Learning to Do Psychotherapy With Psychotic Patients
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. De-compensation 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 defences.
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 was an element of choice involved in having psychotic episodes. He believed that the emotional connection between patient and therapist could help mitigate the need for the patient’s use of psychotic defences:
It’s all very conscious—this regressive behaviour—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 re-compensate (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 re-compensate 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 defences 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 non-psychotic 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.
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Page Two - http://www.psychiatrictimes.com/disp...8?pageNumber=2
Thanks for posting this.
If the mentally ill were treated more like patients and less like criminals then I'm sure there would be a lot more recoveries.
I'm sure that there would be too schiz01; & if we weren't treated like it was all our fault; & blamed for everything; & assumed to be some kind of sub-human.