Breuer & Freud’s pioneering concept of the psychotherapeutic alliance

Psychotherapy in practice differs from many other areas of medicine, particularly with regard to the patient-therapist relationship.

It has been observed that Breuer’s work documented by Freud paved the way for the less authoritarian attitude of the doctor who knows everything and opened the door to a different kind of therapeutic relationship (Bocian & Staemmler, 2013; Grubrich-Simitis, 1997). Freud wrote in the early days of psychoanalysis of his revered mentor, Jean-Martin Charcot, whose research on Hysteria and its treatment method of hypnosis greatly influenced Freud as a young practitioner, “Charcot, however, did not follow this path towards an explanation of hysteria […].” (Freud & Breuer, 1893). The work of Charcot, notwithstanding, greatly influenced Freud’s transition from neurology to psychopathology (Grubrich-Simitis, 1997, p. 12- 13). Freud acknowledges the contribution of Charcot’s work towards bringing to scientific importance the study of Hysteria, that in having successfully inducing hysterical paralyses in hypnotized patients, Charcot proved that the hysterical paralyses were “the result of ideas which had dominated the patient’s brain at moments of a special disposition” (ibid. p. 13).

Freud’s own studies on Hysteria with Breuer, however, demonstrated the importance of a change in the approach towards the therapeutic relationship in the development of the understanding and healing of a psychological condition. When Freud met Breuer, who became his friend and mentor, Breuer was already in his fifties and was a reputed medical practitioner and experimental physiologist. Breuer had already worked with Bertha Pappenheim, better known as Anna O., in 1880 to 1882, some 3 years before Freud went to study with Charcot. Studies of Hysteria (Breuer & Freud, 1955) were written in 1895, 15 years after the said therapy, and the client by then was known to have been cured of her symptoms. Breuer had, together with his patient— who suffered severe hysterical symptoms and who is often regarded as “highly gifted, and the true discoverer of therapeutic reconstruction”— uncovered the dynamics of mental pathology. Unlike the Charcot school, Breuer used hypnosis “not for the purposes of crude behavioural suggestion but as a route to the memories of pathogenic traumatic experiences that were not accessible to the patient in the waking state” (ibid. p. 21).

Relying on the doctor to carry out treatment while the client remains the passive recipient with the goal of attaining catharsis through hypnotic suggestions, Freud exerts, may not amount to a cure, but a suggestion of a cure. In the case of Breuer’s work with Ms. Pappenheim – in listening with interest to her narratives—the therapist and client were able to investigate the actual events in the client’s life that precipitated the neurotic outcome; this is more than just the knowledge of the existence of psychic disturbance, as Charcot describes it, that is behind the symptoms and desensitizing through hypnotic suggestion. This step of gaining a clear understanding required much more effort, attention and empathy on the part of the practitioner (Freud & Breuer, 1893). Early expert critiques of the Studies of Hysteria reflected Freud’s sentiment of his own work, “[…] it still strikes me myself as strange that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science. I must console myself with the reflection that the nature of the subject is evidently responsible for this, rather than any preference of my own (Freud & Breuer, 1895)” (Grubrich-Simitis, 1997, p. 19). With this admittance, we are led to the understanding that procuring a cure requires the abandonment of impersonal scientific learning, but an engagement with the client on a personal level that is different from the conventional attitude of that time, whereby treatment is based on empirical proofs (i.e. what is considered “stamp of science”).

[…] it still strikes me myself as strange that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science. I must console myself with the reflection that the nature of the subject is evidently responsible for this, rather than any preference of my own.

Sigmund Freud in Freud & Breuer, 1895

Here we get a glimpse of Freud’s dilemma. He had found a good healing technique, but alas, it did not seem to conform to certain scientific procedures. It is also added that he who “wishes to plumb and describe the mental cannot completely escape the creative writer’s methods of conceiving and describing, however rigorous the will to cool, sober objectivity” (Grubrich-Simitis, 1997, p. 19-20). In many ways, we still find ourselves in a similar situation today, in our discourse on Psychotherapy Science.

That which is more worthwhile to learn from the case of Anna O. is, however, not found in Breuer’s account alone, but that the “psychodrama that took place in Breuer’s treatment, (…), gave Freud raw material for his theories of the Oedipus complex, identification, transference and countertransference, repetition compulsion and acting out (Britton, 2003, p. 8). As if to prove the significance of this first case, Freud (1914) himself reviewed this case 20 years later, pointing out to us to this unique— and often ethically treacherous— aspect of the psychotherapeutic alliance. The word “treachery” is carefully used to emphasize the fact that the danger is insidious and that special attention is necessary to notice and avoid its consequences. In order to investigate a treacherous situation in a relationship, however, we need to understand what lies in it.

References

Bocian, B., & Staemmler, F. M. (2013). Kontakt als erste Wirklichkeit. Zum Verhältnis von Gestalttherapie und Psychoanalyse. EHP-Verlag Andreas Kohlhage.

Breuer, J., & Freud, S. (1955). Fräulein Anna O, Case Histories from Studies on Hysteria. In V. I.-1. In The Standard Edition of the Complete Psychological Works of Sigmund Freud.

Britton, R. (2003). Sex, death, and the superego: Experiences in psychoanalysis. Karnac Books.

Chew-Helbig, N. (2017). The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship. Bachelor Thesis.

Click to access Helbig_2017_Bachelor_Thesis-nh-s-p.pdf

Clarkson, P. (2003). The Therapeutic Relationship. London: Whurr Publishers.

Grubrich-Simitis, I. (1997). Early Freud and late Freud. Reading a new studies on hysteria and Moses and monotheism. (P. Slotkin, Trans.) NY: Routledge.