Becoming a psychiatrist: Harvard residency notes

Back in 1991-1994, I attended my psychiatry residency at McLean Hospital, the preeminent training program in the Harvard system at the time. I took extensive notes in lectures and have kept and reviewed them over the past few decades. In this column, I plan to gradually transcribe some of those notes, metabolized now after 25 years of practice and experience, and share them with PL readers. Occasionally I'll comment based on my own views now if relevant, but mostly I'll let the notes speak for themselves. For completeness, I'll include the name of those who taught me, some of whom are now deceased, but I do so with the disclaimer that they have not reviewed or examined this material. I believe what is recorded is a faithful transcript of what was said, but if anyone disagrees with any attribution, it will be removed. Nassir Ghaemi

Life and works of William James

Lectures by Eugene Taylor 10/17/1991 and 12/10/1991

Instead of the pejorative connotation of the term "unconscious," just realize that there are alternative states of consciousness, an array of realities.

William James held that eccentric geniuses are considered insane because the worst and the best come through the same channels. They are the ones that open the doors and say: Now it is humanly possible!

James once said: Our knowledge a drop, our ignorance a sea.

James held a naturalistic theism: Beliefs have effects. We can't measure beliefs, but we can measure their effects.

The basic ideas of William James' Varieties of Religious Experience was that we can't prove God's existence, but we must account for his existence.

Before James, the Germans established the field of psychology based on data. James made it a person-based psychology.

Unlike James, Charles S. Peirce considered pragmatism a rule of logic, not a test of belief.

Though James went to chapel every day, he believed in the secularization of the religious impulse.

He upheld pluralism against the monism of science and religion.

Notes on schizophrenia concepts 12/17/1991

Besides Kraepelin, others in the psychoanalytic tradition evolved different concepts of schizophrenia.

Beginning with Freud, he describes the origin of psychosis in the Schreber case as unconscious emotional conflict followed by withdrawal from reality.

Bleuler picked up on Freud, and differed from Kraepelin in three respects: 1. the key characteristic of schizophrenia was disharmony of psychic functions; 2. psychotic symptoms reflected unconscious emotional conflicts; 3. psychotic symptoms could occur in non-ill persons, and what made those symptoms schizophrenic was their severity, not just their duration.

Harry Stack Sullivan later viewed anxiety as the unconscious emotional cause of psychosis, as well as of all neurosis too. He identified three self-states based on anxiety; 1. Good me (low anxiety); 2. Bad me (high anxiety); 3. Not me (intolerable anxiety). The not-me experience based on severe intolerable anxiety is the basis of psychosis.

Sullivan called schizophrenics the loneliest of the lonely.

Seminar on object relations

A lecture by John Maltsberger, 1/10/1992

The self is the totality of the individual.

The inner world is a stage, consisting of fantasy, dreams, and perceptions; behind it is the internal world of the theater machinery, consisting of self and object representations.

The self is represented as an object in dreams and fiction and myths. Half of people do not have self-representations in their dreams. The dream is a camera, taking pictures of one's inner world.

Thoughts, epigrams, observations, and notes from reading and supervision

Fall 1991

Joseph Shays in supervision: If you fear it, predict it. With adolescents, statements are questions.

Robert Frost: Home is where, when you go, they have to take you.

When the patient says, "Why should I come to therapy every week?", you should reply: "Because you deserve it."

A patient: I think I'm dead because I feel nothing. I just am. The paradox is that there's nothing to do, and yet I want to do nothing.

Richard Schwartz: Depression and euthymia are differentially realistic; they are realistic about different things.

Walker Shields: The depressive position is a working position. It's a challenge, a spur to action, a signal that something is wrong. In illness, we try to ignore that signal, and depressive mood becomes transformed into mania, melancholia, or psychosis. The core element of all psychopathology is depression.

There is truth in depression, but true depression is an escape from that truth. Just like mania is another escape from it. There is always a sense of unhappiness with us, often just below the surface, which needs to exist in order to remind us of the trust. Otherwise we would be the "normal" character, something with thinks only in terms of things but which has no meaning in its life. The "normal" character is unable to form relationships because it isn't real; it's a show.

Henry Thoreau: To be a philosopher is not merely to have subtle thoughts, nor even to found a school, but so to love wisdom as to live according to its dictates, a life of simplicity, independence, magnanimity, and trust. It is to solve some of the problems of life, not only theoretically, but practically.

The nature of psychotherapeutic work - part II

A lecture by Leston Havens MD, 12/7/1991

When you first meet a patient, figure out what it is that you admire about them. Otherwise, you cannot encourage them.

We shouldn't want everyone to get what they want.

When you get a feeling for the whole person suppressed, you get a feeling for what they deserve a chance to do.

Should you go and tell your mother? Mothers do not change.

Teaching psychiatry in a medical school is like being a missionary in Borneo.

When we talk, what should we talk about? We talk too much about the patients. When patients are ashamed and shy, it's often better to talk about yourself. They can find out then if they can trust us.

Patients should not trust us. Those patients do best who do not trust us and take a skeptical attitude. I do not want people to trust me. I only trust someone I know well.

Erikson wrote about the tension between trust and distrust, not that you're supposed to trust someone.

How paranoid should you be? Is it wrong to be paranoid, or wrong not to be paranoid?

Harry Caesar Solomon, the chief of the Boston Psychopathic Hospital and full professor at Harvard, used to say, as we walked around in the asylum: "I'm the most paranoid man in this building." We knew what he meant, and we therefore felt safe. He would protect us residents and staff from other administrators and bosses.

The nature of psychotherapeutic work - part I

A lecture by Leston Havens MD, 12/7/1991

Freud really wasn't a therapist. Psychoanalysis thought it could get the right explanation and give it to the patient. But it's not so simple. We penetrate to possibilities but rarely facts. Trauma was a fantasy, then a fact, now a fantasy again.

We're all worried about each other, and about ourselves.

In our therapeutic impotence, Freud brought us a grandeur. Our task today is much humbler, like being an engineer as opposed to a physicist:

Our goal is just to know how we feel.

Seeking explanations for our feelings sends us in the wrong direction. When you seek what's wrong with a patient, you frighten the patient, and yourself. The smallest finding can be blown up out of proportion. We psychiatrists are the only profession that uses adjectives - neurotic, borderline - to diagnose.

Most people are mostly well. Even a dying patient is mostly healthy.

Our minds are not capable of doing this work. You exhaust yourself if each time you see the patient, you try to figure things out. Relax. Freud's evenly hovering attention was good advice. Take no notes, never formulate the case, allow yourself to be surprised. What can we do when aren't primarily figuring things out?

I recommend the maxims of Marcel Proust: The novelist's first invention, he said, was to stand somewhere, to have a different perspective. What the first novelist invented was fallacy. The 1st problem is to make the reader keep reading. What attaches to the human being is not the human being, but the image we form of him (the transference). You suppress the rest of the person; you don't want to know that. I don't want to know that Marilyn Monroe also did the dishes. You create an image, and you keep the whole person out of it.

It's like falling in love: a case of image collusion. Then you get married, and the whole persons get to like each other, because if you like yourself, your humanness, your recognize and like it in another person.

So, in a novel, somewhere around page 1400, you begin to like the whole person.

In psychotherapy, the initial interest is in the image: the doctor; the borderline; the diagnostic concept relates us to the patient. Then the whole person comes back eventually. When the psychiatrists opens us up, like the surgeon, he finds all the usual suspects. The combinations may differ, but the contents are the same.

The whole person always needs some help; he can't do certain things. We need to make movements to help that person along. That's the work of therapy.

How do you give someone courage?

The bodily movement is encouragement: a giving of courage.

That's why the resident's four tasks in training are:

  1. Help someone mourn a loss.

  2. Leave people alone.

  3. Hang up the phone.

  4. Encourage people.

Ned Cassem, 1/5/1993

Five laws for the treatment of pain:

1. If what you’re doing is working, keep doing it.

2. If what you’re doing is not working, stop doing it.

3. If you don’t know what you’re doing, do nothing.

4. Never call a surgeon.

5. ? Never call a psychiatrist.

Walker Shields MD, 9/27/91

Psychotherapy supervision

Freud’s conception of sublimation involved the integration of affect into the self, allowing one to satisfy and utilize one’s drives. The manic person runs away from his affect by organized activity. He is unable to realize the importance of being with affect, of acknowledging despair. The depressed person recognizes depression but is unable to utilize it as an experience of the self: depression becomes an overwhelming conception. The schizophrenic person has a mania of thought -thoughts are all disorder, excessive, separated from each other. The opposite of mania is meditation, the removal of all thought.

Elvin Semrad’s view, which I share, is that there is always a part of the self that can recognize problems, and it can always be addressed, and the task of therapy is to strengthen that part of the self. In Winnicott’s terms, there is a false Self, one’s external characteristics, which is necessary for existence. Beneath it is the true self, You, which cannot be expressed, and which is developed in therapy. But not all of that private You should be expressed; part of it can be expressed at certain times.

9/27/91, Douglas Jacobs MD

Risk management

The most important part of documentation is to record the reasoning behind decisions.

You cannot prevent suicide; you can only intervene.

Statistics: 50% of depressed persons have SI. 30% make suicide attempts. 10% of those who make attempts eventually commit suicide. 60% of suicides occur on the first attempt.

The critical element for suicide is not so much the symptom (e.g., depression), but where the person is in their illness.

Differentiate between depression and despair.

On admission and discharge write: The patient was examined for the presence of suicidal ideation, and it was not found.

9/27/91, John Maltsberger MD

On psychopathology

You should always read a novel and a biography at the same time.

A hallucination is a dream while awake.

St. Dymphna was the patron of mental disease.

9/26/91, John Gunderson MD

On beginning psychotherapy

When you begin psychotherapy with someone, identify roles and goals: Identify your role and the patient's role, and your goals and the patient's goals. And the common goal. There should be clear and explicit agreement on purpose.

The foundation of the therapeutic alliance rests on three things:

1. Mutual liking: an attachment between you and the patient

2. Clear agreement on roles and goals

3. Working together on issues in the patient's life, separate from the therapist-patient relationship