In Practice

A practicing doctor's views on psychiatry and contemporary culture.

Charisma in Psychotherapy

Peter D. Kramer asks: How much charisma do we want in our psychotherapists?

How much charisma do we want in our psychotherapists? Fairly little, I have always thought. But then, my own analyst, “Max,” was dull and staid — nearly invisible, and enormously competent. Think of George Smiley, played by Alec Guinness. I wrote about Max toward the start and finish of my first book, Moments of Engagement: Intimate Psychotherapy in a Technological Age. Implicitly, I was contrasting his self-effacing style with the more imposing manner of certain leaders in American psychiatry.

Three weeks back, I put up what I promised would be the first of a two-part posting about Elvin Semrad, a nearly forgotten but in his time extraordinarily influential teacher of psychiatry. Semrad, a leader in the Harvard system from the ‘50s into the ‘70s, held a belief, now out of favor, that schizophrenia arises from Freudian sexual drives distorted by a flawed family environment. As Joel Paris points out in his debunking study, The Fall of an Icon: Psychoanalysis and Academic Psychiatry, even though the bulk of Semrad’s clinical work was with analytic candidates and wealthy patients with milder conditions, he made his mark through “demonstration interviews” with psychotic patients. These diagnostic sessions were meant also to be therapeutic, even though they were conducted before an audience of staff and trainees.

In Moments, I listed Semrad as a therapist who transcended genre. It is true that, despite his Freudian trappings, Semrad could be immediately present with a patient. In an interview with Paris, Leston Havens (my own mentor, and Semrad’s student) called his teacher “an existentialist behind an analytic façade.” All the same, I mistrusted those performances. To me, Semrad seemed all too comfortable in the guru role. Though I did not name Semrad, anyone who knew his work would take the following passage, from the sixth chapter of Moments, as a critique à clef:

The typical interviewing tour de force in my Freudian medical school was an encounter with . . . a schizophrenic patient . . . The patient would enter mute or babbling word salad, and the understanding interviewer would sit close beside him — this would be in front of a group of twenty onlooking students at various stages in training — and rumble empathic sweet nothings.

The therapeutic instrument was the well-analyzed analyst, a man neither frightened nor disgusted by the patient's unconscious urges expressed through the illness. The interviewer in his soul wanted neither domination nor succor, his chest was a neutral pillow on which the troubled patient could rest his head.

And soon the conversation would turn to the patient's childhood, to memories of a grandmother, perhaps, who had shown occasional kindness amidst the continual abuse wreaked on the child by parents and siblings. The audience held its collective breath as the patient, coherently now and with more feeling than anyone on the ward had ever heard him muster, poured forth his sense of longing and of loss.

The effect of these interviews was odd, because often as not, no one on the ward could ever again elicit a moment of lucidity from the patient. The master interviewer had proved it could be done, and his success served to convince the staff that the patient's illness fit a psychological model of resistance and symptom formation through compromise in the face of inner conflict. But moving further was usually a chore, with the result that the effective message to young therapists was that they needed more inner greatness — freedom from their own conflict — if they were to do the job. It was to this peace and harmony that I aspired, although I was aware even as a medical student that it had it annoying, sanctimonious side.

I should add that I mistrusted Semrad’s power, in these public forums, in part because I had some of it myself. Given the stage and the audience, it is not so hard, finally, to get patients to reveal themselves. But should they? And are we to trust the insights that emerge? I am glad that the demonstration interview is, for the most part, a thing of the past.

To be yet more frank, I think Semrad owed some of his status to his ethnicity. Unlike the leaders of the prior generations, he was not not a wordy, accented, angst-ridden, continental, urban Jew. Like Harry Stack Sullivan, like Murray Bowen, like Carl Whitaker, like Carl Rogers, Semrad, who hailed from Abie, Nebraska, promised a more truly American psychotherapy. He was Will Rogers, full of aphorisms and an ability to like something in everyone.

Students have collected his sayings in a sometimes charming, sometimes cloying book, Semrad: Heart of a Therapist. What do we make of these aperçus:

“There isn’t one girl in this room who hasn’t crossed swords with her mother.”

“I’ve never seen anybody get mad at anybody unless he matters to her.”

“The only thing that shakes up men is their women.”

“American women don’t seem prone to be mistresses, they want it for keeps. It’s okay to be bait, but when she goes fishing, she wants the fish.”

“Home is a place you can’t go back to: it isn’t there anymore.”

“You know, nobody likes to work. It’s a substitute activity for loving.”

They recall a simpler era. But in retrospect (and, honestly, the same was true even at the time), the observations are culture-bound, anti-intellectual, condescending to women, and a trifle self-satisfied. Though they have the form of wisdom, many of the observations strike me as simply wrong. People like work for for its own sake, for the challenges it sets and the competency it elicits.

I would love to see psychotherapy flourish again, as it did at mid-century, but with this difference. No gurus. My ideal of a psychotherapeutic revival is a movement whose leaders are admired but not idolized.

Peter D. Kramer is a psychiatrist and author. His books include Against Depression and Listening to Prozac.

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