Santa Claus in the Cuckoo’s Nest
Decades after his death, we’re still learning from the most famous New England psychotherapist you’ve never heard of.
If you’re a Boston-area shrink with Harvard affiliations, you know this story already: Long ago and far away, in a terrifying fortress of insanity called Mass Mental, where walls peeled and radiators clanged and severely disturbed people sat around being severely disturbed, there lived a wise old creature called the Semrad. In the folk memory of New England psychiatry, he looms spherical and silvery-paternal, puffing a kindly pipe. A healer, a teacher, a one-man band of clinical humanism: Dr. Elvin Semrad. At his approach, it is told, the beside-themselves would find themselves, and the nonsense-talkers would begin to make sense. A generation of trainee psychiatrists sat in awe. You’ve never heard of him, non-shrink reader, because he wrote no books, gave his name to no large theory. His words live in an oral tradition. His teachings cannot be taught: They can only be embodied. But his influence—which is really his essence—can still be felt, 38 years after his death, and his mild (if not uncontroversial) legend has become a profound sign of empathy. And as for what it means to be “Semradian”? Well, let’s see.
“Never idealize anybody: They all stink.” —Elvin Semrad
In the ’60s and ’70s, the Massachusetts Mental Health Center, a.k.a. Mass Mental, was a 140-bed psychiatric facility with a clinical emphasis on psychoanalytically oriented psychotherapy. To unpack that sentence slightly: Mass Mental’s ethos and guiding philosophy was that troubled people, even very troubled people, could be made less troubled by talking with them, and listening to them, along the lines laid down by Sigmund Freud. Materially, the place was a dump. Spiritually, it was high risk. And every year 25 psychiatric residents would enter, blinking, to learn their trade.
“Mass Mental was a public institution,” says Stephen Bergman, who trained under Semrad in the early ’70s and later—as Samuel Shem—wrote the bestselling novel House Of God.“So it got all kinds of patients and some very serious mental illness. Psychotics, schizophrenics, manic depressives, suicidal people. It was a rough place, not squeaky clean at all.” It was also a teaching hospital for Harvard Medical School—the best and the brightest. “If you wanted to be a hotshot psychiatrist, you went to Mass Mental, grubby as it was,” he says. “And the first year, you don’t know what the fuck you’re doing. How do you know anything about doing psychotherapy with anybody? So you learn by observing people and making mistakes and having supervision. And Semrad had a myth about him.”
“I don’t know of any human beings that are free—they all have to make up their minds if they’re going to stay with Judy or go to work.”
Semrad was clinical director of Mass Mental from 1956 until shortly before his death in 1976. He supervised, he guided and encouraged, he set the tone. Now and again he lectured. The Semrad of memory is white-mustached and bellied like the Buddha, shedding rays of teacherly benignity from an almost-always-open office door. “Everybody loved him,” Bergman says. “A rumpled, roly-poly Father Christmas. It was like talking to your grandfather—who is finally listening to you, for a change.”
But it was around his famous case conferences—where he would demonstrate his craft to avid roomfuls of mental health professionals, all eyes on him as he performed live psychotherapy, hot analyst-on-patient action—that the myth of Semrad clustered and grew. To the 21st-century layman, the case conference sounds a little iffy: A lone patient would be “presented” to the assembly by his or her therapist and then interviewed, in front of everybody, by Semrad—after which, still in front of everybody, Semrad would discuss the case with the therapist. High psychiatric theater, you might say, with some fairly obvious structural negatives for the patient.
Nonetheless, the case conference was a standard feature of psychiatric training at the time, and by all accounts a useful teaching tool. Besides, in the aura of Dr. Semrad, its artificialities seemed to be dissolved, or at least suspended. Here he would showcase his celebrated rapport with the unreachable. Over a patient who might be sizzling with psychosis, or schizophrenically abstract, Semrad would calmly open the umbrella of the everyday. “He could sit down with a patient with 25 people watching him,” remembers Aaron Lazare, who trained at Mass Mental and went on to be chancellor and dean of UMass Medical School in Worcester, “and it was like two men sitting on a park bench, just talking. He would get to the heart of the matter. And I was really stunned by that. I said, ‘This is gonna be my teacher.’”
“If you can’t sit with the patient until he can feel it in his own body then you’re in the wrong business.”
Onstage, Semrad would take the patient on his patented “tour of the body,” asking him where, physically, he could locate the sensation that was bothering him. In the head, in the stomach, in the chest? If the latter, Semrad might suggest—courteously—that the patient was suffering from a broken heart. (Jerry Gans, a former Semrad pupil who today practices in Wellesley, once tried this on a particularly intractable Mass Mental patient. Her response: “Don’t give me any of that Semrad shit!”) The body—its reactions, its rebellions—was central in his system, because the body doesn’t lie. “This is what makes the difference, the tissues of the persons involved,” he said, “not the fancy thoughts upstairs.” Patients adrift in their minds would be, as it were, reintroduced to their bodies—to the somatic site of their feelings. And the feelings, crucially, would then be explored, endured, sat with, rather than interpreted and bounced back at the patient. “I don’t like this term point out,” Semrad once said, “because it implies that you’ve made up your mind and he has to take it. I would rather ask, ask, ask, and let him give you the data.”
There was a formidable technical-clinical apparatus undergirding Semrad’s approach, decades of experience and training at work. Gerald Adler, in his paper The Psychotherapy of Schizophrenia: Semrad’s Contributions to Current Psychoanalytic Concepts, refers to Semrad’s “vast array of techniques that responded to the patient’s fear, through the support of the patient’s autonomy…. He constantly reminded the patient that the patient had an observing ego, though rudimentary, and expected the patient to assume optimal responsibility for his feelings, wishes, and predicament.” As a teacher Semrad was not above shoptalk (“A functioning ego split is necessary to interrupt character syntonicity”), and he wrote or cowrote a number of academic papers that are, it is generally agreed, unreadable.
In person, however, and above all with patients, he was atheoretical. With patients he used no jargon—or if he did, it was the jargon of the everyday: the marketplace “(Are you willing to pay the price for what you want?”) and sometimes the farmyard (“If the shit is collecting in the barn, you’ve got to shovel it out. Otherwise before you know it the barn will be full and you won’t be able to manage it”).
And there was a kind of exotic gallantry, at the case conferences, in his treatment of patients. “In that room,” says Jerry Gans, “there are seven of us highly trained residents, nurses, social workers, occupational therapists, and then there’s the broken-down patient. And Semrad would say to the patient, ‘Do I have your permission to talk with these young people about how we might think about what you’ve told us today, and how we might help you?’ And the respect embedded in that question had a profound effect on me. A lot of his teaching was indirect like that.” The courtesy, the formality, was an offering to the autonomy of the patient. When his colleague Leston Havens called Semrad a “great existential teacher,” he was saluting this Semradic stress upon freedom, choice, responsibility, and upon the primacy, clinically speaking, of personal experience—even (especially) for those who seemed to have no control of their situation, or of themselves, and who could make little sense of their experience. Inquiring into the circumstances preceding a patient’s arrival at Mass Mental, he would often ask, “How did you arrange it for yourself?”