by Donald R. Ross, M.D.
[Spring/Summer 1998; Vol. 25 No. 1]
Sheppard Pratt’s Thirty- fourth Annual Scientific Day was held at Sheppard Pratt on March 21, 1998. It was attended by 190 clinicians from the community. The theme of the day was “Psychotherapy with More Disturbed Patients: Strategies for the Twenty-first Century”. This full- day conference featured a number of local and national speakers on a variety of topics having to do with psychotherapy with narcissistic, borderline, and psychotic patients.
Despite the restrictions imposed by managed care and the emphasis on the biomedical model of psychiatry today, it is clear that sophisticated psychotherapy is being done with very disturbed patients. The faculty at this conference included 3 psychoanalysts, a neuroscientist, two psychiatrists who have dedicated their careers to working with institutionalized patients, and a psychiatric resident in training. Listening to the presentations, one got a real sense of excitement. The expanding breadth and depth of knowledge in psychiatry was apparent, and it was invigorating to see efforts at integrating different fields of knowledge (e.g. cognitive science, psychodynamics, and neuroscience research). The unifying force was the wish to be more effective in providing help to sicker patients. New approaches to psychotherapeutic technique and new theoretical constructs were reported. These had been tested by the authors in the crucible of actual work with patients.
Dr. Alicia Guttman, a psychoanalyst and faculty member of the University of Maryland and Sheppard Pratt, discussed the problem of pathological narcissism with two patients in analytic treatment. She used a developmental model to present a very creative synthesis of the approaches of Otto Kernberg and Heinz Kohut that informed her clinical work.
Dr. Richard Munich, medical director of the Menninger Clinic, described his work on psychotherapy with psychotic patients. With the new atypical antipsychotic medications, more patients are in the community and can be reached by psychotherapy if it is intelligently planned and dispensed.
Dr. Salvador Guinjoan, a third year psychiatric resident at Sheppard Pratt, presented his work on the use of metaphor in psychotherapy with “the ambulatory inpatients who are coming to see us in our outpatient consulting rooms and clinics.” By recognizing the patients’ metaphors and staying with them, he was able to work with emotionally charged issues in such a way that the patients could tolerate the work and not regress or flee therapy.
Dr. Miles Quaytman, a senior psychiatrist at Sheppard Pratt and medical director of the Weinberg House, presented his work in understanding the expanding concept of “holding environment.” He shared his experience in the brief intermittent use of the hospital and the quarter way house to provide safety and holding when needed.
Dr. Vassilis Koliatsos, faculty at both Johns Hopkins and Sheppard Pratt and director of the Sheppard Pratt Neuropsychiatry Clinic, discussed the interface of brain research and psychological constructs such as memory, trauma, neglect, and meaningful experience. He discussed the role of the hippocampus in encoding memory, and the effects that corticoid mediated stress response has on this brain structure. It is now clear from neuroscience research that there is constant remodeling of neuronal synaptic structure throughout life, which is responsive to lived experience.
Finally, Dr. Martha Stark, a psychiatrist and educator from Harvard Medical School, discussed her psychotherapeutic work with borderline outpatients. She described her use of “containing statements” to help patients stay safe and in therapy. For example, a chronically suicidal patient might be filled with rage after being disappointed by the therapist. Dr. Stark might say, “You are filled with anger and disappointment that I cannot give you what you feel you need from me. You feel like hurting yourself to stop the pain and get back at me, but we both know that if you are ever to get better, you are going to have to find a way to talk about this and not take another overdose of your medication.” With this type of “interpretation,” she acknowledges the patient’s pain, but brings in reality considerations as well.
Overall, Scientific Day demonstrated that thinking about psychotherapy with more disturbed patients is very much alive in today’s real world. For the interested reader, a more complete summary of this conference can be found in the upcoming issue of Psychiatric Review, published by Sheppard Pratt and edited by John Lion, M.D.
Dr. Ross is the director of the Division of Education and Residency Training at Sheppard Pratt.