Category: Therapeutic Issue

Thomas Szasz has been the leading critic of psychiatry for the past 35 years. In this time, his relationship with psychiatry has been problematic and painful. Critics are rarely loved by the objects of their attention. Thomas Szasz has been hated, mocked, repressed, ignored, and ostracized by psychiatrists who fear his critical gaze. This period of psychiatric history, which is not well known, is highly significant for contemporary psychiatry and for the society in which it operates.

The reader should be informed at the outset that I, personally, have been strongly influenced by Szasz to both my benefit and my detriment. I first met him in 1956, when I was a senior medical student and he had just been appointed professor of psychiatry at the Upstate Medical Center at Syracuse. We have been friends and colleagues for—I am startled by the number—almost 40 years. In this time, both psychiatry and American society have undergone profound changes. Some people have blamed Szasz for some of those changes, for example, the deinstitutionalization of mental patients.¹ Others would deny that he has had any influence at all on psychiatric thought or practice. They say that progress in biological psychiatry has rendered his writings hopelessly obsolete.

It is incorrect and unfortunate, however, to dismiss the corpus of Szasz's work on the grounds either that he has been a negative influence or that his work is no longer relevant to modern psychiatry. Although Szasz has been in conflict with psychiatry because he is an individualist and a champion of individual rights, he is not an individual thinker. Strictly speaking, there is no such thing as an individual thinker, in the sense that individuals think in the intellectual paradigms of their times. Thinking is a social activity. Thinkers think in the framework of thoughts articulated before them. They may interpret and express their ideas uniquely, but they nevertheless swim in the intellectual currents of their Zeitgeist. Szasz represents a current of intellectual history. The fact that most psychiatrists dismiss him as irrelevant means that psychiatry rejects and avoids that current.

If some people regard Szasz's work as wrong, obnoxious, or obsolete it is because it embodies a historical set of concepts and values with which they disagree or by which they are threatened. Szasz has written critically of psychiatry because he disagrees with fundamental psychiatric concepts and values. The relationship between Thomas Szasz and psychiatry is shaped by ethical and philosophical conflicts which are rooted in historical and political currents. Understanding these currents will help to illuminate some vexing problems of modern psychiatry and society.

This Historical Context

Students of the sociology of knowledge have long understood that thought is a commodity. Karl Mannheim observed that thoughts have political and social value.² Some thoughts are enlightening and ennobling while others are false and degrading. Some ideas are congenial and supportive of our particular interests while others are contradictory and threatening. Mannheim, like most social thinkers after Marx and Freud, recognized that individuals and groups are motivated by their desires and interests and tend to support ideas which promote them and to oppose ideas which obstruct them.

History shapes and is in turn shaped by the dynamic conflict between competing desires and ideas. Until the seventeenth century of the Christian era, the prevailing ideology in the West was a cosmology which viewed the world hierarchically. The earth was perceived as at the center of the universe, orbited by the seven visible spheres: the moon, the sun, Mercury, Venus, Mars, Saturn, and Jupiter. Presiding at the pinnacle of this cosmic hierarchy was the Judeo-Christian Sky God, Lord of the World, who governed human affairs through His representatives on earth—kings and popes. They, in turn, ruled by divine right over the descending order of landed nobles and feudal chiefs, soldiers and knights, artisans and merchants, and, at the bottom, peasants and indentured serfs.

In the seventeenth century, this dominant ideology was challenged by the scientific discoveries of men like Giordano Bruno, Johannes Kepler, Galileo Galilei, Isaac Newton, and Rene Descartes. In their new, scientific world view, the earth was perceived as only one of six planets orbiting the sun in a universe governed indifferently by the laws of physics. The New Science threatened the knowledge and, therefore, the authority of the prevailing social powers who consequently opposed it and persecuted its practitioners. Bruno was burned at the stake for teaching that the earth revolves around the sun. Kepler and Descartes were intimidated. Galileo was forced to recant it. His works were censored by the Vatican's index of prohibited books until the end of the nineteenth century.

But the medieval cosmology could not withstand the assault of factual knowledge about the world. At the same time that the facts of the New Science were spreading across Europe, the Catholic Church and the monarchies of its Christian empire were disintegrating from the poisonous effects of their own corruption, cruelty, and hypocrisy. A groundswell of political unrest and revolution overturned the authority of the tyrannical rulers beginning in America in 1776, erupting in France in 1779, and continuing around the world until today.

The twin ideals of the intellectual and political revolutions of the European Enlightenment were science and democracy. Jurisdiction over the problems of human suffering and the pursuit of happiness were transferred from religion to science and from church to state. The new social order would no longer be guided by priests, kings, and scripture toward a hoped-for heaven after death. It would now be guided by scientists and politicians toward the utopian ideal of social progress here on earth.³

The decline of traditional religious authority, the rise of the city, and the corollary disintegration of the clan and family left the individual and the state as the new primary units of society. The democratic revolutions embodied a new political spirit of a community of individuals as expressed in the slogan "Liberty, Equality and Fraternity." This new ideology was fueled by the hope for social progress based on faith in science and an economic policy driven by enlightened self-interest under a minimalist state ruled by law. American constitutional government was designed on the template of this ideology. This is the current of history to which Thomas Szasz belongs. Szasz has been labeled a political conservative but he is, basically, a Jeffersonian liberal.

Szasz's valuation of the individual and of individual rights under the rule of law in an open society also has a personal context. He was born Jewish in Hungary in 1920 when anti-Semitic fascism was on the rise. His family was educated and politically sophisticated. They knew that fascism and communism both meant the hypertrophy of the power of the state and the repression of the individual, especially the Jewish individual. Szasz fled Hungary in 1938 together with his beloved brother George. His parents followed later. They traveled overland to Paris and then overseas to the United States, to Cincinnati, Ohio, where relatives lived. Szasz attended the University of Cincinnati and graduated first in his class with a bachelor of science in physics. He then completed his medical education at the University of Cincinnati medical school.

Szasz's conflict with psychiatry has its historical roots in the growth and expansion of the power of the state over and against the individual. The eighteenth-century ideal of enlightened self-interest was, in practice, more selfish than enlightened. The gap between rich and poor grew wider than it had been under the old feudal and monarchic orders. The modern socialist state has hypertrophied to its present leviathan proportions to mediate the conflicts between classes and groups, to replace the historical functions of the declining family and community, and to socialize, educate, and control its members.

As a social institution, psychiatry has historically functioned both in the service of the individual and in the service of the state. This is the root of the conflict between Thomas Szasz and modern psychiatry. Psychoanalysis and psychotherapy developed in the service of the modern, alienated individual to help resolve and relieve the psychological conflicts and emotional pain of secular life. In this manifestation, the psychiatrist is the heir of the priest, the moralist, the educator, and the critic. Szasz belongs to this tradition. He was trained as a psychoanalyst and, like Freud, was more comfortable in the role of the intellectual and literary critic than of the medical physician.

Psychiatry has another face, however. Psychiatry has also allied itself with the state as a covert agent of social control of the individual. This alliance of psychiatry and the state is a historical consequence of the limitations placed on the power of the state by the rule of law. The rule of law limits the power of the state over the individual. This limitation has motivated the invention of a covert, disguised means by which society can control the individual. Psychiatry has served this social function through its state-sanctioned power to label certain forms of deviant or undesirable conduct as illness and by means of involuntary psychiatric commitment which enables the state to detain individuals against their will, without trial or conviction of a crime, in the name of their mental health.

The conflict between Thomas Szasz and establishment psychiatry began in the historical context of the conflict within psychiatry about whether it functions as an agent of the individual or as an agent of the state. Szasz's critique of psychiatry has two elements: first, the critique of the political function of psychiatry as an agency of social control; second, the critique of the ideology which justifies and facilitates this political function, namely, the medical model of psychiatry.

Szasz's Early Work

Szasz inaugurated his critique of the medical model of psychiatry with the publication of the now classic Myth of Mental Illness in 1961. This seminal work has been widely misunderstood and misinterpreted. Many psychiatrists to this day believe that Szasz denies that mental illness exists and even denies that mental suffering and disturbance exist. On the contrary, Szasz does not deny the existence of suffering. How foolish for anyone to think so. Szasz acknowledges the existence of mental illness, but differs from the conventional view of it. The critical point is that mental illness is not a disease which exists in people, as pneumonia exists in lung tissue. Mental illness is, rather, a name, a label, a socially useful fiction, which is ascribed to certain people who suffer or whose behavior is disturbing to themselves or others.

Szasz developed this point of view while he was a student and teacher at the Chicago Psychoanalytic Institute under Franz Alexander. Alexander's work focused on the psychoanalysis of psychosomatic disorders. Szasz disagreed with his teacher on fundamental philosophical points which Szasz presented in his first book, Pain and Pleasure, published in 1957. In this book, Szasz critiqued the prevailing tendency to psychoanalyze body functions, imputing meanings to and motivations for physical diseases. Szasz's critique was based on the work of modern English philosophers such as Bertrand Russell, Gilbert Ryle, and Karl Popper.

Szasz's critique of Alexander's work was derived specifically from the empirical and logical dualism developed by Russell and Ryle.⁵ Russell took the epistemological position that mind-body dualism is based upon an operational dualism. Mind and body are different because psychology and the physics (including biology) are based on different methods of investigation. Knowledge about the body is obtained by means of the methods of physics observation, description, measurement, and mathematical calculation. Knowledge about the mind is obtained by means of communication through language and the interpretation of meanings. Ryle supplemented this view with the argument that, since our knowledge of other minds is based upon the meaning of the actions and speech of other persons, statements about minds and statements about bodies belong to different logical categories of language.

Szasz applied this point of view to the critique of the medical model of psychiatry. The medical model is so called because it views the mind the way medicine views the body, as an object which is explained either in terms of neurophysiology and genetics or in the language of disease, medicine, and treatment.⁶ In Pain and Pleasure, Szasz argued that it is logically permissible to talk about the meanings of physical disease, in the sense of our reactions to them and interpretations of them. But to talk about meanings as causes of physical disease is to conflate two operationally and logically different concepts. In The Myth of Mental Illness, Szasz moved from psychosomatic disease to conversion hysteria to demonstrate that the classification of thoughts, feelings, and behavior as diseases or as diseased is a logical error. It confuses the logical category of the body with the logical category of the mind. The term "myth," in The Myth of Mental Illness, refers to a category error as described by Gilbert Ryle. Ryle defined a myth as not a fairy story but as the presentation of the f acts from one logical category in the language appropriate to another.

Szasz's first book was not attacked by established psychiatry. In fact, Franz Alexander was so impressed by Szasz's intellect that he offered to make him his heir as Director of the Chicago Institute of Psychoanalysis.⁷ Szasz turned Alexander down for another offer, as we shall presently see. Szasz came into conflict with psychiatry not so much because of his ideas but because of his values. All his life, Szasz has been the emphatic champion of the values of individual freedom, dignity, and autonomy, which are in conflict with the psychiatric practices of involuntary psychiatric confinement and treatment. This is the basis of the conflict between Thomas Szasz and psychiatry.

Conflict in the Department of Psychiatry at Syracuse

I can best tell the story of this historical conflict from my own point of view. I believe it is a story that needs to be told and reflected upon. It illustrates how and why intellectual thought is subtly controlled by academic power brokers and, in this case, how the repression of Thomas Szasz and his students reflects the ironic predicament of modern psychiatry.

After graduating from the medical school at Syracuse in 1957, I served a one-year internship in medicine and psychiatry at the Strong Memorial Hospital in Rochester, New York. The six-month psychiatry rotation was under John Romano, who was chairman of psychiatry, and George Engel, from whom I learned to read electroencephalograms. In 1958, I returned to Syracuse to do my residency training under Szasz. Dr. Marc Hollender had just been appointed Chairman of Psychiatry at Syracuse, by the good graces and influence of Dr. Julius Richmond, who was then Chairman of Pediatrics. Richmond was a Chicago-trained, psychoanalytically oriented pediatrician who became friendly with Hollender and Szasz when he studied at the psychoanalytic institute. He later became Dean of the Faculty at Syracuse and then Director of Head Start and Surgeon General. Later he moved to the post of Director of the Judge Baker Clinic in Boston. Hollender brought Szasz with him to Syracuse as full and tenured professor of psychiatry. The idea was to form a psychoanalytic training institute at Syracuse with Szasz as the leading intellectual. I was a resident in psychiatry at Syracuse from 1958 to 1961, and was fortunate to have read The Myth of Mental illness in manuscript form and to have discussed it vigorously with a brilliant group of co-residents in Szasz's seminars.

To understand the situation at Syracuse, it is important to recall the intellectual context of psychiatry at that time. Psychoanalysis was in ascendance. It had been increasingly popular among American intellectuals during the 1930s. In the postwar intellectual ferment of the 1950s, it became the guiding theoretical framework of psychiatry. Its derivative, dynamic psychotherapy, was the most popular therapeutic modality. Therapists who did not have psychoanalytic training but who were psychoanalytically oriented practiced dynamic psychotherapy. Psychiatric faculties across the country were recruiting training analysts for chairmanships and professorships with the same enthusiasm, conviction, and exclusivity as they now recruit neurobiologists.

Hollender's idea, as I understood it at the time, was to found a unique psychoanalytic center at Syracuse, unique because it would seek to integrate an interdisciplinary faculty and curriculum. Attempts to integrate psychiatry and psychoanalysis with psychology and the social sciences were very much in the air at the time. Hollender's predecessor, Edward Stainbrook, who was a medical psychiatrist as well as a Ph.D. psychologist, had already invited a variety of social scientists and humanities scholars from Syracuse University to participate in the undergraduate and graduate psychiatry teaching programs at the medical school.

At the time, about 35 years ago, Hollender's vision was avant-garde. It was at the cutting edge not only of psychiatric thought but of the social sciences and humanities, which were heavily influenced by psychoanalysis. Stainbrook had invited Professor Douglas Haring, an anthropologist from Syracuse University, to teach general and psychological anthropology to medical students and psychiatric residents. When Hollender took charge, he hired Ernest Becker, who had recently completed his Ph.D. in anthropology at Syracuse under Haring.

Becker and I quickly became close friends, bonded to each other by a common background as first-generation Jews; by a mutual fascination with anthropology, psychoanalysis, and intellectual history; and a by a mutual love of Italian food and films. Becker attended Szasz's seminars for psychiatric residents and began to read extensively in psychoanalytic literature, hoping to integrate psychoanalytic theory with current work in psychological anthropology. In 1961, I completed my residency and, at Hollender's invitation, joined the full-time psychiatric faculty. Gradually, Becker and I shaped a common vision which seemed to be in harmony with Hollender's vision of an interdisciplinary psychoanalytic center, namely, to bring modern knowledge from the fields of psychology, anthropology, sociology, and philosophy to bear on a new understanding of the forms of mental suffering which are designated as mental illness. Toward this end, I took a master's degree in philosophy at Syracuse University and also taught the sociology of personal development and deviance under Paul Meadows.

The next few years were intellectually productive for Szasz, Becker, and myself. Szasz followed The Myth of Mental Illness with Law, Liberty and Psychiatry, the third of 25 books he has published to this date. Becker wrote the first edition of The Birth and Death of Meaning, in which he attempted to integrate psychoanalytic and anthropological concepts of human personality development. Next, he wrote a potentially seminal book which, tragically, has been widely ignored by psychiatrists, The Revolution in Psychiatry. In this book, Becker adopts the eclectic spirit at Syracuse and the spirit of Szasz's critique of the medical model by initiating a project for the development of a nonmedical, interdisciplinary view of such alleged mental illnesses as schizophrenia and depression. I recommend this book highly to those interested in a fresh and non-reductionistic view of depression and schizophrenia. Becker's hopes for the development of a new humanistic science were dashed by developments at Syracuse, but he continued to write as he pursued the painful career of a peripatetic intellectual.

For my small part, I published in two directions. I wrote a number of articles critical of the legal and social functions of psychiatry.⁸ At the same time, I was working with Ernest, in the context of our friendship, toward an interdisciplinary, nonmedical understanding of the various psychiatric diagnoses. In this period, I wrote a nonmedical formulation of the problem of phobias.⁹ I was in the process of developing an introductory textbook of psychiatry for a course taught to sophomore medical students. I was also writing a political and sociological critique of psychiatry, which appeared in 1969 as In the Name of Mental Health: The Social Functions of Psychiatry.

The dark clouds of conflict soon appeared on the horizon, however, and the dream of a school of autonomous, interdisciplinary intellects striving together to understand the problems of human life vanished in the storm.

In 1962, after The Myth of Mental Illness had been published, Szasz testified in the Onondaga County trial of John Chomentowski. Mr. Chomentowski owned a small gasoline station which he sold to a prominent real estate developer. When the developer tried to take over the property earlier than had been agreed, Mr. Chomentowski threatened the company's agents with a shotgun which he fired into the air. He was arrested and the prosecutors, aided by testimony of government psychiatrists, convinced the court that Chomentowski was not mentally competent to stand trial. Chomentowski was then committed to Matteawan State Hospital for the Criminally Insane, in spite of the fact that he had not been convicted of a crime. Szasz testified at a habeas corpus hearing in which Chomentowski was suing to gain his freedom from confinement. The trial, which I attended, was a highly anticipated event in psychiatric circles, since for the first time Szasz was in an adversarial confrontation with conventional psychiatrists in a public forum.

Szasz's testimony was eloquent, witty, and bold. Testifying for the defendant, he stated frankly under questioning that he did not believe that mental illnesses are true medical diseases but, rather, are psychiatric fictions. He believed that mental hospitals are prisons and that, in effect, Mr. Chomentowski had been imprisoned without having been convicted of a crime. He translated the state hospital psychiatrists' psycho-babble testimony into ordinary language with devastating effect. What the psychiatrists called psychotic aggression Szasz called anger at false confinement. What the psychiatrists called psychotic withdrawal Szasz translated as the unwillingness to consort with one's enemies. What the psychiatrists called contractions of his blepharal and facial muscles Szasz called "blinking." The state psychiatrists from Marcy State Hospital in nearby Rome, where Chomentowski was being held for examination and trial, were humiliated and angered.

Present in the courtroom was Abraham Halpern, then Commissioner of Mental Health for Onondaga County. He sat at the prosecutor's table, coaching the District Attorneys. He felt outraged by Szasz's testimony and made his feelings known. His protests reached the ears of the State Commissioner of Mental Hygiene, Dr. Paul Hoch. Simultaneously, the state hospital psychiatrists complained to the director of their hospital, Dr. Newton Bigelow, who was also editor of the then-prestigious psychiatric journal, The Psychiatric Quarterly. Bigelow published an article in his journal condemning Szasz, "Szasz for the Gander."(10) In response to the complaints by the state psychiatrists, Dr. Hoch issued an order banning Dr. Thomas Szasz from teaching psychiatric residents at the Syracuse Psychiatric Hospital. To understand the significance of this order, it is necessary to know how Hollender's department of psychiatry was set up.

Hollender had a dual appointment as both chairman of the department of psychiatry at the medical school and as director of the Syracuse Psychiatric Hospital, which was a state hospital. In addition, many of the faculty of the department of psychiatry also had joint appointments as visiting staff at the hospital, including Szasz. This arrangement was and is today quite common. Many of the faculty of medical school departments of psychiatry around the country are also directors or staff of government-run hospitals. The critical fact in this case is that Hollender decided to locate his office for both positions at the state hospital. Using state funds, he constructed for himself a very comfortable office at the hospital from which he conducted departmental business. In addition, Hollender refurbished a meeting room at the hospital where the department held its weekly scientific and faculty meetings.

When Szasz was notified that his appointment as visiting psychiatrist at the Syracuse Psychiatric Hospital was terminated, he boycotted the hospital, including the departmental meetings which were held at the hospital, on the basis that if he was not permitted to teach there, he should not attend teaching clinics conducted there. This created a conflict between Szasz and Hollender which split the department apart. Several faculty members, including the psychologists Ed Engel and Charles Reed, Becker, and myself joined Szasz in boycotting the hospital. Those who joined the boycott did not all necessarily agree with Szasz's analysis of the concept of mental illness, but they all found unacceptable the attempt by an official of the state to censor and repress a member of an academic faculty.

Hollender responded by offering to move the scientific faculty meetings to the medical school. This did not satisfy Szasz or other members of the faculty, however. They believed that Hoch's and Hollender's repression of Szasz made it clear that the teaching faculties of an academic department of psychiatry must be autonomous and independent of the state or the freedom of inquiry and expression would be jeopardized. They requested that Hollender choose between being director of the state hospital or being chairman of the department of psychiatry. If he was to continue as chairman of psychiatry, he should resign as director of the hospital and move his office to the medical school.

Hollender declined to choose. He took the position that the state hospital was the flagship of the department and he was admiral of both. Interpersonal tensions in the department intensified. Szasz's supporters took seriously the threat by the state to intimidate and repress academic faculty. Most of the faculty who had joint appointments at the medical school and the Syracuse Psychiatric or the nearby Veteran's Administration Hospital, which also had a closed ward with involuntary patients, were hostile toward Szasz. They rejected his critique of the medical model and believed he was creating unnecessary conflict. Some people believed that Szasz should not even be allowed to teach The Myth of Mental Illness to students, interns, and residents at the medical school. The conflicts were both personal and ideological, the one fueling the other until the department was divided into two hostile camps.

Some members of the faculty contrived a secret scheme to lure Szasz into insubordination so they could fire him in spite of his tenure. One principled member of the group, Dr. Richard Phillips, withdrew and notified Szasz of the attempt. Szasz hired a young lawyer from the local law school, George Alexander, later dean of the law school at the University of California at Santa Clara, to defend him against his accusers. The dean of the medical school, Carlysle Jacobsen, appointed faculty committees to investigate the conflict. The AAUP committee, chaired by Dr. Peter Witt, found that Szasz's academic freedom had, indeed, been violated.

Hollender was exasperated by this conflict, which had stalled his quest for psychiatric empire. One day, Hollender telephoned Becker to request his appearance in Hollender's office at the Syracuse Psychiatric Hospital. Some medical students had asked Hollender whether the psychiatric teaching program had been compromised by the conflict between him and Szasz. Hollender asked the students where they had heard such a story. They told him they heard it from Becker. Hollender was indignant. He accusingly demanded to know from Becker whether he was warning prospective interns and residents away from the department.

I was present when Becker returned Hollender's call. We had discussed how he might respond. Becker told Hollender that he would not meet him at the hospital because he was not on the staff of the hospital, he was on the faculty of the medical school. The administrators of the hospital had banned a faculty colleague from teaching there and so he would prefer to meet Hollender at the medical school. Hollender refused and, once again, ordered Becker to come down to Hollender's office in the state Hospital. Becker refused. Hollender fired him on the spot!

On the one hand, Hollender might seem to have had some justification for firing Becker on the grounds of insubordination. On the other hand, Becker was one of Szasz's most vocal defenders. His ideas and writings were influenced by or were in harmony with Szasz's views. Becker was even interviewing a few patients by Syracuse Psychiatric Hospital under Szasz's supervision. Firing Becker was a way for Hollender to strike back at Szasz.

After leaving the medical school, Becker had a tragic-glorious peripatetic career.¹¹ He spent 1965 in Rome writing what he thought would be his monumental work, The Structure of Evil.¹² He then returned for a one-year appointment in the department of anthropology at Syracuse University, sponsored by his close friend Professor Agehananda Bharati. This was followed by a second year in Sociology, hosted by his friend Professor Paul Meadows, who was chairman. The following year, Becker replaced Erving Goffman at Berkeley on Goffman's recommendation. He won a brief moment of fame there when he was written up in Time magazine because the student body at Berkeley petitioned for Becker to be rehired, and, in an unprecedented move offered to pay his salary out of the student organization's treasury. But the university refused. It would have been too dangerous for them to rehire a professor who was a social critic and also popular with the students at time of political protest and upheaval.

Becker then moved across the bay to San Francisco State University where he worked happily until 1968, when S.I. Hayakawa, then president of the university, called police on campus to repress student demonstrations against the war in Vietnam. Becker resigned in protest in a heroic gesture, since he had three children and no prospect of any job elsewhere. The only offer he received was from Simon Fraser University in Vancouver, Canada, where he remained in exile until his premature death from colon cancer in 1974.

Two months after he died, Becker was awarded the Pulitzer Prize in Nonfiction for his book The Denial of Death. This highly prestigious award represents the recognition by the literary community of the high merit of Becker's work. Yet Becker has never been recognized by establishment psychiatry in spite of the fact that he wrote continuously on psychiatric issues from his days in Syracuse until he died. His work has been totally ignored. To establishment psychiatry, Becker was tainted by his association with the reviled Szasz. In effect, Becker was indexed and repressed. He was the victim of modern society's favorite method of repressing its critics—what the Germans call Todschweigen (Tod = death; schweigen = silence)—death by silence.

After Becker left, I continued as an assistant professor at the department of psychiatry, teaching, writing, and speaking my mind on a variety of psychiatric issues, including the social functions of psychiatry and nonmedical conceptualizations of the problems of human suffering. During this period, I completed the manuscript of In the Name of Mental Health. In 1966, frustrated by his hostile standoff with Szasz, Hollender resigned as chairman of the department and was replaced by Dr. David Robinson, an ally of Hollender's who even more vehemently opposed Szasz's critique of psychiatry and the concept of mental illness.

The department was still trying to continue its liaison with social scientists and other scholars from Syracuse University. A committee was formed, of which I was an appointed member whose job was to nominate social scientists from Syracuse University to teach the psychiatric residents and interns. I taught at Syracuse and knew the faculties of the social sciences and humanities, and I nominated Ernest Becker and Stanley Diamond, an outstanding anthropologist who later became professor at the New School, as the best suited to teach medical students and psychiatric residents. My colleague on the committee, Dr. Robert W. Daly, now Professor of Medical Humanities at the Health Sciences Center at Syracuse, agreed on these nominations, as did Dr. Bradley Starr, chairman of the committee, although Starr was doubtful that Robinson would approve of either of these men.

A few days later, Starr informed me that Robinson had indeed vetoed both Becker and Diamond as candidates to teach the psychiatric residents. I could understand why he vetoed Becker. Hollender, although no longer chairman, was still in the department and it would have been awkward for him to face Becker. I could not imagine, however, why Robinson objected to Diamond, who had nothing to do with Szasz or the Szasz affair. I protested to Starr. The next day, Robinson burst into my office and announced that he did not intend to renew my appointment. Since I was a junior faculty member without tenure, this meant, in effect, that I had been fired.

I appealed to the local and national chapters of the AAUP on the grounds that, although I did not have tenure, the university did not have the right to dismiss me because of my views. They could fire me without reason, or for such justifiable reasons as insubordination, dereliction, incompetence, or flagrant immorality. But they could not fire me because the chairman opposed my views, my speech, or my writings.

In a meeting with Dr. Jacobsen, Dean of the Faculty at the medical school, Robinson said he would not renew my appointment because he "did not need two French professors in his department," meaning that he had been sufficiently provoked by Szasz and did not want another thorn in his side. In other words, everyone else in the department could share Robinson's views, but if I shared Szasz's views, I was excess baggage.

To my further amazement, Robinson boldly admitted that he did not want me on the faculty because he did not want my book published while I was a member of the department. He said that he was afraid that with both Szasz and me writing, publishing, and teaching our heretical views, the department at Syracuse might become known as "anti-psychiatry" and might not be funded by the NIMH, with obvious unpleasant consequences for him and the department. Jacobsen, acting in the great tradition of academic administrators, chose to avoid conflict with a department chairman. He imposed a compromise. He conceded that the department had fired me without adequate notice since Robinson had fired me in March effective the following September while AAUP regulations provided for one year's notice to give the rejected member time to find another job. So Jacobsen gave me a six-month extension on my appointment—a delay of execution.

On another occasion, Robinson arrogantly admitted to me that he did not want either Becker or Diamond to teach in his department because he believed both men were eastern radical-liberal troublemakers who were stirring up dissent by participating in civil rights and anti-war protests. The implication was clear that Robinson believed that I, too, was a member of this group of traitors.

Becker and I were both victims of the psychiatric repression of Thomas Szasz. In my view, Robinson, Jacobsen, and the State University abridged my First Amendment rights of free expression. If one believes in the value of ideas and the right to express ideas, which is supposedly protected by the First Amendment, this is a serious matter. I do not think that my experience is unique. I saw a generation of brilliant intellectuals driven off university campuses because they studied and talked about Marx or some other out-of-favor thinker, or because they fought in the civil rights and anti-war struggles of the 1960s. In my view, the same situation exists today in universities and medical school departments of psychiatry. I do not believe thought is free in America. Thought is a controlled substance, repressed and regulated by representatives of various prevailing interests. Many of my friends on the medical school faculty were horrified by this situation, but felt powerless to do anything about it. The AAUP committee of the medical school, after painful debate, decided not to challenge the administration on constitutional grounds.

It was a painful experience, but my fate, or that of Becker or Szasz as individuals, is relatively insignificant in the scheme of history. More significant, it seems to me, are the questions of whether the right to the free expression of ideas was violated at Syracuse and, if so, what are the motives and consequences of such repression?

We can only speculate what course psychiatric history might have taken had Szasz not been repressed and had Becker and I not been fired from the medical school at Syracuse. Our dynamic trio would likely have attracted at least a few interested students. And some of these students might have matured, made their own unique contributions, and, in turn, drawn more interested students. Possibly, a school of thought might have developed at Syracuse which would provide a critical alternative to the current ideological hegemony of contemporary medical-coercive psychiatry.

As it is, neither Szasz, Becker, nor I have had any students, in the sense that most university professors and elders of various intellectual traditions usually have the opportunity to teach and guide their heirs of the next generation. After the crisis with Hollender was resolved, Szasz remained at Syracuse as full professor, but out of the spotlight and off stage. He was not asked and did not volunteer to teach psychiatric residents. He no longer presented papers or participated in the discussion at faculty meetings. He wrote and published prolifically, traveled and lectured widely and frequently, but was silent at Syracuse.

I too was, in effect, blackballed from academic psychiatry. I applied for faculty positions elsewhere, but I was condemned by my association with Szasz and by the evidence of my own writings. I submitted the manuscript of In the Name of Mental Health to Basic Books. They accepted and I went to Mexico on an extended adventure. When I returned, the editor at Basic Books, Irving Kristol, called me and withdrew the offer. Basic Books would have to reject my book, he confessed apologetically, because the psychiatrists to whom they gave the book to review were so outraged by it that they threatened to boycott Basic Books if they published it. Todschweigen! I was repressed and negated by psychiatrists who threatened to boycott my prospective publisher.

I have spent the last 30 years in the glorious isolation of private practice, continuing to study and write, striving to develop a nonmedical view on the problems of mental and emotional suffering. Having been disillusioned by the coercive and repressive influences in Western psychiatry and psychology, I turned elsewhere for insight and understanding. Over the years, my interest has increasingly turned to a study of the Buddhist view of mind.

Over the past 20 years, I have studied under several distinguished Tibetan Lamas, particularly Khenpo Karthar Rinpoche, Abbot of Karma Triyana Dharmachakra, a Karma Kagyu monastery near Woodstock, New York. I was one of the organizers of the first Karma Kagyu Conference on Buddhism and Psychotherapy at International House in New York in 1987. I invited Tom Szasz and R. D. Laing to be two of the main Western speakers at this conference. For the past two years, I have been a student at the Namgyal Monastery Institute for Buddhist Studies in Ithaca, New York, which was founded by the Dalai Lama. I have just completed a comparative study of Buddhist and Western views on suffering and the causes of suffering, called The Happiness Project.¹³ I am now working on a manuscript on the emotions as viewed from a combined Buddhist and Western perspective.

In my view, obviously textured by my own personal experiences, the events at Syracuse are significant because they represent the repression and abortion of a school of ideas. I believe that ideas are important. E. A. Burtt once wrote that the concept a people has of its world is its most important possession. How we see the world shapes how we act in it. The repression of Szasz at Syracuse is symptomatic of a society which, like Oedipus Rex, blinds itself to the truth it does not want to see.

Szasz was banned from the Syracuse Psychiatric Hospital because of his views and his values. In contrast to the followers of the medical model, Szasz acknowledges and appreciates the differences between mind and body, and does not try to reduce the former to the latter. Unlike most modern psychiatrists, Szasz opposed the common practice of oppressing individuals through psychiatric labeling and involuntary commitment.

Szasz was repressed because his critique of the medical model threatened the medical identity of psychiatrists. Becker and I were fired not simply because we defended the academic freedom of a colleague, or even because we were friends of Szasz. We were fired because we were writing and publishing prolifically and thus also represented a threat to psychiatric ideology and psychiatric identity. In my view, the events at Syracuse constitute the control and suppression of thought for social and political purposes, something we assume does not happen in this country, but which happens so persistently and inexorably that we choose to ignore it.

The Significance of the Psychiatric Repression of Szasz

What is the significance of the repression of Thomas Szasz and the possible abortion of a critical school of thought in psychiatry? To probe this question, we must trace the recent history of psychiatry. In the early 1960s when Szasz was first repressed, psychiatry was at a crossroads, a crisis of identity. The psychoanalytic tradition had reached the zenith of its influence and several formidable problems had been exposed. Psychoanalytic therapy had become the most powerful and most popular form of treatment of mental illness. The problem was that it is a nonmedical treatment. It can be practiced equally well by psychologists, social workers, and other skilled nonmedical professionals as well as by physicians. The increasing number of nonmedical psychotherapists not only threatened the medical identity of psychiatrists, it also threatened the economic interests of psychiatrists by competing for psychiatric patients at a lower fee. A second and related problem was that the basic sciences of psychoanalysis are psychology and the social sciences. A sophisticated spectrum of neo-psychoanalytic, nonmedical theories of mental illness was under development by men like Erving Goffman, Norman O. Brown, and particularly by the French existentialists. Szasz, with his reinterpretation of conversion hysteria in The Myth of Mental Illness, Becker, with his new theories on schizophrenia, depression, and the neurotic sexual fetishes, and my contribution on phobias¹⁴ were on the frontier of this development.

The problem for psychiatry was that its medical identity was being eroded by psychoanalysis. Szasz's critique of the medical model and of coercive psychiatric practices was perceived by medical psychiatrists as an added threat to their legitimacy. Medical doctors in other specialties were growing increasingly skeptical that psychiatrists were really kin under the sheepskin. Nonmedical therapists, often well trained and competent, were competing with medical psychiatrists for fees. Psychiatrists who worked for the state, particularly those who worked with involuntary patients in mental hospitals or clinics and who adhered to a Kraepelinian model of medical diagnoses, were becoming increasingly hostile toward psychoanalysis and psychoanalytically oriented psychiatrists in private practice.

Over the years, psychiatric anger toward Szasz and those who agree with his point of view has been further provoked by the mental patient's survivor movement. The medical- coercive psychiatrists and their sympathizers have come increasingly under criticisms and attack by survivors of psychiatric abuse—victims of involuntary confinement and forced drugging and electroshock.¹⁵ We have recently become more sensitive to the endemic horrors of sexual abuse and child abuse, thanks to the media. However, we have not discovered, or have not yet been willing to admit, the degree of endemic psychiatric abuse by means of involuntary confinement and forced treatment. Our denial is reinforced by psychiatrists who regard the victims of psychiatric abuse as mentally ill and therefore incompetent to form valid feelings or complaints. This is similar to saying that a rape victim asked for it. The mental patient survivors and self-help movement is autonomous and driven by its own motives, but it has, over the years, been inspired and supported by Szasz, Peter Breggin¹⁶ (a student of Szasz's and mine at Syracuse), me, and other critics of coercive medical psychiatry. This has contributed to the psychiatric anger toward Szasz and his supporters.

Hollender embraced both sides of this inner conflict of psychiatry in that he was both a psychoanalytically trained chairman of an academic department of psychiatry and a director of a state hospital. The situation at Syracuse was representative of the conflict within psychiatry as a whole and, thus, was primed and ready for the explosion that occurred.

At the same time, other developments in psychiatry were strengthening the hand of those who subscribe to the medical model. The era of tranquilizers had arrived with the introduction of Thorazine in 1954. The success of the new tranquilizers in controlling the inmates of psychiatric institutions was exploited by medical psychiatrists to bolster their argument that mental illnesses have a biological basis. Increasing funds were invested by pharmaceutical companies to develop new anti-psychotic and antidepressant drugs and the NIMH increasingly favored research to study the safety and efficacy of these drugs, thus underwriting the medical model.

As narrowly funded research seemed to confirm and explain the efficacy of psychoactive drugs, the false impression was created that psychiatry had become an objective, quantifiable, "hard" biological science. As new generations of drugs were developed, the pharmacological treatment of mental illness appeared to be more cost- effective and became more popular. This trend has continued to the present day, when, under managed care, drug treatment of mental illness is the preferred modality and psychiatrists are now primarily trained as psychopharmacologists rather than as psychotherapists. Psychotherapy has largely been taken over by nonmedical therapists! This is the historical context of the conflict between establishmentarian, medical-model psychiatry and its critics such as Szasz, Becker, and me.

But the pendulum of history may now be swinging the other way. The biological approach to mental illness may have reached a point where its weaknesses, problems, and contradictions are becoming clear, just as they did after psychoanalysis was in vogue for a few decades. The biological model of mental illness has been successful, in part, because it has identified itself with modern science and, thus, basks in the prestige of modern science. Present-day psychiatric theories assert that mental illness is basically brain disease, that schizophrenia and depression are basically caused by genetic predisposition to "chemical imbalances"—excessive dopamine in the case of the former and insufficient serotonin in the case of the latter. This point of view helps to solidify psychiatric identity as medical and carves out for psychiatrists a monopoly on the pharmacological treatment of mental illnesses.

Present biological theories of mental illness, however, are highly problematic. In the first place, they are incomplete, because they are biological, reductionistic, and ignore the psychological dimensions of human experience and thus ignore what is most characteristic of and fundamental to the human experience. Secondly, they are weak in themselves, having been deduced entirely, and not entirely logically, from the actions of tranquilizers and antidepressants on neurotransmitters.

The fact that Prozac, for instance, which boosts intersynaptic serotonin, can help lift depression does not logically imply that the depression is caused by low brain serotonin. It may equally well be, and is in my opinion more likely, that the individual's psychological response to life events conditions the levels of brain serotonin. In spite of the strident brain reductionism of modern biological psychiatrists, there is strong scientific evidence that experience influences the brain's physical structure and development. Spitz's famous studies showed that babies will die without sufficient love. Children will lose their capacity for speech if they have not learned to talk by a certain age. A crowd of sports fans in a frenzy over the last-minute victory of their team will undoubtedly have elevated blood catecholamines. Is their excitement due to the elevated catecholamines or to the thrill of victory?

While psychiatrists are publicly engaged in a media blitz to propagandize the idea that mental illnesses are medical diseases which are treatable with medications, privately they admit that their research is flawed and their theories are, as yet, unproved. Every few years they convene a committee to write a new diagnostic and statistical manual (DSM), in which the primary proof of the existence of the diagnostic categories of mental illness is that psychiatrists, who train each other to see them, believe they exist. Natalie Angier, science writer for the New York Times, says what no psychiatrist will publicly admit: that they "want badly to transform their discipline into a hard, quantifiable science that is on a par with molecular biology, or genetics, but they have often been frustrated. Every time they think they have unearthed a real, analyzable gene to explain a mental disorder like manic depression or alcoholism, the finding dissolves on closer inspection or is cast into doubt."¹⁷

To make matters worse, psychiatry bears the historical guilt of having purged itself of critics. No supporter of Szasz's views on mental illness would be appointed to full-time position by an academic department of psychiatry to teach psychiatric residents. I know this from my own personal experience. In spite of his international reputation, Szasz's papers are routinely rejected by psychiatric journals. He has, in effect, been excommunicated.

“As a result of the persecution of Szasz at Syracuse and elsewhere, there are no critics of psychiatry from within its ranks. This, in itself, should disqualify psychiatric theory as scientific.” The essence of scientific method is critical inquiry. The basic principle of scientific discovery is the null hypothesis, that is, the hypothesis which, when it is advanced, is presumed to be false and is subject to exhaustive testing, checking, and criticism before it is even accepted as provisionally valid.

Psychiatric thought more closely resembles political ideology than it does science in that it is presented and certified by a power elite, the psychiatric establishment, who promote and propagandize their views as official dogma and who dismiss, exclude, and persecute dissenters. Psychiatric thought is not the product of a free market of ideas. It is carefully controlled and disseminated. And it serves the economic and psycho-social interests of those who purvey it by promoting their medical identity and justifying their right to receive part of the national health care budget. This does not mean that the costs of alleviating the emotional sufferings of life should not be distributed equally through insurance programs, whether private or public. It means that if we distort our perception of the problems of life by viewing them as medical illnesses, we are disabling our abilities to deal with these problems effectively in order to justify the sharing of its costs.

The persecution and repression of Thomas Szasz and his school of thought, and the corresponding supremacy of the medical model of mental illness, presents two critical problems, one for psychiatry and the population it serves and the other for society as a whole. An exclusively biological approach to problems of mental suffering and disability is, at best, partial and incomplete and, at worst, disempowering and disabling to the consumers of mental health services. It sends the explicit message that people are not responsible for the forms of suffering which are labeled as mental illness.

There are certain kinds of suffering for which the individual cannot be held responsible, and others for which he or she can. Certainly, people are not responsible for their medical illnesses, except in cases where they are self-induced, like cancer of the lung from smoking cigarettes. On the other hand, there is a degree of suffering that we cause ourselves because of our ignorance, our selfishness, our greed, and our aggression.

Ancient wisdom teaches that a portion of our suffering is the result of defects of moral character. The Greeks, too, knew that character is fate. Sophocles said that "the greatest griefs are those we cause ourselves."¹⁸ The Judeo-Christian Bible is a book of ethics based on the belief that evil-doing is punished with suffering and virtue is rewarded with happiness. The moral teachings of the Judeo-Christian prophets, on which the values of Western civilization are based, tell us, in effect, that although life is a "valley of tears" we are, nevertheless, responsible for some portion of our suffering.

We are responsible, at least, for how we suffer, for example, whether we suffer patiently, like Job, or with aggression. We are also responsible for that portion of our suffering that we cause ourselves. We are responsible for the consequences or our words and deeds. This is the law of Karma, or, as the saying goes: "What goes around comes around." These are profound moral teachings and they are compatible with the view of most modern psychotherapists, who, whether or not they believe in the medical model, practice therapy on the assumption that we can increase our measure of happiness through self-knowledge and self-discipline.

Innumerable patients have come to me with the complaint that they have a "chemical imbalance." They have been told by other therapists, or have heard in the media, or have read in misleading NIMH pamphlets, that their sufferings—their depression, their anxiety, their guilt, their anger, their enthusiasm, their addiction to drugs or food, their obsessions and compulsions—are due to biochemical imbalances in their brain. They have no idea what these chemical imbalances are. But they believe they are the cause of their misery. As a result, they have not the slightest insight into or interest in the way in which their mental attitudes, orientations, and responses to life events cause their suffering and symptoms. They have become blind to the human dimensions of their lives, to the nature of their own experience, and thus have handicapped their ability to deal with the problems of life.

By discouraging people from taking responsibility for themselves, for their own behavior, emotions, and modes of thinking, biological psychiatry contributes to the current political atmosphere of the dissipation of moral values and the abandonment of personal responsibility. In this century, we have seen the balance between individual freedom and state power swing away from the individual and toward the state. As it swings toward the state, the individual is deprived both of freedom and the responsibilities which are intrinsic to the exercise of freedom. Modern psychiatry has contributed to the momentum of this swing by promoting an ideology which is biologically reductionistic and explains human thoughts, feelings, and behavior on the basis of brain physiology.

After completing his presidency, Dwight Eisenhower warned the American people that the military-industrial complex, which was largely responsible for victory in World War II, was the greatest danger to peace. As we approach the millennium, we must be aware of a new danger. The State-Science Alliance, upon which our forefathers relied instead of religion for human progress, is now the greatest threat to that progress.

The psychiatric repression of Thomas Szasz is a symptom of the rise of the State-Science Alliance—the ascendance of the ethics and technology for managing and controlling people and the simultaneous decline of the ethics of individual freedom, dignity, and responsibility. In the context of history, the conflict is between a narrowly scientific, biological-reductionistic view of human beings, which interprets behavior as the product of brain chemistry and justifies depriving certain individuals of their freedom against their will, and a humanistic view which integrates biological science into a multidimensional perspective on the individual as moral agent. To humanists all over the world, Szasz is a hero who has fought long and hard and with great personal sacrifice for the values of individual rights, freedom, and dignity, and against the paternalistic state and psychiatrists who function as agents of the state to manage, control, and repress the individual.

The issue came to a focus recently when Darryl Strawberry, star outfielder of the Los Angeles Dodgers, quit playing baseball, reportedly because he had a problem with drugs and had to enter a treatment program for addiction. Tommy Lasorda, manager of the Dodgers, criticized Strawberry for his lack of moral character because he yielded to the temptation of drugs. Tipper Gore, wife of the U.S. Vice-President and champion of medical-model coercive psychiatry, chastened Lasorda for his ignorance. Every educated person today knows, Tipper Gore said, that addiction is a disease and that Strawberry, therefore, is the victim of mental illness. Perhaps only old Szasz fans and old Dodger fans like me believe Tommy Lasorda.

Notes

1. Rael J. Isaac, and Virginia C. Armat, Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill. (New York: The Free Press. 1990).
2. Karl Mannheim, Ideology and Utopia (New York: Harcourt, Brace and World, 1929).
3. Ronald Leifer, The Happiness Project (Ithaca: Snow Lion Press, 1997).
4. Ronald Leifer, In the Name of Mental Health: The Social Functions of Psychiatry (New York: Science House, 1969); Ronald Leifer, "The Medical Model as the Ideology of the Therapeutic State," Journal of Mind and Behavior, 11, nos. 3 and 4 (Summer and Autumn 1990), pp. 247-258; Thomas Szasz, Law, Liberty and Psychiatry (New York: Macmillan, 1963).
5. Bertrand Russell, The Analysis of Matter (New York: Dover Publications, 1954), and Logic and Knowledge, Charles Marsh, Ed. (London: Allen and Unwin, 1956); Gilbert Ryle, The Concept of Mind (New York: Barnes and Noble, 1949).
6. Szasz is uncomfortable with the term "medical model" because, he says, "medical doctors don't deprive people of their freedom" (personal communication). Psychiatrists use only those aspects of the medical model that are useful to their interests. By this definition, the medical model refers to a view of the mind on the template of the body and the brain. This results in a biological or neurophysiological reductionism for explaining thoughts, feelings, and behavior.
7. Personal communication from Tom Szasz.
8. Ronald Leifer,"The Competence of the Psychiatrist to Assist in the Determination of Incompetency: A Skeptical Inquiry into the Courtroom Functions of Psychiatrists," Syracuse Law Review, 14, no. 4 (Summer 1963), pp. 564- 575. See also Leifer, "Psychiatric Expert Testimony and Criminal Responsibility," American Psychologist, 19, no. 11 (November 1964), pp. 825-830.
9. Ronald Leifer, "Avoidance and Mastery: An Interactional View of Phobias," Journal of Individual Psychology, 22, no. 1 (May 1966), pp. 80-93.
10. Newton Bigelow, "Szasz for the Gander," Psychiatric Quarterly 36, no. 4 (1962) pp. 754- 767.
11. Ronald Leifer, "Ernest Becker: A Biography." In International Encyclopedia of the Social Sciences, Volume II (New York: Harper and Row, 1978). See also Leifer, "The Legacy of Ernest Becker." Kairos,2, (1986), pp. 8-21.
12. Ernest Becker, The Structure of Evil: An Essay on the Unification of the Science of Man (New York: Braziller, 1968).
13. Ronald Leifer, The Happiness Project: Transforming the Three Poisons Which Are the Causes of the Suffering We Inflict on Ourselves and Others (Ithaca: Snow Lion Press, 1997).
14. Ernest Becker, Revolution in Psychiatry (New York: The Free Press, 1969); Ernest Becker, Angel in Armor: A Post-Freudian perspective on the Nature of man (New York: George Braziller, 1969); Leifer, Avoidance and mastery.
15. Kate Millet, The Loony Bin Trip (New York: Simon and Schuster, 1990).
16. Peter Breggin, Toxic psychiatry (New York, St. Martin's Press, 1992).
17. Natalie Angier, Review of Torrey, E.F., et al., Schizophrenia and Manic Depressive Disorder, in New York Times Book Review, April 17, 1994.
18. Sophocles, Oedipus Rex. In The Oedipus Plays of Sophocles, Paul Roche, trans. (New York: Mentor Books, 1991).

Caitlin had been referred by her physician because he could find no organic cause for her symptoms. She had complained of a variety of medical problems that led to being run through a gauntlet of tests, scans, and diagnostic procedures, all negative. Yet her problems, regardless of their origin, seemed to worsen over time. Caitlin was hardly the most expressive or verbal client I'd seen.

Although in her mid-twenties, she reminded me of some adolescents who would rarely speak; in her case she was virtually mute.

"What can I help you with?" I asked to begin our first session. Shrug.

"You're not sure?" Another shrug.

Was she playing a game with me? Was I being tested? Did she have laryngitis or a mental handicap? I could not be sure.

After five long minutes of silence in which she stared at the floor, seemingly fascinated by the weave of the carpet, I had finally had enough. "Look Caitlin, I'm not sure what you expect of me or why you're here. The only thing that I know is that your doctor sent you to me because he couldn't help you. I understand you are having a lot of problems, and, apparently, he thinks it might be helpful for you to talk about them. But I can't help you unless you tell me what's going on."

Incredibly, Caitlin shrugged again but this time offered a wry smile.

Now I was determined to wait her out. There was something going on here that I did not understand, but I sensed that pushing her further was not going to work. I just wanted to get through the hour and send her on her way. Obviously, she was not ready for therapy.

We sat silently for the rest of the session, Caitlin alternately staring at the floor and some undetermined spot over my left shoulder. I checked a few times, just to see what was so interesting, but it was one of the few blank spots on the wall. Maybe she was projecting her own images. At this point I did not know or care; I was already thinking about my next client and what I could do to make up for this disaster.

Imagine my surprise when the session finally ended and Caitlin said to me, "Same time next week?"

I was taken by such surprise that all I could do was nod my head. Now I was the one who was rendered mute.

The second session repeated the pattern of the first: Caitlin took her seat but would not speak. She just sat there, apparently comfortable and unconcerned with the silence. Even though I was prepared for this eventuality, and had rehearsed several things I might do to draw her out, each overture was met with a shrug or ignored altogether. By the time the second session ended, I was resolved that I'd had enough: no more "same time next week."

I was just about to call for an end to this charade, pretending to be therapy, when Caitlin abruptly stood up, handed me an envelope, and exited, stage left. I was dumbfounded, frozen in place, holding this offering in my hand, unsure what to do next. I told myself that I should just put it aside for now—it could not be good news—but my curiosity got the better of me. I ripped open the envelope to find a five-page single-spaced letter in which Caitlin had outlined the sorry state of her life. It included all the things that a client would normally reveal in the first few sessions, talking about her early history, her family situation, her living arrangements, employment, and cogently reviewing all her various physical symptoms. She ended the self-report by stating that she hoped I understood how difficult it was for her to talk about these things and asked if I could be patient with her. She said she would return the following week if I'd still be willing to see her.

What could I say to that? I just shook my head, eager to resume this "conversation" during our next meeting. Oh, did I mention that I assumed that the structure of our communication might change? No such luck. It was more of the same: continual and unremitting silence. In response to everything I brought up from her letter, Caitlin would smile or shrug or sometimes frown and shake her head. I was so desperate, that seemed like progress: at least now I could get a tentative yes or no in response to a question.

"Caitlin," I tried again, "you wrote in your letter that you live with your brother. How's that working out?" Shrug.

"Just okay? You mentioned in your letter that you were close." She nodded her head.

And so it went, another frustrating, laborious, tedious (did I mention frustrating?) hour.

Fast forward five months. I have now seen Caitlin every week at our appointed weekly time. We are talking now. Or at least I am mostly talking and she occasionally rewards me with an actual verbal yes or no response, and sometimes she even utters a whole sentence. But basically she does not say much—until she hands me a letter at the end of the session that basically answers every question I asked the previous session and even a few things I wondered about but had not yet broached. I have certainly never done therapy quite like this, and it sure is hard work, but I tell myself that she is coming back, so she must be getting something out of the experience.

Another few months go by and I eventually learn a lot about Caitlin's life and her predicament. Her physician has been increasingly concerned because of abrasions in her vagina and burns on her breasts, wounds that appeared to be self-inflicted. When I asked her about this, Caitlin immediately clammed up and would not talk about them at all, even in a follow-up letter. The doctor called a week later to tell me that he "fired" Caitlin as a patient, refusing to see her any longer. I assumed this was because she was playing the same kind of silent treatment games with him that she was acting out with me, but I was wrong. Apparently, Caitlin had been left alone in an examining room when a nurse unexpectedly entered and found her holding the thermometer that had been placed in her mouth underneath the flame of a lighter to artificially raise the temperature and fake a fever. All of a sudden things started to fall in place, and the doctor realized that he was dealing with a case of Munchausen syndrome in which Caitlin had been manufacturing various disorders and diseases all along as an excuse for attention. This was clearly a case for psychological treatment, way out of his domain—and firmly back into mine.

But this called into question everything that she had thus far told me in her letters. How much of this was really true? How much could I trust anything that she had related to me? If she had been willing to fake her various ailments, and lie about her symptoms, what was to say that anything about her history was true? How could I work with a client who was now identified as a chronic liar?

I'm hardly the first therapist to work with someone with Munchausen syndrome, or a factitious disorder, or a sociopath, or any other client who knowingly lies, but once these fabrications and deceit are uncovered, what are we to do with them?

After so many months invested in our relationship, I initially felt betrayed, just as I had with Jacob. But in Caitlin's case, I quickly realized this was one very vulnerable, terrified, disturbed young woman who was doing the best she could to hold things together. If she was willing to go to such extremes for attention and self-protection, what did that say about anything she would tell me in therapy? And how and when is it appropriate and safe enough to confront this issue directly?

I decided that I really did need to confront the issue of truth with Caitlin, not for my own satisfaction, but to make it possible for us to have a truly trusting relationship, maybe the first one in her life. I had by this point learned that there were all sorts of weird things going on in her family, lots of secrets and lies that had been kept hidden.

It was during the middle of one of our silent conversations that I took a deep breath and told Caitlin that I had a few things that I wanted to bring to her attention. One of the advantages of having a client who does not talk is that it is very easy to carve out time to say whatever I want and expect a fairly compliant audience. She cocked her head and actually made eye contact, signaling that she realized that something important was coming.

I told her everything that I had recently learned, that she had been making up her various ailments and faking the symptoms in order to visit the doctor, perhaps for attention and sympathy, or perhaps for other reasons that she might reveal. I presented specific, irrefutable behavioral evidence, complete with witnesses, so there would be no sense denying the "charges." Furthermore, I shared with her my concerns that all along she had been playing games with me, just as she had with the doctors giving me the silent treatment and refusing to talk (except in carefully constructed letters). She seemed to be taking this with relative calmness, so I went further and talked about how this made it difficult for me to trust her. I told her how much I cared about her, how much I wanted to know her better, how important it was for me to help her if she would let me, and how I was bringing all this up because it felt like we could never go much further unless we were more honest with one another. Maybe this is coming across as harsh, but I tried to be as gentle and loving as I could while bringing the deceit into the open. And I insisted on thinking about this as an issue of honesty in our relationship rather than as a pathological condition named after an obscure German baron.

Caitlin looked at me thoughtfully after I finished what I had to say. I fully expected complete silence and so was surprised—and delighted—that after close to nine months we had our first real face-to-face conversation. It was as if a door had been opened and she had decided to walk through and meet me, if not halfway, then a few tentative footsteps in my vicinity. For the rest of that session, and the few that followed, she told me about the sexual abuse she had experienced since she had been a child by her brother, the same brother who was still living with her, and still sneaking into her room at night. She admitted that she had been hurting herself, sticking objects in her vagina and burning her breasts with lit cigarettes, in order to discourage her brother from continuing to have sex with her. She talked about all the guilt she had been feeling and how she understood the meaning of the self-punishment. She even understood that her silence in her relationship with me was a way for her to maintain control, to take care of herself while in the room with a strange man who might hurt her the way she had been betrayed before.

Yes, I know what you are thinking: Was this true?

This time I can say, unequivocally and without reservation, yes, I am convinced that Caitlin did eventually trust me to risk revealing herself in a more honest and authentic way. How do I know that? Well, for one thing her symptoms disappeared. She moved out of the apartment where she had been living with her brother. She became functional in a whole host of other ways related to her work and other relationships. She confronted her brother, finally, and told him to never, ever come near her again or she would call the police. (I was able to get corroboration that this, in fact, did take place, and I was prepared to testify on her behalf.)

Yet would I be surprised if I ever learned that I had been scammed, that she made the whole story up, that she was still playing me—but simply changed tactics once I caught on to the previous game? Yes I would. I will never know of course. Most of the time we can never really know what is true and what is not. We have to live with this uncertainty and give people the benefit of the doubt. To do otherwise, we could never do this work or function at all.

Maybe you are not very surprised that there would not be much neat closure to our topic. You already knew there is no certainty in what we do, given the complexities and ambiguities or the territory in which we operate.

Clients Who Lie and Deceive

It is the client's job description in therapy to tell us what is going on as fully, completely, and honestly as possible, providing the most detailed and robust descriptions of complaints, life history, contextual features, and innermost thoughts and feelings. The reality of what we actually get from clients is less than ideal for a number of reasons. There are unconscious distortions and imperfect memories. Defense mechanisms operate to protect the client against pain, discomfort, and perceived attacks. Character traits may compromise trust and intimacy.

In a blog (psychcentral.com), psychologist John Grohol (2008a) asked people why they would ever lie to therapists. This was a question that he could never really understand. "If you lie to your therapist," he pointed out, "especially about something important in your life or directly related to your problems, then you're wasting your time and your therapist's time." He cites lies of omission as an example, such as a client saying he is depressed and uncertain why, yet failing to mention that his mother recently died. Or another example in which someone complains about low self-esteem but neglects to say that she binges and purges after every meal.

When Grohol first wrote his essay, musing about the ridiculousness of lying to the person who is paid to help you, he was completely unprepared for the barrage of clients who would respond on his blog. Here are a few representative reasons posted why people lie to their therapists:

I don't yet trust my therapist, partly because I'm not confident that this therapist has the skills or experience to handle my problems in the first place. (Adrivahni, January 9, 2008)

i lie to my therapist about what i'm feeling towards her. i'm embarrassed about these feelings, and when i do try to share them, they come out wrong. those are that i feel too dependent, that I want more than what she can give me, and that i find these feelings to be a sort of weakness in me. (Cameron, January 9, 2008)

We all lie to our shrinks, just like we lie to our dentists (Sure, I'll floss twice a day) and our mechanics (It's not so much a click as a drum roll). But the point of repeat visits to our shrinks is to allow for the time necessary to figure out what's a lie, what's a misconception, and what the truth (for that day) is. (Gabriel, January 10, 2008)

Dozens of other confessions led Grohol (2008b) to write a follow-up essay about common reasons to lie to your therapist. Contributions from him and from other sources (DeAngeles, 2008; Gediman & Leiberman, 1996; Kelly, 1998) identified several of the most common reasons for deception in therapy sessions.

Some Reasons Why Clients Lie

We have seen how lying is a natural and normal part of daily life, a practice that first begins about age 3 or 4 when we first learn we have choices about what we tell others, each presenting different consequences. Biologist Lewis Thomas once observed that if people stopped lying, the world would end, politicians would be arrested, media would be cancelled, and people would stop talking to one another. Lies, or at least half-truths and other fractions of complete honesty, allow trust to build. In therapy, deception is just another in a series of defenses that clients use to remain in control and to protect themselves.

Many, if not most, clients keep certain things from their therapists in order to present themselves in the best possible light. Whereas previously it was believed that lying or deceiving a therapist would only sabotage the treatment, it would appear as if clients may actually benefit by keeping some things private (Kelly, 1998). People lie to their spouses and partners, their family and friends, especially to coworkers and others in which favorable impressions are critical to continued success. It should come as no surprise that clients also lie to their therapists, a lot.

Fear of Shame and Humiliation

Let's face it: it is hard to talk about secrets, about sex, about mistakes and failures, about shortcomings, about feeling helpless to take care of one's own problems, about almost anything that people bring to sessions. It hurts.

Many clients lie to their therapists to avoid feelings of shame, embarrassment, and what they believe will be critical judgment by their therapists (DeAngelis, 2008). We may think of ourselves as neutral, accepting, and nonjudgmental, and advertise ourselves as such, but that does not mean that people actually believe us. And they aren't far wrong. The reality is that we are sometimes critical and judgmental (at least inside our heads) when clients do or say things that seem stupid, even as we keep the poker face in place, nod our heads, and pretend we do not care one way or the other.

Much of the content of therapy involves talking about things about which people feel most ashamed and embarrassed, and most reluctant to admit. It takes awhile for clients to warm up, to feel safe enough, in order to broach the subjects that are most sensitive. It is during this period in which the therapist is on probation that clients will take any steps necessary to risk greater vulnerability. When we think about it, it is absolutely ridiculous for us to anticipate anything different—that is, to actually expect a new client during the first few weeks to spill his or her guts and come clean with anything and everything that has been previously disguised or hidden. Lying during the initial (and subsequent) stages of therapy is not only normal but highly adaptive and healthy.

Disappointing the Therapist

Whether clients are afraid of disappointing their therapists, or whomever he or she represents as an authority or parental figure, there is often concern (or perception) that the naked truth will result in a loss of respect. One client explains why she lied: "For myself, one of my biggest problems has been worrying that I was letting my therapist or psychiatrist down in some way. I try to hide when I feel depressed, fearing that my mood is somehow going to wreak havoc on others. My therapist is a cognitive behaviorist and I used to fret that she'd think I hadn't been doing my homework. Also, she was so clearly concerned for my well-being that it upset me to come in when I was feeling lousy!" (MacNamarrah, 2008).

It is ironic, but all too often the case, that clients do not talk about what is really bothering them, or even cancel sessions when they need help the most. They believe that others—even someone who is paid to be helpful—cannot really handle their deepest secrets and innermost selves. In addition, therapists are required by law to report suspected (or confessed) cases of physical, emotional, or sexual abuse. We are also forced to act when there is a risk of harm to self or others. Then there are other illegal or moral transgressions that may have been committed in the past, or are still currently going on. It behooves such an individual to be less than completely forthcoming with anyone, much less a professional who is mandated to contact authorities.

Ignorance

Some clients, who are relatively unsophisticated about therapy, or about how change takes place, leave out all kinds of important stuff because they did not know it was particularly important. It wasn't exactly that they were lying as much as choosing to ignore, deny, or otherwise gloss over things that did not seem all that important—and besides, they are uncomfortable to mention.

Physicians are able to run all kinds of diagnostic tests—blood work, magnetic resonance imaging (MRI), electrocardiograms (EKGs), ultrasound, urine analysis, biopsies, X-rays—because they do not fully trust self-reports as accurate data. We are left with what clients choose to tell us based on their beliefs about what is relevant, awareness of what they know and understand, and willingness to share information selectively. It is no wonder that we are operating with imperfect, flawed, and incomplete data. Even in cases of clear success, how confident do you feel that you really understood what was going on? How certain are you that the results reported were truly accurate? If you answer, unequivocally, that you are very confident, perhaps you should consider your own degree of honesty.

Living Alternative Realities

For those with personality or factitious disorders, lying is a way of life. It has become so habituated that the person actually comes to believe the fantasies that are spun; they become an alternate reality.

When Meghan first contacted me, it was in a letter she had written after discovering one of my books at a garage sale (the first book I ever wrote that she purchased for a dollar). At the time she was a teenager and we struck up a correspondence that lasted for 20 years. Meghan struggled with depression throughout most of her life, had contemplated and attempted suicide many times, never deciding on the best method to end her life.

I'm still not sure what role I played in her life, but I always responded to her letters with support and caring, encouraging her to stay in therapy and continue to work on herself. She ended up reading many of my books over the years and, each time, would send her comments and reactions. Over the years she also told me a lot of things about herself, sent photos, brought me up to date on her family and relationships, and occasionally asked for advice. Even though she was not a client, and I never actually met her, I felt a certain responsibility to be as kind as I could; there was obviously some kind of transference going on and I wanted to be careful.

Eventually I learned that much of what Meghan had told me over the years were lies. I believe the part about her depression and suicidal thoughts, but I discovered that the photos she sent me were of someone else, the stories she told me were fictions, and that she had even sent me e-mails masquerading as other people. It was a bizarre case that I did my best to extricate myself from, although every few years Meghan will contact me again in some other disguised form.

There are other people like Meghan in the world and you have met them, perhaps worked with them. Sometimes you recognize them before you are sucked into their fantasy worlds; other times (most of the time in my experience) you do not realize the level of deception until it is far too late. One of the reasons it is so difficult to detect such mendacity is because the individuals have managed to confuse lies from truth; they cannot seem to tell the difference.

Unlike Jacob, I did have the chance to confront Meghan directly (and repeatedly) about the games she had played over the years. After each instance of discovering a lie, she would first deny it, then apologize profusely and beg for another chance. I gave up trying to negotiate a more honest form of communication with her soon after she sent me a draft of her autobiography, which she claimed would soon be released by a major New York publisher (another lie). It was titled: "I Will Tell You No Secrets and Tell You All Lies."

As with Meghan, some clients are not really lying to "us" but to individuals we represent, whether transference objects or surrogate authority figures. When all is said and done, therapists are never going to be very good at detecting client lies. It is just not part of our constitution, or our training, in which so much of what we learn to do is build trust.

Given the uncertainty and doubt we must accept and live with related to our work, the question remains: How do we work with issues of deception and lies in therapy?

This excerpt from The Assassin and the Therapist: An Exploration of Truth in Psychotherapy and in Life was reprinted with permission from the publisher. For more information and to purchase the book, visit Amazon.com.