomes friends with his patients, they continue in various forms of contact, ranging from a holiday card to visits to each others' homes for meals. In this sense, this is a different world from my professional life where it's hard to imagine purposeful on-going social relationships (including spouses) with my former patients. Perhaps it's the difference between being a psychiatrist, a non-analyst, practicing in a different decade, and in a different state (California has it's own rules, right?).
In thinking about this book as a teaching tool for young therapists-- or psychiatry residents in training-- I'm not sure that it's value lies in contrasting a warmer, more responsive therapy to traditional psychoanalysis. I'm not aware of any young psychiatrists who are entering training in traditional psychoanalysis, but perhaps that's a function of where I practice, Still, this book provides a historical perspective that is difficult to capture as psychoanalysis fades as a primary treatment of mental disorders.
The biggest strength of this little book, however, is Breger's easy writing and warm, inviting, and caring style. At just over 120 pages, it's a quick, compelling, and enjoyable read, written by a man whose masterful skill as a psychotherapist weaves through every page.
Posted by Dinah on Tuesday, July 03, 2012
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You would kind of expect an analyst to write a book of only 120 pages. Even that is a lot considering p-analysts don't say a whole heck of a lot. Um, 6:15 sessions. was the analyst awake? Would the patient even know? All that aside, most of the people I know who trained as psychoanalysts do not really practice the way they were trained. Not enough paying customers these days. They may incorporate some of what they learned but, on the whole, they tend to end up practicing an eclectic form of psychotherapy. Who doesn't?
I was just thinking that he probably really is from another time. There is a retired professional clown I haven't talked to for years, but he was an old school clown. I think he is in his 80s now. I can't even remember his real name. Just his clown name and that white face makeup he always wore. But he was really into traditional "clowning." I was talking to a younger clown, who makes balloon animals, and he mentioned that the older clown considers balloon tricks separate from clown acts and he is very old school. Different style. Different world. Different generation of clowns.
Anyhow, I wanted to mention that this clown, who worked for a friend of mine that owns an entertainment company, was booked for a child's birthday party. He had a heart attack the day of the party. He called my friend and told her to let the parents know that he couldn't make it because he had a heart attack and was being taken by ambulance to the hospital.
I have no clue how he was even able to communicate or think straight while having a heart attack. But talk about dedication. My friend, who owns the entertainment company, was saying that entertainers are not like that anymore. They blow things off, cancel last minute. He was truly from another generation of truly dedicated professional entertainers.
And he was a really good clown. I only remember three clowns from my childhood: My mom, that clown, and another one. And my mother was not as good as the older clown...even given her younger years. She was a good face painter and jolly, and the other young clown was good with balloon animals. But that senior citizen clown had skills! And he never missed a child's birthday party unless he was having a heart attack.
Thanks. Interesting review. I will read it. My psychiatrist was trained as a multiple-times-a-week analyst, and practiced that way at the beginning of his career, but changed his practice based on his own reflections, the times, and insurance company requirements. My doctor is in California, but does not have relationships with his patients after seeing them as patients. I'd guess it may be different for someone whose patients are psychotherapists themselves. Perhaps he feels they are colleagues. I don't think it is a "California thing". We aren't that much different. We have boundaries between psychiatrist and patient here, also.
I'm with you on the ICU thing. I can't imagine even wanting to call my therapist or physician while they're hospitalized so I can launch into my tales of woe. What is wrong with a patient who can't stop for a minute and think about the needs of other people? Offered or not, I think that's weird.
I haven't read the book but I'm trying to imagine the scenario.
Therapist - It's ok to call me when I'm in the hospital, even in ICU
Patient - Gee, thanks, Doc!
Ring, ring, ring.
Therapist - hello?
Patient - Uh, yeah, sorry to bother you, I know you're in ICU and all, but my mother is coming to visit and I'm just feeling really stressed right now.
Therapist - Oh, hey, can you hold on a minute, the nurse is here to change my dressing.
Patient - Yeah, I guess so, sigh...
Therapist - Ok, I'm back. About your mother...
Patient - blah, blah, blah...
Therapist - sorry, can you hang on a minute while they suction me, gurgle, gurgle, cough, cough, cough....
Sucking sounds heard...
From the book's author:
I want to thank Dinah Miller for her review of my book "Psychotherapy: Lives Intersecting". Her chatty, free associative style fits with the book very nicely. I also want to clarify a few points from her review and the four comments made so far. In past years my wife used to introduce me to people as "my husband the psychoanalyst" and I told her to stop and just say I'm a shrink. Psychoanalysis is still associated with Freud -- about whom I have written two critical biographies -- and I have moved far past that. I practice a kind of psychodynamic psychotherapy that certainly has its origins in Freud but is far different. What my patient's responses, that make up the core of the new book, show is that it is the relationship that is most helpful: close listening in a non-judgmental manner; catharsis; a friendly, caring attitude; admitting and repairing mistakes; flexibility with fees; humor; and insights that are mutually constructed for each unique individual rather than taken from some theory. This way of working can be done multiple times per week over years or once a week for brief periods. But, as one commentator put it, "the relationship rules."
I also wanted to comment on the use of psychiatric medications. For a few conditions they are essential. But it is also the case that the pharmaceutical industry has grossly oversold them. In addition, recent research has show that they work best in combination with psychodynamic psychotherapy.
As the incident in which a patient phoned me when I was in the ICU -- which both Dinah and a commentator referred to I want to make clear that I was not doing therapy when I was there (I am a bit of a workaholic but not that bad.) This was a patient I had seen for a number of years and she wasn't calling for her own therapy but just to see if I was all right.
Finally, as a minor point, I did not use a questionnaire with these former patients but simply an open-ended quarry which allowed them to go off in many different directions.
I will end by pointing to two things about the book that are unique: getting the patients side of the story as opposed to the typical case history that is written by the treating therapist and the, second, the long-term nature of the follow-up.
"I will end by pointing to two things about the book that are unique: getting the patients side of the story as opposed to the typical case history that is written by the treating therapist and the, second, the long-term nature of the follow-up."
Dr. Berger, have you seen this site?
It is owned by a psychologist, Dr. Gail Hornstein, who has felt for many years that the patients accounts of their experiences with mental illness have been greatly ignored by mainstream psychiatry.
She wrote the book, Agnes’s Jacket: A Psychologist’s Search for the Meanings of Madness.
@ Lou: how do we know it is really you?
I exchanged emails with Dr. Breger and he said he was going to comment, so Lou is Lou.
I did assume the patient called in the ICU because of concern about the therapist and not to burden him with his/her issues. But the need for reassurance is still about the patient, and someone else could provide this. Obviously, Lou didn't mind (or wouldn't have done it), but I think I might. On the other hand, if I wasn't deathly ill, and the ICU didn't have wi-fi and my toys, I might be thrilled to talk to anyone.
Blogger still thinks I might be a robot. What if I am?
That would be a Dinah nightmare---trying to talk while intubated! (Notice the balanced dash? Roy will be pleased.)
Looking forward to podcasting this weekend.
I listened to Michael Krasny's interview with Dr. Berger on KQED public radio station's Forum program last month here in Northern California. The book sounded interesting. As someone who was hurt by my first psychotherapy experience, I never tire of hearing how important empathy, kindness, care, attention, and non-judgement are to a transformative/healing alliance.
Here's a link to the interview for anyone who's interested:
As someone who was hurt by psychotherapy, I don't believe in healing alliances.
As someone who was hurt by psychotherapy I believe that the potential for harmful effects of psychotherapy needs to be taken at least as seriously as the potential for harmful side effects of medication.
Agreed, Alison. Too bad we do not hear about the patients whose suicides can be attributed to harmful effects of psychotherapy and too bad that we only ever of the ways in which patients are harmed by therapists who abuse them sexually or financially.So little attention is paid to how real damage can be caused by therapists.
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