I am interrupting my postings on neurobiology to turn to an issue that has both sentimental and practical implications for me: the virtues and shortcomings of psychiatry a few decades back, in the era when to prescribe medication was to expose a failure of (the doctor's own) imagination.
The stimulus for this line of thought is a seminar I attended, at the recent psychiatric meetings, on the clinical work of Elvin Semrad. I expect to discuss Semrad’s approach in two separate postings and then – with interruptions for breaking news – to consider more broadly the state of the evidence for psychotherapy in the treatment of mental illness.
For over twenty years, from the 1950’s to the mid-1970s, Semrad was Clinical Director of the most influential psychiatric training program in this country, at the Massachusetts Mental Health Center. Back then, the noblest traineeships set beginners to doing therapy on psychoanalytic lines with hospitalized patients who experienced hallucinations and delusions. The idea was that psychosis exposed violent, sexual fantasies; after learning to observe and tolerate these thoughts and feelings in extreme form, young doctors might be ready to approach the subtler working of the unconscious neurotic mind.
My own training came toward the end of this era. (Semrad died the year I left medical school, in 1976.) As a student, I saw Semrad conduct his famous interviews, in which, before a small audience of admiring trainees and staff, he might, through the force of his presence and kindly understanding, catapult a psychotic patient into an interval of lucidity.
At this year’s psychiatric meetings, as in the prior two years, Semrad’s students and his students’ students presented a workshop on his technique, based on a film recording, one of a handful that survive, of Semrad conducting a didactic interview.
The patient in this case was a likeable young woman with a deadpan style and a flat Boston accent. She had evidently been on the ward for weeks. Semrad seemed to believe that her mental illness arose from her relationship to her abusive father. Taking that abuse as a given (what occurred was not discussed), Semrad insisted to the woman that her failure to progress in life arose from difficulty in acknowledging the love that attached her to this same father. The session was not one of Semrad's best; after the patient left, Semrad more or less apologized for having badgered her with preconceived formulations. But you could see how in his person Semrad embodied a certain ideal, of the analyst as homespun philosopher.
Autre temps, autre moeurs. Today, any teaching session with a similar patient would likely take a different tack, encouraging the patient to feel the full extent of her hurt or rage in the face of the abuse or to come into touch with the vulnerability and need that the abuse preyed on. Now, the emphasis is on harm to development (what is called “deficit”) that childhood trauma leaves in its wake. Then, cure came through acknowledgment of the patient’s own desires even in abusive settings; the focus was on a tension between differing drives, or between drives and values (or “conflict”). Today’s ideal analyst would be less confident in his or her formulations and more genuinely deferential to the patient.
Semrad’s approach, along with his followers’ veneration of him, has come under criticism, notably in Fall of an Icon: Psychoanalysis and Academic Psychiatry, by Joel Paris. As will become apparent in a later posting, I never entirely bought into the Semrad magic. I questioned it in my first book Moments of Engagement; in my recent biography of Freud I ask about the harm done by attributing shameful desire to the abused.