A Szaszian Approach To The Right To Refuse Treatment

THE ETHICS OF PSYCHOANALYSIS:
A PSYCHIATRIST'S GUIDE
by
Donal T. Conley, M. D,
Psychiatrist, Private Practice, St. Augustine, Florida
E-mail: dtconley@yahoo.com

(From the proceedings of a special conference entitled _Asclepius At Syracuse: Thomas Szasz, Libertarian Humanist_, April 17-19, 1980, sponsored by The Institute for Humanistic Studies, State University of New York at Albany, M.E. Grenander, Director, pp. 219-225.)

A frequent criticism of the works of Dr. Szasz is that he provides no solutions for those human problems that he insists are neither mental nor medical. The Ethics of Psychoanalysis is a guide for an effective solution to those problems through autonomous psychotherapy. This book provides a methodology consistent with the highest principles of medical doctrine. Adherence to the rules laid down in the book enables the physician to fulfill his most important role to do no harm.

THE ETHICS OF PSYCHOANALYSIS, A THERAPIST'S GUIDE

In 1971 I discontinued the practice of Obstetrics and Gynecology and embarked upon a psychiatric residency. I rather quickly discovered despite my expectations that, psychiatry was not medicine. The physician armed with certain technical instruments and knowledge of the basic medical sciences constructs and uses algorithms that lead to specific diagnoses and treatments. In psychiatry, there are no technical instruments and the basic non-sciences are conjectural and inconsistent. The medical diagnostic process can be and is simulated in psychiatry but the diseases are at best unreliable and invalid and at worst "Through the Looking Glass absurdities." It is however, in the area of treatment that the medical model of psychiatry breaks down completely. Two of the somatic therapies, electroshock and psychosurgery are so distasteful that, it is difficult to understand why the thousands of psychiatrists, who never use these treatments do not abjure them completely. Armed with a healthy skepticism for the blandishments of the drug companies, a result of my experience in medical practice, I was able to appraise the third somatic therapy, psychopharmacology. Realistically, the average first year, psychiatric resident should be able to learn all the substantive information about psychopharmacology in a few afternoons. The classes of drugs are few and within the classes the characteristics are very similar. The main skill if any, consists in treating side effects, and near fatal overdoses or documenting the use of the drugs to protect against malpractice suits. It is here that the young resident often makes a category error that colors his career. Instead of saying, "This is easy," he says, "I must be smart."

The major skill to be learned in a psychiatric residency program is how to "do" psychotherapy, but what psychotherapy? I could devote the remainder of the time for this paper to listing the various kinds of psychotherapy much less to explaining or defining each of them. Psychoanalysis, because of it's traditional domination is of course the most visible. The unsuitability of this discipline for a psychiatry resident who was almost 50 (and not analyzable?) is obvious. The basic principles of psychoanalysis pervade the majority of the psychotherapies. Because of this I was very much attracted to it and made some furtive attempts to get in to therapy as a start, I managed to obtain a precious, weekly hour with one of the city's leading analysts by feigning family problems. My therapy lasted three visits (5 counting 2 resistance loaded absences). Later while reviewing for board exams, I discovered that the average number of psychiatric visits was three. I wondered how many had followed my pattern. My first visit was to find out what a psychiatrist was like the second because I didn't believe what I had seen the first time, and the third to tell him that I wasn't coming anymore. His clever, stylized responses to ordinary conversation were intolerable. This concept, that Analysts or Psychiatrists have the skill to know what people need is basic to all the psychotherapies as presently practiced.

The Myth of Mental illness and The Manufacture of Madness although philosophically and politically mind expanding offered little practical suggestion as to what I, should do, other than quit psychiatry and go back to delivering babies, a thought that I entertained daily during the seven long years of my residency. I did develop a kind of personal style out of desperation to fill those necessary, therapy hours of my second year. It consisted of making conversation. I made neither diagnosis nor interpretation. Only another psychiatric resident can appreciate the pain and anguish with which my weekly supervisory sessions were blessed. My technique was variously described as avoiding, naive, inept and dangerous and variously attributed to causes ranging from senility to adolescent rebellion. The whole painful process came to a climax when I admitted to exchanging favorite books with a male homosexual patient. Shortly after this while relaxing in Florida (between residencies) I read The Ethics of Psychoanalysis. One criticism of Dr. Szasz's works, frequently heard from psychiatrists who are generally sympathetic with his views, is that he offers no solutions to those realities which he denies are mental or medical. Like all his books, this one is rich in sophisticated and meaningful philosophy. The section on the contractual relationship in psychotherapy is a model used in training programs where his other views are seldom expressed. His interpretations of game theory are instructions for living in society. The major significance of the book however is the answer it gives to the question that is habitually asked by medical students. The question, "What do you do for this?" or more properly as the "Ethics" is structured, admonitions for what must not be done. Unlike standard textbooks or the more popular "psychobabble books," the ethics of Psychoanalysis does not make suggestions as to what you may do or can do. Rather, It gives a concise explication of what must be done or more important, what must not be done. It is a book of meta-rules which can apply to all forms of psychotherapy, psychiatric interventions even the entire spectrum of human social relationships.

In the 1950's several studies suggested that the outcome for patients on the waiting list was as good as, if not better than, those who received psychotherapy. More recently studies have suggested that organized psychotherapy is slightly better than informal therapy (presumably, no one, in this day and age, gets no therapy.) Other studies suggest that all the psychotherapies are about equal in terms of results. Perhaps the biggest flaw in this research is the emphasis placed on outcome or output rather than input. In the Ethics Dr. Szasz has given us a formula for evaluating input. Those things that the therapist does that increase his client's capacity to act as a moral agent or "...increase the patient's knowledge of himself and others and therefore his freedom of choice in the conduct of his life..." are allowable those which decrease this capacity are not. "...people influence one another. Who is to say whether such interactions are helpful or harmful...?" The awesome power of the psychiatrist to influence is one of the most seriously undervalued aspects of the psychotherapeutic relationship. To dilute this influence, which is often more harmful than helpful, the therapist must "frankly...disclose the principles he supports and opposes and the practices he employs and eschews." This one dimensional, if you will, focus on what the therapist is doing, based on a moral-ethical stance of freedom makes it possible to practice in a "pseudo-autonomous" manner in the most restrictive setting.

I have tried to explain how the "Ethics" provides a guide for the practice of psychiatry. Initially, I saw this guide as a "how to" structure into which a specific technique or formula could be inserted. The truth is that when the guide is followed very little else is necessary. All that is necessary to "do" psychotherapy is to sit down with another person and through conversation attend to "...what he tells you, being able to hear what is in his heart as well as on his lips; and to tell him -- frankly simply and without humiliating him what we think of his predicament and of his options to extricate himself from it."