What Works in Analytic Psychotherapy?

by Louis Breger, Ph.D.

Analytic psychotherapy has changed and developed since the time of Freud, with an increasing emphasis on the therapeutic relationship.  In my recent book, Psychotherapy: Lives Intersecting (Transaction Publishers, 2012), I conducted a survey of a number of former patients — seen over a period spanning five decades — which highlights how the unique relationship between patient and psychotherapist is at the heart of successful treatment.

From Freud’s time, and for many years thereafter, psychoanalysis and psychoanalytic psychotherapy have been pictured with a patient lying on a couch, with the analyst — usually a bearded man — sitting behind taking notes.  In the public mind, being “analyzed” means having your personality and actions interpreted — being told what your motives and acts “really” mean — by a wise doctor who knows your unconscious better than you do.

In many fields, when ideas and methods change, such new developments percolate down to the general population.  But this has happened very little with psychoanalytic psychotherapy.  It is a shame, for the old version of psychoanalysis is dying out; it is confined to an increasingly small number of aging analysts.  In its place is an interrelated set of new approaches that go by different names: psychodynamic psychotherapy, self-psychology (associated with Heinz Kohut and his followers), the relational approach (Philip Bromberg’s work is a fine example), intersubjectivity (see Stolorow, Brandchaft and Atwood), the interpersonal school (a later development of the work of the Neo-Freudian Harry Stack Sullivan), and others.  While there are differences between these various approaches, the similarities far out-weigh them.  In addition to these contemporary versions of analytic psychotherapy, a great deal of research supports these modern approaches (see Shedler, 2010, for a summary).

The general reader, as well as anyone seeking therapy for psychological difficulties — anxiety, depression, the effects of trauma, relationship problems, addictions, eating disorders, and the like — should be aware that there are new forms of analytic therapy that can be extremely helpful.  Let me add just one caveat here.  There has been a long tradition for the field to be divided into “schools” or “movements” associated with a revered leader.  Thus, there are “Freudians,” “Jungians,” “Adlerians,” “Kleinians,” and, “Kohutians.”  I think this has been unfortunate, and has few parallels in medicine or other scientific fields.  What I think would have been preferable, and what has been happening more in recent years, is to take the best ideas and methods — those that have been proven helpful both in clinical work and research — from all these schools, and other sources, and use what is effective with each individual patient.

What are the components of contemporary analytic psychotherapy?  Here I will draw on my recent book where an informal survey of more than thirty patients whom I had seen over the last fifty years were asked them to describe, in their own words, what they found most helpful, curative, or therapeutic in our work together, as well as what was not helpful.  Since, for a number of them, the therapy had ended more than twenty years earlier, the study is also a long-term follow-up in which we can see if the gains they made lasted, expanded or regressed.  Such a follow-up is relatively rare in the literature, as is a study in which the outcome is primarily described by the patient rather than the therapist.

As one reviewer of the book put it, “the relationship rules.”  The most striking finding of the survey was that relationship factors were far and away most commonly described as the key ingredients in successful treatment.  Here is a summary list of them:

  1. A therapist who listens closely in a non-judgmental manner.
  2. Empathy: attempting to see things from the patient’s point of view.
  3. Catharsis: the open expression of a range of emotions.
  4. Friendliness, as contrasted to the traditional psychoanalytic stance of neutrality and abstinence.
  5. Flexibility with fees.
  6. Interpretations that were individually crafted to each unique person, as opposed to those taken from one theory or another.
  7. Humor.
  8. Admitting and repairing mistakes.
  9. Self-disclosure.

When I acted in accord with these ideas, the patients reported lasting changes in their conceptions of themselves — such as increased self-esteem and self-acceptance; changes in their patterns of relating to others; and marked reductions in anxiety, depression and other painful emotional states.  These changes lasted and, in some cases, expanded over the years.  I will cite just a few examples here.

A depressed woman whom I saw for a number of years, said, “I no longer hated myself. I only got to like myself because I finally felt that you liked me.”  Another woman said, “Throughout my therapy experience with you, I always felt like a person in a relationship, rather than a specimen to be understood by you, and then explained back to me.  You treated my own assessments and insights with respect.  My sense was that you were looking to me to tell you about myself, and that we would work together to figure things out.”  Others spoke of the liberating effect of “blowing off steam”: being able to fully express emotions that had been pent up for years.

Humor was an important element in a number of cases and I will cite just one example here.  An office mate had put up some photographs – close-ups of purple orchids – in the hall between the waiting room and my office.  I picked up my patient, a brilliant writer who I had been seeing for several years, and he strode past the photos in his usual determined way, not seeming to even glance at them.  He came in, sat down, and said, “Must I talk about those vaginas, or can I say whatever I want?”  We both cracked up laughing and I felt no need to explore the meaning of his remark which was – besides being very funny – a complex commentary on our therapy.  It alluded to the way I – like the good Freudian he knew I wasn’t – had put up the pictures to deliberately push his thoughts toward sex and the question of whether he had to comply with such a manipulation.  Most important, the whole interchange showed how we could play with our relationship in a relaxed and humorous way.

Insight into aspects of themselves that they were not aware of — the hallmark of traditional psychoanalytic approaches — was mentioned as important by a number of patients, but it was typically not as central as the relationship factors discussed above.  As one example, a man I was seeing almost fainted in the delivery room when he witnessed his wife undergo a cesarean section during the birth of their child, a reaction he could not understand until we were able to trace it back to a severe car accident he was involved in, where there was a great deal of blood, at the age of nine.  All the old fear and pain of the accident was set loose by the sight of his wife’s blood.

It is an irony that, while all the contemporary approaches stress the relationship, most case studies are still written by the therapist and the patient is almost never consulted, or even heard from.  In addition, patient’s lives, symptoms and problems are typically described in detail while, in traditional psychoanalysis the analyst remains a blank screen.  This is much less true in contemporary approaches where therapists feel free to disclose aspects of their own lives.  This is a complex issue since revealing things about oneself may or may not be helpful.  I try and follow what I call “the new fundamental rule”: you can do all kinds of things in psychotherapy – including revealing aspects of your own life and history – if they are done for the patient’s needs and not your own.  In other words, it is a big mistake to turn things around and try and talk about your troubles: to make the patient into your therapist.  But sometimes sharing aspects of your self is genuinely helpful.  I have found that patients typically don’t want to know much about me early in the therapy but, as time passes, may find such information helpful.  Since I am mainly retired now, I thought it would be in the spirit of the book to include autobiographical material: hence the subtitle, Lives Intersecting.  In this sense the book is truly relational.

I include a chapter that describes my childhood, especially those aspects that led me to become a psychotherapist.  Like so many in our field, I had a depressed mother who also subtly tried to keep me tied to her as her sweet little boy.  It was a struggle to break free of this and become a man in the world and I had several unconscious symptoms that I struggled with well into adulthood.  In addition, I had a failed father, though I did absorb many of his core values, including anti-materialism, identification with the underdog, and a critical stance toward society.  I reacted against his lack of success by driving myself to achieve in at least two careers, by becoming something of a workaholic.

In addition to a chapter describing my childhood, I devote some space to my professional development.  Like many who come from families where there is a good deal of psychological disturbance, I was drawn to Freud’s writings as an undergraduate in an effort to understand all the craziness I grew up with.  This led me to get a Ph.D. in Clinical Psychology with the goal of becoming a therapist, though I also became a professor/teacher and scholar/researcher.  I was early taken with the work of John Bowlby and his ideas about patterns of attachment, separation and loss – work that was relational in its essence – and his ideas have remained central to my thinking.  I did work on the function of dreams, using the REM techniques of monitoring sleep throughout the night, and published in that area.  I also wrote a psychological study of Dostoevsky and a book on psychological development. In the 1970s I underwent full training at a psychoanalytic institute.  This included a training analysis – my first foray into therapy for myself, talk about emotional control! – that was personally very helpful. In the last few years I published a biography of Freud that several leading scholars in the field have called the best one available, and a shorter book on Freud, Breuer and the birth of psychoanalysis.  All of these experiences shaped the kind psychotherapist I became.

The majority of my former patients who responded to my questions had positive experiences that lasted over the years.  Several of those who found their work with me less helpful, or who had predominantly negative experiences, simply did not respond but – lest the book sound too self-congratulatory — I do present several cases where the patients did not like the kind of therapy I did or where my own tendency toward emotional control interfered with my being as helpful as I might have been.  Psychotherapy is, indeed, the intersection of two people, two lives, and the outcome is a function of each unique mixture.  I was able to tailor my way of working to the needs of a variety of patients, was quite successful with a number of them, moderately helpful with others, and not at all able to work with a smaller group.

References:

  • Breger, L. (2012) Psychotherapy: Lives Intersecting. New Brunswick, NJ: Transaction Publishers.
  • Bromberg, P. M. (2011) The Shadow of the Tsunami: And the Growth of the Relational Mind.  New York, NY: Routledge.
  • Kohut, H. (1977) The Restoration of the Self.  New York, NY: International Universities Press.
  • Shedler, J. (2010) ‘The Efficacy of Psychodynamic Psychotherapy’, American Psychologist 65: 98-109.
  • Stolorow, R. D., B. Brandchaft, and G. E. Atwood (2000) Psychoanalytic Treatment: An Intersubjective Approach.  Hillsdale, NJ: Analytic Press.
  • Sullivan, H. S. (1953) The Interpersonal Theory of Psychiatry.  New York and London: W. W. Norton.


Louis Breger (born November 20, 1935) is an American psychologist, psychotherapist and scholar. He is Emeritus Professor of Psychoanalytic Studies at the California Institute of Technology.

Breger was born and grew up in Los Angeles, California. He received his undergraduate education at Cornell University and U.C.L.A., following which he obtained his Ph.D. in Clinical Psychology at The Ohio State University in 1961. He then taught at the University of California, Berkeley, the University of California Medical School in San Francisco, and the University of Oregon.

In 1970 Breger became Professor of Psychoanalytic Studies in the Humanities and Social Sciences Division of the California Institute of Technology. He graduated from the Southern California Psychoanalytic Institute in 1979, where he became a Training and Supervising Analyst and was the recipient of the Franz Alexander Essay Award and the Distinguished Teaching Award. In 1990, he resigned from that institution and, with a group of colleagues, created the Institute of Contemporary Psychoanalysis (ICP) where he was the Founding President from 1990 to 1993. ICP reflected Breger’s commitment to an open, democratic form of education: it is a non-hierarchical training institute, not affiliated with the American Psychoanalytic Association.

He is the father of three grown children and two stepsons, married to Barbara Gale Breger; together, they have 13 grandchildren.

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