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On the future of psychotherapy

Thomas Szasz


Today, the term "psychotherapy" is used to refer to all manner of interventions, ranging from a voluntary dialogue to electrical, pharmacological, and surgical procedures imposed on persons against their will. This usage reflects the fashionable failure to distin¬¬guish between bodily disease and "mental disease"; between treating diseases with chemical and physical methods and influencing persons with "religion, rhetoric, and repression"; and between help that people seek for themselves and harm that people seek to impose on others (and call "treatment").

I use the term "psychotherapy" as the name of a freely contracted relationship between two competent and responsible adults, one paying the other for assisting him, by means of a dialogue, to live his life better. The wellspring of voluntary medical-therapeutic relationships is the patient's need for helping the Self, whereas the wellspring of involuntary psychiatric interventions is the family's (or the court's) need for controlling the Other. The former rests on consent, the latter on coercion. It is as absurd to conflate voluntary and involuntary "therapeutic" relations as it is to conflate sexual relations between consenting adults and rape.

The contractual conception of psychotherapy requires that the client / patient pay the therapist. Accordingly, most contemporary psychotherapeutic practices, based on the therapist's being paid by an insurance company or other "third party," preclude the practice of such "autonomous psychotherapy." If the client/patient does not obtain psychotherapeutic help by paying for it with money, then he will find himself in a situation of having to pay for it by producing symptoms.

Correlatively, if the therapist does not get paid for service by the client/patient, then he will find himself in a situation of having to receive reimbursement for it by producing diagnoses. The result is a deceptive, intrinsically anti-therapeutic collusion between patient and therapist.

When a person suffers - from disease, oppression, or want - he naturally seeks the assistance of persons who have the knowledge, skill, or power to help him or on whom he projects such attributes. In ancient times, priests - believed to possess the ability to intercede with gods - were the premier wielders of power. For a long time, curing souls, healing bodies, and relieving social-economic difficulties were all regarded as priestly activities. Only in the last few centuries have these roles become differentiated, as Religion, Medicine, and Politics, each institution carving out its "proper" sphere of influence, each still overlapping with and struggling to enlarge its scope and power over the others. One of the results of this process of role-differentiation is the dual function of the modern healing professional, sometimes acting as the individual's ally, sometimes acting as his adversary (albeit officially he is always defined as his ally).

The therapist's integrity depends largely on his representing his role to the patient truthfully and on keeping the promises he makes to the patient. Because an element of dependency is intrinsic to the "patient role", the only way to compensate for the asymmetry of power between therapist and patient is by limiting the therapist's behavioural repertoire vis-Ý-vis the patient.

Psychotherapy aimed at enlarging the patient's liberty and responsibility requires that the therapist and the patient view themselves as existentially equal moral agents, each responsible for his own conduct and self-control.

The major obstacle preventing psychotherapy from reaching its promise in the past - and boding ill for its future - is the spirit of paternalism and the passion for coercion that animates many of its practitioners. The following statement by two prominent therapists is illustrative: "Once the patient's suicidal thoughts are shared, the therapist must take pains to make clear to the patient that he, the therapist, considers suicide to be a maladaptive action, irreversibly counter to the patient's sane interests and goals ... Suicidal intent must not be part of therapeutic confidentiality. ... The therapist must be prepared to step in with hospitalisation, with security measures, and with medication."

Most contemporary psychotherapists cling to the concept of mental illness and reject limiting their discretionary powers to interfere in the life of the patient. This vitiates what I regard as a requirement for "autonomous psychotherapy" and for the maintenance of the therapist's role integrity. The plumber does not install wiring and the ophthalmologist does not remove appendices. The psychotherapist who professes to heal with words ought not to prescribe drugs, prevent suicide, or otherwise interfere with the patient's life. Today, this kind of therapeutic self-restraint is professionally censured as "withholding essential treatment" from the patient and is rendered de facto illegal by tort law.

Our attitude toward the relationship between the individual's need for mental health services and the state is the very opposite of our attitude toward the relationship between the individual's need for religious services and the state. The American government provides no religious services for its citizens. Clergymen provide no involuntary religious services for atheists or others who do not voluntarily seek it. Were an educated American to interpret this as "withholding" religious services from people who need and would benefit from them, he would be dismissed as a person ignorant not only of the relationship between Church and State but also of the constitutionally imposed prohibitions against coercion in the name of God. Coercion in the name of mental health is permitted, indeed mandated.

In our present collectivised medical-economic climate, mental health professionals have grown estranged from, and hostile to, reciprocity and responsibility in human relations. As a result, ostensibly in the patient's best interests, they not only coerce patients, they also defraud employers and insurance companies. A prominent American psychotherapist declares that "the mentally ill deserve job protection" and describes "Jill", one of his patients, as deserving  such protection despite being "dour, deeply and chronically depressed, consider[ing] suicide every day of her adult life, gruff, and lack[ing] drive." Were Jill's employer - let us call him James - to display the same set of behaviours towards her, psychiatrists would rush to help Jill and her lawyers extort compensation from James on the ground that he is the cause of Jill's "mental illness." Yet when Jill displays such behaviour, psychiatrists rush to enlist the formidable powers of the government's criminal law enforcement apparatus to prevent James from firing her as an unsatisfactory employee.

Burke warned that "it requires a deep courage to be temperate when the voice of multitudes (the specious mimic of fame and reputation) passes judgement against you. The impetuous desire of an unthinking public will endure no course, but what conducts to splendid and perilous extremes. Then, dare to be fearful, when all about you are full of confidence..."

I am fearful for the future of psychotherapy, not only because the unthinking revolutionaries of mental health and the public they have successfully gulled are full of confidence, but also because I share Burke's concept of liberty which, as he put it, is that state of things in which liberty is secured by the equality of restraint. Mutatis mutandis, the therapy I value is that sort of human relationship in which personal assistance is secured by an equality of self-restraint.

Thomas Szasz is Professor of Psychiatry Emeritus at the State University of New York Health Science Center in Syracuse, New York.  He is the author of 25 books, among them the classic The Myth of Mental Illness (1961) and most recently, Fatal Freedom: The Ethics and Politics of Suicide (Westport, CT: Praeger, 1999).

Szasz is recognized as a foremost critic of psychiatric coercions and excuses. A frequent and popular lecturer, he has addressed professional and lay groups, and has appeared on radio and television, in North, Central, and South America as well as in Australia, Europe, Japan, and South Africa. His books have been translated into every major language.



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