Making the Most of Rough Times in Therapy

A beautiful sunrise
Is there any way to learn but the hard way?

My wisest mentor, the legendary professor of psychiatry, Dr. Elvin Semrad, asked/observed: “Is there any way to learn but the hard way?”

During the course of therapy, the occasions when major discomfort develops between the patient and the therapist are the times that, if handled with courage and honesty, present a valuable opportunity for growth.

What matters to my patients is, I believe, my commitment to see it through with them, whatever the issues may be.

When first I meet a patient, the key matter is to find a point of common ground from which we can begin the work. One particular patient presented many critical challenges both through the course of the work and, notably, right from the start.

Emily was a woman in her late twenties who had been thrown out of therapy by her former psychiatrist, whom she had stressed beyond that person’s tolerance for bizarre behavior.

My office consists of two confluent rooms: a spacious consulting room, beyond which opens another large room with bookcases, file cabinets, and a piano. At our first meeting, on entering my office, Emily sat down on the floor facing away from me and behind a chair, and did not speak. At one point, she stood up and walked into the far room and to the right, out of my field of vision and in the vicinity of the file cabinets. The uncomfortable thought came to me that she might be looking at patients’ records.

I called out to her: “Emily, are you looking in the files?”

Emily spoke for the first time, and in fury: “How dare you accuse me of looking in your files?”

I said, and not gently: “So, I was paranoid. You, of all people, can’t understand and forgive that?”

And so we found our common ground.

When we first met, in the spring of 1979, Emily was physically healthy, psychotic, and did not want to live. When we said good-bye late in the summer of 1996, she was mentally clear, coping with cancer, and did not want to die. She had taught me most of what I know about psychosis — a lot, and over a major hunk of both our lives. She learned well enough to manage her inside and outside world experience such that the sinister creatures she met in childhood (and could still see and hear if she chose to pay attention to them) were no longer much of a factor in her life. Emily and I both learned that for her psychosis is a set of symptoms that can be managed by the rest of the personality, if only that personality has what it needs to develop. Remarkably, she came no longer to require antipsychotic medication.

Getting there was a long and at times harrowing journey. Early in the course of our work I realized that I would have to be clear with myself and honest with Emily as to the limits of what I could tolerate. She had already messed up several therapy relationships with other good doctors. Her symptoms were truly miserable. She had auditory hallucinations – something like several radio stations playing simultaneously in her head. Even in ninety-degree weather, she wore gloves and sweaters “to keep the molecules in.” She lived with the conviction that she is an evil person and deserves to be punished. She had scars on her forearms from self-inflicted burns and slashes.

Many of Emily’s fantasies were violent and disturbing, and at one point, when the dramatis personae included members of my family, I came finally to set a limit on what I was willing to hear. In this instance, in violation of a familiar paradigm, Emily was distinctly not free to tell her psychiatrist everything she was thinking. But it was in this way that she learned to take into account her impact on another person and her responsibility for respecting that person’s tolerances. Eventually, and crucial to her growth, Emily learned to protect even herself from the disturbing elements that came into her own mind.

Two hours per week for seventeen years I did my best to help Emily to know herself, to accept and love herself, to manage herself, and occasionally even to enjoy herself, while, in the process, she came to know me and others, to tolerate being with me and others, and even occasionally to enjoy me and others. This was the work of psychotherapy. In Emily’s life, knowing herself required tolerating noises in her head, weird discomfort in her body, and at times nearly unbearable chaos. Together we acknowledged what had to be borne, and tried to hold it as lightly as possible, to remain in the moment, and to let it go.

In the spirit of Semrad’s observation:

No therapy is comfortable, because it involves dealing with pain. But there’s one comfortable thought: that two people sharing pain can bear it easier than one,

I was prepared to be a partner to this anguished young woman, but I could not inure myself to her self-mutilation. The bottom line: if she did not control her impulse to hurt herself, I would no longer work with her. It eventuated that Emily did not want me to quit, and however it came to be so, she did not harm herself again.

In my private practice of psychiatry, I have had the satisfying experience of “seeing it through” with hundreds of patients, a precious handful of whom were initially psychotic and eventually came no longer to qualify for this diagnosis. I have learned that while regression to overwhelming psychosis is caused by neurochemical imbalance, if a schizophrenic or manic-depressive patient has the roots of the capacity to relate to a skillful and committed therapist, and if the “fit” is a good one, with time and great effort, great gains are possible.

Rough times happen in therapy not only with psychotic patients but with all patients. In fact, if the course of ongoing therapy feels smooth and comfortable, I am concerned that my patient and I may be avoiding important uncomfortable dynamics.

And, as all experienced therapists know, not all rough times yield constructively to our best efforts. But when we do get through in a useful way, what we learn through the process is the sweetest experience that comes in this extraordinary work.


Rako, S. (2005) That’s How the Light Gets In: Memoir of a Psychiatrist. New York, NY: Random House.

Rako, S, & Mazer, H. (2003). Semrad: The Heart of a Therapist. iUniverse.