30 May The Wisdom of a Master Psychotherapist: A Review of Semrad: The Heart of a Therapist, Edited by Susan Rako, M.D. & Harvey Mazer, M.D.

Posted at 9:32 am in Individual Therapy by jlbworks

By Philip Chanin, Ed.D., ABPP, CGP
Board Certified Clinical Psychologist
Assistant Clinical Professor, Department of Psychiatry
Vanderbilt University Medical Center

“Experienced psychiatrists and trainees alike would look forward to the conferences (Dr. Semrad) chaired as the high point of their week.  There we saw his patience, warmth, respect for others, and his deep commitment to the necessity for people to make their own decisions…

He demonstrated the importance he placed on loss and lost objects in life, and on the need to grieve these losses adequately in order to go on…He had a special ability to simplify the complex, to recognize, identify and describe the feelings common to people, and to communicate this in his clinical work and teaching.” (pp. 11-12)

Elvin Semrad, M.D., (1909-1976) trained a generation of Harvard Psychiatric Residents as the Clinical Director at the Massachusetts Mental Health Center.  According to the editors of this book, Doctors Susan Rako and Harvey Mazer, “On October 7, 1976, news that Dr. Elvin Semrad had suffered a sudden and fatal heart attack spread rapidly and painfully through the Boston psychiatric community.  With his death at age sixty-seven, we suffered the loss of an extraordinarily gifted clinician and teacher, loved and respected by generations of colleagues and students.” (p. 11)

This volume is a collection of quotes from Dr. Semrad that the editors wrote down during their years of training with him, along with other quotes that other residents remembered.  The editors write, “To some extent this project has been part of our own grieving, as we continue to mourn Dr. Semrad and to put him and his teaching into perspective in our lives.” (p. 19).  The editors divided the book into sections, reflecting the topics that Dr. Semrad commented on most often.

The section on “Feeling,” includes the following quotes: “The most important part of a person’s life is his affect…The one thing all people have is feelings—their actions and thoughts are often means of disguising these feelings from themselves…First feelings have to be acknowledged, then one has to bear them, and finally one has to decide what to do with them.” (pp. 27-30)

I have often quoted to patients Dr. Semrad’s teaching in the section entitled “Love.”  “All men scheme to get their ideal woman, and all women scheme to get their ideal man.  Sometimes they do it in such a subtle and sophisticated way that it’s not even conscious.  They call it ‘love.’  Nobody thinks when they’re in love.  If they did, the honeymoon would be over.  Don’t get me wrong.  I’m not against it.  I got hooked myself.  I don’t know who started it.  I just observe it as it as it happens…When people are having trouble loving currently, it’s because they have an old love that they’ve never given up…One of the saddest things in life to accept is that those you love often love others more.” (pp. 33-36)

I’ve also quoted to patients from the section entitled “Men and Women.”  “A girl’s a girl—sometimes you make it with her and sometimes you don’t.  Sometimes if you make it with her, you make a contract for a life of excitement, contentment, and difficulty… Can a woman love more than once?” (p. 40)

The book’s next section is entitled “Growing, Maturing and Sadness.”  Grief and sadness were themes that Dr. Semrad returned to again and again: “The only fuel for learning is the sadness you feel from your mistakes.  It’s important not to waste this fuel…People grow only around sadness.  It’s strange who arranged it that way, but that’s the way it seems to be…It’s sad and painful not to have what you want…Pretending that it can be when it can’t is how people break their hearts…You have to be able to say (feeling and bearing the pang of sadness that goes with it), ‘I want that, but it’s not for me, and I accept it.’  Renunciation is the mechanism of adaptation…Becoming one’s self is the saddest experience anyone can have.  It means taking your feelings for the most important people to you, separating these feelings from them, then taking the idealized meanings of these feelings and introjecting them into one’s self.” (pp. 45-46)

The following quotations from this same section are the ones I have most often shared with patients: “Maturity is a matter of people learning to be alone together.  The more mature a relationship, the more able the two people are to give up their dependency and learn how to live alone together…Nothing is ever mutual…In everyday life each one of you, to the extent of your maturity, lives alone.  You make your own decisions, which is very lonesome.  You feed yourself and look after your own physiology.  Then, periodically, by mutual agreement with someone in your life, you have some human contact.  And the more mature you are, the less you insist that the other person change to fit your mold, albeit one does not give up that wish altogether.  Nor do others give up the idea that you ought to change to fit into their mold.  But it becomes a relatively minimal matter.”  (pp. 47-49)

The section entitled “Marriage” includes the following: “People need to marry—to have peace of mind…If people chose partners by what they are rather than what they think they are, there wouldn’t be any deals.  That hopefulness is what makes the deal.  Getting married is a terrific loss experience.  You have to take yourself out of circulation for your own peace of mind.  You shut the door behind you.  You open a door, too, but you don’t know what’s ahead.  Getting married is a sad thing.”  (pp. 59-60)

Here are some of Dr. Semrad’s words in the section “Decision Making”: “The most important task of a human being to make up his mind—what’s for him and what’s not for him…As soon as you make a commitment, you put yourself in line for a lot of pain.  It means choosing a niche for yourself and giving up all those other possibilities.”  (pp. 76-77)

The “Happiness and Normality” section includes: “A person has to face the pain in his life in order to put it in perspective.  If the shit is collecting in the barn, you’ve got to shovel it out.  Otherwise before you know it the barn is full and you won’t be able to manage it…What people avoid is what hurts the most…Everything is all right as long as it’s at the right time with the right people in the right place…Normality is essentially a function of where, with whom, and when.” (pp. 86-87)

Another section is entitled “On Therapy and in Therapy.”  Dr. Semrad is quoted as follows:

“I don’t know many ‘ordinary people.’  I never treated anyone who didn’t need treatment…

A therapist is a kind of service man.  There are so many things a patient can want to use you for—and if you can swallow your own ideas of how things should be, you can perform a real service…As long as you take the position of talking to a person about what matters to him, then he can feel secure.  Someone cares enough and is concerned enough about him to work with him and listen.”  (pp. 101-102)

This same section also includes: “We must insist on talking to patients only about what they actually experience…not the stock they came from, their heredity, their genes, their biological propensities to growth.  All we deal with is their reaction to their life experience; how much of it they integrated and how much of it isn’t integrated; how much they can handle and how much they can’t handle, but have to postpone or avoid or deny.  And the more infantile the personality, the more they handle by avoidance…We must help the patient to acknowledge, bear, and put into perspective his feelings.” (pp. 103-104)

“In response to a resident’s request for advice regarding what to say to a patient:” “We all have the same question and problem, and I follow a very simple rule: If it’s comfortable for me to say it, then it is the right thing, the right time, and the right way to say it…Go after what the patients feels and cannot do himself.  Help him to acknowledge what he cannot bear himself, and stay with him until he can stand it…As a psychiatrist, your job is to help the patient stand his pain, and this is directly contrary to the rest of the medical profession.”  (pp. 104-105)

This section continues: “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…If you can’t sit with the patient until he can feel it in his own body then you’re in the wrong business…Don’t get involved in judgments; concentrate on working through feelings.” (pp. 106-107)

“In answer to a resident’s question as to how long to tell a patient he will need therapy:” “As long as it takes…Investigate, investigate, investigate…Whenever you don’t know what to do: investigate…Stay with the person’s experience, and don’t get seduced by some of the fancy concepts you’ve heard about…A man’s either scared, mad, or sad.  If he’s talking about anything else, he’s being superficial…Anything short of the patient talking about the actual circumstances of his life is resistance, and you don’t go along with resistance…The things that work are all worked out.  It’s the things that don’t to which we have to address ourselves.  So talking about anything short of problems is a waste of time…Don’t get set on curing her, but on understanding her.  If you understand, and she understands what you understand, then cure follows naturally.” (pp. 109-122)

The following section is entitled “Case Conference Comments to the Patient.”  Here Dr. Semrad speaks to the patient as follows: “I don’t know how it is with you.  That’s what I want to find out…What’s in your life for you?…You must talk only about what really matters to you…You need your sleep, but you have to settle the important issues in your life to enable you to sleep.” (p. 131)

The next section is entitled “Case Conference Comments to the Therapist and Staff.” “The  issue is the overwhelming pain she can’t face right now…She just doesn’t want to know what she knows, because it’s all so sad…What’s going on in his living and loving that he can’t stand to look at?…He may reject the therapist because he cannot tolerate what he begins to feel.” (p. 139)

This sections continues: “ From a letter to a private therapist who had sent a patient for consultation:” “He has little experience bearing his sadness, and is warding it off through depressive activities…I asked him to tell me what he wants—‘a crutch,’ he says…I told him to return to you and level with you about the life issues that matter to him most…The initiative falls on his therapist to help him acknowledge, bear, and put these issues into perspective…You must help him come to terms with his limitations and decide what he will do in his life that is consonant with his talents.” (p. 142)

This same section includes the following: “A therapist who is not oriented to going after what the patient avoids could sit with this woman for five years and get nowhere…Dying is a very serious matter, because you can do it only once.  Nobody knows if an afterlife is a fact or a belief, because no one’s come back to discuss it.  If she wants to believe there’s an afterlife, that’s her decision.  As psychiatrists, we’re interested in making sure she knows the difference between belief and fact…My favorite question is, What do you really want to do?  It’s a question I’ve thought out over the years.  And it’s important, because it involves how he wants to spend all the years of his life…Time means nothing in this business.” (pp. 143-148)

This book ends with the following exchange: “Resident:  What do you think helped build your  capacity to help people bear intense feelings of loneliness and loss?”  “Semrad:  A life of sorrow, and the opportunity some people gave me to overcome it and deal with it.” (p. 206)

In the book’s Introduction, Dr. Mazer writes, “I learned more about being a psychotherapist from Elvin Semrad than I have learned from anyone else in my life.  What he taught was not theoretical.  By example, he taught respect for people and for life.  He demonstrated how to sit with people and their pain—to listen, to hear, and to sort out what mattered to them.  He showed how to help them look at their lives in a way that would enable them to find their own solutions to their difficulties.”  (pp. 14-15)

The introduction also includes Dr. Rako’s reflections on her training with Dr. Semrad.  She writes, “He allowed the impression that he had been there, wherever, or that he would readily go, using the man or the woman in himself, as he would say.  And there he sat, in his amplitude, very often smiling mischievously, teasingly, wisely, kindly, enigmatically, diabolically, attesting to the safety of taking life on, simply—of acknowledging, bearing, and finally putting into perspective the feelings that went with the living of it.  ‘We’re just big messes trying to help bigger messes, and the only reason we can do it is that we’ve been through it before, and have survived.’” (p. 16)