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Il volo: le ali della libertà

Sabato 22 Ottobre 2005

Thomas Szasz, M.D. (Syracuse, NY)

Psicoanalista, psichiatra, scrittore, professore emerito della State University of New York (SUNY, Syracuse, NY), fondatore del Cybercenter for Liberty and Responsibility

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Ore 16

Sala polifunzionale Centro Interparrocchiale San Michel

Psychoanalysis: What It Is Not, And What It Might Be
Thomas Szasz

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Professor Fratini, organizers and officials of he conference, “Psicoanalisi e dintorni,” ladies and gentlemen:

When I received your kind invitation to participate in your conference, I was both puzzled and pleased. Puzzled, because I left psychoanalysis long ago; pleased, because, while I am no longer a part of psychoanalysis, psychoanalysis is still a part of me. Such is the nature of our identity. I left Hungary and Europe a long time ago, but I am still a Hungarian and a European. My parents died a long time ago, but I am still their son. My children are middle-aged, but I am still their father. 

The first time I participated in a psychoanalytic conference was in 1950, when I presented a paper at the annual meeting of the American Psychoanalytic Association in Detroit, Michigan.[1] During the subsequent decade and a half, I published a book, The Ethics of Psychoanalysis, and numerous articles in psychoanalytic journals, all of which  attracted considerable attention.[2] For example, Jacques Lacan, who rarely cited the works of American analysts, discussed my paper, “The concept of transference”at some length, objecting to my view that the psychoanalyst ought to eschew having power over the patient.[3]

            In his book, Four Fundamental Concepts of Psycho-Analysis (1973), Lacan  wrote: "There is a crisis in analysis and, to show that there is nothing biased in this, I support my view by citing a recent article ... it is the work of no mediocre mind. It is a closely argued, very engaging article by Thomas S. Szasz.” Although he disagreed with what I wrote, Lacan generously characterized my essay as having been “inspired by  ... a truly moving search for the authenticity of the analytic way. It is quite striking that an author, who is indeed one of the most highly regarded in his circle, which is specifically that of American psychoanalysis, should regard the transference as nothing more than a defense on the part of the psychoanalyst."[4] I must note here that, in my paper I did not write that transference is "nothing more than a defense on the part of the psychoanalyst." Instead, I observed -- as part of my systematic critique of the abuses of psychoanalytic power[5] -- that the analyst is at liberty to interpret some of the patient's behavior as transference, and some of it as not transference, and that the patient has no means of refuting these so-called interpretations.[6]

My criticisms -- together with my unqualified rejection, in books such as The Myth of Mental Illness and The Ethics of Psychoanalysis, of psychoanalysis as a medical-psychiatric enterprise -- quickly led to my demotion from the lofty position as "one of the most highly regarded" American analysts to the decidedly unlofty position of persona non grata, a dangerous psychoanalytic heretic whose name must henceforth not be mentioned by mainstream American analysts or in mainstream psychoanalytic publications.[7]

Fortuitously, in 1954 I was called to serve a two-year stint in the United States Navy, leaving behind my position as staff member of the Chicago Institute for Psychoanalysis and the full-time practice of psychoanalysis. Following my Navy service, I secured an academic position in the medical school of the State University of New York in Syracuse, ceased to identify myself as a psychoanalyst, and limited my private practice to part-time work. Soon, the pages of psychoanalytic journals closed to my writings and my contributions, not unexpectedly, were written out of the history of psychoanalysis.

 After a passage of fifty-two years, I participated once again in a psychoanalytic conference when, in 2002, I received the Hans Loewald Award from the International Federation for Psychoanalytic Education in Fort Lauderdale, Florida. On that occasion I presented an address, titled “The cure of souls in the therapeutic state,”

which pleased some and displeased others.[8] And now, thanks to your kind invitation, here I stand, one of the oldest living psychoanalysts in the world.

                                                                             2

In this brief presentation, I shall review what I see as the birth and death of psychoanalysis and offer some speculations about its potential afterlife as a type of cure of souls for modern, post-religious man. 

Let us begin by asking, “What is psychoanalysis?” Freud gave so many contradictory answers to this question that we cannot look to him for help.[9] Familiarity with the contemporary cultural and psychoanalytic scene should be enough to convince anyone that the term “psychoanalysis” now means virtually anything the speaker wants it to mean; for believers, it serves primarily as an honorific, a term of praise and self-aggrandizement.

For a concept to have a clear meaning, its content must be limited; the term we use for it must have clearly identified referents; and there must be ideas and interventions incompatible with it. It is not enough to say what psychoanalysis is. We must also be willing to say what psychoanalysis is not, and stand by it. I shall try to do this, as I see it. 

Freud is often credited with having “discovered” psychoanalysis and the unconscious. This is nonsense. One can discover only that which already exists in nature, for example radioactivity. Freud did observe something important, but it was not a discovery, as many others before him had also noted it. I refer to Freud’s recognition that there are many persons who claim to be ill and have all kinds of “symptoms” -- that is, complaints -- which alarm those around them and often the “patients” themselves, yet who have no demonstrable bodily diseases. In Freud’s day, such people were said to suffer from hysteria, neurasthenia, psychasthenia, and so forth. Today, we say they are mentally ill and have hundreds of “diagnoses” for them. The simple truth is that these persons are not sick and that the diagnoses physicians create and attach to them serve only to expand the concept of illness and increase the prestige and power of medical and so-called mental health professionals.  

Freud and his followers also used the term “psychoanalysis” to name a particular method of “treating” certain mentally ill persons. However, the so-called psychoanalytic method refers to a special type of dialogue, not a special method of “treatment.” Freud rightly compared it to the Socratic dialogues and to the Catholic confessional.

The person diagnosed as suffering from, say, “hysteria” is not sick, he only pretends to be sick, or mistakenly believes he is sick, and uses the language of bodily symptoms to convince himself and others. The psychoanalyst is not a medical healer, he only pretends to be one, or mistakenly believes he is one, and uses the language of medical therapy to convince himself and others. All this is expressed with the utmost clarity and naivete in a now forgotten book by Karin Stephen, titled, Psychoanalysis and Medicine, subtitled, A Study of the Wish to Fall Ill.[10] Stephen, who happened to be the sister-in-law of Virginia Woolf, confused the sick role with bona fide medical illness: “It is claimed [by psychoanalysis] that psychogenic illness is a piece of behavior as purposive as putting up a hand to ward off a blow. The purpose of this kind of illness is to prevent anxiety from developing.”[11] Note the language: We do not speak, because it is nonsensical to speak, of the purpose of real diseases, such as nephritis or leukemia. Diseases have no purposes, only persons do.  

Critical observers of the theoretical and therapeutic claims of psychoanalysis lost no time perceiving the basic epistemological-scientific fault upon which Freud built his sandcastle. Precisely one hundred years ago, the Viennese journalist Karl Kraus famously observed: “Psychoanalysis is that disease for which it pretends to be a treatment!” ("Die Psychoanalyse ist jene Krankheit, für deren Therapie sie sich halte!”). Sartre put it in less convoluted terms. He satirized hysteria as a lie without a liar. Psychoanalysis, too, is a lie without a liar: both parties lie to themselves or, in Sartre’s terms, display bad faith and suffer its consequences: "Thus psychoanalysis substitutes for the notion of bad faith, the idea of a lie without a liar."[12]

During the two decades between the World Wars, psychoanalysis grew and flourished, mainly in the German-speaking countries of Europe and England. It did so largely because it offered a non-medical, existential perspective on understanding what ailed so-called mentally ill persons and a non-coercive, “anti-psychiatric” method of helping persons seeking relief from their personal problems. As a consequence of Nazism and the Second World War, the center of psychoanalysis shifted from Europe to the United States, where it enthusiastically fell into the embrace of psychiatry, became briefly popular and lucrative, and died as a “treatment for mental illness.” In other words, psychoanalysis committed suicide, perhaps in a state of non compos mentis.

The view that psychoanalysis, and much else in contemporary life, is now thoroughly medicalized, is not simply an opinion. It is a phenomenon deeply characteristic of the modern Zeitgeist, and is intrinsic to the political system I call the Therapeutic State.[13] Its absurdities form the faith of the faithless, immune to intellectual criticism, exposed only in jokes, such as the following:           The psychology instructor had just finished a lecture on mental health and was giving an oral test. Speaking specifically about manic depression, she asked, "How would you diagnose a patient who walks back and forth screaming at the top of his lungs one minute, then sits in a chair weeping uncontrollably the next?" A young man in the rear raised his hand and answered, "He's probably a basketball coach."  

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I have asserted that psychoanalysis is not a medical activity: it has nothing to do with psychiatry, neurology, neuroscience, or pharmacology. I now outline what I believe psychoanalysis “is” or ought to be, by dividing its essential elements into a number of discrete, but interlocking, categories that I call Principles of the Ethics of Psychoanalysis (EP)

The First Principle of the EP restates a truism. The subject who seeks and receives psychoanalytic services is not sick (or, if he is, that fact has nothing to do with his role vis-a-vis the analyst). He is not, and ought not to be called, a “patient.” The analyst is not a medical healer (or, if he is, that fact has nothing to do with his role vis-a-vis the analysand). He is not, and ought not to be called, a “therapist.” Perhaps we should call him a minister, inasmuch as he ministers to the needs of another in need.  The point is that so-called psychoanalytic treatment is not a type of medical healing or health service.

The Second Principle of the EP articulates a feature of the psychoanalytic situation borrowed, as Freud noted, from the Catholic confessional. As minister -- the  verb, “to minister” Websters’ defines as “to give aid or service” -- the psychoanalyst is his client’s agent: he owes the client unconditional confidentiality and must promise him that he will unconditionally limit his “help” to the time- and space-frame of his interactions with the client. This and other aspects of the “analytic contract” should be clear from the outset and agreeable to both parties. For example, should the client inform the analyst that he, the client, has engaged in a serious crime against another person or persons, the analyst’s contractual obligation is to sever the relationship.

He must not allow himself to become involved in his client’s legal and social affairs: outside the walls of the consulting room, the analyst is neither the client’s ally nor his adversary.     

            The Third Principle of the EP situates the core value of psychoanalytic relationship in the conceptual and institutional-social category in which it rightly belongs: Psychoanalysis is a particular form of secular cure of souls. There are a virtually infinite number of secular forms of soul-cures, just as there are a virtually infinite number of religions. This phenomenon reflects the human soul’s unquenchable yearning for peace with itself and others, for comforting and understanding human contact and communication, for confession and forgiveness, for guidance from and dependence on authority, and for escape from loneliness.

Defining psychoanalysis as a ministerial, not a medical, enterprise accomplishes another important goal. In the United States, church and state are separated by the Constitutional and by tradition and custom. This protects religious bodies from being “bought” by the limitless funds available to governments. Psychiatry began as government property: it is an agent of the state. Association with psychiatry is incompatible with psychoanalysis. The psychoanalytic minister must not receive any compensation for his ministerial work from the government or any government-regulated institution or business, such as an insurance company. He must be paid for his work by the individual to whom he ministers, in the tradition of a voluntary, contractual exchange between two consenting parties.

Led by the Soviet Union, modern Western governments have bought and own the medical profession, which has been duly corrupted as a result. In the United States, Canada, the United Kingdom, France, and Germany, for example, organized psychoanalysis has successfully claimed to be a part of medicine, psychiatry, and the so-called mental health professions; as a result, it has forfeited its moral integrity, intellectual value, and professional distinctiveness. All of this and more could, perhaps, be regained by a radical separation of the psychoanalytic cure of souls and the state. 

The Fourth Principle of the EP defines the limits of the analyst’s role. Those  limits are implicit in the aim of analysis, which can only be to help the client increase his responsibility, and hence his freedom, in the management of his life. This is not the way Freud defined the aim of psychoanalysis. It is the way Camus defined the aim of the life of man liberated from the shackles of religious, political, and “scientific” superstitions, yet still unfree: “The aim of life can only be to increase the sum of freedom and responsibility to be found in every man and in the world. It cannot, under any circumstances, be to reduce or suppress that freedom, even temporarily.”[14]

Intimations of this lofty aim are present in the classic Anglo-American political concept of limited government, that is, a system of government in which the rulers willingly limit the scope of their authority and power over the ruled. Mutatis mutandis, the psychoanalytic relationship is distinguished from other helping relationships -- especially paternalistic relations typically associated with the family, religion, and medicine -- in which the helper feels morally justified to use force in the best interests of the helped. In Shakespeare’s immortal words, this paternalistic-coercive posture -- which has always characterized psychiatry -- rests on the premise that: "Diseases desperate grown / By desperate appliance are relieved, / Or not at all."[15]   This premise and the doctor’s power to coerce the patient implicit in it are antithetical to the psychoanalytic ethic. Moreover, in the early days of psychoanalysis, the typical analytic patient was a wealthy person who voluntarily sought analytic help and possessed more social power than did his analyst, especially if the analyst was a lay person. In the United States, these conditions ceased decades ago. Long ago, psychoanalysis -- especially in the United States -- became absorbed into psychiatry and mental health care. Psychoanalysts enthusiastically embrace the dominant coercive-pseudotherapeutic ethic, making them responsible for controlling the patient’s violence toward himself and others.

New York State, for example, licenses psychoanalysts. “The applicant for licensure must have obtained a master’s degree or higher in any field, but if the degree is not in medicine or a health-related field, he must complete a “program of study including course work equivalent to that required in a health or mental health field of study.”[16] Add to this the fact that, beginning in the 1970s, lawyers began to bring civil suits -- in the style of the tobacco litigations -- against psychotherapists for not protecting third parties from  patients under their care by “failing to warn” the endangered persons, that is, by keeping their patients’ communications confidential. Henceforth, anyone practicing psychotherapy, however loosely defined, had the double duty to protect his patient from harming himself and / or others. At the 1980 annual meeting of the American College of Forensic Psychiatry, a prominent attorney explained: “The trend toward imposing liability on a psychotherapist for failing to inform on his dangerous patients is now firmly established. ... If the therapist unyieldingly clings to his old ethical considerations and refuses to divulge this material, the simple truth is that he will find himself having to pay a jury’s verdict of $1 million or more in a wrongful death action.”[17]

Invited to respond to the attorney’s presentation, I observed that the legal requirement that the psychotherapist predict his client’s “dangerous” behavior is absurd and incompatible with the moral and psychological premises undergirding relations assumed to be private and confidential. I stated: “The patient does not pay the therapist to have his or her behavior predicted ... the issue of predicting patient behavior simply has no relevance to the private psychotherapy situation: the therapist is the patient’s hired servant, not his parole officer.”[18] Like the confessional, the psychoanalytic situation allows for the presence of no third person or party. Because the therapist’s participation in insurance coverage negates the privacy of the relationship, and because the law no longer protects the therapist who wants to keep his patient’s communications confidential, the very concept of psychoanalysis as a private and confidential relationship between two competent and responsible individuals is now an oxymoron and an anachronism.[19]

Predictably, American psychiatrists saw these legal-political developments as a fresh opportunity to reinforce their image as the protectors of both the patient and the public and thus expand their powers. The American Psychiatric Association’s new “policy for therapist confidentiality requires mental‑health professionals to take actions that might violate confidentiality if a patient explicitly threatens to kill or seriously injure someone.”[20] A president of the American Psychiatric Association opined: “In principle, the duty to protect is difficult to reject, especially for members of a profession dedicated to assisting others in need. Indeed, I suspect that ... by seeking to guard potential victims of their patients from harm, clinicians as a group would endorse the trend toward broader duties to rescue.”[21]  In 1988, the Association formally declared that “breaching confidentiality is acceptable when required to protect third parties.”[22]

There is worse. Daniel Widlocher, a recent president of the International Psychoanalytical Association, declares: “When we refer to the presence of psychoanalysis ... in the world of mental health care, we are actually talking about the achievement of a therapeutic consensus accruing from an in‑depth knowledge of the differences between our therapeutic targets. This joint purpose calls for the active participation of psychoanalysts in mental health care institutions and the establishment of interdisciplinary research programmes.”[23]

Bizarrely, Glenn Gabbard, editor of the International Journal of Psycho‑Analysis, tells psychiatrists: “[B]ehavior 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.”[24] 

I regretfully conclude that, as a private, confidential personal relationship, psychoanalysis is morally bankrupt, intellectually corrupt, and professionally dead. Viewed as a treatment for disease, it is time to bury it. Only after burying medicalized, “therapeutic” psychoanalysis, will we be in a position to try to resurrect it as a secular cure of souls.

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What ideas and values motivated and united persons such as Freud, Jung, Ferenczi, Jones, and the other founders of the psychoanalytic movement in a common endeavor? I venture to say that it was opposition to the then prevailing organicist-reductionist principles and practices of psychiatry. Unlike psychiatrists, psychoanalysts wanted to understand their patients (and wanted to help their patients understand themselves). Recognizing the age-old wisdom that the only person who can change a person’s “mind” is that person himself, they created psychoanalysis on the basis of the time-honored Socratic proposition that the unexamined life is not worth living. Yet, steeped in medicine and profoundly unfamiliar with the political philosophy of Anglo-American limited government, they failed to protect psychoanalysis from the psychoanalysts, specifically, from their thirst for power, not only in the analytic situation but in all spheres of life, especially ethics and politics.

      I submit that rebuilding an intellectually persuasive and morally respectable psychoanalysis as a cure of the modern secular soul must begin by clearly limiting the role and power of the analyst as “helper.” Thanks to history, we know, in principle at least, how to do that: by denying the would-be do-gooder the option to justify defining coercion as care by appealing to necessity. Why necessity? Because necessity, emergency, dangerousness, the threat of suicide or murder have been and continue to be the jokers in the deck of human relations -- personal, political, therapeutic.  

            Consider the warning of Oliver Cromwell (1599-1658 ) in a speech to Parliament:   “Necessity hath no law. Feigned necessities, imaginary necessities, are the greatest cozenage men can put upon the Providence of God, and make pretences to break known rules by.” Or the almost identical words, also addressed to Parliament, of William Pitt, 1st Earl of Chatham (1708-1778): “Necessity is the plea for every infringement of human freedom. It is the argument of tyrants; it is the creed of slaves.”[25] Or, more recently, Camus’s reminder that “The welfare of the people in particular has always been the alibi of tyrants, and it provides the further advantage of giving the servants of tyranny a good conscience.”[26]       In closing, let me offer this highly personal opinion. Assuming that there will be persons in the future interested in developing the ideas I have presented to you today, and have presented elsewhere over the past half a century; and assuming that they will live in societies sufficiently open to tolerate the anti-authoritarian, individualistic subversion intrinsic to the kind of secular cure of souls I have sketched, they ought to eschew any effort at being “original.” Novelty belongs to science and technology. In human affairs, respect for history and human nature requires the utmost modesty. Indeed, the reformation of psychoanalysis depends on the reformers’ adopting Orwell’s statement, “Sometimes the first duty of intelligent men is the restatement of the obvious," as their initial job-description.[27] 

In the same vein, the future psychoanalyst would do well to take as his model Camus’s idealized yet realistic description of the moral mandate of the writer:

By definition, he [the writer] cannot put himself today in the service of those who make history; he is at the service of those who suffer it. ... his art must not compromise with lies and servitude which, wherever they rule, breed solitude. Whatever our personal weaknesses may be, the nobility of our craft will always be rooted in two commitments, difficult to maintain: the refusal to lie about what one knows and the resistance to oppression.[28

References     

[1]. Szasz, T., “Oral mechanisms in constipation and diarrhea.” International Journal of Psychoanalysis, 32: 196-203, 1951.

[2]. The Ethics of Psychoanalysis: The Theory and Method of Autonomous Psychotherapy [1965]. Syracuse: Syracuse University Press, 1988. 

[3]. Szasz, T., “The concept of transference.” International Journal of Psychoanalysis, 44: 432-443, 1963.

[4]. Lacan, J. The Four Fundamental Concepts of Psycho-Analysis [1973]. Edited by Jacques Alain Miller. Translated by Alan Sheridan. New York: Norton, 1981, pp. 131-132.

[5]. Szasz, T. "On the experiences of the analyst in the psychoanalytic situation: A contribution to the theory of psychoanalytic treatment." Journal of the American Psychoanalytic Association, 4: 197-223, 1956; "On the theory of psycho-analytic treatment." International Journal of Psychoanalysis, 38: 166-182, 1957; and "Psycho-analytic training: A socio-psychological analysis of its history and present status," International Journal of Psychoanalysis, 39: 598-613, 1958.

[6]. Szasz, T. "On the experiences of the analyst in the psychoanalytic situation: A contribution to the theory of psychoanalytic treatment." Journal of the American Psychoanalytic Association, 4: 197-223, 1956; "On the theory of psycho-analytic treatment." International Journal of Psychoanalysis, 38: 166-182, 1957; and "Psycho-analytic training: A socio-psychological analysis of its history and present status." International Journal of Psychoanalysis, 39: 598-613, 1958.

[7]. Szasz, T. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct [1961]. Revised edition. New York: HarperCollins, 1974;The Ethics of Psychoanalysis: The Theory and Method of Autonomous Psychotherapy [1965]. Syracuse: Syracuse University Press, 1988. 

[8]. Szasz, T. “The cure of souls in the therapeutic state.” The Psychoanalytic Review, 90: 45-62 (February) 2003.

[9]. Szasz, T., “What is psychoanalysis?” In Ann Casement, editor. Who Owns Psychoanalysis? London: Karnac Books, 2004, pp. 25-39.

[10]. Stephen, K., Psychoanalysis and Medicine: A Study of the Wish to Fall Ill (Cambridge; University Press, 1933).

[11]. Ibid., p. 27.

[12]. Sartre, J.-P. Being and Nothingness: An Essay on Phenomenological Ontology. Translated by H. Barnes. New York: Philosophical Library, 1956), p. 51.

[13]. Szasz, T. Pharmacracy: Medicine and Politics in America [2001]. Syracuse: Syracuse University Press, 2003.

[14]. Camus, A., “The Wager of Our Generation” (1957). In Camus, A. Resistance, Rebellion, Death. Translated by Justin O’Brien. New York: Alfred A. Knopf, 1961, p. 240. 

[15]. Shakespeare, W., Hamlet, Act IV, Scene 3.

[16]. Stein, S., “NYSPA lawsuit challenging new regulations for licensed psychoanalysts.” The Bulletin, New York State Psychiatric Association, 46: 1 & 8 (Summer), 2005.

[17]. Belli, M. M., “Warning of the dangerous patient: A practical approach,” American Journal of Forensic Psychiatry, 2: 6-7, 1981-82; p. 6.

 [18]. Szasz, T.  “Szasz on the dangerous patient,” American Journal of Forensic Psychiatry, 2: 6-7 & 17, 1981-82; pp. 6-7.

[19]. Szasz, T. Liberation By Oppression: A Comparative Study of Slavery and Psychiatry. New Brunswick, NJ: Transaction Publishers, 2002.

[20]. Leinwand, D., “Secret‑telling sparks some ethical conflicts,” USA Today, July 30, 2001, Internet edition.

[21]. Appelbaum, P. S. Almost a Revolution: Mental Health Law and the Limits of Change. New York: Oxford University Press, 1994, p. 103.

[22]. Ibid., p. 100.

[23]. Widlocher, D., “The President's Column.” International Psychoanalysis, 12: 8 & 47, 2003 (Issue 1).

[24]. Gabbard, G., quoted in Arehart‑Treichel, J., “Evidence is in: Psychotherapy changes the brain.” Psychiatric News, July 6, 2001, p. 33.

[26]. Camus, A., “Homage to an Exile” (1955),in Camus, A. Resistance, Rebellion, Death. Translated by Justin O’Brien. New York: Alfred A. Knopf, 1961, p. 101.

[27]. Orwell, G. Quoted. Simpson’s Contemporary Quotations, compiled by James B. Simpson.  © 1988 by James B. Simpson. Published by the Houghton Mifflin Company. http://www.bartleby.com/63/67/

[28]. Camus, A. “Acceptance Speech,” Nobel Prize for Literature, 1957.

http://www.nobel.se/literature/laureates/1957/camus‑acceptance.html

 


  


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