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

February 5, 2010
Stephanie Adler, PhD , Max Day, MD
Volume 27, Issue 2

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 men-tally ill patients could benefit from long-term psychoanalytically oriented psychotherapy.

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.”

Doing something with the person to help master a problem and doing something to the person (like treating him or her with medications) don’t have to be mutually exclusive if one goes with the first approach. Medications may be part of what some patients need, but Dr Semrad rarely felt that drugs were necessary or usually used in this fashion. On the other hand, he thought that simply medicating someone to mask psychotic symptoms without helping him or her to move forward was likely to doom him to becoming a chronic patient.

The idea that by talking and encouraging patients to experience feelings we could help such seriously impaired people seemed both incredibly exciting and humane but, at the same time, overwhelming. Trainees were stuck between those supervisors who said, “medicate these patients, get them out of the hospital as quickly as possible,” and “don’t talk to them about emotionally loaded subjects-they can’t stand that and will regress,” and Elvin Semrad who urged us (within the context of establishing an empathic relationship with the patient) to go right to those emotionally loaded subjects. He said, “In order for it to heal, it has to hurt like hell!”

The following quote illustrates Dr Semrad’s focus on the underlying emotional struggle that can result in psychosis:

Psychosis is a detour in development in which the patient is not functional. Something happens which is intolerable. Decompensation is due to a loss or a failure. You need to diagnose the loss and help the person mourn. In the failure situation, you diagnose the discrepancy between the person’s expectations of himself and his achievements. You help him bridge the gap or mourn the expectations. You are aiding and abetting the integration of actual life experiences that have been avoided by the regressive defenses.

Clearly, his attitude was that in order to help the patient, one has to understand the nature of the regres-sion and not just focus on the clinical presentation.

Dr Semrad had the conviction that there is an element of choice in the presentation of psychotic behavior. He believed that the emotional connection between patient and therapist could help mitigate the need for the patient’s use of psychotic defenses:

It’s all very conscious-this regressive behavior-as if it has a specific design, a specific purpose, and if one is lucky enough to make the impression that you know what they’re talking about, they will talk. Emotionally touching the patients-what matters to people is what they are actually feeling, irrespective of content, irrespective of the issue. But what matters most is the feeling, the reverberation in that person, in his total being.

Elvin Semrad believed that a patient needs the therapist’s presence to help him get back into life’s circulation and that a psychotic patient could and did recompensate (ie, was able to return to the previous level of psychological functioning) on the basis of a therapeutic relationship. Dr Semrad convinced trainees of the power of a “holding relationship” to at least temporarily obviate the need for psychosis, as we observed him interview patients. Watching a floridly psychotic patient recompensate during a teaching conference and carry on a perfectly normal conversation about something important that had happened in that person’s life provided a dramatic example of the potential power of the therapeutic relationship.

The difference between a patient who regressed and one who was able to bear intolerable feelings and move forward lay in what Dr Semrad called “Giving with one hand and taking away with the other.” The taking was taking away the defenses and talking directly about what hurt. The giving was the empathy in the therapeutic relationship. With these powerful demonstrations, Dr Semrad showed us that during empathic contact with another person, a patient could begin to experience feelings that he could not tolerate alone.

Dr Semrad taught us that it is the empathic, often loving relationship between patient and therapist that allows patients to become nonpsychotic and have the psychic strength to tackle their individual life struggles. And that “relationships can provide the only true healing there is from human pain, and that is love.” The questions of what love and empathy meant in the context of psychotherapy often became anguished topics of discussion in our weekly supervision sessions.

Being empathic is not, as is often thought, being nice or avoiding what is painful. Elvin Semrad would say, “It’s all so simple if you can think simply . . . the simplicity of life . . . and use your experience to get some appreciation of what this poor person, overwhelmed by it, is going through.” Some of us thought of empathy in Rogerian terms, repeating back a patient’s words. But we wondered, for example, was it being empathic to agree with a patient who felt hopeless? Dr Semrad’s response was:

You don’t reassure, you don’t encourage, you don’t agree with her that it’s hopeless. That’s a diagnosis. Going after the specificity of the reality events is an indication that you’re not hopeless, that you’re willing to be there with her. As a matter of fact, you’re insisting to be there with her. The kind of question that gets her attention comes closest to hitting the nail on the head in terms of what she did to create a situation which she now wishes she had not done, and it carries with it the empathic effort on your part to get into the same shoes that she’s standing in, to indicate to her that you have some appreciation of what she’s really up against, not only as it really is, but as she really feels it and lives it.

He stressed the importance of using our own experiences to get a sense of what our patients might be feeling and thereby to communicate our understanding in a more emotionally connected way.

And what about love? One of the most difficult feelings that beginning therapists have to bear is the love our patients feel for us. Many of us had anxieties regarding our patients’ expressions of strong love for us. Even more difficult to acknowledge and bear were the intense feelings that our patients sometimes aroused in us. Dr Semrad helped us see that it is, in part, the love that we as therapists can feel for our patients, our acceptance of them as they are, that enables them to stick to the painful process of facing previously unbearable feelings.

The bottom line is that every person, psychotic or not, has to struggle with the same developmental issues and it is built into us to have the capacities, more or less, to do this. As Dr Semrad would say, “We’re all messes, some are just bigger messes than others.” Some people are either fortunate enough to have good genes or to grow up in an environment that allows them to carry on relatively smoothly. Others may inherit genes that predispose them to illnesses, physical or emotional, that affect the ways they respond to life experiences and traumas. Dr Semrad taught us that through an empathic psychoanalytical approach, even the most disturbed individuals can become psychologically strong enough to bear their feelings without the need to regress into psychosis. Finally, if they are no longer psychotic, then within the context of the therapeutic relationship, it’s time to get back out there and deal with life.