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Learning to Do Psychotherapy With Psychotic Patients: In Memory of Elvin Semrad, MD

Learning to Do Psychotherapy With Psychotic Patients: In Memory of Elvin Semrad, MD

Dr Elvin Semrad was a much-loved psychiatrist and psychotherapy supervisor who had a profound influence on hundreds of psychotherapists and psychoanalysts in the Boston area. One of his unique qualities was his ability to connect empathically with even the most psychotic patients. He supervised at Boston State Hospital and then for 4 decades at the Massachusetts Mental Health Center (MMHC) in Boston, where he conveyed his strong conviction that psychotic and other seriously mentally ill patients could benefit from long-term psychoanalytically oriented psychotherapy.

Our wish is to honor Dr Semrad’s memory and to find a way to communicate what was so special about his message and his style of teaching. All quotes come directly from transcripts of weekly supervision sessions at MMHC from July 1975 until Dr Semrad’s death in October 1976.

Elvin Semrad was a teacher and investigator in psychiatry, psychoanalysis, and group therapy. He was born in 1909 and came from a working-class family in Abie, Neb, where his father delivered mail. Dr Semrad never lost the down-to-earth quality of his Nebraskan/Czech background and often used the homespun wisdom of his family elders to illustrate a point he was making. Living through the 1918 flu epidemic deeply touched him. He said that the experiences of death and loss at such an early age were major factors in his becoming first a physician and later a psychiatrist.

Dr Semrad started out by playing the alto saxophone, and with the money he earned, he put himself through college to become a teacher. Teaching turned out to be his lifelong work. He attended medical school in Omaha. In 1935 he came East for psychiatric training, first at the Boston Psychopathic Hospital and later at McLean Hospital.

He always kept the physical side of the human being in mind. Although headed for psychiatry, he was board-certified in psychiatry and neurology. He spent 6 years as clinical director of Boston State Hospital, a facility of 3000 severely ill psychiatric inpatients, where he was the first clinician to institute individual and group therapy.

Next, he became the clinical director at Boston Psychopathic Hospital, later called Massachusetts Mental Health Center (a public psychiatric facility and also a Harvard Medical School psychiatry residency training site). Dr Semrad worked his way up through the Harvard Medical School department of psychiatry to become a professor of psychiatry. He also had teaching appointments at Boston University, the Hartford Retreat, and Simmons College School of Social Work. He became a psychoanalyst and a training analyst, and later he was president of the Boston Psychoanalytic Society.

Dr Semrad gradually developed his theories of psychoses, which he incorporated into the first year of training for psychiatry residents at MMHC. Perhaps the most profound aspect of his teaching occurred while residents watched him interview inpatients during weekly case conferences. With his no-nonsense empathic style, he was able to engage even the most disturbed patients, and for those moments, the patients were able to talk nonpsychotically about the painful events in their lives that had led to their hospitalization.

The climate in the mid-1970s had begun to swing to the view of schizophrenia as a chronic neurological illness, a perspective that called for quick treatment with antipsychotic medications, minimal time spent in the hospital, and supportive therapy. Elvin Semrad represented what seemed to be a more humane approach. He emphasized the ordinary human pain of the people we saw in the hospital who expressed their struggles in the most extraordinary ways. He gave us the strength and encouragement to persist in doing intensive psychotherapy aimed at helping patients “acknowledge, bear, and put into perspective” the feelings associated with the life losses and disappointments that had driven them to have a psychotic episode.

The experience of coming face to face with a person in the grips of acute psychosis can be terrifying. Those with more chronic psychoses often appear less frightening but more off-putting with their bizarre mannerisms. In either situation, most psychotherapy trainees have a natural inclination to distance themselves from their patients. While we can feel sympathy and concern for patients, it is very tempting to regard them as their illnesses, waiting to be diagnosed and cured, rather than as human beings unable to navigate some life situation because of feelings that have become intolerable. More than anything else, Dr Semrad helped us understand that our patients are more similar to us than we like to admit.

Elvin Semrad’s major contributions to the training of psychotherapists were to help us see our patients truly as human beings; to understand their psychopathology as defenses against intolerable feelings of loss or failure; and to teach us that through empathic connections with our patients, we could help them bear these feelings and thereby begin to help them heal. He often told us that “people become psychotic because they are mad, sad, or scared and cannot stand it.” He stressed that rather than getting preoccupied with treating symptoms, we need to help patients feel the feelings that have become unbearable to them and then find ways to solve the same kinds of life dilemmas with which we all struggle. He once said in response to a presentation of a psychotic woman, “There are 2 main approaches: A, do something with the problem, with the person who has the problem and help her master it; or B, stay away from the problem, from the person and do something to her.”


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