Elvin V, Semrad (1909-1976): Experiencing

the Heart and Core of Psychotherapy

Training

MICHAEL I . GOOD, M.D.

Elvin Semrad was among the most influential and beloved teachers of
psychotherapy in his generation. His legacy as a clinician, teacher, and
mentor is still felt today, even among those who never knew him directly.
What and how he taught remains as relevant as ever in the psychotherapeutic
care of troubled individuals. His was primarily a psychiatry of affects and
bodily feelings, and he focused uncannily and empathically on the patient's
experience. The basis of his rich, heartfelt, wise, and inimitable approach wa
not just classically psychoanalytic, or existential, or ego-oriented, or sel
psychological, or interpersonal-relational, or even humanistic or adaptation
Rather, it was all of these in a uniquely "Semradian" integration geared
toward elucidating patients experience that had arrested them during their
life course and their avoidance of "acknowledging, bearing, and putting into
perspective" what they were up against. This paper describes who he was and
gives a personal perspective on his influence—how and what he taught and
why he had such an effect on those who knew him.
KEYWORDS: psychotherapy; psychiatric education; mentoring; life
experiences; defense mechanisms; clinical interviewing
The skills needed to become a seasoned
therapist are slowly developed through
errors and disappointments, and most
psychiatrists require around 10 years to
grow into maturity
(Semrad, 1969a, p. 1 3 ) .

Love is the standard issue; only the

objects change.
(Rako 8c Mazer, p. 33)

Associate Clinical Professor of Psychiatry, Harvard Medical School, Faculty, Psychoanalytic

Institute of New England, East. Mailing address: 74 Craftsland Road Chestnut Hill, MA 02467.
e-mail: michaeligood@pol.net
A M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol. 6 3 , No. 2 , 2 0 0 9

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In a special—modest and homespun yet profound and inimitable—way,

Elvin V. Semrad taught and influenced a generation of psychiatrists and
psychoanalysts in the Boston area and elsewhere by example and through
his reputation as a psychotherapeutic sage or even genius. He was among
the most influential teachers of psychotherapy in his generation (Roth,
1970; Day et al., 1977; Margulies, 1989; Vaillant, 1992; Smith 1993; Sayfer
& Hauser, 1994; Gardner, 1995; Schwaber, 2002; Levine, 2002; Russell,
2006). Many knew him in various ways, including in his roles as a clinician,
healer, teacher, supervisor, colleague, friend, and mentor (Levinson, 1978;
Rako & Mazer, 1980; Margulies, 1989; Rako, 2005; Martin, 2005). Levin-
son (1978) considered him one of the great mentors of his time. Having
had the good fortune of being one of those whom Semrad taught and
affected, I share here some recollections and thoughts about my formative
experience with him and the setting in which he worked. My introduction
to the Massachusetts Mental Health Center (M.M.H.C.) and Semrad
pivotally influenced my own choice of psychiatry and psychoanalysis as a
career. I now write with the perspective of more than four decades in
which to reflect upon his role. It is not that Semrad was the only influence;
indeed, there were many at M.M.H.C. At that time a great many of them
had psychoanalytic backgrounds or allegiances, even though many also
had their own passions that carried them from classical psychoanalytic
thinking. It was a true center for psychodynamic teaching and dialog, and
at its epicenter was Semrad.

HUMBLE ORIGINS AND EARLY EXPERIENCE

Elvin Vavrinec Semrad was born on August 10, 1909, in the village of
Abie, Nebraska. Abie—in the heartland of the United States—had a
population of "good peasant stock," preponderantly of Czech ancestry,
which then numbered about 150 (http://www.epodunk.com/). Found
literally at the end of a paved road, Abie is in the eastern part of Nebraska,
near Prague, about 64 miles west of the center of Omaha. Although
Semrad's parents were born in the United States, he spoke Czech before
he learned English. The family called themselves Bohemians—Bohemia
being the westernmost province in what we would come to call the
Republic of Czechoslovakia (established on October 18, 1918). Semrad
said he had to get over the "culture shock" after coming to Boston, when
he had to explain that he was "Bohemian." Upon learning that Bohemia
and Moravia had become part of Czechoslovakia, he subsequently referred
to himself as Czech. Sanford Gifford, M.D., himself from Nebraska
(Omaha) relates that when he first met Semrad in 1946 at Boston State
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Hospital, the latter never failed to tease him about coming from "the other
side of the tracks." Gifford assumed this meant coming from South
Omaha but later learned that Semrad meant "the other side" of the tracks
going through Abie! (Gifford, 2005).
Semrad's father, Theodore, was the village postmaster and operated a
farm where Semrad worked after school. His mother, Alvina (a name
seemingly echoed in Elvin), had a third grade education and sometimes
served as an unoffical midwife (Rako & Mazer, 1980, p. 206). After the
11th grade, his father asked Elvin whether he wanted to become a farmer
or a teacher. Because of an experience with a runaway mule-team, he chose
to become a teacher (Gifford, 2005), and his younger brother, Wilfred,
eventually became superintendent of schools in another county.
Semrad graduated from high school in Schuyler, a town about 10 miles
from Abie, with a population of, at most, a few thousand people. After
high school he worked as a schoolteacher for two years in a one-room
schoolhouse. In 1932 he earned an A.B. from Peru State Teachers College
in Nebraska and went on to receive his medical degree in 1934 from the
University of Nebraska School of Medicine in Lincoln, the state capital.
He ordinarily wrote letters home from college in English, but if he wanted
money, he wrote in Czech (Day in Youngren, 2005, p. 2). He also earned
some money by playing alto saxophone at traditional Czech dances and by
working in a grocery store, where he acquired a sense of business. In later
years as a psychiatrist, he would ask, "How does the patient do business
with you?" and "How do you do business with the patient?" (Day in
Youngren, 2005, p. 2). As Max Day, M.D., (Youngren, 2005, p. 3) points
out, that was not the way an analyst usually talked, but Semrad did, and it
had its roots in Nebraska. It was from his family life on the prairie that he
apparently acquired his ethic for hard work and long hours, taking
examples from his father. In working for the post office, his father saddled
up the horses no matter what the weather conditions were, even in a
blinding snowstorm; he would work the farm from dawn to dusk.
After interning at University Hospitals in Omaha, Semrad came to the
Boston Psychopathic Hospital (the former name of M.M.H.C. and often
referred to as "The Psycho") in 1935 and spent three years there as one of
only four residents, with an additional residency year at McLean Hospital.
To his mother's distress, he chose not to go to the Menninger Clinic, which
was much closer to home. In 1939 he became a psychoanalytic candidate
(trainee) at the Boston Psychoanalytic Institute and, after returning from
the military, graduated in 1948. His training analyst was Hanns Sachs, a
disciple of Freud's who immigrated to Boston. Semrad was thus one step
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from Freud in the psychoanalytic family tree. In order to pay for his
1

analysis and support his family, he took a staff job as senior physician at
Metropolitan State Hospital at a time when staff salaries were $3,300 per
year with room and board for his family. For analytic supervision he met
with John Murray, M.D., during Murray's lunch hour at a charge of $5.00
a session. Other analytic supervision was with Drs. Ives Hendrick, Edward
Bibring, and Helene Deutsch (Gardner, 1978; Gifford, 2005; Day in
Youngren, 2005).
Semrad once described his experience in supervision with the re-
nowned analyst Helene Deutsch (herself an analysand of Sigmund Freud),
who taught him "many an important thing":
One day I was reporting my patient. This was about the third week of
analysis and the patient was talking about oral impregnation and anal
delivery. In my fantasy I thought this would probably be the fastest analysis
on record. Dr. Deutsch listened patiently and then shefinallysaid, 'Why
do you think she's telling you that?' I said, ' I don't know.' 'Well,' she said,
'why don't you ask her?'" So I did. And the patient said, 'Isn't that what
analysts want to hear?' And then we got to work (Gardner, 1978, p. 376).
He was in military service from 1941 to 1946 and served in the Army
Medical Corps in Georgia, attaining the rank of major. Given the hun-
dreds of patients returning with shell shock or battle fatigue (what we now
refer to as posttraumatic stress disorder), the general asked him what he
could do about it. Semrad replied, " I don't know." (He later noted how
those three words have saved him so many times.) So he conferred with a
colleague, and they decided to put the patients into groups, which had
quite successful results (Gardner, 1978, p. 401). Semrad later wrote a
number of papers about psychoanalytic group therapy (e.g., Semrad &
Day, 1966). In 1946 he became Director of Clinical Psychiatry at Boston
State Hospital before moving to M.M.H.C. in 1952 as Chief Medical
Officer, and then he became the Director of Psychiatry (Clinical Director)
in 1956. In 1962 he became a Full Training Analyst at the Boston
Psychoanalytic Institute (B.P.S.I.), and in 1968 he was promoted to full
Harvard Professor of Psychiatry at M.M.H.C. From 1968-1970 he was
President of B.P.S.I. As described in his Harvard Memorial Minute,
Patients who appeared very psychotic became in their contacts with him
understandable human beings. In a short interview he enabled many
1
Hanns Sachs (1881-1947) also analyzed other notable analysts, including Michael Balint, Karen
Horney, Ella Freeman Sharpe, Erich Fromm, and Rudolph Loewenstein (Falzeder, 1994). Sachs had
a degree in law rather than medicine and was a member of Freud's Inner Circle (Grosskurth, 1991).

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patients literally to give up word salad, used for years in back wards, and
to speak in plain English—often to explain succinctly and poignantly their
need to stay withdrawn and sick. . . . What he used on all these occasions
was himself, his ability to put himself close to another human being and
grasp and accept what was there. . . . He never seemed surprised by what
he heard. . . . His was primarily a psychiatry of affects and bodily feel-
ings. . . . He was above all a great teacher and a beloved human being (Day
et al., 1977, p. 11).
Milton Greenblatt, a former Commissioner of the Massachusetts De-
partment of Mental Health, writing about M.M.H.C., stated:
Patient care was greatly aided by the appointment of two remarkably
effective teachers—Dr. Ives Hendrick and Dr. Elvin V. Semrad—who not
only introduced the psychoanalytic point of view, with its almost revolu-
tionary effect upon the teaching climate of the hospital, but also helped
make the detailed study of every aspect of the patient's inner life and
reaction to his total environment a more legitimate area of inquiry (Green-
blatt, 1978, p. 303; for discussion of the rise of the psychoanalytic point of
view in American psychiatry, see Hale, 1995, pp. 245-256).
As described by Dr. Daniel J. Levinson (1978), Semrad was the
inspired [and inspiring] clinical teacher enabling apprentice psychothera-
pists of many disciplines to learn the meaning of a therapeutic relationship.
He was the moving force and guiding spirit of the clinical training
program—an archetypal psychotherapist-healer (p. 208).
According to Day (Youngren, 2005), a mentee and friend of Semrad's
since their days at Boston State Hospital, starting in 1948 and subsequently
at M.M.H.C., the name "Semrad" in Bohemian means " I am happy," or
"I'm glad" (p. 2)—and that was one part of him; he enjoyed warmth. On
the other hand, I found that he more commonly exhibited a certain
WeltschmerZy a sadness that comes with compassion and wisdom, despite
his not infrequent mischievous smile. "Sorrow," he said, "is the vitamin of
growth" (Rako & Mazer, 1980, p. 45). When a resident once asked him
2

what helped build his capacity to help people bear intense feelings of
loneliness and loss, he replied, "A life of sorrow, and the opportunity that
some people gave me to overcome it and deal with it" (p. 206).
Wondering about this apparent antinomy between happiness and
2
Susan Rako, M.D., and Harvey Mazer, M.D., both former residents at M.M.H.C. during Semrad's
tenure, published a representative compilation of Semrad's remarks that stand by themselves on
various clinical topics. A more recently published memoir by Rako that includes material about Semrad
is titled That's How the Light Gets In: Memoir of a Psychiatrist.

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sorrow, I looked into the Czech origin of the name "Semrad," which is a
variant of "Semerad," which is from the old Czech personal name,
"Semirad" (semi = person + rad = nimble or swift) (http://genealogy.
familyeducation.com/surname-origin/semrad). In what was called "Sem-
rad's time," however, his manner was unhurried, not swift at all, and he
was often late for meetings—even if his mind was ever nimble. In his
interviewing and teaching, his words were deliberate, laconic, and slow
enough for others readily to take them in.
In addition, the name "Semrad" is an anagram for "dreams" (Jacque-
line Olds, 1971, personal communication). This rearrangement of letters is
remarkable because, like many of Semrad's pithy comments that tap into
the unconscious, dreams are cryptic yet revealing of a psychic truth.
Dreams are from one's experience, past and recent, and they tell of hidden
wishes about what one wants that experience to be. Semrad taught from
the outer and inner (including bodily) facts of a patient's experience,
something dreams can encapsulate. His clinical approach would gently and
directly resonate with the patient's elusive issues and feelings in the
manner in which dreams have affect as their guidepost. He had an uncanny
ability to make this kind of contact with patients. His was a brilliance of
intuition and empathy. Among his questions about affective pain were
"Where do you feel it?" (see Deutsch & Semrad, 1959; Mann & Semrad,
1959). If patients were not clear where they felt it, he would verbally "tour
the body," akin to asking for associations to the parts of a dream. As with
dream analysis, his interviews could reveal the affect and experiential
meaning behind a symptom. For Semrad, unbearable affects are discern-
ible in psychotic symptoms (Khantzian, Dalsimer, & Semrad, 1969). The
way out of psychosis, Semrad concluded, was for it to move out of
perception and into the body and then, through the therapeutic alliance,
into secondary process and an understanding of how it came to be in the
first place (Garfield, 2001, p. 115). His approach in the clinical interview
helped patients own their affects and defenses. He would ask, for example,
"What is anger like for you?" (Garfield, 2003, p. 50). With paranoid
patients, he emphasized the need of the patient to find someone who could
share the responsibility for the unacceptable feelings, including acknowl-
edging the "kernel of truth" in the patient's delusions (Semrad, 1969a;
Garfield, 1988, p. 42).
Semrad often observed, "People affect each other" (author's recollec-
tion, circa 1971). By itself this maxim seems obvious and perhaps simplis-
tic. Yet it has deep significance for clarifying people's psychic pain in
relation to one another. When he spoke those words, it explained some-
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thing. They helped sort out what was coming from whom—a common
problem of psychic muddlement. It was his way of pointing out the
interpersonal source of feelings, without getting technical—love, disap-
pointment, separation, anger, sadness, as well as projective identification.
He was, in a sense, fundamentally pluralistic in his frame of reference well
before this perspective gained wide currency among psychoanalytically-
trained therapists.
SEMRAD AND M.M.H.C.
In the late 1960s, as a student in the third year of medical school doing
the required clinical rotations in the various medical specialties, I had the
good fortune of landing at "Mass Mental" for the rotation in psychiatry.
Despite the grunginess of the building, which was built in 1912 as one of
the nation's first public psychiatric teaching hospitals, the people there
radiated a warmth that was unlike what I had experienced in other hospital
settings. (For history and a photo of M.M.H.C, see Tsuang, 1997;
http://www.massmentalhealthcenter.org/about/historyandphotos. htm.)
Leston Havens, M.D., was in charge of medical student teaching at
M.M.H.C. His approach was refreshingly forthright, at times irreverent,
questioningly skeptical, and seductively fascinating as he recounted tales
about the idiosyncrasies of the psyche. Among his observations, he cate-
gorized these narratives from the perspectives of the major schools of
thought in psychiatry (Havens, 1973).
At the time for fourth-year medical students there were, beyond the
required rotation in psychiatry, fifty-four block and longitudinal elective
courses in psychiatry from which to choose. The first elective I selected (and
happily got into) was a longitudinal seminar taught by Dr. Elvin Semrad,
which extended over five months. It was described as "Basic Principles of
Psychotherapy" and was "designed to teach the adaptational approach to
psychotherapy, emphasizing indications, goals, methods, and maneuvers
. . .with particular attention to the physician factor and the use of his person
as a therapeutic tool" (from the Harvard Medical School Schedule of Fourth
Year Elective Courses and Research Opportunities, 1968-1969, p. 50). Here
was a chance to see and hear a master clinician. It also was the first course I
took where medical students had patients (in this instance an outpatient) all to
themselves. It included separate supervision with an advanced psychiatry
fellow and patient conferences with Semrad. My patient was a woman in her
early 20s who recently and suddenly lost both of her parents in an automobile
accident. She was beside herself in grief and thought she recognized them still
when her eyes fell upon certain strangers in public places. My job was mainly
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to listen, since she had no obvious difficulty talking about her bereavement. In
Semrad's terms, she needed to "acknowledge, bear, and put her loss into
perspective." Among Semrad's many aphorisms, this one was central. Cer-
tainly, he provided a medical student a conceptual framework that seemed
atheoretical and could readily be grasped.
While some in our field have felt that Semrad oversimplified complex
psychological matters, to the neophyte he supplied an educational scaf-
folding from which to learn to listen, understand, and comment. This
teaching process was also evident in his annual grand rounds lecture,
particularly geared to the new first-year residents. The subject was "De-
fense Patterns." He outlined defenses into overarching categories, such as
"survival patterns" (denial, projection, distortion), "support patterns"
(hypochondriasis, neurasthenia, obsessive-compulsiveness), "sacrifice pat-
terns" (dissociation, conversion, psychosomatization), and "anxiety pat-
terns. Within these categories he described the underlying affective need,
the symptoms, and the developmental dilemma. It was clear, straightfor-
ward, even elegant. (For a more extended discussion of Semrad's basic
principles and formulations, see Semrad, 1969a,b,c; Adler, 1979, 1997; &
Buie on "Elvin Semrad's Principles for Diagnostic Interviews and Psycho-
therapy" in Youngren, 2005.) Regarding hypochondriasis, for example, he
explained that "Hypochondriasis is when someone says, If you don't love
me for what I am, at least give me some sympathy—if not for all of me, at
least for my liver. Treat me like when I had the mumps" (Rako & Mazer,
p. 175-176).
While first-year residents, we regularly met with Semrad as a group of
25 squeezed into his office. It was a bright, at times tendentious, bunch,
and Semrad sometimes needed to "put a resident into his place" and
refocus the task. One time an erudite resident, fresh from a two-year stint
in psychopharmacologic research at the NIMH, queried Semrad regarding
his caution (seeming aversion) regarding the use of "poison" pills that
"separate the mind from the body" (Rako & Mazer, 1980, p. 179; see also
Thomas G. Gutheil, M.D., in Youngren 2005, p. 8), and, Semrad believed,
could interfere not only with the patient's experiencing, but also with the
doctor's attention to the psychotherapeutic task and process. Semrad also
clarified, " I don't object to the use of pills. I just want to be sure why
they're given" (Rako & Mazer, 1980, p. 180). As he had once put it, "If
they have to get addicted, I would rather have them addicted to psycho-
therapy than to drugs" (p. 179). In that particular resident meeting,
Semrad benignly yet resolutely affirmed to all of us that, while we may
know a lot—even more then he did—about those new-fangled medica-
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tions, he had something that we as residents did not have: That was
experience.
The issue of "sitting with the patient" to support empathically the
acknowledging and bearing of affect rings anew today. Steven Sharfstein,
M.D., a former president of the American Psychiatric Association, as well
as president and C.E.O. of Sheppard Pratt Health System, recalls that as
a resident at M.M.H.C. he admitted a patient with acute mania (and
numerous previous admissions as part of his unstable bipolar illness, then
called manic depression). Sharfstein presented the patient to Semrad and
asked for his permission to try lithium. Semrad responded, "How is it that
you cannot sit with this patient?" Three and a half months later—in
1970—the FDA approved lithium. Sharfstein started the patient on
lithium therapy and dramatic improvement allowed Sharfstein to do some
psychotherapy with the patient. But as Sharfstein recalled it 35 years later,
Semrad's question—"How is it that you cannot sit with this patient?"—
resonates anew. He cited 2001 data from the APA's Practice Research
Network showing that only 37% of patients with bipolar disorder who
were in outpatient treatment with psychiatrists and had indications for
psychotherapy were receiving it (Moran, 2005). Sharfstein also recalled
another occasion when he presented a patient to Semrad and asked, "Dr.
Semrad, does the patient have manic-depressive illness or schizophrenia?"
Semrad answered, " I would call the patient Mr. Smith" (Sharfstein, 2002).
As Semrad also observed, "So often, when you get to know a patient, they
lose their diagnosis, you know" (Rako & Mazer, 1980, p. 176). Indeed,
during Semrad's interviews, his empathic approach often would permit
patients temporarily to lose their psychotic presentation and speak lucidly.
As Havens (1978; see also Margulies, 1989) described it, "Suddenly the
patient did not seem odd or even sick as Semrad reached and shared the
patient's suffering of life and love. Suddenly there were just two human
beings groping toward some perspective on the human condition"
(p. 471). In Semrad's words, "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" (Rako & Mazer, 1980, p. 195).
Some contemporary psychiatrists, such as Michael I . Bennett, M.D., a
former president of the Massachusetts Psychiatric Society, question
whether Semrad's approach of sitting with patients to help them acknowl-
edge and bear affect was overvalued and potentially detrimental for many
patients who simply cannot tolerate expressed emotion (personal commu-
nication, December 14, 2005). The point he makes is that the problem may
be "not that psychic pain causes psychosis but rather that psychosis causes
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pain." It is, of course, likely that some of each applies, and the matter is
complex. Some patients benefit from being able to experience feelings with
a caring, empathic therapist, and some apparently never do. Perhaps "as
long as it takes" can be "never." Yet we may not be able to know how long,
if at all, ahead of time. Some patients do take years to be able to
acknowledge what they have been unable to bear, and we might never
know unless we are open to it. It can take a great deal of patience, which
Semrad had.
Medication can facilitate psychotherapy, but it is not always the answer.
I have seen chronically ill patients in a state hospital setting who take such
a brew of medications that theoretically "all their neuroreceptors are
blocked"—and it's a wonder that there is any neurotransmission at
all—yet they want to talk, even to tell me their dreams. Perhaps they wish
to relate their dreams all the more because they feel that the hospital wants
to focus exclusively on what they are doing to be discharged, not on their
emotional experience. In many instances the pendulum today may have
swung too far from the other equally extreme point of view in which
medication is seen as interfering with "sitting with the patient."
TEACHING, WRITING, AND ACCESSIBILITY
Even though Semrad contributed a number of important articles to the
psychiatric literature, estimated to number well over 200 (Rako & Mazer,
1980), many of these are not readily accessible. PubMed (http://www.
ncbi.nlm.nih.gov/sites/entrez/) lists only 29 articles that he had authored
or co-authored between 1951 and 1973, while Gardner (1978) notes 72
published papers and chapters authored or co-authored since 1936.
Semrad did not promote himself by citing his writings in the presence of
trainees. In typically modest fashion, he would refer to himself as a farm
boy, "just a hayseed from Nebraska" (Rako & Mazer, 1980, p. 12). Given
the disparity of information on the extent of his writing, I obtained a copy
of Semrad's 30-page curriculum vitae. In fact, if one counts everything
written and published anywhere, whether singly or with co-authors,
including original papers, books written or edited, book chapters, book
reviews, proceedings, discussions, panels, digests, and pieces in "throw-
aways," the total is 140. Adding to this, the many papers read in various
venues but not published, the number rises to precisely 280. His work
covers a diverse range of topics. He was Board Certified in psychiatry and
neurology; thus, several early papers (prior to World War II) discuss
medical or neuropsychiatric subjects, such as blood protein in delirium
tremens; the use offluidsand lumbar puncture in delirium tremens; hernia
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repair in mentally ill and mentally "deficient" patients; metrazol therapy;

dementia paralytica; and pneumoencephalographic and electroencephalo-
graphic findings in patients with chronic mental disorders.
By the time he completed his psychoanalytic training in Boston, his
writings became more oriented towards psychotherapy and psychoanaly-
sis. He also wrote or cowrote various papers on group therapy, including
psychoanalytic group therapy; the treatment process in psychosis; vulner-
ability to psychosis; schizophrenia and language; hysterical conversion;
training resident psychiatrists, including the role of the psychoanalyst in
teaching psychotherapy in resident training programs; brief psychother-
apy; brief hospitalization; establishing rapport; religious belief; treatment
of character neuroses; defense hierarchies; object anxiety and primitive
defenses; interpretation in the psychotherapy of narcissistic neuroses;
psychotherapy in the therapeutic milieu; borderline states; ways of mea-
suring change; development of an ego profile scale; and the effect of
first-year residents' "identity crisis" on training.
And yet, despite the quantity and diversity of his writing, he was a far
more gifted teacher than writer. His seminal teaching of empathy, for
example, was disseminated far more by clinical demonstration than
through his writing. Edward J. Khantzian, M.D., (Youngren, 2005, p. 9)
saw Semrad as a frustrated author who would dictate his thoughts but
could not fit his genius into the body of a paper. His ideas tended to be
convoluted in text, and his insight and humanity were displayed more in
the footnotes. Yet, he encouraged others to write. Sanford Gifford related
that once when Max Day was complaining about the conditions at Boston
State Hospital, Semrad listened for some time and then dryly asked, "Why
don't you write a paper about bitterness?" (personal communication,
December 11, 2005). Levinson (1978) opined that Semrad had few pre-
tensions or illusions about his abilities, such that he sought collaborators
who had more talent for formal research. Although he wrote articles both
3

singly and with able colleagues, he never found the special research
collaborators with whom he could establish an ongoing productive
complementarity (p. 208). His stacks of interview tape reels, which con-
tained the raw data for clinical research, grew in profusion in his office.
Thus, his splendid intuitive, clinical insights were not transformed into a
defined body of literature (p. 208-209).

3
One research tool is the "Merrifield, Carmichael, Semrad Scale for Work Capacity, Affective
Capacity, and Interpersonal Capacity." The project using this tool, however, did not find its way into
print (Merrifield, personal communication, December 11, 2005).

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Some considered him to be anti-intellectual clinically. But as a teacher, he

was mti-'mteHectualization as an avoidance of the patient's intolerable expe-
rience that led to major regression. When we were first-year residents, he
advised us to "sit with the patient" (a precept to follow come hell or high
water), and not to read articles from the psychiatric literature, which might
foster intellectualization and distract us from the real business at hand:
Stay with the patient's experience, and don't get seduced by some of the
fancy concepts you've heard about. . . . You've got to read the patient, the
original textbook, and not a book (Rako & Mazer, 1980, pp. I l l , 186).
In addition, I would conjecture that his clinical focus on the patient's
experience and not on the literature had a group "reactive reinforcement"
(Hinsie & Campbell, 1970, p. 657), whereby those whom he influenced
came to know him primarily through their experience of his person instead
of his writing. Learning to sit with the patient, as described by Margulies
(1989), was "the royal road to empathy" (p. 17). The administrative side of
M.M.H.C. at times countered this open-ended "sitting with the patient"
with pushes to get us to discharge patients, especially when the census rose
so high that some patients had to sleep on mattresses in the corridors. At
one time, patients could be transferred from M.M.H.C to Boston State
Hospital, but that arrangement changed under new catchment area poli-
cies that came into effect in the late 1960s to early 1970s. Although
patients' residents changed over the years, chronically ill patients often
developed an "institutional transference" to M.M.H.C. To a certain extent,
this was indirectly a transference to Semrad and his influence on the
institution.
Despite his discouraging residents from using the literature as a dis-
traction from sitting with the patient, there was one article that his
first-year residents were expected to read and master. That was on the
psychodynamic formulation, a contribution of John C. Whitehorn, M.D.,
of Baltimore, published in the 1944 Archives of Neurology and Psychiatry.
Every new resident received a 32-page mimeographed copy of Whitehorn s
Guide. This was no DSM-type handbook concerned primarily with psy-
chopathology, but rather the description of an approach to (a) understand-
ing the patient's personality and attitudes that underlay the presenting
problem, (b) eliciting the necessary information and subtleties from the
clinical interview while trying to be psychotherapeutic and not psycho-
toxic, and (c) organizing a psychiatric case report. This history, mental
status examination, and formulation were compiled in the onerous "ana-
mnesis," which each first-year resident prepared for every new patient
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within seven days of admission using the old, blue floppy-disk dictating
devices. Because grasping what was really going on with the patient was
often a mystery to inexperienced residents, these formulations tended to
go on for multiple pages, including "The Premorbid Personality," "The
Precipitating Stress," and "The Nature of the Reaction." The formulation
and its development guided Semrad's interviewing. His empathic sense
and the patient's responses little by little allowed him to form hypotheses
he tested with further questions. Almost always, the precipitating stress
involved a significant loss relating to whatever was identified in the
premorbid personality as a vulnerability managed by dependency on an
important source of support. The reaction involved a regressive loss of
function and the employment of various possible defensive patterns.
Treatment involved helping deal with the precipitating stress, usually
requiring grieving a loss—which meant helping the patient to "acknowl-
edge, bear, and put into perspective" the painful reality. Once back more
or less to where he or she started in terms of premorbid personality, the
patient could choose to work on the vulnerabilities. For patients with
borderline disorders, vulnerabilities in personality structure usually guided
the work (see Buie in Youngren, 2005, p. 6).
Semrad seldom held formal teaching lectures. I recall attending two of
them in the five years of training I had at M.M.H.C. But he regularly
presided at rounds on the wards, during which patients' cases were
presented by their respective residents, psychologists, social workers,
nurses, and aides or mental health workers. His presence was a high point
in the activities of the ward. After all involved staff had a say about what
he or she knew and observed about the patient, Semrad would conduct the
interview—pipe in one hand, the palm of his other hand resting at his
cheek next to his mustache—asking the patient about the details of his or
her life and teaching from the patient's example. He sat side by side with
patients so that he could look at the world from their view, turning only his
head towards them. His interviews and discussions were models of clarity
and conciseness. (For a written example of Semrad interviewing a patient,
see Good [2006, pp. 24-26].) Vaillant (2006) recalls Semrad
. . . astonishing us residents by his extraordinary ability to speak 'the
language of the heart' to reach the most isolated catatonic schizophrenic
patients. To our dismay once the patients left his loving presence, the
patient was again out of control (p. 557).
The basis of Semrad's inimitable approach (which most of us tried on
with our patients) was not just classically psychoanalytic, or existential, or
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ego-oriented, or self-psychological, or interpersonal-relational, or even

humanistic or adaptational—but, in a sense, all of these—geared toward
elucidating the experience that had set the patient awry. The approach
was, in a word, "Semradian." This description is consistent with Havens'
view that for Semrad, as for Sullivan, "what he did was not a method he
could separate himself from and describe, but the way he was" (Havens,
1999, p. 860). Havens adds that Semrad himself provided no description
of his working methods:
He was simply using his intuitive strengths, who he was, a man of
disarming simplicity, often indifferent to explanations and interpretations,
intent on being available to others. He liked to say, 'If you have to tell
someone something, it's already too late' (1999, p. 858).
More than with any other teacher, supervisor, or mentor I have known,
Semrad placed the individual's affective experience (and its avoidance) at
the center of his attention. This was at a time in the 20th century when a
preponderance of psychoanalysts attended more to drives, psychic struc-
ture, and intrapsychic processes, and rather less on affects and experi-
ences. He focused on the specifics of the precipitating event or experience
with which the person could not adequately cope, from a premorbid
adjustment, which made the individual vulnerable. He homed in at the
point at which the patient regressed from a higher level of function or
adaptation:
You have to respect his adulthood. To do this you have to treat him with
respect and approach him on his highest level of function. Don't take away
from him what he has, or you'll foster regression (Rako & Mazer, 1980, pp.
108-109).
In the opinion of Levine (2002, p. 309), Semrad was far ahead of his
time in his espousal and awareness of the "softer" values of human
attachment and the supportive relational matrix on which he believed
successful treatments depended. By the same token, while Semrad could
gently explain how acknowledging and bearing the reality of experience
could bring the patient pain and grief, he could also constructively
confront the patient with what was being avoided. "The way to make a
mule pay attention," he liked to say, "is to hit him on the side of the head
with a two-by-four!" (Levine, 2002, p. 310). (Recall that in his youth
Semrad had had actual experience with mules). It was understood, of
course, that confrontation with the patient was done in the context of a
supportive and helping relationship for facing what had been so tena-
ciously avoided through a retreat from reality: "Hold the reins in one hand
196
Elvin V. Semrad (1909-1976)

and a lump of sugar in the other" (Rako & Mazer, p. 112). This meant
providing optimal support and optimal frustration; in numerous clinical
case conferences, as Levine recalls (2002), Semrad would redirect the
attention of the assembled trainees to this crucial dimension of the
therapeutic relationship by pointedly and ironically asking them, "Does
this patient have a doctor?" (p. 309). Indeed, hearing such queries, some
who had contact with Semrad felt that he had a sadistic streak. Dan H .
Buie, M.D., (Youngren, 2005, p. 6) opined that Semrad used sadism
adaptively in therapeutically confronting patients and in the service of
teaching, such as by making residents feel guilty if he thought they didn't
care enough about their patients, or if they "cut off the patient's mind from
his body" by giving too much medication. In helping patients face their
painful experiences, "The most important therapeutic element we have is
empathy. Be empathic—just long enough" (Rako & Mazer, p. 106).
Semrad observed that the grief and the sadness of loss are intolerable to
patients with psychosis, who use gross denial to avoid their feelings. The
therapeutic task is to help the patient stand his pain, he said, and that is
directly contrary to the rest of medicine (Rako & Mazer, p. 105).
Regarding facing reality and the view that psychoanalysis is the study of
self-deception, Semrad remarked, "I've always thought that some of the
things people suffer most from are the things they tell themselves that are
not true" (Rako & Mazer, p. 5). (At the same time, "Everyone has to
believe in something" [p. 67]). On types of therapy for reducing this
suffering, Semrad simply explained that
Therapy is therapy—talking to the patient about what matters to him, no
matter at what pace he can take it . . . 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 (Rako & Mazer, p. 102).
"My main interest," he unassumingly claimed, "is to kibitz and learn"
(Rako & Mazer, 1980, p. 203). But his kibitzing was savvy. To some
observers, his views at time might have seemed old-fashioned or sexist—
perhaps also Midwestern, "unfancy," or plain, down to earth, and even
earthy, much like the plains of his origins. I felt an affinity for this man of
the Midwestern prairie. He would talk about someone's 'roots,' pronounc-
ing it in the Midwestern twang ("root" rhyming with "soot" instead of
"boot"), a pronunciation to which I could relate based on my own roots.
His wry and self-effacing humor could be found in his Nebraska hayseed
description. There also was a bovine view of his rather heavy-set, Buddha-
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like self. Havens recalled how Ives Hendrick was the "bull" and Elvin
Semrad the "cow" (Youngren, 2005, p. 9). The rustic analogy went further.
According to Semrad, "[Jack] Ewalt says that he was brought up with
horses [in Texas] and I was with mules" (Rako & Mazer, 1980, p. 203). His
view of himself also could be found in terms of his selection of residents:
"We choose residents who are not sadistic and who are comfortable with
their own passivity" (p. 185).
People often tried to emulate him. According to Donald Gair, M.D.,
(Youngren, 2005, p. 8), some even picked up his hand gestures—imitation
preceding identification—so that one might recognize his clinical descen-
dants by their gestures. I believe that in his role as a mentor to many early
in their training, it was natural to see him as an idealized figure, even if
some challenged him at times. The extent to which this idealization has
been pervasive may be seen in the auditorium of the Boston Psychoanalytic
Institute, where, among the wall of photographs of the many presidents of
B.P.S.I., that of Elvin Semrad is the only one with a halo of illumination
around his head.
Semrad's unadorned second-floor office was midway between the
offices of Jack Ewalt, M.D., the superintendent, and Les Havens. This area
was the clinical-academic-administrative hub of the hospital. Just beyond
Ewalt's office was the library, replete with wonderful old and new volumes.
The newer Research Building was at the end of one of the spokes. In his
office, Semrad's stack bookshelves contained dozens of large reel-to-reel
tape recordings of his interviews. A simple, worn, reddish-leather analytic
couch rested alongside a wall. Many residents kept their offices under-
rated, like his office. A faded hand-written note was always taped to
Semrad's door. It read:
When door is ajar, come in.
When closed, am busy.
If emergency, please knock (Rako & Mazer, 1980, p. 16).
Semrad was remarkably available to listen to others who might just
drop in during his long hours at the "Psycho." One day I arrived for a
scheduled meeting with him. The door was ajar, but I heard his voice,
evidently on the telephone. I waited outside, not to interrupt. Soon his
voice began to escalate into loud anger at the person on the other end of
phone, and he interjected a series of choice, irate profanities. I was mildly
shocked at this primal upsurge, never having heard such language from
this usually mild-mannered, avuncular man with a sometimes Cheshire-cat
grin (even though he certainly talked about a patient's anger, as well as
198
Elvin V. Semrad (1909-1976)

sadness, guilt, joy, and despair). He seemed to be personifying the teakettle

building up steam that he mentioned when patients needed a homey
analogy for anger. For a trainee like me, seeing this real side of an admired
teacher was a revelation. There was no question, however, about his calm
but firm capacity to confront defenses, including those against anger, in
getting to the heart of the matter with patients, residents, and staff.
"Everyone is either mad, sad, or afraid" (Rako & Mazer, 1980, p. 94). In
comments to a chief resident, for example, he is quoted as saying:
It is not your job to kiss asses. It is your job to set limits about the
appropriate treatment of a patient and to point out to a resident that he's
fucking up (Rako & Mazer, 1980, p. 188).
There was, then, a gruff, no-nonsense aspect to his character that some-
times came to the fore. Semrad could be remarkably patient but also set
limits. Max Day recalls bemoaning to Semrad one Sunday afternoon at
Boston State about how tiresome it was interviewing relatives of patients
for hours on end on Sunday afternoons. Semrad said, "Look, Doc, when
they bother you, just push your right big toe down in your shoe and keep
quiet" (Youngren, 2005, p. 3).
He did not mince words with patients either and was unfazed by
whatever they told him. Buie (Youngren, 2005, p. 7) described how
Semrad unhesitatingly talked with patients at the level of their concern, no
matter how primitive or sexual. Buie was caring for a patient with
schizophrenia, with whom he had been working for months. He was
shocked when Semrad asked the patient to tell him about his concern with
his "mother's ass hole." With another patient Semrad interviewed, a
beautiful young woman whom Buie felt he had not been effective in
helping, he described his own discomfort when Semrad asked her about
her interests in "genital kissing"—a topic Buie stated he could not explore.
Patients could talk to him with relative comfort about such matters
because he was comfortable with just about everything. In response to a
resident's request for advice about what to say to a patient, Semrad once
replied:
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 right way to say it (Rako & Mazer, pp. 104-105).
"People," he open-mindedly and compassionately observed, "make all
sorts of arrangements" (Rako & Mazer, 1980, p. 59). Sometimes patients
remarked that they felt understood as never before after being interviewed
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by Semrad. At other times, if Semrad brought a patient's defenses into

sharp focus for the first time, the resident might have to "pick up the
pieces" afterwards. He had a persistent way of calling patients' avoidance
to their attention. These were his views on addressing defenses and
eliciting experience in hospitalized patients:
We must insist on talking to patients only about what they actually
experience. In other words, go right through the defenses, rather than lose
our efforts in helping them strengthen their already strong defenses. The
only thing we really deal with in our relationships with patients is their
actual life experience—not the stock they came from, their heredity, their
genes, the biological propensities to growth. All we deal with is their
reaction to their life experience; 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 (Thompson, 2003, p. 115).
Semrad had ways of moving behind defensive avoidance. For example,
he would say to a psychotic patient who was hoping to interest him in her
florid symptomatology as an avoidance of the impoverishment of her life,
"You're pulling my leg" (Hallowell & Smith, 1983, p. 152). His approach
differed from the early interpretation of id content as represented by John
Rosen's "direct analysis" or Melanie Klein's method of "deep" interpre-
tation. On the other hand, on one occasion when Semrad and I were
discussing child psychiatry training, he contrasted work with adults and
children by noting how "children show you what they feel" (personal
communication, March 1974). By talking with patients about "what really
matters to them," based on their experience, he tried to help them see that
they were avoiding before going to what they were avoiding: " I don't know
what it is with you. That's what I want to find out." Later, "As you study
this feeling, what does it tell you?" (Rako & Mazer, 1980, p. 131). And, in
his consultative role, "Can I talk to your doctor about your problem?"
(p. 134). Regarding why the patient did not disorganize during the
interview, he explained, " I let him know I meant business, and he was
reassured and settled down." Or when a woman patient who had lost a
male love asked, "Well, what can I expect from my therapy?" he replied,
"Nothing but work," and this, he explained, was very consoling to her
(Rako & Mazer, p. 141). To those doing psychotherapy, he advised,
Go after what the patient feels and cannot do himself. Help him to
acknowledge what he cannot bear, and stay with him until he can stand it
(Rako & Mazer, p. 105).
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Elvin V. Semrad (1909-1976)

Furthermore,
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 (Rako & Mazer, p. 106).
Patients with psychosis, according to Semrad, "had to choose among
homicide, suicide, or going crazy." In response to a resident's question
regarding what to tell a patient about how long he will need therapy,
Semrad answered, "As long as it takes" (Rako & Mazer p. 109). He
observed that "when you feel loved, you don't have to be crazy" (Rako &
Mazer, p. 141). As a therapist, "You've got to love your patients" (Rako &
Mazer, p. 119); but "A little love can go a long way" (Rako & Mazer,
p. 120). At the same time, he emphasized the importance of the therapeu-
tic frame. Relevant to current expositions on boundary violations, for
example, I recall that he tersely and clearly cautioned, "When the touching
begins, the therapy ends." As pointed out by Celenza (1991), mistaking the
transference [and countertransference] as real is one of letting go issues
encountered in cases of sexual intimacies between therapists and patients.
It is tempting to feel flattered by an erotic transference; even for the
seasoned therapist, experiencing it can be replete with ambivalence.
Semrad is remembered to have said to an adoring female patient, "You feel
this way for neurotic reasons and when you get better, I will be very sad"
(Celenza, 1991, pp. 501-502). On the subject of countertransference
feelings, he observed, "Your own associations can be very helpful if
presented in the spirit of inquiry and help (Rako & Mazer, 1980, p. 117).
And regarding the sadness of parting, Semrad spoke at length about how
parents have as much trouble letting go of children as children have about
going (Rako & Mazer, 1980, pp. 204-206). As for mothers and patients, he
noted that " . . . everybody says, 'Get him away from his mother,' except
me, who says, 'It's the only Mama he's got. When he can leave her, which
is not easy, he will!'" Rako & Mazer, p. 204).
SEMRAD ON PSYCHOTHERAPY AND PSYCHOANALYSIS
As noted by Buie (Youngren, 2005, p. 6), Semrad taught that psycho-
therapy and psychoanalysis were conducted altogether differently. Key to
this difference was his view that psychoanalysis deals with defenses that
depend on repression, whereas psychotherapy deals not only with repres-
sion but also with other "avoidance devices." Repression, he taught, could
be lifted only by free association. "The only way to forget is to remember"
(Rako & Mazer, 1980, p. 106).
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Denial, which is at the other end of the defensive spectrum, yields with
offering interpersonal, mostly nonverbal support (caring). As the patient
accepts the therapist's supportive presence, suppressed recollection and
sharing of distressing matters follow. In that manner with patients Semrad
was extremely adept (Youngren, 2005, pp. 6-7). My recollection from his
lectures and supervisory sessions was consistent with Buie's description:
For anxious patients, he advised the therapist to "just be there and keep
your mouth shut." For the defense of projection, the need is for "caring
and responsibility sharing." For distortion, it is for "just the facts." In
hypochondriacal patterns, the patient needs the therapist to "love all of me
instead of only parts," and for neurasthenia (usually a manifestation of
depression) it is to "love me because I am rather than for what I can do,"
and so on (my lecture notes, August 2, 1972). For "people who are digging
their heels in and won't budge, you have to work with them and take them
through the stages from I don't know to I cant to I won't, and show them
how they are using their defenses" (Rako & Mazer, 1980, p. 173). A central
prerequisite of Semrad's method was offering enough support so that the
patient could relinquish avoidance defenses and thereby share the pain.
Semrad felt that sadness is one of the hardest feelings to bear—more so
than depression or anxiety—and it needed attention first and foremost
(Russell, 2006, p. 627; Buie in Youngren, 2005, p. 7).
On the other hand, he believed that analysis required analysands to
follow the fundamental rule on free association and to take responsibility
for what comes to mind. Thus, Semrad advised psychoanalytic candidates
to "help a fellow to free associate and then get out of his way" (Levine,
2002, p. 311). Although he did offer clarifications, interpretations, and
confrontations, not uncommonly all he would say in an hour was, "You're
not following the basic rule." To his analytic patients he would explain, " I
have nothing to give you but my technique," whereas with students and
patients in psychotherapy he was warmly caring, albeit relentless in
pursuing understanding, particularly at an emotional level (Buie in Youn-
gren, 2005, pp. 6-7). As regards the analysis of resistance (which is
universal) and the question of ending treatment, he offered this: "By the
time the patient stops saying no the analysis is over" (Rako & Mazer,
p. 117).
Louis Brenner, M.D., a colleague who years ago had a successful
analysis with Semrad, recalled some of his experiences on and off the
couch. Usually Semrad did not answer the phone during the analytic hour
(since this was before the days of answering machines). During one
session, the phone rang and rang and rang. Finally, Semrad apologized
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Elvin V. Semrad (1909-1976)

and picked up the phone. He said nothing at first. Then he said, "Yes . . .
yes . . .," followed after a bit by "thank you," and he then hung up. There
was what felt like a long pause in the hour. At length, Semrad asked if he
could end the session early. There was a fire in the basement, he explained,
and he thought they should get out of the building (personal communi-
cation, December 11, 2005). Semrad was almost totally unflappable.
Decades after the analysis, Brenner fondly recalled Elvin Semrad. He
related how, encountering Semrad at a party several years post-analysis, he
explained to Elvin how successful the analysis had been—"with one
exception." He put his hands on his residual and substantial belly and
noted: "This!" Without skipping a beat, Semrad put his hands onto his
own substantial abdomen and quipped, with a twinkle in his eye, "Well,
what did you expect?" (personal communication, 1991). 4

Semrad retired from his Harvard professorship on July 1, 1976, but

remained as a senior clinican at M.M.H.C. He died on Thursday, October
7, of that year, in his chair (not while taking a postprandial nap on his
couch, as some have reported it). Attempts to revive him in his office were
unsuccessful (Gutheil in Youngren, 2005, p. 8). A funeral mass the
following Tuesday at St. Philip Neri Church in Newton, MA was attended
by throngs of those who admired, appreciated, and mourned this special
man. He left his wife, Henrietta (Steva), whom he marrried in 1936, two
sons, Theodore L. Semrad of Carlisle, MA, and Elvin L. Semrad of Waban,
MA, and two daughters, Susan Dianne Semrad of Waban, MA, and Mrs.
Henrietta Marie Rycroft of Chelmsford, MA (Anderson, 1976).

Acknowledgement: An earlier version of this paper appeared in the Newsletter of the Psychoana-
lytic Society and Institute of New England, East.

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For a possible relationship between the influenza epidemic of 1918, loss, and Semrad's over-
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