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European Association of Psychoanalysis

ARTICLES

WB01540_.gif (632 byte) Ward Round (Thomas Szasz) 

WB01540_.gif (632 byte) Taking Drug Laws Seriously, II (Thomas Szasz) 

WB01540_.gif (632 byte) Psychoanalysis today:  science or psychotherapy? (Antoine Fratini) 

WB01540_.gif (632 byte) Soteria-California and Its Successors: Therapeutic Ingredients (Loren Mosher) 

WB01540_.gif (632 byte) The New Psychiatric Deal (Thomas Szasz)

WB01540_.gif (632 byte) Mental Illness: Psychiatry's Phlogiston (Thomas Szasz)

WB01540_.gif (632 byte) Straight talk about suicide. Ideas on Liberty (Thomas Szasz)

WB01540_.gif (632 byte) Cleansing the Modern Hearth (Thomas Szasz)


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The New Psychiatric Deal

In 1950, the population of the United States was about 150 million and there were nearly one million patients in public mental hospitals. Today the population is more than 250 million, and there are fewer than 150,000 patients in public mental hospitals. This dramatic decrease is attributed to antipsychotic drugs and deinstitutionalization.


LAYING THE GROUND FOR DEINSTITUTIONALIZATION

In the seventeenth century, the edifice of psychiatry was built on a solid foundation, sunk deep into the bedrock of developing Western society, namely, on the incarceration of insane individuals in madhouses. In a free society, only the state has the authority to deprive an individual of liberty, and only if he has been convicted of a felony. Hence, a new principle was needed to justify depriving persons innocent of lawbreaking of liberty. The new science of mad-doctoring or psychiatry provided the justification: Insanity. As only persons convicted of a criminal offense could be lawfully confined in prison, so only persons diagnosed as mentally ill could be lawfully confined in an insane asylum. The state assumed the dual obligation of protecting itself from the madman and the madman from himself, and authorized the mad-doctor to implement and enforce this principle. Thus did the systematic, forcible incarceration of unwanted persons, qua dangerous mental patients, become the social policy, called "mental hospitalization."

In the 1950s, the principle and practice of involuntarily hospitalizing the mental patient was supplemented by the principle and practice of involuntarily dehospitalizing him, called "deinstitutionalization." The term refers to the policy of medicating mental hospital patients with psychotropic drugs, evicting them from public mental hospitals, transferring (many of) them to other public facilities, and refusing them re-admission, especially if that is what they want. Like institutionalization, deinstitutionalization also required the use of state-sanctioned coercion. Moreover, this policy ran counter to the traditional practice of confining crazy people for long periods, and thus also needed to be justified. This was accomplished by means of the interlocking claims that psychotropic drugs offered an effective treatment for mental illness and that the mental patient’s best interests required that he be discharged from the hospital "to the least restrictive setting in the community."

In 1955, Daniel Blain, the medical director of the American Psychiatric Association, promised that "the 750,000 patients now in this country’s mental hospitals" would soon be returned to the community, "cured." The truth is that after treatment with neuroleptic drugs, mental patients tend to be sicker and more disabled than before. Many exhibit the toxic effects of the drugs, suffering from a disfiguring neurological disturbance called "tardive dyskinesia." Virtually all of them continue to depend on family or society for food and shelter. The contrast drawn between the mental hospital and the
community is a lie. The domiciles now housing chronic mental patients are neither more nor less a part of the community than the state hospital. Before deinstitutionalization, psychiatrists claimed that the best treatment for seriously ill mental patients was long-term hospitalization, combined with insulin shock or electric shock. Now they claim that the best treatment for them is short-term hospitalization, combined with antipsychotic medication and deinstitutionalization. Both claims are pseudoscientific fables, concealing heartless bureaucratic-psychiatric policies of storing unwanted persons. A British report on American mental health policies makes precisely this point: In New York State, for example, a large number of psychiatric patients were recently thrown out of large institutions, almost literally overnight, and left to wander the city streets... Yet when winter comes, those very people are rounded up and herded into huge warehouses, not much different from the workhouses of old, where they are "kept" for the winter. I maintain that neither long-term mental hospitalization nor deinstitutionalization has anything to do with illness, treatment, or medicine. Both are legal and socio-economic policies, using medical rhetoric as justificatory pretexts. World War II: Psychiatry Gains Medical Legitimacy For centuries, psychotics and psychiatrists alike were banished to madhouses, located on the outskirts of cities or in the countryside. The typical psychiatrist worked in a public insane asylum, overseeing desolate scenes of human misery. Between roughly 1935 and 1955, two events radically transformed both the image and the reality of American psychiatry. One was the influx of European psychoanalysts, the other the introduction of psychiatric drugs.

Most of the European psychoanalysts who managed to escape from Nazism emigrated to the United States. London, where Freud died, became the shrine of the Freudian cult. The United States, especially New York City, where the influential analysts and their wealthy backers settled, became the movement’s new power base.

Psychoanalysts were generally better educated and more cultured then psychiatrists. Thrown together in the Armed Forces, the analysts outshone the psychiatrists. Furthermore, General William Menninger, the Armed Forces’ Chief Psychiatrist and the younger brother of famed Karl Menninger, was an accredited psychoanalyst. Both Menningers were talented promoters of what, in fact, was traditional, hospital-based psychiatry cloaked in the beguiling mantle of psychoanalysis. For young psychiatrists in the late 1940s, the psychoanalyst -- with cigar, or at least cigarette or pipe, perpetually between his lips -- became an irresistible role model. As a result of American psychiatry’s war experience, the profession became seemingly psychoanalytic. I say seemingly because the influence of psychoanalysis on psychiatry was purely cosmetic, imparting to it its pretentious jargon and bogus therapeutic claims, but not its authentic spirit. Drafted into the Service, psychiatrists left their hospitals and offices, donned uniforms, mingled with other physicians and, presto, became accepted as real doctors, on equal footing with other physicians. The military mad-doctor did not need to display any genuine medical skills. His status as a medical officer was enough to legitimize him as a regular physician. Also, a crucial fact of military life lent support to the psychiatrist’s becoming recognized as a real doctor. Being tired of the war was defined as a bona fide disease, "battle fatigue"; servicemen exhibiting symptoms of it were diagnosed as "neuropsychiatric casualties"; and, mirabile dictu, many of these patients were easily cured. Since the illnesses were non-existent, this should not have surprised anyone. For the serviceman, psychiatric disability was an honorable escape from the dangers of war. For the military bureaucracy, it was a convenient method of getting rid of unwanted personnel. Naturally, this was not the way military psychiatrists interpreted their patients’ behavior, which they regarded as genuine diseases; or their own ministrations, which they regarded as genuine treatments. When the war ended, the victorious psychiatrists returned to civilian life, determined to conquer America for psychiatry. Deutschland uber Alles lost. Psychiatry uber Alles won, and was let loose on the American population.

Meanwhile Psychiatry Loses Medical Legitimacy on the Home Front Ensconced behind the war zone, military psychiatrists thrived on malingerers, defined as neuropsychiatric casualties. Meanwhile, back on the home front, the prisoners of America’s snake pits languished in the wretchedness to which they and their keepers had become accustomed. The returning psychiatric veterans, who spent their formative years in the Service, found state mental hospital conditions appalling, reminiscent of the horrors of concentration camps. Even makeshift psychiatric wards in military hospitals provided a far more humane environment than did the best civilian state hospitals. The perennial complaints of mental patients, together with a fresh spate of exposes in the press, suddenly acquired credibility. Phrases such as snake pit and shame of the states, lifted from the titles of best-selling books, quickly gained popularity. The medical legitimacy of psychiatry, qua state hospital psychiatry, reached its nadir. The word was out that psychiatrists were merely warehousing people. Like the picture of
Dorian Grey, the portrait of the American state hospital underwent a sudden transformation, from hero to villain. The following two statements -- excerpted from the addresses of presidents of the American Psychiatric Association separated by thirty years -- tell the whole story: ***William A. White (1925): "The state hospital, as it stands today, is the very foundation of psychiatry." ***Harry C. Solomon (1958): "The large mental hospital is antiquated, outmoded, and rapidly becoming obsolete ... [It is] bankrupt beyond remedy... and should be liquidated as rapidly as possible." Unfortunately, both the psychiatrists’ blind support of the state mental hospital as a therapeutic institution and their righteous rejection of it as an anti-therapeutic institution were insincere and wholly self-serving.

THE PSYCHOANALYTIC INTERLUDE

The advent of psychoanalysis and office-based psychotherapy in the early decades of the twentieth century introduced a new element into the established social-economic order of psychiatry. Traditionally, being a psychiatrist meant being an employee of a state hospital. In most of Europe, Jewish doctors could therefore not become psychiatrists. However, they could become general practitioners and neurologists, or so-called nerve doctors, listen and talk to their patients, call it "psychotherapy" or "psychoanalysis," and sell their services to fee-paying customers. Psychoanalysis thus came into being as part of the private practice of medicine, then one of the so-called free professions. The psychoanalytic patient, like the customer of any service supplied by entrepreneurs in the free market, sought out the analyst, went to his office, received a service, and paid a fee for it. The client was on top, the therapist on tap. The practice of psychoanalysis sprouted in the soil of the free market and depended on it for its integrity and survival. But Freud and the early analysts neither understood the market nor supported its values. They only took advantage of it, like spoiled children taking advantage of wealthy parents. No sooner did Freud get on his feet, economically and professionally, than he embraced the style of the conquering hero, to whichhe always aspired. In 1900, he wrote: "I am not at all a man of science, not an observer, not an experimenter, not a thinker. I am by temperament nothing but a conquistador -- an adventurer, if you want it translated..." Four years later, he added: "I have never doubted [my] posthumous victory." To Jung he announced that psychoanalysis must "conquer the whole field of mythology." Freud’s self-image as a "conquistador" thus meshed perfectly with his ambition to conquer psychiatry for psychoanalysis. Clearly, neither Freud nor the Freudians had any intention of honoring the promises implicit in the psychoanalytic contract. Freud and his expansionist followers were not satisfied with limiting themselves to their contractually defined role, aspiring instead to be magical healers in the grandiose tradition of medical-messianic quacks. They claimed, and themselves came to believe, that they were treating real
diseases and that their treatment was more scientific and more efficacious than that offered by other medical specialists. Few European or British psychiatrist bought this boast. However, many influential American psychiatrists did. This is the reasons why psychoanalysis was so readily integrated into American psychiatry. Fifteen years after visiting the United States, Freud reminisced: "As I stepped on to the platform at Worcester to deliver my Five Lectures on Psycho-Analysis, it seemed like the realization of some incredible day-dream: psycho-analysis ... is recognized by a number of official psychiatrists as an important element in medical training." After World War I, American state hospital psychiatrists embraced psychoanalysis, and the analysts gratefully reciprocated by embracing coercive-statist psychiatry.

Psychoanalysis Has Its Moment of Glory Unlike in Europe, psychoanalysis was well received in the United States. However, this friendly reception, as I noted, rested on the totally mistaken belief that psychoanalysis was an effective method for treating mental illness. During World War II, the status of psychoanalysis was elevated, while its integrity was utterly destroyed, by the analysts’ uncritical acceptance of their role as agents of the Armed Forces. Long ago, civilian society delegated to the psychiatrist the task of separating the sane from the insane. In the military, he was assigned the analogous task of separating those fit and willing to fight and die for their country from those unfit and unwilling to do so. This job required fabricating appropriate pseudomedical explanations for why people are unwilling to die in battle. Psychoanalysts, adept at explaining why anyone did anything, took to their military role like the proverbial duck to water. Many were recent refugees from Nazism. Grateful to their adopted country, they were happy to do the bidding of the military authorities: They found "neuropsychiatric casualties" by the millions. The pragmatic necessities of the military thus found a loyal ally in psychoanalytic theory. This was an utterly phony, albeit expedient, use of psychoanalysis. The upshot was that psychiatrists spouting psychoanalytic jargon enjoyed a brief moment of glory as professionals valued for their arcane knowledge and ardent patriotism. During the war, psychoanalysis and psychiatry were joined together, much as a veneer of fine mahogany may be bonded to the body a cabinet made of common pine. For a brief period, the glamor and prestige of this superficially psychoanalyticized psychiatry carried over into civilian life. But it was all show, devoid of substance. Chairmen of psychiatry departments in medical schools, directors of state hospitals, and psychiatrists in private practice who used ECT (electroconvulsive therapy) on their patients all displayed psychoanalytic credentials and spoke in psychoanalytic jargon. In the process, the tiny nucleus of truth in psychoanalysis vanished, and "psychoanalysis" became a corrupt cult that had forsaken and forgotten its core values. The Incompatibility of Psychiatry and Psychoanalysis Like the core elements of the classic concept of liberty, the core elements of psychoanalysis are best stated as negatives, that is, as the absence of factors antagonistic to its aims and values. Political liberty is the absence of the coercions characteristic of the traditional relations between rulers and ruled. Similarly, psychoanalysis is the absence of the coercions characteristic of traditional relations between psychiatrists and mental patients. Consider the contrasts. The psychiatrist controls and coerces, the psychoanalyst contracts and cooperates. The former wields power, the latter has authority.

Political liberty is contingent on the state’s respect for private property and its non-interference with acts between consenting adults. Psychoanalysis is contingent on the therapist’s respects for the client’s autonomy and his non-interference with the client’s life. This (ideal) psychoanalytic situation represented a new development in the lunacy trade, introducing into psychiatry and society a new form of "therapy," one in which the expert eschewed coercing deviants and housing dependents, and confined himself to conducting a particular kind of confidential dialogue. In the psychoanalytic situation, there is, in the medical and psychiatric sense, neither patient nor doctor, neither disease nor treatment. The dialogue between analyst and patient is therapeutic in a metaphorical sense only. Purged of jargon, the psychoanalytic "procedure" consists only of listening and talking. So conceived, psychoanalysis undermined rather than supported psychiatry as a medical specialty and extra-legal system of social control.

When Freud remarked "that analysis fits the American as a white shirt the raven," he would have been closer to the mark if, instead of "American," he had said "psychiatrist" or "psychiatry." Psychiatry did not acquire, and could not possibly have acquired, any of the real substance of psychoanalysis. The two enterprises rested on completely different premises and entailed mutually incompatible practices. The typical psychiatrist was a state-employed physician who worked in a mental institution; the typical psychoanalyst (often not a physician) was a self-employed provider of a personal service who worked in his private office. The typical psychiatric patient was poor, was cast in the patient role against his will, and was housed in a public mental hospital. The typical psychoanalytic patient was rich (usually wealthier than his analyst), chose to be a patient, and lived in his own home (or a hotel). The marriage between the psychiatrist and the psychoanalyst was a misalliance from the start, each party disdaining and taking advantage of his partner. Psychiatry acquired the worst features of psychoanalysis -- a preoccupation with sex and the past, an elastic vocabulary of stigmatizations, and a readiness for fabricating pseudo-explanations. Psychoanalysis acquired the worst features of psychiatry -- coercion, mental hospitalization, and disloyalty to the patient. Bereft of professional integrity, post-war American psychiatry relapsed into its old habit of embracing prevailing medical fashions, which, as it happened, was more-drugs-and-less-discourse. The curtain was now ready to go up on the next act in the drama of modern psychiatry, the tragi-comic episode called "deinstitutionalization."

Thomas Szasz

 


Mental Illness: Psychiatry's Phlogiston

"The madman is not the man who has lost his reason. The madman is the man who has lost everything except his reason."

Gilbert K. Chesterton

In physics, the same laws are used to explain why airplanes fly, and why they crash. In medicine, the same principles are used to explain why people live and why they die. In psychiatry, however, one set of rules is used to explain sane behavior, and another set of rules to explain insane behavior: sane behavior is attributed to reasons (choices), insane behavior to causes (diseases).

God metes out Divine Justice without distinguishing between sane and insane persons. It is hubris to pretend that we know better. Yet, it is received wisdom that "geniuses" are responsible for their creative acts, but "madmen" are not responsible for their destructive acts. Hence the preposterous conclusion that civil commitment and the insanity defense are compassionate, just, scientifically-enlightened practices.

Mental illness is to psychiatry as phlogiston was to chemistry. Establishing  chemistry as the scientific study and explanation of matter depended on the investigators' willingness to recognize and acknowledge the nonexistence of phlogiston. Similarly, establishing psychiatry as the scientific study and explanation of human behavior depends on psychiatrists' willingness to recognize and acknowledge the nonexistence of mental illness.

THE CONGENITAL EPISTEMOLOGICAL ERROR OF PSYCHIATRY

Benjamin Rush (1745-1813) was an American patriot and a signer of the Declaration of Independence who served as physician general of the Continental Army and as professor of physic and dean of the University of Pennsylvania medical school. In 1774, he declared: "Perhaps hereafter it may be as much the business of a physician as it is now of a divine to reclaim mankind from vice." In that act of medicalization lies the root error of psychiatry.

To distinguish himself from the doctor of divinity, the doctor of medicine could not simply claim that he was protecting people from sin, or vice, as Rush put it. Badness remained, after all, a moral concept. As medical scientist, the physician had to claim that badness was madness, that his object of study was not the immaterial soul or "will," but a material object, a diseased body. However, Rush did not discover that certain behaviors are diseases, he decreed that they are: "Lying is a corporeal disease. ... Suicide is madness. ... Chagrin, shame, fear, terror, anger, unfit[ness] for legal acts, are transient madness." Today, some of these and many other unwanted human behaviors are widely accepted as real diseases -- "chemical imbalances in the brain" -- their existence ostensibly supported by scientific discoveries in neuroscience.   

Modern natural science rests on laws uninfluenced by human desire or motivation. We do not have one set of medical theories to explain normal bodily functions, and another set to explain abnormal bodily functions. In psychiatry, the situation is exactly the reverse. We have one set of principles to explain the "rational" behavior of the mentally healthy person, and another set to explain the "irrational" behavior of the mentally ill person. The former is viewed as an active moral agent -- he makes choices, for example, to marry his sweetheart; the latter is viewed as a passive body or object -- subject to the effects of injurious biological, chemical, or physical forces that create diseases (of the brain), manifested for example by an irresistible impulse to kill.

"The epileptic neurosis," wrote Sir Henry Maudsley (1835-1918), the founder of modern British psychiatry, "is that it is apt to burst out into a convulsive explosion of violence. ... To hold an insane person responsible for not controlling an insane impulse ... is in some cases just as false ... as it would be hold a man convulsed by strychnia responsible for not stopping the convulsions." It is a false analogy. Killing is a coordinated act. Convulsion is an uncoordinated contraction of muscles, an event.

We are proud of our unending quest to abolish prejudiced beliefs about the differences between the human natures of different genders and races. At the same time, we are even prouder that we have created a set of psychiatric beliefs about the differences between the neuroanatomical and neurophysiological natures of the mentally healthy and the mentally ill.

Oxidation, a real process, explains combustion better than does phlogiston, a nonexistent, imaginary substance. Attributing all human actions to choice, the basic building block of our social existence, explains human behavior better than attributing certain (disapproved) actions to mental illness, a nonexistent, imaginary disease. Regardless of the condition of an "irrationally" acting person's brain, he remains a moral agent who has reasons for his actions: like all of us, he chooses or wills what he does. People with brain diseases -- amyotrophic lateral sclerosis, multiple sclerosis, Parkinsonism, glioblastoma -- are persons whose actions continue to be governed by their desires or motives. The illness limits their freedom of action, but not their status as moral agents.

ANSWERING OBJECTIONS

According to psychiatric theory, certain actions by certain people ought to be attributed to material causes, not moral reasons. When and why do we seek a causal explanation for personal conduct? When we consider the actor's behavior unreasonable and do not want to blame him for it. We then look for an excuse masquerading as an explanation, rather than simply an explanation that neither exonerates nor incriminates. Holding a person responsible for his act is not the same as blaming or praising him for it: it means only that we regard him as a moral agent.

It is a mistake to believe that offering an excuse-explanation for an act is tantamount to showing that the actor has no reasons for his action. Offering an excuse for doing X -- "God's voice commanded me" -- is not the same as not having reasons for doing X. To the contrary: what we have shown is not that the actor has no reasons, but that his reasons are wrongheaded  -- "deluded," "mad," "insane." We conclude that his actions are caused by his being deluded, mad, insane. But we have not proven anything of the sort; we have postulated it.    

The "mental patient" who attributes his misdeed to "voices" is not a victim, a robot responding to an irresistible impulse; he is a victimizer, an agent rationalizing his action by attributing it to an irresistible authority. The analogy between a person who "hears voices" and an object, say a computer responding to programmed information, is false. The mental patient responding to the commands of "voices" resembles the person responding to the commands of respected authorities, exemplified by the "suicide-bomber" who martyrs himself for a cause blessed by God. Both persons are moral agents, albeit both portray themselves as slave-like objects, executing the will of an Other, often identified as God or the devil.

Such representations are dramatic metaphors that actor and audience alike may or may not interpret as literal truths. It is not an accident that the "voices" a schizophrenic "hears" never command him to be especially kind to his wife. That is because being kind to one's wife is not the sort of behavior to which he, or we, want to assign a causal -- psychiatric -- explanation. There is method in madness.

Thomas Szasz


Straight talk about suicide. Ideas on Liberty, 52: 34-35 (September), 2002.


Suicide -- like accident, illness, death, poverty, persecution, and war -- has   always been with us and has always been regarded as a part of life. Believing that a person's life belongs to God, not himself, the Jews declared it to be a grievous sin, and Christians and Muslims followed suit. 
Enlightenment thought did not overtly repudiate this position. Instead, it supplemented it with a secular version of it. Suicide, declared the mad-doctors ("psychiatrists"), is due to a disease of the mind, which it is the duty of mad-doctors to prevent (by imprisoning / "hospitalizing" the madman / "patient"). The mainstream media and most people accept this ostensibly scientific doctrine as truth.
Although we now have more so-called rights than we have ever had -- such as  welfare rights, disability rights, patients' rights, the right to choice, the right to treatment, the right to reject treatment, ad infinitum -- we have no right to suicide.
In the immediate aftermath of the attacks on the World Trade Center and the Pentagon, President Bush - with his disarmingly gauche use of language -- called the act "cowardly" and the terrorists "cowards."
That characterization of our Muslim enemies was quickly abandoned in favor of our "scientific" cliches: brainwashing and mental illness. Declared George Will: "And although Americans are denouncing the terrorists' ‘cowardice,' what is most telling and frightening is their lunatic fearlessness."
William Safire opted for brainwashing. He explained: "A more powerful weapon [than surprise] of radical Islam is its ability to erase from the brains of recruits the basic will to live. The normal survival instinct is replaced with a pseudo- religious fantasy of a killer's self-martyrdom leading to eternity in paradise surrounded by adoring virgins."
One of the effects of the September 11 attacks on the World Trade Center and the Pentagon was that every politician and pundit suddenly became an expert about the fine points of Muslim theology. "This perversion of the world's great faiths," pontificated Safire, "produces suicide bombers. How to build a defense against the theological brainwashing that creates these human missiles? That is the challenge to Muslim clerics everywhere... "
How wrong can our most respected pundits be before we begin to view their expertise as we regard the expertise of the Enron accountants? The Muslim suicide bombers are a challenge to their victims, not to their teachers and paymasters. Any other interpretation is our collective folly, serving to indulge our love affair with a misguided concept of multiculturalism. 
Are brainwashing, cowardice, and lunacy our only choices? Surely, it is not difficult to see an Arab youngster training to become a suicide bomber and becoming a celebrated patriot and martyr as engaging in what he considers a rationally motivated series of actions. From the point of view of the future terrorist, his family, and his society, his actions are just as rationally motivated as are the actions of a young American engaged in going to college, studying medicine and becoming surgeon.
I maintain that, from the point of view of the suicidal actor, planning to kill himself and carrying out the act is also rationally motivated. However, we regard this interpretation as so flagitious -- so indecent -- that, for most Americans, it is as good as taboo. The only socially acceptable view is that suicide is a "cry for help," uttered by a person who has a mental illness (depression) and denies that he is ill.

Caused by Depression?
A large, multi-story shopping mall in Syracuse -- the Carousel Center -- has become one of the favorite places for young men and women to jump to their deaths. Every  time this happens, the newspapers present the story as if the act were a symptom of -- that is, were "due to" -- the subject's mental illness. "Suicide jumpers often disordered," was the headline of a long report on the suicide of a young woman in April. "[She] had been battling the disease [depression] for several years," her father said. The rest of the long, double-headed article -- the other title was "Suicide-prevention counselor says barriers to jumping should be considered" -- was devoted to telling the reader that (most) people who commit suicide, or think of doing so, suffer from "bipolar illness"; explaining that the disease is genetic and chemical in origin; and that it usually responds well to treatment with drugs. This and other newspapers never mention that persons suspected of being "suicidal," or who try to kill themselves and fail, are  routinely incarcerated in prisons called "mental hospitals." 
Muslim clerics engage in theological brainwashing. Does the mainstream American media -- not to mention organized American psychiatry -- engage in therapeutic brainwashing? Of course not. We call this "educating people about mental illness" and "eradicating the stigma of mental illness."  
Kay Redfield Jamison -- professor of psychiatry at John Hopkins University Medical School -- is America's poster girl for suicide as a preventable and treatable illness. She advertises herself "As someone who studies, treats and suffers from a severe mental illness--manic depression"; preaches the psychiatric mantra: "Suicide is due to mental illness and mental illness is treatable"; and explains: "I drew up a clear arrangement with my psychiatrist and family that if I again become severely depressed they have the authority to approve, against my will if necessary, both electroconvulsive therapy, or ECT, an excellent treatment for certain types of severe depression, and hospitalization."
Well and good. Does Jamison approve of other persons, similarly afflicted, having the right to reject psychiatric coercion and kill themselves? Certainly not.
We are so blind to the essentially human (non-"pathological") nature of voluntary death that we deny the reality of what people throughout history viewed as "heroic suicide." "Of all the ‘isms' produced by the past centuries, fanaticism alone survives," declares memory-champion Elie Wiesel. "We have witnessed the downfall of Nazism, the defeat of fascism, and the abdication of communism. But fanaticism is still alive."
Our political-ideological prejudgements prevent us from acknowledging Zionism as the reason why some Palestinians choose to kill themselves for political reasons. Our psychiatric-ideological  prejudgements prevent us from acknowledging the slings and arrows of outrageous fortune as the reason why some Americans choose to kill themselves for personal reasons.  
We are as squeamish and superstitious about suicide as people used to be about demonic possession and witchcraft. And we will remain so until we begin to take seriously how we talk about it.

Thomas Szasz

 


Cleansing the Modern Hearth
Is there a Place for a Pacific-Secular Cure of Souls in the Therapeutic State?

Every man's work, whether it be literature or music or pictures or architecture or anything else, is always a portrait of himself.
Samuel Butler

John Selden, a seventeenth-century English jurist and scholar, warned: "The reason of a thing is not to be inquired after, till you are sure the thing itself be so. We commonly are at, what's the reason for it? before we are sure of the thing" (cited in Keith Thomas, Religion and the Decline of Magic, p. 435, emphasis in the original).
We know what physics is: the study of matter and energy. What biology is: the study of living things. But what is psychoanalysis? Who speaks for psychoanalysis?
We are familiar with Freud's many contradictory teachings and the diverse practices he engaged in, calling them all "psychoanalysis." We know that the term is used to refer to a method of diagnosing and treating mental illnesses, detecting mental illness in famous dead persons and in characters invented by poets and writers, explaining and influencing human behavior, and interpreting the "meaning" of works of art. Here are two current examples of what persons officially authorized to speak for psychoanalysis say about it.
In an essay titled, "Will the real psychoanalyst please stand up?" Richard Fox, president of the American Psychoanalytic Association in 2001, declares: "Psychoanalysis today is a far cry from what it was thirty to forty years ago ... We lobby in Washington ... We work with other groups such as the ACLU to further our goals" (The American Psychoanalyst, 2001, p. 27). Are these activities we ought to applaud? At present, the ACLU is engaged in formulating commitment laws, the better to justify incarcerating innocent Americans accused of mental illness. During World War II, it was engaged in supporting and justifying the incarceration of innocent Americans of Japanese ancestry (see Chales L. Markmann, 1965, and Thomas Szasz, The Therapeutic State, 1984, pp. 58-66).
The American Psychoanalytic Association, Fox proudly reports, no longer bars psychologists from membership: "We have extended our membership ... We have shed our medical orthodoxy and have become more egalitarian." This is not good enough. For its past policies, the American Psychoanalytic Association owes a collective apology to psychologists and homosexuals as well.
It would be a mistake to conclude that psychoanalysts have finally acknowledged that they do not treat diseases, because problems in living are not diseases and because listening-and-talking is not a medical procedure. On the contrary, analysts join psychiatrists in expanding the concepts of disease and treatment, assert that "psychotherapy changes the brain," and then use that claim to prove that they treat brain diseases. According to Glenn Gabbard, M.D., Professor of Psychiatry and Director, Baylor Psychiatry Clinic and editor of the International Journal of Psycho-Analysis, "behavior therapy and drug therapy [are] affecting the same brain areas and in the same manner. ... Psychotherapy seems capable of favorably influencing the minds and bodies of persons with bodily diseases and perhaps is even capable of countering those diseases.... [It is important] to get scientific results that lend credibility to psychotherapy as a real treatment" (cited in Joan Arehart-Treichel, "Evidence is in: Psychotherapy changes the brain," Psychiatric News 2001, 36 (July 6), p. 33, emphasis added). Why is it important to claim that conversation with a psychoanalyst changes the client's -- but presumably not the analyst's -- brain? To qualify as loyal agents of the therapeutic state and be paid by the state for one's services to it.
Many years ago, I ceased to identify myself as a psychoanalyst. Why? Because I wanted to be faithful to my belief, which I have held ever since I knew anything about psychoanalysis, that psychoanalysis is a moral, not a medical, activity. Psychoanalysis has nothing whatsoever to do with illness or health, medicine or treatment, or any other idea that places "professional" listening and talking within the purview of the state's licensing authority. Because psychoanalysis is a moral enterprise, we must recognize and acknowledge that the analyst's personal moral conduct shapes and is a relevant to our moral judgment of his professional activities and persona.
Few, if any, contemporary psychoanalysts share these views. Most analysts equate psychoanalysis with psychotherapy, consider psychotherapy to be a part of psychiatry, and believe that problems in living are diseases and that verbal and nonverbal communications are treatments.
My aim here, then, is to restate my faith in psychoanalysis as a secular-moral "cure of souls." Psychoanalysis possesses a valuable moral core that has never been properly identified and is now virtually unrecognized: It is, or ought to be, a wholly voluntary and reliably confidential human service, initiated and largely controlled by the client who pays for it. Rightly, Freud himself compared the psychoanalytic relationship with the Catholic confessional. If psychoanalysis is to have a future -- which, in our disease- and treatment-obsessed culture seems doubtful -- it lies in adopting that model to the needs of modern secular man, increasingly isolated from his fellow man and community, and betrayed by the therapeutic state in which he mistakenly seeks protection from the vicissitudes of life.


II
At the end of nineteenth century, Vienna was the crown jewel of Austria-Hungary, a flourishing, multi-ethnic, multi-lingual, multi-religious empire, with glittering sister capitals in Budapest and Prague. Although the country had a sizeable, intellectually vibrant middle class and its politics was increasingly liberal (in the classical sense), it was nevertheless still a highly traditional, Roman Catholic country, with German as its official language. Much like the United States prior to World War II, Austria-Hungary was also a country that was simultaneously anti-Semitic and hospitable toward Jews, especially if they were assimilated and patriotic. Freud's career as a "Nervenarzt" must be clearly situated in this context.
Freud had many intellectual interests and was not keen about becoming a practicing physician. However, medicine was one of the (then) so-called "free professions," open to Jews, and Freud decided to go medical school. He completed his medical studies but did not want to become a general (family) physician, like his later friend Josef Breuer. Accordingly, Freud studied neuropathology, spent a few months in Paris studying the work of Jean-Martin Charcot, and then started a private medical practice as a "Nervenarzt" (literally, "nerve doctor"), specializing in "nervous diseases." It is important to keep in mind that these were nebulous terms used to identify a medical specialty that was neither neurology nor psychiatry. Why do I say this is important? Because it is here that the misrepresentation of problems of living as diseases and of interpersonal dialogue as treatment originates. The roots of this misconception -- similar to the view that consecrated wine is, literally, blood -- go very deep.
I use this Catholic metaphor here to re-emphasize the crucial importance of confidentiality in psychoanalysis, and its predecessor, catharsis. Actually, it was Josef Breuer who first used the confessional to explain the workings of his method of "mental treatment." In Studies on Hysteria (1893-1895) (The Standard Edition of the Complete Psychological Works of Sigmund Freud [SE]), Breuer writes: "We meet the same urge [to verbally reveal secrets] as one of the basic factors of a major historical institution -- the Roman Catholic confessional" (vol. 2, p. 211). In a similar vein, Freud uses the model of the confessional in The Question of Lay Analysis (1926): ... our Impartial Person [says]. "You assume that every neurotic has something oppressing him, some secret. And by getting him to tell you about it you relieve his oppression and do him good. That, of course, is the principle of Confession, which the Catholic Church has used from time immemorial in order to make secure its dominance over people's minds." We must reply: "Yes and no!" ... In Confession the sinner tells what he knows; in analysis the neurotic has to tell more. Nor have we heard that Confession has ever developed enough power to get rid of actual pathological symptoms" (SE, vol. 20, p. 189, emphasis added).
Revealingly, Freud condemns the confessional in Catholic hands as a tool of religious domination, and praises it in psychoanalytic hands as a medical method of psychical liberation. Why medical? Because it frees the "patient" of pathological symptoms. To top it off, Freud advances the absurd claim that whereas the penitent in the confessional tells only what he knows, the client in analysis also tells what he does not know. The rest, as the saying goes, is history: the analyst knows the client better than the client knows himself. This is not the place to dilate on the consequences of this pernicious idea.
Despite the historical record, many people -- mental health professionals, writers, book reviewers -- often erroneously identify Freud as a psychiatrist ("Who was Sigmund Freud? Freud was a Psychiatrist and Psychologist,"
2002, http://www.top-psychology. com/0050-Sigmund%20Freud/freud.htm;
http://www.who2.com/sigmundfreud.html;
see also
http://www.breakpoint.org/Breakpoint/ChannelRoot/FeaturesGroup/BreakPointCommentaries/Grow+Up+or+Wake+Up.htm). Freud was not, and could not have been, a psychiatrist. Why not? Because he was a Jew.
"Psychiatry" is a nineteenth-century term. What did it mean to be a psychiatrist in those days? It meant being an employee of the state: the psychiatrist oversaw the operation of a state insane asylum or worked as an asylum physician, assumed that mental diseases are brain diseases, and studied the brains of deceased mad persons. His patients were, de facto, prisoners (Thomas Szasz, 2002). In 1925, William A. White, the famed director of St. Elizabeths Hospital in Washington, D.C. -- founded in 1855 as the Government Hospital for the Insane -- stated: "The state hospital, as it stands today, is the very foundation of psychiatry" (cited in Sylvano Arieti, ed., American Handbook of Psychiatry, vol. 2, p. 686).
Many young and not so young psychiatrists are no longer aware that, from its birth in the eighteenth century until the beginning of the twentieth century, psychiatry (originally mad-doctoring) was synonymous with practice in the insane asylum and the state mental hospital; that all patients were committed patients; and that all psychiatry was actually or potentially adversarial psychiatry. To be sure, it was not seen or defined that way. How was that possible? By not questioning the transformation of the cooperative-contractual doctor-patient relationship typical of medical practice into the coercive-paternalistic guardian-ward relationship typical of psychiatric practice. De jure, the guardian represents the ward's best interests. Similarly, by definition, the coercive-paternalistic psychiatrist represents the involuntary mental patient's best interests. The practice of psychoanalysis created a new polarity, between the psychiatrist who controls and coerces, and the psychoanalys t who contracts and coop erates. In this political (not biological) sense, Freud "medicalized" psychoanalysis, that is, made its practice resemble medical, not psychiatric, practice.
Since being a psychiatrist meant being an employee of a state hospital, in Austria-Hungary Jewish doctors could not become psychiatrists. However, they could become "nerve doctors," listen and talk to their clients, call what they do "psychoanalysis" (or "psychotherapy"), and sell their services to fee-paying customers. The psychoanalytic client, like the customer of any service supplied by entrepreneurs in the free market, sought out the analyst, went to his office, received a service, and paid a fee for it. The client was on top, the therapist on tap. This was -- and still is, if indeed it exists except as a great rarity -- a radical departure from the tradition of psychiatry. For centuries, the only patients of mad-doctors, alienists, and psychiatrists were persons who did not want to be patients. Court-ordered mental hospitalization and treatment and the threat of such sanctions still form the core of the practice of psychiatry and the mental health professions generally (Szasz, 2002).
It is instructive to compare the differences between the roles of the psychiatrist and the psychoanalyst in Freud's Vienna with the differences, in medieval Christendom, between the roles of a priest and a rabbi. The priest and psychiatrist had power: the priest could burn the heretic at the stake, the psychiatrist could imprison and torture the psychotic. In contrast, the rabbi and the psychoanalyst lacked power: the rabbi could engage only in voluntary relations with his fellow Jews, the psychoanalyst could "treat" only person who sought his services.
The psychoanalyst, unlike the psychiatrist, lacks power over his client: either because he is economically, socially, and politically weaker than the client, or because he voluntarily renounces the use of force, even if the state offers it to him. Thus, a weak and noncoercive psychoanalysis is antagonistic to and incompatible with a powerful and coercive psychiatry, just as peaceful Diaspora Judaism is antagonistic to and incompatible with militant Zionism (or as pacific Christianity or Islam are incompatible with their militant versions). I maintain that the single most fundamental characteristic of the psychoanalyst is his principled rejection to coerce his client, or indeed engage in any action for or against him outside the boundaries of their meetings.
Sadly, this posture did not issue from Freud's moral outlook on human relations but was forced on him by his social circumstances. Freud did not reject medical power. He loved it. He never questioned the psychiatrist's paradigmatic practices, involuntary mental hospitalization and the insanity defense. Like psychiatrists, Freud made medical diagnoses of his clients and maintained that they suffered from mental illnesses that were, at bottom, brain diseases. As a result, psychoanalysis became absorbed into psychiatry and medicine, especially in the United States after World War II.
Although the seeds of the practice of psychoanalysis were sown and germinated in the soil of the free market and depended on it for their survival, neither Freud nor the early analysts understood the market or supported its values. They only took advantage of it, like children taking advantage of wealthy parents. As soon as Freud got on his feet, economically and professionally, he embraced the style of the conquering hero, to which he always aspired. In 1900, to Wilhelm Fliess, he wrote: "I am not at all a man of science, not an observer, not an experimenter, not a thinker. I am by temperament nothing but a conquistador" (p. 398). To Jung he announced that psychoanalysis must "conquer the whole field of mythology" (cited in Clark, p. 339). Freud's self-image as a "conquistador" meshed with his ambition to conquer psychiatry for psychoanalysis. The result was exactly the opposite: psychoanalysis became corrupted by psychiatry.

III
Like the core element of the classic concept of liberty, the core element of psychoanalysis is best stated as a negative, that is, as the absence of factors antagonistic to its aims and values. Political liberty is the absence of the coercions characteristic of the traditional relations between rulers and ruled. Similarly, psychoanalysis is the absence of the coercions characteristic of traditional relations between psychiatrists and mental patients. As Freud put it, "Analysis ... presupposes the consent of the person who is being analyzed..." (SE, vol. 14, p. 49). But Freud didn't mean it. If he did, he would have opposed the "psychoanalysis" of children, involuntarily hospitalized mental patients, and dead persons, none of whom can consent to their existential assassination. In fact, he enthusiastically embraced and encouraged these practices.
Ironically, when I speak of my ideal model of psychoanalysis, I am simply taking seriously how Freud sometimes characterized it. I refer to Freud's likening the relationship between analyst and client to the relationship between the vendor of an expensive personal service -- say, a portrait painter -- and a financially independent adult purchaser of his services. Neither party has power over the other; each is responsible for his side of an agreement. In his Introductory Lectures on Psychoanalysis (1915-1917), Freud framed this as the rule "of not taking on a patient for treatment unless he was sui juris, not dependent on anyone else in the essential relations of his life" (vol. 16, p. 460, emphasis added). Thanks to the untiring efforts of enthusiasts for pharmacratic regulations -- giving us Medicare, Medicaid, SSSI, HMOs, the DEA and drug regulations, the wars on depression and suicide, the duty to protect patients from themselves and others from the patients, and malpra ctice litigation -- anal ysts and clients alike are effectively deprived of the very possibility of being sui juris. The therapeutic state compels everyone, without exception, to be dependent on the state in the essential medical and pharmacological aspects of his life (Szasz, 2001). Political liberty is contingent on the state's respect for private property and its non-interference with acts between consenting adults. Psychoanalysis is contingent on the therapist's respect for the client's autonomy and his non-interference with the client's life. This means that the therapist must limit his interaction with his client to listening and talking to him in the therapist's office and must abstain from meddling into the client's affairs and social life. Thus conceived, the psychoanalytic relationship was a new development in the history of mad-doctoring: it introduced into psychiatry and society a new form of "therapy for mental illness," one in which the expert eschewed coercing deviants and housing de pendents and confined himself to conducting a particular kind of confidential dialogue. In the psychoanalytic situation, there is, in the medical and psychiatric sense, neither patient nor doctor, neither disease nor treatment. The dialogue between analyst and client is therapeutic in a metaphorical sense only. Purged of jargon, the psychoanalytic "procedure" consists only of listening and talking. So conceived, psychoanalysis undermines psychiatry as a medical specialty and system of social control.
Psychiatry did not acquire, and could not have acquired, any of the real substance of psychoanalysis. The two enterprises rested on different premises and entailed mutually incompatible practices. The marriage between the psychiatrist and the psychoanalyst was a misalliance from the start, each party disdaining and exploiting its partner. Psychiatry acquired the worst features of psychoanalysis -- a preoccupation with sex and the past, an elastic vocabulary of stigmatizations, and a readiness for fabricating pseudo-explanations. Psychoanalysis acquired the worst features of psychiatry -- coercion, mental hospitalization, and disloyalty to the client. Bereft of professional integrity, post-war American psychoanalysts enjoyed a brief period of irrational professional exuberance, followed by moral bankruptcy.

IV
What do I mean when I say that psychoanalysts, qua psychoanalysts, have become morally bankrupt? I mean that psychoanalysts do not mind their own business and instead mind the client's business. The analyst's business is to earn the client's confidence and trust by entering into a clear contract with him and by conscientiously abiding its terms. The Bill of Rights limits the powers of the state vis-a-vis the citizen, not the citizen's vis-a-vis the state. Similarly, the analytic contract limits the powers of the therapist vis-a-vis the client, not vice versa. The analyst's overriding obligation to the client is to protect his confidences. This obligation permits no exceptions. If the analyst morally abhors what his client tells him, he has the option, like a defense attorney, of discontinuing the relationship. Under no circumstances does the psychoanalyst have the option to betray his client's confidence and use the information he has acquired, especially against what the client considers his own intere st.
We often speak of empowering this or that politically weak or disfranchised individual or group. But people cannot be empowered directly. They can be empowered only indirectly, by taking power away from, or not giving power to, individuals or institutions that have actual or potential control over them. This is a lesson every parent must learn if he wants his child to become an independent adult. It is a lesson that all forms of psychiatrized psychotherapy violate, indeed indignantly reject -- by assuming responsibility for the client's health, safety, and general well-being.
In Freud's time, as now, some people committed suicide. It did not occur to anyone in Vienna -- least of all to lawyers or psychiatrists -- that it was the analyst's duty to protect his client from himself. Nor would it have occurred to them that it was the analyst's duty to protect so-called third parties or the community from the potential violence of the client. Today, protecting the "mental patient" from himself -- the anorexic from starving to death, the depressed from killing himself, the manic from spending his money -- is regarded as one of the foremost duties of anyone categorized as practicing as a mental health professional, psychoanalysts included.
For half a century, I have argued and showed that a person professing to help a fellow human being in distress cannot be a double agent: he must choose between serving the interests of the client, as the client defines them; or serving the interests of the client's family or employer or insurance company, or the interests of his profession, religion, community, or the state, as they define them. As a rule, this view is either ignored or dismissed out of hand with the claim that a so-called mental patient's "true (mentally healthy) interests" cannot conflict with the interests of his "loved ones" or those of the community. If they do, it is because of his mental illness. The denial that the therapist deals with persons in conflict with others and that the process called "therapy" cannot -- except accidentally or derivatively -- help persons whose interests oppose or thwart those of the client characterizes virtually all modern therapies. For example, Constance T. Fisch er, professor of psychol ogy at Dusquesne University, introduces the 2002 special double issue of The Humanistic Psychologist with this sentence: "In this collection of articles, psychologists' approaches to assessment are compassionate, caring, deeply respectful of the humanity of the clients, and courageous in efforts to be genuinely helpful to all parties" (p. 1, emphasis in the original). This is self-congratulation concealing personal and professional self-aggrandizement. People whose lives are full of harmonious cooperation with others do not seek and are not subjected to mental health services.
Virtually everyone in and out of the therapy business now believes that, when the chips are down, the therapist must betray his client's confidences, in his "own best interest." Thus, in the present American legal and political context, there can be no secular cure of souls. For such a cure to be possible, it is necessary not only for the therapist to disarm himself of the power he possesses over the client, but also for custom and law to permit him to do, much as the priest in the confessional disarms himself and is permitted to do so. It is not priest's duty to protect the penitent from himself or the community from the penitent. He is not expected to protect the would-be suicide from killing himself, or the community from the acts of a would-be murderer, by denouncing them to the health or law enforcement authorities of the state. Indeed, he is expressly forbidden to so betray the person whose confession he hears.
Regrettably, psychoanalysts have shown no interest in what, some forty years ago, I called "the ethics of psychoanalysis," a term by which I meant, inter alia, the analyst's moral obligation to protect the client's confidences unhindered by conflicting obligations (Szasz, 1965/1988). Nor were psychoanalysts in a position to do so as long as they categorized their activity as belonging under the umbrella of health care and treatment. Had they been willing to acknowledge that all they do is listen and talk to the persons who seek their services, they might, like librarians, have been able to secure genuine legal recognition and protection of their role.
Librarians and booksellers do not pretend that they help their patrons improve their minds, their mental health, or their morals, or that they protect the public by preventing patrons from reading "dangerous" books. They recognize, and everyone recognizes, that their function is to manage libraries and sell book. Our right to freedom of the press and speech includes the right to privacy about what we read. Accordingly, librarians and booksellers have no obligation to reveal what their patrons read, even if their reading material is deemed to pose a threat to the patrons or the public (see "Tattered Cover victorious in battle against search warrant,"
http://www.freeexpression.org/newswire/0408_2002.htm).
Is the privacy of librarians and booksellers more deserving of legal protection than the privacy of psychoanalysts? Or is it that the former have valued and fought for their liberties, and the latter have neither valued nor fought for them?

V
Sad to say, there has never existed an institutionalized system of psychoanalytic practice truly respectful of the client's autonomy and privacy. A few analysts may have aspired to such an ethic, but, as a group, psychoanalysts rejected it. The image of the analyst, a man sitting in a chair listening sympathetically to a woman lying on a couch, the analyst recoiling from the very idea of harming her, let alone imprisoning her, has no basis in reality. Many celebrated psychoanalysts -- Harry Stack Sullivan, Erik Erikson, Karl Menninger, Frieda Fromm-Reichman, Thomas Freeman -- "analyzed" involuntarily hospitalized "patients."
Actions speak louder than words, says the proverb. I would go further: when actions and words conflict, we must view the actions as the truth, and the words as lies.
To dramatize the disjunction between words and deeds in psychoanalysis, I cite the practices of two famous psychoanalysts. First, here is a vignette of the work of Jacques Lacan.
In 1945, when Picasso rejected his long-time mistress and model Dora Maar in favor of Francoise Gilot, Maar became depressed and annoyed Picasso. In a review in the Times Literary Supplement (2002, April 25), Marilyn McCully, writes: "A terrified Picasso, who abhorred illness, especially in women ... contacted Jacques Lacan, who had her admitted to a psychiatric clinic. Doujoune Ortiz [the Spanish author of a biography of Maar] goes into details about Lacan's machinations in looking after Maar and the horrific shock treatments that were prescribed as part of her therapy. She also makes the perceptive observation that Picasso's paintings of Maar as the weeping woman eerily anticipate the terrors she must have suffered in the moments before the shock treatments were administered" (p. 28).
The Scottish psychiatrist and psychoanalyst Ronald D. Laing's name is often bracketed with my name. Thus, Laing is often credited with the view that he opposed involuntary mental hospitalization and coercive psychiatric treatment. This is not true. In The Divided Self, Laing wrote: "When I certify someone insane, I am not equivocating when I write that he is of unsound mind, may be dangerous to himself and others, and requires care and attention in a mental hospital" (p. 27, emphasis added). In a 1979 review of three of my books in the New Statesman, Laing contemptuously dismissed my critique of the medical metaphor and my call for the abolition of psychiatric slavery. Even if all that I propose came to pass, he declared, "it would all be much the same." British psychoanalyst Anthony Stadlen did not let Laing's review stand uncorrected. He wrote:
Dr. Laing's new role as the "perfectly decent" defender of psychiatry against Szasz's "insulting and abusive fuss" calls for comment. Laing is saying unequivocally that "it would all be much the same" to him whether involuntary psychiatry be retained or abolished. He is saying "it would all be much the same" whether voluntary interventions, including his own, are intended as medical treatments for illness or as interpersonal counseling, ethical exploration, existential analysis. He implies quite clearly that he is one of "the rest of us" who do use the medical metaphor ("Dropping the medical metaphor," New Statesman, 1979, 17 August).
Although Laing co-invented the stupidly self-stigmatizing label, "antipsychiatry," he claimed he was not an antipsychiatrist. In the Introduction to his book, The Dialectics of Liberation (1968), David Cooper wrote: "The organizing group [of the "Congress on the Dialectics of Liberation," held in London in 1967] consisted of four psychiatrists who ... counter-label[ed] their discipline as anti-psychiatry. The four were Dr. R. D. Laing and myself, also Dr. Joseph Berke and Dr. Leon Redler" (p. 7).
Citing this passage, Adrian Laing, in a sympathetic biography of his father, comments: "Ronnie made two mistakes with David's introduction. First, he did not insist on reading it prior to publication. Ronnie did not consider himself an ‘anti-psychiatrist' ...The damage, however, had been done. David managed to label Ronnie an anti-psychiatrist. Ronnie was furious at this move, but made a more serious mistake in not taking immediate and effective action to rectify his position" (p. 138).
But were these inactions "mistakes"? Or did they represent Laing's typical way of having his cake and eating it too, as Adrian aptly puts it? The evidence supports Adrian's interpretation. Laing's response to his oldest daughter Fiona's existential crisis is emblematic of his rejection of parental responsibility and lack of moral and intellectual integrity. In 1976, Fiona, then twenty-four years old, is rejected by her boyfriend: "She had ‘cracked up,' and had been found weeping outside a church" near the family home. Committed to a local mental hospital, she is given ECT. Laing biographer John Clay writes:
He [Adrian] rang his father up and asked him "in despair and anger" what he was going to do about it. Laing reassured him that he would visit Fiona and "do everything in his power" to ensure that she was not given ECT, but when it came to the crunch, as Adrian Laing relates, all he could say was "Well, Ruskin Place [the family home] or Gartnavel [the mental hospital] -- what's the difference?" Such a scathing and deprecatory remark showed once again an avoidance of responsibility for his first family, indefensible since his line had been that the breakdown of children could be attributed to parents and families. Instead, Laing went into denial. When he gave an interview shortly afterwards in New Society he declared, "I enjoy living in a family. I think the family is still the best thing that exists biologically as a natural thing" (p. 181).
There is worse. According to Adrian, Laing pitied himself, was a petty despot, and, when drunk, which was often, he was prone to violence. In one such episode, "No sooner had he got through the door ... than he attacked Karen [his daughter], then aged seventeen, and started to beat her unmercifully, until Paul and I intervened and restrained him. It was very frightening for all concerned" (Adrian Laing, p. 176).
An honest man is said to be as good as his word. By that measure, Laing was a very dishonest man indeed.

VI
I have endeavored to re-articulate what I regard as the moral and political-economic core of, and the social conditions for, the psychoanalytic situation. They are: the inviolable privacy of the professional-client relationship; the client's willingness to assume responsibility for his behavior and pay for the service he receives; the analyst's willingness to eschew coercion justified by the legal-psychiatric principle of the "duty to protect" (the client from himself and the community from the client); the legal system's willingness to exempt the analyst from this principle (at present an integral part of the mental health professional's legal and social mandate); and the public's willingness to accept that a secure guarantee of privacy and confidentiality, similar to that granted the priest, as an indispensable condition for the proper conduct of psychoanalysis as a secular "cure of souls." These conditions are absent in the therapeutic state. The result is a tragic loss of liberty for client, "therapist," and society (Szasz, 2001).
Psychoanalysis was conceived, raised, and over-indulged by medicine. Like many spoiled children, it chose not to reject its comforting but crippling patrimony, medical-therapeutic paternalism. As a result, it has failed to grow up and fulfill its potential, that is, adopt an explicitly anti-paternalist, libertarian stance as the proper posture towards adults who seek and are willing to pay for a private, confidential, secular, and trustworthy setting for looking into their hearts and souls and, perhaps, making themselves better persons.
The psychoanalyst's job is to help his client live his life as honestly and as responsibly, and hence as freely, as he can or wants to. This task has nothing to do with illness and treatment in the sense in which these terms are used in medicine and psychiatry. However, it has a great deal to do with custom, law, economics, politics, and especially with religion as ethics. The term "psychoanalytic treatment" refers to, or ought to refer to, a particular kind of strictly confidential, private human relationship, similar to the Catholic confessional: it is a type of secular "cure of souls." The analyst's duty is to listen, speak, and fulfill his contract with the client, for example, by keeping the client's communications inviolably confidential and punctually collecting the fees due for his services.
The Christian believes that God does not hear the sinner. To be heard, the person must first cleanse his heart. That is a powerful metaphor. The wisdom it express is timeless. Where does it leave the atheist, the man who does not believe in and hence does not fear God? It leaves him fearing himself and having to cleanse his own heart.
The God-fearing man has it easier: he can more effortlessly persuade himself that God is listening to his prayers than the godless man can persuade himself that he is listening to himself. For the former, cleansing the heart can easily become an empty ritual. For the latter, it cannot. It is easier for a man to hide from God than from himself.

References

Arieti, Sylvano. American Handbook of Psychiatry. Second edition. New York: Basic Books, 1974.
Breuer, Josef and Freud, Sigmund. Studies on Hysteria (1893-1895). The Standard Edition of the Complete Psychological Works of Sigmund Freud . London: Hogarth Press, 1953-1974. Cited as SE.
Clark, Ronald W. Freud: The Man and the Cause (London: Jonathan Cape and Weidenfeld & Nicolson, 1980.
Clay, John. R D Laing: A Divided Self. London: Hodder & Stoughton, 1966.
Cooper, David. The Dialectics of Liberation. Harmondsworth: Penguin, 1968.
Freud, Sigmund. Introductory Lectures on Psychoanalysis (1915-1916). SE, vol. 16.
Freud, Sigmund. The Question of Lay Analysis: Conversation with an Impartial Person (1926). SE, vol. 20.
Freud, Sigmund. The Complete Letters of Sigmund Freud to Wilhelm Fliess, 1887-1904. Translated and edited by Jeffrey M. Masson. p. 398. Cambridge, MA: Harvard University Press.
Gilot, Francoise and Lake, Carlton. A Life with Picasso: The Love Story of a Decade (1964). New York: Discus Book, 1981.
Laing, Adrian C. R. D. Laing: A Biography. London: Peter Owen, 1994.
Laing, Ronald D. The Divided Self: An Existential Study in Sanity and Madness. London: Tavistock Publications, 1960.
Markmann, Charles L. The Noblest Cry: A History of the American Civil Liberties Union. New York: St. Martin's Press, 1965.
Sigal, Clancy. Zone of the Interior. New York: Popular Library, 1978.
Szasz, Thomas. The Ethics of Psychoanalysis: The Theory and Method of Autonomous Psychotherapy (1965). Syracuse: Syracuse University Press, 1988.
Szasz, Thomas. The Myth of Psychotherapy: Mental Healing as Religion, Rhetoric, and Repression (1978). Syracuse: Syracuse University Press, 1988.
Szasz, Thomas. The Therapeutic State: Psychiatry in the Mirror of Current Events. Buffalo: Prometheus Books, 1984.
Szasz, Thomas. Pharmacracy: Medicine and Politics in America. Westport, CT: Praeger, 2001.
Szasz, Thomas. Liberation By Oppression: A Comparative Study of Slavery and Psychiatry. New Brunswick, NJ: Transaction Publishers, 2002.
Thomas, Keith. Religion and the Decline of Magic. London: Weidenfeld and Nicholson. 1971.

Notes

1. Psychoanalysis is a particular kind of dialogue, one person providing a service, and another person receiving and paying for it. Accordingly, wherever possible, I refer to the recipient of the service as a client, not patient. I continue to use the word "therapist" because we lack an appropriate term to identify his role and function as secular, moral counselor.
2. Eager to establish the medical bona fides of his "therapy," Freud was faced with the problem of the absence of somatic lesions or laboratory markers in his patients. He sought to overcome this problem by using "clinical material," that is, "case histories." (The term "clinical material" is an indispensable part of the incantatory magic of today's practitioners of the "misbehavioral sciences" (Jacques Barzun's term). As a result, he went so far as to explicitly reject the confidentiality of the psychoanalytic relationship. In "The history of the psycho-analytic movement" (1914), he wrote: "... I cannot allow that a psycho-analytic technique has any right to claim the protection of medical discretion" (SE, vol. 14, p. 64).
3. For another, similar version of this story, see Francoise Gilot and Carlton Lake. They write: "He [Picasso] wanted to call Doctor Lacan, the psychoanalyst he used for most of his medical problems, but didn't want to telephone in front of Dora, so he sent Sabartes [his chauffeur and all-purpose lackey] out to call, ... Lacan came at once. ... Professor Lacan kept Dora at the clinic for three weeks. At the end of that period he let her go home. He continued to treat her and she underwent analysis with him" (pp. 83-85, emphasis added).
4. Clancy Sigal's Zone of the Interior provides a vivid account of the moral squalor of Laing's life style and psychoanalytic practice.  

The Hans Loewald Award Address, The International Federation for Psychoanalytic Education, Fort Lauderdale, Florida, October 25-27, 2002.

Thomas Szasz

 


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