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« Why science and religion don't mix well # 1874 | Main | The un-American president »

July 18, 2012

Comments

Norm, thanks for posting a very interesting interview. Sorry, it took me a while to write a response. I was quite busy in the last few day and being mostly ignorant of the science, art or philosophy of psychotherapy, I wanted to read the questions and answers carefully. I am unable to contribute any scholarly comments except to say that Louis Breger's line of thinking makes much sense to me.

I was struck by this observation:

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.

It appears that above all, what a severely disturbed person needs is a sympathetic ear. I am sure there are patients who are beyond mere psychotherapy and need medication to control their symptoms. But a vast majority of people who experience psychological upheavals may be helped enormously by "talking" to the right person. How simple that sounds and yet how rare the opportunity.

Professor Breger seems to be the most useful kind of therapist - one who values common sense over dogma. I have no idea how "common" that approach may be in practice. In light of the recent massacre in Colorado by a young man who, I am sure we will learn had been battling unseen monsters of the mind, it is a pity that the access to good therapists is hard to come by but the doors to gun shops are wide open.

I look forward to the rest of the interview. (Has Elatia seen this post?)

Elatia has not seen it, Ruchira, until now. My computer with all its RSS feeds onto my home page has been in the shop. I know NOTHING!

Very interesting interview, and a very unusual subject -- a psychotherapist following his patients beyond their time of treatment to gauge their impressions of therapy many years out. In 1980, when the psychoanalytic movement was still riding high, though no longer at the high water mark, Janet Malcolm, the legendary "New Yorker" writer, devoted almost an entire issue to conversations with an analyst, whom she did not identify but to whom she gave the pseudonym Aaron Green. He was a classical model Freudian analyst, and a better look inside the thinking of one such would be very hard to find. Subscribers can read it free -- "Psychoanalysis: The Impossible Profession" Nov. 24, 1980. A book Malcolm published, by the same name, is almost the article between hard covers. Malcolm asked "Aaron Green" how he might know, many years later, whether an analysis had been successful. He answered by way of describing two women who had been his patients more than 15 years earlier, when he was a very young doctor. Patient One told him her analysis was the most meaningful experience of her life, and that no day passed without her being conscious of benefiting from it. Patient Two told him that she felt quite well, most of the time, and never gave the analysis a thought. "Dr. Green" averred that the successful analysand, in that case, simply had to have been Patient Two. Because she was the more well of the two.

Of course, in medias res, the analytic patient is obsessed with the analysis, but that's true of most people in therapy, whatever therapy they are in. Anyone in long term therapy is in danger of forgetting Nietzsche: "Good things end by overcoming themselves." And of prioritizing the experience of therapy, and its length, over its outcome. The exiguous length of psychoanalysis sets the trap for this to happen, but there was a time when a Jungian analysis took longer than a Freudian one. Freud would have been astonished at the very idea of four to seven years on the couch, and Jung thought a year of intensive analysis was about right. It is later comers who have turned the couch into the dinghy for Narcissists that it now is.

Analytic therapy too may be culturally relative -- it had better be! In the mid-70s, there was a Psychoanalytic Society of Bombay with 36 members. Their patients were mainly the daughters of the upper bourgeoisie, symptomatic in ways that deeply resembled the ills of the same type of girl in the Vienna of 80 years earlier when Freud was treating his first patients. Now, psychoanalysis is looking good to the newly moneyed middle class of China. It seems that deep cultural shifts, like that from agriculture to industry, may bind together societies with otherwise disparate folkways, and produce conditions favorable to disordered young people with money and time -- analytic patients, in other words. What have we moved onto, in that case?

I want to comment but I'm eating a cold chicken lunch, and then I have work to do. Later.

Just got around to reading this. I have not followed this world, don't know much about the discipline, so my impressions will seem hazy and maybe off topic. It's a very nice interview, looking forward to the rest!

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.

What does this mean for the training and credentialing of therapists? To what extent is this teachable? What advantage does the trained therapist have over the wise old woman with a good memory?

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.

I guess this already partly answers the previous set of questions. But I was thinking of the list 'Freud, Jung...Kohut.' No doubt scientifically oriented therapists can be taught to navigate and balance between theories. But an alternate, also scientific approach would be to expose them to a large number of examples. (Like the example of 'Gregor')

In particular I am trying to understand this: "The supervision of cases, with one exception, was mainly a waste of time. The supervisors seemed bored and just applied standard formulas. " Especially since clinically speaking the results don't seem to show strong impact of theory and very strong impact of personal and relationship factors (which sounds intuitively right..), I would have thought that the 'practical' aspect would be -more- valuable. Does this point to a defect in current training methods?

And in addition to actual cases, we have a rich supply from literature, history and biography. I In fact, why isn't Tolstoy (for example; and if abnormal psychologies are preferred, there's plenty of writers for that!) on the list?

@ Elatia,

"I know NOTHING!" Fat chance of that ever happening.

Thanks for taking the time to read and comment. I was unable to read Janet Malcolm's The New Yorker article, since I don't want to spring for the subscription cost. Getting access to her book was just as unsuccessful, though a couple of reviews on Amazon were helpful.

"Patient One told him her analysis was the most meaningful experience of her life, and that no day passed without her being conscious of benefiting from it. Patient Two told him that she felt quite well, most of the time, and never gave the analysis a thought. "Dr. Green" averred that the successful analysand, in that case, simply had to have been Patient Two. Because she was the more well of the two."

My personal view of Aaron Green is based on an impression from your mini-retelling from Malcolm. My impression is not favorable at all. It communicates not just an indifference to an understanding achieved by the analysand (hadn't used that label before), but a manipulation of the patient's own commonsense judgment. "Trust only me, no one else, and not even yourself," is symptomatic of the insidious and self-serving nature of the analyst in that relationship. This is characteristic of cult leaders who maintain a physical and/or psychological control over the behavior of their followers.

Having been in Graduate School in New York City in the 1970s I absorbed some of the vibe of the New York psychoanalytic scene by osmosis. A couple of aspiring therapists among my student colleagues easily and unselfconsciously betrayed their contempt for the field and their prospective clients. "The trick was to make them think they were sick and that they needed you."

@ prasad,

Thanks for taking the time to read and comment. As usual, you disclose that such a topic is not one with which you are greatly familiar. However, you have that knack to see through to the essential elements and pose the right questions.

"What does this mean for the training and credentialing of therapists? To what extent is this teachable? What advantage does the trained therapist have over the wise old woman with a good memory?"

Lou Breger or another therapist would be in a better position to answer your question. I have had a fair amount of counseling in my work history, and a limited experience with psychotherapy. So, from my own experience one can be trained to be a decent therapist, or to do a decent job at counseling, all things being equal. In my career as a psychologist with IBM Corporation I had the good fortune to do educational, vocational, and adjustment counseling under the supervision of two APA Diplomates in Psychology. I never had that innate sense of reading other people. I always envied those who did. When I had a good history, a thorough intake interview, feedback from my supervisors, and various test results I did a very decent job.

At one point I held a management position in general and technical education for one of the semiconductor development and manufacturing divisions. I wanted to keep my hand in counseling/therapy so I had a small psychotherapy practice on my own. I came to realize that I did not have the emotional strength to deal with very difficult and complex problems for individuals and couples. What I dealt with in IBM among employees and managers was a cake walk by comparison. Also, I came to appreciate what was required of those who wanted to make a difference as a psychotherapist.

We can all profit from a friend, wise old woman, a good parent who listens and can give us advice and encouragement. Sometimes a bit of loving chastisement or a stern admonition to "Snap out of it," can be what we need. If your life is ruled by fear, great insecurity, disabling anxieties, suicidal thoughts, self-destructive behaviors, a succession of failed relationships, depression, emotional instability, somatic symptoms, etc., then you need a wise old women with lots of skills and training.

MORE IN THE NEXT COMMENT.

@ prasad: continued...

"In particular I am trying to understand this: "The supervision of cases, with one exception, was mainly a waste of time. The supervisors seemed bored and just applied standard formulas." Especially since clinically speaking the results don't seem to show strong impact of theory and very strong impact of personal and relationship factors (which sounds intuitively right..), I would have thought that the 'practical' aspect would be -more- valuable. Does this point to a defect in current training methods?"

We need some comic relief, and one that makes a valid point. Here's an old psychotherapist joke.

A newly minted PhD clinical psychologist joins the staff of a world famous psychotherapist. He has high hopes to be able to study and do practice under the supervision of this master practitioner. The aspiring therapist sees clients in his office, eight hours a day, five days a week. At the end of each day he is tired and emotionally spent. At the end of his first week he comes out of his office completely spent, and in need of a recuperative weekend. Each day he observed the master therapist emerge from his office just as fresh and energetic as when he started the day. That Friday at the end of work, the young clinician asked, pleadingly, of his mentor, "How can you look so calm and undisturbed after a whole week of listening to all the problems of your clients?" The master looked at him, smiled, and spoke. "Who listens?"

Yes, the practical aspect, under supervision, should be one of the most valuable experiences for the training of a psychotherapist. But, when the elder teacher gives a pat diagnosis that is a page from the dogma of a particular school or club of therapy, it makes you wonder if anyone is listening - or even cares to listen. Would you tolerate something like this in your own field of study and practice? Of course not, because no one could get away with it for very long.

A therapist friend in training presented a case to the supervising therapist. The immediate comment from the supervisor was something like, "A borderline personality, with oral fixations, who has not resolved his Oedipal complex." My friend who had not been indoctrinated with inflexible dogma said, "Maybe what we have here is simply a person who was terribly traumatized in childhood, and is now trying to deal with alcohol and drug addiction." My friend's observations were dismissed. This is what Breger was talking about as a waste of time. My friend finished the required hours of supervision and then found other teaching therapists who were from planet Earth.

We will hear more from Breger about his own training and learning from his experiences over a long career as a psychotherapist.

In my view, only people who have read Freud are welcome to hold him in contempt. Coming to conclusions about Freud on the basis of his worst exponents -- or his most vicious detractors who have not read him -- avails nothing. He was a towering genius who opened the door. What bothers me about many of his detractors is that they are simply not worthy to take the measure of the man. Dismissing Freud wholesale because of some aspect of him you don't like is as stupid as boycotting Brahms because you don't admire the German Requiem. If you want to read some highly intelligent people on the subject of why Freud was wrong, there are a handful and they are worth reading -- names furnished on request.

I don't like "Aaron Green" either, nor did I 32 years ago when that article appeared. But at the time, orthodoxy was a refuge for a certain type of analyst. It looks more like a foxhole now. But ask Oliver Sacks -- he's been seeing the same orthodox Freudian for more than 40 years. We'll never know if the way he lives -- as a celibate with many associates but no intimates, as a person whose work consumes him -- is a triumph over misery and terror, or a retreat to a bolt hole orchestrated by the wrong doctor. The trouble with any long term therapy is that it becomes its own business, and the longer it lasts the less likely the patient can do without it. Or even wants to do without it. Because there is no other relationship in life that can literally be all about the patient. Thus many lengthy therapies unfit the patient for the
sort of life he/she once might have desired to live, and may even have sought treatment in order to live.

Analytic therapies are guiltier than most. I disagree that Analysis and analysts posit the patient is too sick to be on the loose -- all they have to do is provide an emotionally richer life than the patient has any other way to get. They are for that reason tremendously attractive and powerful tools for making "lifers" of Narcissists, to whom no relationship that doen't center on themselves is adequate. All across the mental health services delivery system, but in analysis especially, you see the illness the patient ostensibly seeks delivery from delivered right back to him. "Trapped in the mirror," as the saying goes. All this without the well-intentioned doctor meaning it, of course.

But please don't blame Freud -- he thought analysis should take a few very intense months. If you read one of his most famous case histories, "The Wolf Man," you will learn about the lengthiest treatment he ever conducted. When Freud died, Sergei Pavlovitch, the Wolf Man, was a pensioner who then signed on with Dr. Ruth Mack Brunswick as his analyst for the duration. But -- the details of the case will convince you that Sergei Pavlovitch needed every session he ever had.

@ Elatia,

As usual, you give us informed views and much food for thought. I hope you will follow the case stories when I do Parts 2 and 3. Of course, I can only give brief coverage to a few of the cases in Breger's book. The story about Elizabeth is a good one. What she experienced with other therapists before Breger is what I have heard from a good number of people with recent dealings with therapists. The therapists are quick out of the gate with a diagnostic label [Borderline Personality Disorder seems to be a popular favorite,] and making the client feel like they are under a microscope.

As I talked to more and more people who have been in therapy in the past few years there appear to be therapists who do not know how to manage a client in their sessions. For example, the therapist was great at getting the client to open up, recall, and discuss very difficult and painful experiences from childhood. The psychologist had no idea about titrating the experience during the session and 'cooling down' the client before the end of the session. The closing was usually abrupt with an encouraging, "You are doing great, and we will pick up at our next session." The client, an alcoholic who was trying to stay sober, had to resort to drinking to subdue her emotional state following each therapy session.

Speaking of Freud, Lou Breger asked me early this year if I would join him in doing a discussion or article on the movie, "A Dangerous Method," which was about the relationship of Freud and Carl Jung, and Jung's relationship with Sabina Spielrein, his patient, student, and mistress. For the benefit of other readers, Breger joined me in my third article on Freud at 3QuarksDaily.

You can find the third article here [with links to the first two articles]: http://www.3quarksdaily.com/3quarksdaily/2010/05/psychological-science-sigmund-freud-a-dream-of-undying-fame.html

Anyway, I got around to watching "A Dangerous Method" but thought the movie making, writing, and acting were not that good. Besides, I am not a scholar of Freud and Breger is. What I was more interested in was his new book. I liked it a lot. I am not the best person to do a review of the book, or any book on psychotherapy, but I bring a perspective as a consumer and observer of psychotherapy. The interview with the author seemed like a good way to focus on substantive content rather than broad praises or pans in a short review.

Also, for the benefit of readers, I wrote a two-part non-fiction piece on a predator psychiatrist.

Part 1 can be found here: http://www.3quarksdaily.com/3quarksdaily/2009/04/my-life-as-a-crime-fighter-the-case-of-the-predator-psychiatrist.html

Part 2 can be found here: http://www.3quarksdaily.com/3quarksdaily/2009/05/my-life-as-a-crime-fighter-the-case-of-the-predator-psychiatrist-part-2.html

Excellent post. Prior to beginning the book, I had read a number of promising reviews, as well as heard positive feedback from colleagues. Thanks for sharing such a lovely interview. Perhaps the most interesting aspect of Costa's analysis seems to be the feedback gathered from patients who did not have a positive experience with psychotherapy. While I see the usefulness of the practice, I too have witnessed a number of individuals in long-term therapy sessions that seem to have mixed feelings about the outcome. Certainly everyone could use a healthy dose of reflection and guided psycho-analysis, but I'm concerned that in many instances such sessions may digress into self-wallowing psychological expeditions. Nevertheless, the book is fascinating and fosters an ongoing dialogue that I'm certain may prove useful for further research. Again, thanks for sharing.

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