Ryan Howes

Ryan Howes PhD, ABPP

In Therapy

Seven Questions for Thomas Szasz

Seven Questions for Thomas Szasz

Posted Jan 28, 2009

"If you talk to God, you are praying; If God talks to you, you have schizophrenia" - The Second Sin, 1973

Well, today Dr. Thomas Szasz talks to us, and we're fortunate. My honored guest is a genuine maverick in the mental health field, a man who has "done more than anyone else to challenge psychiatry to abandon the destructive use of force and replace it with consent, trust, and adherence to the Hippocratic injunction to do no harm." (G. Annas from Szasz website)

Thomas Szasz was born in Hungary in 1920, received his M.D. from the University of Cincinnati in 1944, and trained at the Chicago Institute for Psychoanalysis. He is Professor Emeritus of Psychiatry at the Upstate Medical University, State University of New York, Syracuse, distinguished life fellow of the American Psychiatric Association and a life member of the American Psychoanalytic Association. His 33 books, hours of lecture  and innumerable articles share a similar message: biological disease and (mis)behavior aren't the same, yet psychiatry mistakenly links the two.

Needless to say, Szasz is a psychiatrist at variance with his profession. In 1961 he penned the classic The Myth of Mental Illness where he refuted the idea that mental disorders were on par with physical illness and could therefore be treated with medication. In his view, mental illness does not constitute actual disease, but rather "problems in living." He wrote and spoke vehemently against the dominant paradigm, as he continues to this day.

Szasz is labeled an anti-psychiatrist, but this misnomer will be clarified in his forthcoming book Antipsychiatry: Quackery Squared, which Szasz described to me as: "My quixotic attempt to dissociate myself from this stigmatizing term and category." Szasz is not an anti-psychiatrist; he supports psychiatry if it is contractual and non-coercive.

I'm thrilled to include Dr. Szasz's iconoclastic, dissenting opinions to my project. In true form, he agreed to submit his answers with the following caveat:

My view is that there is no mental illness and hence also no "therapy/psychotherapy." Therapy, then, is a particular kind of human relationship (arrangement, contract), aimed at helping people cope with their "problems in living." This makes it necessary to reframe some of the questions you pose. 

I wouldn't have it any other way. When Dr. Szasz has taken the time to subvert the Seven Questions, I know I must be on to something. Enjoy these responses from a living legend in the field of mental health.

Seven Questions for Thomas Szasz:

1. How would you respond to a new client who asks: "What should I talk about?"

I have retired from nearly fifty years of private practice, which was limited to adult, voluntary clients, and was based on the following principles:

□ There is no such thing as mental illness, hence also no such thing as psychotherapy.

□ "Psychotherapy" is a private, confidential conversation that has nothing to do with illness, medicine, or healing.

□ The therapist must not directly participate in the client's "real life": he must not use his power to coerce or excuse the client or intervene in the client's life for any reason.

□ The therapist must keep his client's communications absolutely confidential and the client must pay the therapist for the service he receives.

□ The client must be fully informed that these are my beliefs and conditions for engaging in my practice of "therapeutic dialogue." (See The Ethics of Psychoanalysis 1965, and The Myth of Psychotherapy, 1978).

The therapist's initial task is to create a context of comfort, safety, and trust in the therapeutic situation, enabling the client to feel in control, especially about the beginning and ending of the relationship.

It was my practice to never meet with a prospective patient without first speaking to him on the telephone. I used this opportunity to ascertain the sort of help the client was seeking and to inform him of the sort of assistance I was, and was not, offering. If these matters are properly clarified, the question, "What should I talk about?" does not arise, just as it does not arise in, say, the office of a divorce lawyer meeting a client seeking a divorce. Nevertheless, a new client may feel embarrassed, fearful, or tongue-tied for other reasons and ask, "What should I talk about?" In such case I said, "How can I be of help to you" or "What made you decide to come and see me (today)," or something similar.

2. What do clients find most difficult about the therapeutic process?

Assuming responsibility for their contribution to the problem they seek to resolve.

3. What mistakes do therapists make that hinder the therapeutic process?

"Therapy" is many things to many people. If a therapist does not help his client, the client must assume responsibility for leaving him. (Suffice it here to reiterate my opposition to therapists' using the coercive power of the state to deprive their patients of liberty, ostensibly to "protect" them from themselves and society from the patients.)

4. In your opinion, what is the ultimate goal of therapy?

The "ultimate goal" of therapy must be determined by the client: he defines his problems and aspirations and he pays for the service he receives. In general, my goal was to encourage the client to engage in critical self-examination (as Socrates said, "The unexamined life is not worth living"). Liberation from painful, constricting relationships or situations can be achieved only by assuming responsibility for one's own contributions to them and by extricating oneself from them. The only person who can change a person is that person himself.

5. What is the toughest part of being a therapist?

Individual psychotherapy -- that is, engaging a distressed fellow human in a disciplined conversation and human relationship - requires that the therapist have the proper temperament and philosophy of life for such work. By that I mean that the therapist must be patient, modest, and a perceptive listener, rather than a talker and advice-giver. In addition, he must not want to "play doctor," seek to produce dramatic "cures", convert clients to his own beliefs or values, save persons from their own follies or passions, and be able to resist the temptation to exploit his patients' dependence on him for his own financial gain or personal self-aggrandizement. Perhaps most importantly, the therapist must grasp and value that the therapeutic situation must be a contractual human relationship, which is a requisite for the client's self-liberation. (In this connection, see Sir Henry Maine's classic treatise, Ancient Law: Its Connection With the Early History of Society, and Its Relation to Modern Ideas, 1864/1986.)

Even if the foregoing conditions are satisfied, the therapist's task may not be easy or enviable, as he may be required to be passive in the face of the client's self-destructive behavior and tolerate the client's choosing to stick to his familiar, self-limiting life strategies and not risk entering on the path of liberation.

Unfortunately, modern psychiatry has declared war on the fundamental moral and political value of relations based on contract rather than on relations based on status or domination-submission. In 2003, Marcia Goin, M.D., then president of the American Psychiatric Association, declared: "We can make contracts with builders and car dealers, but not with patients." Many therapists reject forming contractual relations with their clients; instead they patronize and "protect" them and justify doing so with self-flattering bioethical slogans, such as "beneficence," "non-maleficence," and "fairness."

In sum, "doing (contractual) psychotherapy" is neither exceptionally difficult nor very easy. Assuredly, it is not "just talk" (as in "talk therapy"); nor is it, as I emphasized at the beginning, "therapy" (in the sense of something that one person does or gives to another person).

6. What is the most enjoyable or rewarding part of being a therapist?

The most rewarding parts of being a therapist are: 1) engaging in a serious, in-depth, private, confidential relationship with an intelligent fellow being; 2) learning about what William James might have called "the varieties of human experience"; and 3.) being able to help a client set himself free by assuming more, not less, responsibility for his behavior and feelings.

7. What is one pearl of wisdom you would offer clients about therapy?

My advice for a prospective client is to investigate his prospective therapist, to not trust him unless he proves himself to be trustworthy, and to be clear in his own mind what he expects the therapist to do for him. Becoming a psychotherapy client or patient is like becoming married: it may be a trap which it is much harder to escape than to avoid. In short, beware of therapists, especially if you have reason to suspect that they will lock you up if they think you may kill yourself.

In this series of interviews, Dr. Nada Stotland, president of the American Psychiatric Association, states: "Setting limits with self-destructive or suicidal patients requires balancing the risk of letting the patient harm him or herself against the risk of setting off an escalating cycle of more frequent contacts, more desperate threats, and repeated hospitalizations."

None of the contributors explicitly eschews the option of forcibly "hospitalizing" and "treating" the patient.

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