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.

“It’s a necessary condition of human health to be able to bear what has to be borne, to be able to think what has to be thought.”

It may have helped that Semrad was raised, unlike 99.9 percent of psychiatrists, on a farm. He was born in Abie, Nebraska, in 1909, the son of an amateur midwife and a village postmaster/farmer. He spoke his parents’ Czech before he spoke English, and he worked the farm when he wasn’t at school: hands in the shit, driving the mules. As a young man he also played the alto saxophone, sometimes for cash. In 1935, armed with a medical degree from the University of Nebraska, he arrived in Boston for a three-year residency at “The Psycho”—the Boston Psychopathic Hospital, later to be renamed the Massachusetts Mental Health Center. After World War II, which he spent in the Army Medical Corps in Georgia, he returned to graduate from the Boston Psychoanalytic Institute. Semrad’s training analyst was Hanns Sachs, a member of Freud’s “Secret Committee”—his inner ring, his gang of six, his most trusted crew—who had immigrated to Boston from Berlin in 1932. The association placed Semrad at a single analytic remove from the great Sigmund himself.

So this was the man who sat at the heart of the Mass Mental case conferences, with his fist in his cheek and his pipe wagging. Invisible dirt was under his fingernail; his roots reached back through the soil of the Midwest and into Eastern Europe, and something clung to him, too—some mist, some aroma—from the original Black Forest of psychoanalysis.

And then there was his gift, his miraculous knack. Where did it come from? In the confrontation or casting out of demons, a certain bouncer-esque affability and restraint will come in handy: One thinks, for instance, of Jesus of Nazareth, whose psychospiritual heave-hos were accomplished not with towering exorcisms but with a firm quiet word, the biblical equivalent of “All right, sunshine, out you go.” There is something of this in any good shrink, and there was an extraordinary amount of it in Semrad. “There’s no reason to think that in spending half an hour with a patient there’s going to be any radical and permanent change,” Gans says. “It was more watching him with the person. In order to relate to some of these patients, you had to get in touch with parts of yourself that you’d had the luxury of not getting in touch with before, and it could be pretty rough. There was something about his way of being that was hard to explicate, but you knew that something powerful was happening.”

No tricks. No quaking curative breakthroughs. The confusion or fragmentation of the patient would be met with a sort of dogmatic wholeness. “Don’t you believe what you feel?” Semrad would ask. “It’s pretty bad if a man can’t believe in himself.” Or, he would challenge, “Can you prove it? If you can prove it, I’ll believe it.” Here we touch upon a paradox of Semrad—the ineffable solidity, the unwobbling personal substance that took on, in the moment of encounter, a transcendent value. “He wasn’t mystical at all,” says Susan Rako, a Newtonville psychiatrist and author who with fellow Semrad pupil Harvey Mazer compiled Semrad: The Heart of a Therapist. “He was very grounded, very real. He had fat ankles. He wore white socks and black shoes.” A typical Semradism rode the wild edge between Zen mind-zap and rustic commonplace: You could tack up one or two of his sayings right next to You don’t have to be crazy to work here—but it helps! “Occasionally,” Mazer wrote in the introduction, “I would wonder whether he had lifted them directly from the Reader’s Digest.” But at its most proverbial, the Semradism is simply common sense, cubed. “If you have to tell someone something, it’s already too late.” Chew on that for a while.

By his disposition and presence Semrad signaled—at the deepest level—that he wasn’t going anywhere. To his pupils he would talk of “putting a floor under a patient.” And the patients, as if miraculously, would calm down, or open up. Therapists at the demonstration interviews would routinely hear their patients tell Semrad things, after 10 minutes, that they themselves had been unable to elicit in months of treatment. “That was one of the most powerful teaching points for me,” Gans says. “It left me with the question, ‘Is there something about me and the way I was approaching the patient that is keeping this material from emerging?’ And I think that’s a really important question for a therapist.”

 

“Pretending that it can be when it can’t is how people break their hearts.”

The patient was the thing, always: your reason for being there and your truest text. “I was a very lonely guy when I first got to Mass Mental,” remembers Aaron Lazare. “I was up from Cleveland, and I was the loneliest guy in the world. And they assigned me a patient who hadn’t spoken for three months. He was seriously depressed! So nobody’s talking to me in Boston and all I had was my patient and he’s not talking to me either. I didn’t know what to do about this guy and I said, ‘Dr. Semrad, what book should I read?’ And he said, ‘Just read your patient.’”

“What he taught us how to do,” says Susan Rako, “was to sit with a patient, and be there, and let what happened between you affect you. And to take responsibility for not burdening the patient with stuff that was your own. So you don’t misuse the patient, which is very easy to do. You have to know yourself and take care of yourself.” She refers me to a Semradism collected in her book: “A psychiatrist can’t expect to get his narcissistic supplies from his patients. He has to look elsewhere for gratification, like taking an extra helping of flapjacks on Sunday morning.” (“He really did like flapjacks,” she adds.) Aaron Lazare remembers bumping into Semrad in a liquor store near his home: “I’d stopped in there to get a bottle of scotch or whatever and there he was, and he looked at me and he said, ‘Aha! You’re taking care of yourself.’” Lazare laughs. “He didn’t do much more than that, but he did that all the time.”

 

“The reality of the world is cold and uncompromising. Reality doesn’t change for anybody. It’s simple and clear-cut. Nothing fancy about it at all.”

“Elvin Semrad, in spite of the influence he had in his own time, has been gradually forgotten,” wrote Joel Paris in his 2005 book The Fall of an Icon: Psychoanalysis and Academic Psychiatry. “One reason is that he worked in oral culture, and wrote almost nothing. The other is that his ideas were never supported by data. Semrad was a guru, but most young psychiatrists today would not even recognize his name.”

We’ve spent some time with the Semrad of memory, the Semrad of inspiration. But look at Joel Paris’s Semrad, the Semrad of history—trapped there, dwindling into psychiatry’s yesteryear. Can it be? For sure, there’s been an ideological sea change since his day. “He seemed to help people,” Stephen Bergman says. “And that’s the good news. Because it’s good to help people in a 40-minute interview. And he was very modest; he didn’t stand up and take a bow. The bad news, frankly, is that the generation of psychiatrists that he taught took away from that that there was a psychoanalytic-based treatment for severe psychosis, schizophrenia, manic depression, and severe depression. He was the leader, and along with many other classic Freudian analysts he took that stance. And what he did was, he gave us evidence of that in these sessions, because the people seemed to be calmer. The point is, there is absolutely no evidence that doing psychotherapy with severely disturbed people, especially in a psychoanalytic way, has any good effect.”

Psychiatry is no longer dominated, as it was in Semrad’s time, by psychoanalysis. And even during Semrad’s lifetime, the ground was beginning to shift beneath his feet. For him, as for many of his peers, the burgeoning fields of neurobiology and psychopharmacology held little interest, and most medication was “poison.”

“This was absolutely mainstream,” says Peter Kramer, author of Listening to Prozac. “As medical students [in the ’70s], we were barely exposed to pharmacology. Maybe in a month of psychiatry you’d have one session with a pharmacology researcher.” Kramer, who attended some of Semrad’s later case conferences, was also made uneasy by the old man’s swami-like centrality. “He had that presence with patients, and we aim for it and I’m constantly in despair that I don’t have it. But the method of getting people out of their stereotyped behavior and into some existential empathic connection fairly quickly…. There was something about that I found kind of corny. It just made me skeptical even as I saw it work.”

The data don’t support Semrad. So far. Chemistry is required. Or is it? This could be a scientific question, or a moral one, or both. We live in a transitional age. Are there places in the mind, in the heart, where the angels of sanity cannot go? Semrad thought not. “You can always relate,” Susan Rako says.

 

[To a doctor asking to prescribe lithium] “How is it that you cannot sit with this patient?” 

“What will survive of us is love,” wrote Philip Larkin—and love, in a sense, is the Semradic transmission. “You’ve got to love your patients,” he said, the point being that otherwise you won’t have the faintest hope of understanding them. Which isn’t just good therapy: It is goodness itself. Leston Havens, in a 1983 lecture, opined that Semrad—in privileging the patient’s feelings, and in his resistance to interpretation, extrapolation, psychological glibness—“turned the procedures of psychotherapy upside down.” The elevation of Semrad into a larger-than-life figure, in Havens’s telling, was a trick the world played on him: “The world made him a guru, a venerable one…so that the world would not have to confront what he meant. They would only have to confront him. His message disappeared into his person. And it was safe in his person.”

And the person is gone, leaving this rather basic but somehow mysterious heat imprint on the history of psychiatry. It may fade, even as his acolytes quote him, channel him, remember him. But when he was present—in his supreme patience, in his undemonstrative commerce with the way, way out—he was really, truly, radically present. So perhaps to be Semradian means simply this: to sit there. And stay there.

  • David Mobley

    As the project director for the Semrad Oral History Archive at Harvard Medical Library, I very much appreciate the thoughtful comments of the author. Lots of eminent teachers have felt that they “own” Semrad, for Semrad thought well of almost all of his trainees. This article offers us a fresh look at the man and his Legend. There are 200 audio tapes and CD’s still alive at the Archive. Semrad published 90 articles, not all of them deadly. I urge those who want to draw their own conclusions about Semrad to make use of this material. My own view after 18 years of studying him, knowing his son and his daughter-in-law, and some of the major players pro and con; is this Semrad quote which is in the Archive: “Affection is the least understood and the most important component of life”.

    • Susan Rako MD

      re: “Santa Claus in the Cukoo’s Nest” — Boston Magazine February 2014
      Parker quotes Stephen Bergman as saying that there is no proof that psychoanalytically oriented therapy is of help to psychotic patients — that medication is the therapy needed. My experience over three decades of work is that while medication is most often essential, some psychotic patients do benefit greatly from skilled psychotherapy. I have had several psychotic patients “outgrow” their psychoses as a consequence of psychotherapy — to the point where they no longer require medication.
      James Parker lifted liberally and verbatim — and unfortunately without attribution — from “Semrad: The Heart of a Therapist,” edited by Rako and Mazer, most of the quotations he used in his piece.

      Susan Rako MD

  • Harold Bursztajn M.d.

    The legacy of Elvin Semrad continues at the Massachusetts Mental Health Center where patients overwhelmed by suffering continue to be treated with respect.
    Harold J. Bursztajn, MD
    Associate Clinical Professor of Psychiatry Co-founder, Program in Psychiatry and the Law @ BIDMC Psychiatry of Harvard Medical School