G . O . R . I . L . L . A .

For the post-Socratic philosophers, especially the Stoics, the philosopher was a physician of the soul who, employing the healing word (iatroi logoi), offered counsel to persons perplexed by problems in living. Seneca, for example, advised his mother, grieving over his exile to Corsica, to give herself up to "the study of philosophy, sovereign remedy for sadness" (McNeil, 1951, p.28).

After the triumph of Christianity, the priest as confessor and/or counselor replaced the philosopher as rhetorician of consolation. For most of the next nearly 2,000 years, doctors of divinity (and parish priests) served as the curers of the Western soul. The cure of bodies, at the same time, became the domain of doctors of medicine (and barber surgeons). The ensuing distinction between the cure of souls and the cure of bodies was recognized as early as the 14th century. Petrarch (Francesco Petrarca, 1304-1374)the great Renaissance poet and philosopher, often called "the first humanist"-warned against the literal interpretation of the medical metaphor of rhetorical healing. Declaring that "the care of the mind calls for the philosopher," he urged that doctors should use herbs not words" and leave the cure of minds to the "true philosophers and orators" (McClure, 1991, pp.20, 51).

I should now like to summarize how I see the birth, growth, and present state of modern psychotherapy.

The real name of Anna 0.-the patient who, according to Freud, discovered catharsis and psychoanalysis-was Bertha Pappenheim. In 1880, when Pappenheim became Joseph Breuer's patient, she was a 21-year-old woman living the existentially stifled life of an intelligent, overprotected daughter of wealthy Viennese Jewish parents. In an effort to escape from the meaningless existence to which her family and social station condemned her, she pretended to be ill and was duly diagnosed as suffering from hysteria. Aided by the affection and sympathy of an exceptionally humane physician, who lavished vast amounts of time on her, Pappenheim rediscovered the ancient power of the healing word or, more precisely, of the healing dialogue. The patient used the English terms talking cure and chimney sweeping to describe the therapy. Her physician named it catharsis, a Greek term (Breuer & Freud, 1893-1895; Freeman, 1972). It was unthinkable, for patient as well as doctor, to call a spade by its proper German name, that is, to call the healing word das heilende Wort or its use Heilung durch den Geist (spiritual healing) (Zweig, 1932). Using ordinary German words to describe these phenomena would have risked having the patient labeled a malingerer and the physician a quack.

To be sure, the word treatment, like the word disease, has a wide range of meanings. For example, we say that a man treats his dog badly, and we call seeing a good play a treat. I do not wish to quibble about the meaning of words or constrain their colloquial use. However, I do wish to draw a clear distinction between the physical (impersonal) cure of bodily diseases (exemplified by the surgical removal of an inflamed appendix) and the spiritual (personal) cure of souls in distress (exemplified by the Catholic confessional and psychotherapy). I regard the former as literal treatments, the latter as metaphorical treatments.

It is important to note here that many of the so-called symptoms Pappenheim exhibited were plainly self-made and related to her use of speech. For example, she had mysterious spells, during which she was mute in German, her mother tongue, but could speak in English. Not surprisingly, Breuer, an astute and scientifically trained physician, realised that the talking cure was not a genuine medical treatment and quickly abandoned its use.

As fate had it, one of Breuer's protégées was a young physician named Sigmund Freud, to whom Breuer related his misadventure with Pappenheim. Thereupon, Freud decided to make listening and talking to patients his lifework-not as an incidental part of the therapeutic effort, like other physicians, but as an integral part of it, indeed its sole ingredient. In the sophisticated intellectual climate of pre-World War I Vienna, it did not take long before Freud's sweeping claims about the efficacy of the treatment he called psychoanalysis were exposed as 'The disease of which it claims to be the cure" ("Die Psychoamalyse istjene Krankheit, fur deren Behandlung sie sicht halt") (cited in Szasz, 1990, p.24). Karl Kraus, the author of that aphorism, objected to the talking cure, not because it consisted of talking but because it was miscast as a treatment.

Because Freud was a practicing physician who treated persons officially denominated as patients and because he defined psychoanalysis as a treatment of mental diseases, we must now situate psychoanalysis-as the paradigm of modern psychotherapy-in the context of the history of psychiatry

For centuries, madmen and "mad" doctors alike were banished to madhouses, located on the outskirts of towns or in the countryside. Alienists-renamed psychiatrists in the 19th century-worked, and often lived, in insane asylums, where they oversaw desolate scenes of human misery When Freud came on this scene, insane persons were considered to be legally incompetent, insanity was considered to be an incurable illness, and individuals denominated as insane were incarcerated in insane asylums, usually for life. Because Freud's work appeared to have little relevance to the work of professionals engaged in caring for insane persons (many of whom suffered from the neurological ravages of syphilis), European psychiatrists first ignored psychoanalysis and then rejected it as unsuitable for serious cases of mental illness.

In contrast, American psychiatrists, imbued with characteristically American therapeutic optimism considered no disease indefeasible and embraced psychoanalysis as an ally in the war on mental illness. Pari passu, American psychoanalysts defined psychoanalysis-ostensibly to protect the public from quacks-as a medical activity and excluded nonmedical analysts from among their ranks. This marriage between psychiatry and psychoanalysis was a catastrophe for both parties but more so for psychoanalysis and, derivatively, for psychotherapy It is important that we understand the nature and consequences of this fateful misalliance.

In the 18th century Western societies began to delegate to mad doctors (subsequently called alienists, psychiatrists, mental health professionals, and therapists) the task of separating insane persons from sane persons and incarcerating the, former in mad-houses. To justify this enterprise, psychiatrists fabricated appropriate pseudomedical explanations about why some people display certain kinds of unwanted behaviors, about the dangers they pose to themselves and society as a result, and about the interventions mental healers must use to protect patients from themselves and the public from the patients.

At the beginning of this century; psychoanalysts appeared on the scene and claimed to be especially adept at explaining why people behave the way they do. American psychiatrists seized on these explanations as useful addenda to their own mystifications. The amalgamation of psychiatric and psychoanalytic theories received further impetus during World War II. Many of the analysts were recent refugees from Nazism who felt it was their patriotic duty to respond to the needs of the military. There, they were happy to do the bidding of their superiors, finding men fit or unfit for duty as the military authorities decreed. This use of psychoanalytic concepts was phony, but expedient, for the military as well as for psychoanalysis. The result was that psychoanalysis and psychiatry were joined, and for a brief period, the prestige of this superficially psychoanalyticized psychiatry carried over into civilian life.

But, it was all show. Psychiatrists in public mental hospitals, privately practicing psychiatrists who treated their patients with electric shock, and psychiatrists accredited as analysts all pretended that the similarities far outweighed the differences among them. In the process, the core elements of curing souls with healing words (noncoercively, facilitating personal freedom and responsibility) were replaced by the core elements of treating mad minds (coercively, imposing statist-medical controls on the insane). The aims and values of these two conflicting undertakings may be summarized as follows:

·   To effect a cure, the psychiatrist coerces and controls the patient: He or she incarcerates and imposes various chemical and physical interventions on the subject against his or her will.

·   To conduct a dialogue, the psychoanalyst contracts and cooperates with the patient: He or she listens and talks to his or her interlocutor, who pays for the service received. (Szasz, 1988)

These differences between the psychiatric and psychoanalytic relationships replicate the differences between two familiar types of political relationships, namely, paternalistic absolutism (unlimited government) and classical liberalism (limited government and the rule of law). The essence of individual liberty is the absence of capricious, unlawful coercions (traditionally present) in relations between rulers and ruled. Failure by the state to respect private property and its interference in voluntary acts between consenting adults destroy individual liberty. Mutatis mutandis, the essence of psychoanalysis, is the absence of coercions (traditionally present) in relations between psychiatrists and mental patients. The analyst's failure to respect the analysand's personal autonomy (paternalism) and his or her interference in the client's life (betrayal of confidentiality and coercion) destroy the psychoanalytic relationship.

In its initial stages, psychoanalysis represented a genuinely new social development, namely a noncoercive, secular help (therapy) for problems in living (called neuroses). The term psychoanalysis was then used to denote a confidential dialogue between an expert and a client, the former rejecting the role of custodial psychiatrist, the latter assuming the role of responsible, voluntary patient. Recast in such light, it is hardly surprising that psychiatry acquired neither the aims nor the practices of psychoanalysis. It could not have done so and fulfilled its social mandate. The two enterprises rest on totally different premises and entail mutually incompatible practices.

·   Traditional psychiatrists were salaried physicians who worked in mental institutions; their source of income was the state; they functioned as agents of their bureaucratic superiors and patients' relatives. 'Typical mental hospital inmates were poor people, cast in the patient role against their will, housed in public mental hospitals.
·   Classical psychoanalysts were self-employed professionals who worked in private offices; their source of income was their patients; they functioned as their patients' agents. Typical analytic patients were rich people (usually wealthier than their analysts), cast in the patient-role by themselves, living in their own homes or wherever they pleased.

The basic differences between psychiatry and psychoanalysis are dramatically captured in the following statements by, respectively, Benjamin Rush, the father of American psychiatry and Sigmund Freud, the father of psychoanalysis:

Rush:   Let our pupil be taught that he does not belong to himself, but that he is public property" (cited in Richman, 1994, p.45). "Let us view them [mankind] as patients in a hospital. The more they resist our efforts to serve them, the more they have need of our services,, (as cited in Woods, 1967).

Freud:   Nothing takes place in a psychoanalytic treatment but an interchange of words between the patient and the analyst" (Freud, 1905, p.283). "The patient should be educated to liberate and fulfill his own nature, not to resemble ourselves" (Freud, 1919, p.165).

The merger between psychiatry and psychoanalysis was a hope-less match, a marriage of convenience in which each party proceeded to rob its partner of whatever seemed of value. Psychiatry acquired the worst features of psychoanalysis its pseudo-explanations and vocabulary of stigmatizations; psychoanalysis acquired the worst features of psychiatry-disloyalty to the patients self-defined interests and coercion. In short, psychoanalysts (along with psychotherapists) sold their noble, but financially unprofitable, birthright for a mess of pottage, the fakery of psychodiagnostics and psychotherapy The result is an ignoble mental health profession masquerading as biological science and medical treatment.

How did psychotherapy get itself into this mess, if a mess it be? Ironically, it was Freud himself who insisted on the self-contradictory proposition that psychoanalysis is both a dialogue and a treatment. In 1905, he wrote, "Words are the essential tool of mental treatment" (p.283). Yet, elsewhere, he asserted, "As a method of treatment it [psychoanalysis] is one among many; though, to be sure, primus inter pares [first among equals]" (Freud, 1919, p.167). Finally, in 1919-at a time when neighboring Hungary had a communist government and the Soviet Union became established as a new nation-Freud welcomed the historical inevitability of a socialist psychoanalysis administered by the modern bureaucratic welfare state as medical treatment.

It is possible to foresee that at some time or other the conscience of society will awake and remind it that the poor man should have as much right to assistance for his mind as he now has to the life-saving help offered by surgery; and that the neuroses threaten public health no less than tuberculosis, and can be left as little as the latter to the impotent care of the individual members of the community . Such treatments will be free. It may be a long time before the State comes to see these duties as urgent. Some time or other, however; it must come to this. (p.159)

Ironically, this passage appears only two pages after Freud's (1919) claim that the aim of psychoanalysis is to liberate the patient, a proposition that formed an integral part of Freud's thesis that psychoanalysis is not a treatment. Instead of curing the patient, the analyst's task, he declared, is "to bring to the patient's knowledge the unconscious repressed impulses existing in him" (p.159). Finally, in An Outline of Psychoanalysis-the summation of his lifework-Freud (1938) wrote, "We [psychoanalysts] serve the patient in various functions, as an authority and a substitute for his parents, as a teacher and educator" (p.181).

Freud's dexterity as a high-wire artist, balancing himself between his role as personal counselor and medical doctor, never deserted him. After identifying the therapist as parent, teacher, and educator, Freud quickly reasserted his lifelong commitment to a materialist medical treatment for personal problems as mental diseases. He wrote,

But here we are concerned with therapy only insofar as it works by psychological means; and for the time being we have no other. The future may teach us to exercise a direct influence, by means of particular chemical substances, on the amounts of energy and their distribution in the mental apparatus. (Freud, 1919, p.182)

As a result of Freud's labors, it is now a part of received wisdom that psychoanalysis is a method for analyzing human behavior; that it is a valid theory for explaining the behavior not only of living persons but also of dead persons and of persons who never existed-that is, of myth, religion, legend, and literature; and that listening and talking to a person, called talk therapy, is a bona fide medical treatment.

The degeneration of psychoanalysis-and of psychotherapy in general-is an inexorable consequence of the medicalization of life, that is, of the tendency to regard despair and deviance as diseases and talking as a treatment. Viewing a person's complaints about his or her life as if they were the symptoms of a mental illness defines the complaint as a disease and the effort to ameliorate it as a treatment. However, ideas have consequences that have a habit of coming back to haunt us. If we view diabetes as a disease we rightly consider it a serious error, prima facie medical negligence, to treat a diabetic person solely by listening and talking to him or her. The same goes for viewing mental illnesses, whose disease status is established as legal fact by the DSM-IV diagnoses attached to them, as chemical disturbances in the brain treatable with drugs. The upshot is that practicing the talking cure (especially by a physician) has been rendered, de jure malpractice, and hence de facto impractical and irrelevant. And that is not all. With the liquidation of the most essential prerequisite of psychotherapy, namely, that the relationship between therapist and client be based on a free contract between them, the nature of the "correct therapy" is no longer defined jointly by the two parties to the agreement; instead, henceforth, the DSM-IV "scientifically correct diagnosis" of the patient's disease determines the American Psychiatric Association-authenticated "scientifically correct treatment" that he or she needs and that the therapist must provide. (Despite this political-economic climate, or more likely because of it, many American psychologists are clamoring for prescription privileges.)

Freud's assertion that his method was a genuine treatment for genuine diseases, superior to all other treatments, naturally provoked a torrent of controversy and criticism that is still continuing. Eager to eclipse Freud, competitors typically gave faint praise to psychoanalysis as an early form of psychotherapy, the better to claim superiority for their brand of mental healing. Eager to execrate Freud, critics typically claimed that psychoanalysis "is no more effective than no treatment at all" (Eysenck, 1952). Recasting psychotherapy as dialogue transcends this futile controversy and dispels the mystery that continues to envelope mental healing, especially the question of its so-called effectiveness.

Since ancient times, people have recognized that words power-fully affect the listener and that, like double-edged swords, they cut both ways. Indeed, our vocabulary possesses numerous adjectives for characterizing both types of speech acts, such as blasphemous, impious, obscene, perjurious, pornographic, profane, and sacrilegious for words deemed to be harmful; and calming, cheering, comforting, consoling, encouraging, heartening, inspiring, motivating, and reassuring for words deemed to be helpful.

Dreading the effects of harming words and desiring the effects of healing words, every society prohibits speech acts it considers deleterious and encourages those it considers beneficial. It seems to me that the fact of censorship is proof enough that words can heal. My point here is simply to show that it is absurd to contend, as many people have contended and continue to contend, that psychotherapy is (inherently) ineffective. The truth is far simpler: The benefit or detriment of a particular discourse depends on the subject's susceptibility to the speaker's message. In the final analysis, just as the beauty or ugliness of a face lies in the eyes of the viewer, the benefit or detriment of a speech act lies "in the ears" of the listener. it is a priori impossible to marshal objective evidence to support or refute claims about the effectiveness or ineffectiveness of psychotherapy. The validity of this assertion is intrinsic to the ontological character of psychotherapy as discourse.

Let me now briefly restate my concept of psychotherapy as the name of a class of interactions in which two (or more) persons voluntarily listen and talk to one another. In this view, psychotherapists dispensing diverse therapies resemble clerks in a department store, each selling different merchandise under the same roof. To be sure, psychotherapists differ from clerks: Selling merchandise (or performing a standardized medical procedure) is an impersonal act that a person does in his or her persona as the purveyor of goods (or services), whereas healing with words is a personal activity, not just a job a person does but something that he or she is. It is morally fitting that it should be so. The person who seeks help through the healing word suffers not from an impersonal illness, such as an inflamed appendix, but from a distinctively personal perplexity It follows that just as it would demean both marital partners to speak of a method a husband uses to relate to his wife or vice versa, so it demeans both therapist and client to speak of a method of psychotherapy

Mental illness and psychotherapy are fictions. Neither exists. Only the patient, the therapist, and a particular relationship between them exist. Both participants are responsible moral agents. Each is existentially equal to the other, each influences the other, and each is responsible for his or her behavior. The therapist can neither cure the patient nor make him or her sick. However, the patient can do both of these things, for or to himself or herself, by making use of the therapist's helping or harming words (Bohart & Talman, 1996). These simple insights, commonplace to the early religious and rhetorical curers of souls and their clients, have disappeared into the mystifications of the mental health professions and the gulag of the therapeutic state.

In my view, there are as many authentic types of psychotherapies as there are authentic persons using words to help. I respect every one of these methods, provided their practitioners eschew force and fraud. My own work as a therapist was based on the premise that the focus of the therapeutic relationship can only be how the patient lives, how he or she might live, and how he or she ought to live. The expert's role is to engage the clients in a process of searching self-examination, with the aim of enabling them, if they so choose, to become more free and more responsible. To accomplish this task, the therapist must eschew interfering, in any way possible, in his or her client's life outside the walls of the consulting room (including receiving information from, or giving information to, anyone other than the client). Such a curer of souls must reject playing doctor or therapist. Instead of promising relief from suffering or promising any particular outcome, his or her duty is to fulfil a promise to the client, that is, to respect his or her autonomy and confidences and engage him or her in a searching, open-ended dialogue. The outcome of the interaction must be left in the client's hands because he or she has more control over it than the expert does and, more important, because that is where it rightly belongs. Although it is obvious that practicing mental healing in accordance with these principles is, in the United States today, synonymous with malpractice, mental health professionals continue to pretend that it is not.

When I assert that the outcome of the interaction must be left in the client's hands, I am simply rearticulating an insight W H. Auden phrased far more elegantly

Though it is absolutely required of a man that he should intend to help others, the power to do so is outside his control.... The final aim of every critic and teacher must be to persuade others to do without him, to realize that the gifts of the spirit are never to be had at second hand. (Auden, 1948, p.13)

To paraphrase Shakespeare, I have come to praise the healing word, not to bury it. But I must report to you that the healing word is no more: It has committed suicide by overdosing on therapy.

The modern soul doctors succumbed to the temptation to treat people as material susceptible to improvement by experts, ceased to respect the Other as a moral agent, and renamed discourse treatment. They are the sinners whose offence Auden (1968) satirized thus: "We are all here on earth to help others; what on earth the others are here for, I don't know" (p.14).


NOTE
1. In ancient Greek, as in modern German, there is no word for "mind" as a noun.


REFERENCES
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THOMAS SZASZ, M.D., D.Sc., is professor of psychiatry emeritus at the State University - New York Health Science Center in Syracuse. He is the author of 24 books, among them the classic The Myth of Mental illness (HarperCollins, 1961). His most recent work is The Meaning of Mind Language, Morality, and Neuroscience (Praeger, 1996). The foremost critic in the world of psychiatric coercions and excuses, Dr. Szasz has received many awards for his defense of individual liberty and responsibility threatened by a totalitarianism masquerading as therapy. 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.

Reprint requests: Thomas Szasz, MD., Department of Psychiatry, 750 East Adams Street, Syracuse, NY 13210; e-mail: tszasz@aol.com