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.