Peter D Kramer

In Practice

Psychoanalytic Wisdom: The Mixed Blessings of the Good Old Days

Psychotherapy for psychotic patients: The good old days and their shortcomings

Posted May 20, 2008

Does psychotherapy work for psychotic patients? And does practicing psychotherapy with psychotic patients work for psychiatric trainees?

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.

But I have always loved the ambition of the project, treating psychosis through encouraging growth in self-knowledge, and I loved my teachers. One of them, Max Day, used the APA workshop as an opportunity to reminisce about his own development as an analyst and Semrad’s role in that process. I re-introduced myself to Day — he had taught the rudiments of group therapy to generations of medical students and residents — but he did not remember me. I remember him, as one of a series of wise elders who were generous with their time and affection, welcoming neophytes into the fold.

My short answer to the question about psychotherapy and psychosis is that the old approach, offering the gravely mentally ill endless hours of attention, did a great deal of good. My reading of the research literature is that it agrees. Psychotherapy leads to improvement even in schizophrenia; and the same held in the ’sixties and ’seventies. (That said, the extent of change is limited; it's a matter of "better but not well.") The question is what that result, if it is accurate, means, in the face of the extensive changes in our theories and methods. Why should treatments grounded in shaky premises have worked?

As for the training, it contained invaluable lessons about one’s own (I mean my own) shortcomings and patients’ humanity. A psychiatrist who is also a photographer, Allen Palmer, has assembled an on-line gallery of portraits of Boston-based psychoanalysts who were seventy-five or older at the time of the sitting. Titled “The Face of Experience,” it is posted on the website of the Boston Psychoanalytic Society and Institute. The image of Max Day, above, is from that collection. I was pleased to discover that I had had extensive professional contact with a third of these wise men and women. (I spoke to two this month. I count a third, Bob Eisendrath [below], as a good friend.) You have only to look at the photographs to feel better.

Speaking of feeling better in Boston (and moving from the sublime to the sometimes scatological), in the wake of Jon Lester’s no-hitter, today would be a good day to make acquaintance with one of my favorite Websites, The Soxaholix.

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