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Psychol. Soc. no.42 Durban Jan. 2011
Social class and psychotherapy: a critical reading of Thomas Szasz's The ethics of psychoanalysis
Rory du Plessis
Division of Philosophy and Ethics of Mental Health University of Pretoria, Pretoria
This paper aims to offer a critical reading of Thomas S. Szasz's The ethics of psychoanalysis: The theory and method of autonomous psychotherapy (1965 / 1988a). In particular, the critical reading is focused on revealing and investigating the presence of attitudinal biases and beliefs pertaining to the social class of psychotherapy. It will be argued that in Szasz forwarding his thesis, a number of statements regarding social class are raised. In particular, and for the purposes of this paper, the key focus will be an investigation of Szasz's proclamation that the poor and uneducated do not need psychoanalysis but require freedom, knowledge and skills. The paper will argue that this statement may not necessarily be presenting an attitudinal bias or belief against the poor and uneducated. Rather, Szasz is professing the nature and limitations of psychotherapy. Nonetheless, Szasz's text still reflects attitudinal biases through the disapproval of the efforts made by Sigmund Freud to make psychotherapy available to all people.
Keywords: Psychoanalysis, psychotherapy, social class, Thomas Szasz, Sigmund Freud.
This paper aims to offer a critical reading of Thomas S. Szasz's The ethics of psychoanalysis: the theory and method of autonomous psychotherapy (1965 / 1988a). In particular, the critical reading is focused on revealing and investigating the presence of attitudinal biases and beliefs pertaining to the social class of psychotherapy. In order to do so, the paper first proceeds to provide a background regarding psychotherapy's exclusion of the poor. Subsequently, a delineation of Szasz's text is provided. The text is defined as offering an approach to psychotherapy that is in contrast to the reigning norms of therapy that are based on coercion, control and influence. As such, he delineates a theory and method of psychotherapy that is based on autonomy and an analytic contract. However, in forwarding his thesis, a number of statements regarding social class are raised. In particular, and for the purposes of this paper, the key focus will be an investigation of Szasz's proclamation that the poor and uneducated do not need psychoanalysis but require freedom, knowledge and skills. Yet, it will be argued that this statement may not be presenting an attitudinal bias or belief against the poor and uneducated. Rather, Szasz is professing the nature and limitations of psychotherapy. For Szasz, psychotherapy holds the possibility of enlarging a patient's freedom but not in generating the freedom. Szasz's idea that psychoanalysis only offers personal freedom is neither validated nor invalidated within the epistemology of psychotherapy. Instead, this paper offers a discursive investigation of Szasz's aforementioned idea within The ethics of psychoanalysis (1988a). In doing so, the paper argues that Szasz's text still reflects attitudinal biases but through the disapproval of the efforts made by Freud to make psychotherapy available to all people.
SOCIAL CLASS AND PSYCHOTHERAPY.
Psychotherapy for the poor has been a topic of discussion in psychology for the past 40 years (Springer-Kremser, Eder, Jandl-Jager and Hager, 2002; Smith, 2005). The need for such a discussion is largely in response to the fact that psychotherapy has largely excluded the poor from treatment (Springer-Kremser et al, 2002). Yet, this act of exclusion is not an idiosyncrasy from the past few decades. Rather, it can be defined as a 'classical problem' of psychotherapy. Originating from the pioneers of psychotherapy to the later ego psychological versions of psychoanalysis there has been an exclusion of patients of lower socio-economic status (Altman, 2010). The following section outlines further the exclusionary discourse that operated within the pioneers of psychotherapy.
The pioneers of psychotherapy.
The social class basis of Sigmund Freud's psychotherapy is evident in him being described as the first to elaborate a therapy that would appeal to middle-class sensibilities (Shorter, 1997). This was of such an appeal that the middle-class enthusiasm for psychoanalysis is credited as supporting its uptake in Europe (Shorter, 1997). Beyond the uptake by the middle-class, psychoanalysis also became fashionable and highly regarded by the wealthy. By the 1910s, many patients journeyed to Vienna specifically for treatment by Freud (Appignanesi and Forrester, 2000). In addition, Freud's patient records highlight that his patients were often distinguished, well-connected and intelligent (Appignanesi and Forrester, 2000). These are not just secondary accounts but were even acknowledged by Freud (1955: 166) himself when he stated that psychoanalysis had become a treatment for the "well-to-do classes".
This social class basis is not just limited to Freud, but is also apparent in Carl Gustav Jung. From the onset, it is important to recognise that Jung's ideas were only applicable for a specific class of people (Fordham, 1978). Jung (2010: 62-63) knowingly admits to this in describing that:
"My contribution to psychotherapy is confined to those cases in which rational treatment yields no satisfactory results. ... About a third of my cases are suffering from no clinically definable neurosis, but from the senselessness and emptiness of their lives. ... Fully two-thirds of my patients have passed middle age. It is difficult to treat patients of this particular kind by rational methods, because they are in the main socially well-adapted individuals of considerable ability, to whom normalization means nothing".
To explore further, the class of person that sought Jung's help were often well adapted, successful, intelligent, middle-aged or elderly and for whom life had lost its meaning (Fordham, 1978; Howard, 2000). This grouping of people did not need to prove their social usefulness - they had already "made it" in society by all the usual criteria of social success - rather they could no longer find significance in their value to society, and had started questioning the meaning of their individual lives (Jung, 2010). Their plight was described by Jung (2010: 48) as follows:
"To be 'normal' is a splendid ideal for the unsuccessful, for all those who have not yet found an adaptation. But for people who have far more ability than the average, for whom it was never hard to gain successes and to accomplish their share of the world's work - for them restriction to the normal signifies the bed of Procrustes, unbearable boredom, infernal sterility and hopelessness. As a consequence there are many people who become neurotic because they are only normal, as there are people who are neurotic because they cannot become normal".
This quote clearly reflects that the individuals that sought Jung's help were bored by their position and identity, they had achieved success, but that this success brought with it only barrenness and bleakness. Yet, this grouping of individuals is but one of a number that seek psychotherapy - a fact that Jung is explicitly conscious of. Jung is deliberately transparent about the limitations regarding his theory and methods of therapy (cf Jung, 2010: 205; 236).1 This aspect can be discerned in Jung (2010: 236) describing that, "In so far as this enquiry was restricted to educated persons, it is only a straw in the wind. ... But I am inclined to accept the results as a more or less valid indication of the views of educated people ...".
In sum, Freud and Jung established a clientele that primarily consisted of the middle-class and up who were educated, intelligent, successful and powerful. Of consequence, Freud and Jung were not interested in unsophisticated, unsuccessful people suffering from basic social dysfunction (Howard, 2000). In other words, psychotherapy was practiced within a framework of social class that embraced patients from the middle class and higher. However, while these social groups found acceptance, the poor and disadvantaged were largely excluded from the practice of psychotherapy. This act of exclusion continued into classical versions of psychotherapy which have mostly excluded people of a lower socio-economic status (Altman, 2010).
The theory and practice of psychotherapy.
From the above discussion, it is clear that psychotherapy developed as an exclusionary discourse (Altman, 2010). Altman (2010) argues that this development has become embedded in the theory and practice of psychotherapy - from its conception to contemporary manifestations. In terms of exploring the exclusionary discourse embedded in the theory of psychotherapy, a recent article by Kumar (2012) proves invaluable. Kumar analyses the themes of poverty and deprivation within psychoanalytic scholarship available on the Psychoanalytic Electronic Publications from 1933 to 2003. The findings of the analysis indicate that psychoanalytic research has only marginally addressed issues of poverty and the poor. Kumar (2012) attests this neglect to the attitudinal biases and beliefs held by the psychoanalytic authors who act to withhold any acknowledgement that the poor and deprived are worthy of attention.
One of the attitudinal biases and beliefs that Kumar (2012) outlines is namely that the poor are considered to have deficits in their psychic life (lacking desires, thoughts and intellectual capacities) and thus are un-analysable. Such a belief, which becomes embedded in the theory of psychoanalysis, justifies the medical treatment of the poor and is used to account for their apparent absence from therapy (Altman, 2010; Kumar 2012). Yet, the truth of the matter is that the poor find it difficult to enter psychotherapy (Botticelli, 1997; Springer-Kremser et al, 2002)2 owing to an attitudinal tendency amongst therapists to dismiss them as suitable candidates for psychotherapy (Altman, 2010; Smith, 2005). This dismissal is directly at odds with a growing body of research that concludes that the poor are neither less interested in nor less able to benefit from the psychotherapeutic process than other demographic groups (Smith, 2005).
The previous section indicated how attitudinal biases and beliefs act to maintain the exclusion of the poor from psychotherapy. Thus in order to address the exclusion of the poor, these attitudinal biases and beliefs need to be identified and countered. This approach is supported by Altman who calls for research in order to expose, grapple with, and counter the exclusionism of psychotherapy (Altman, 2010). However, it is crucial that such research engages with the details of the text - through a process of careful documenting and analysis - in order to provide justification and support for the claims of exclusionism forwarded. In cognisance of the above points, this paper aims to offer a critical reading of Thomas Szasz's The ethics of psychoanalysis (1988a) in order to reveal and investigate the presence of attitudinal biases and beliefs regarding the poor.
Szasz is not only acknowledged as a key philosopher of psychiatry (Fulford, Thornton and Graham, 2006), but his ideas are now used liberally by psychiatrists and physicians in their conversations with the lay public. In this sense Szasz has an influence on the mental health community and larger society (Buchanan-Barker and Barker, 2009). However, he is also frequently misrepresented (Leifer 2000; Cresswell, 2008) and of consequence, the secondary literature pertaining to Szasz's proclamations are primarily limited to debates and arguments in which the interlocutors - Szasz and his critics - are positioned on opposing sides while expediting their key points of disagreement, their individual points of view and their specific judgments. One recent text in this trajectory is the 2004 publication edited by Jeffrey A Schaler titled Szasz under fire: The psychiatric abolitionist faces his critics. In this text, leading experts justify their opposition to Szasz's notions which are then met by replies from him. Although such a publication affords an opportunity to reconsider Szasz's thesis in light of both sustained and recent critiques (Cresswell, 2008), what is still omitted is a critical reading of Szasz's specific texts: an examination of the claims forwarded in his text; the soundness of arguments; the framing and / or selection of information presented; and the presence of ideology in the text. Such an approach holds the potential of examining and analysing Szasz's claims by the means of an overt acknowledgment of the implicit ideological framings and selection of information presented within his texts, yet without lapsing into personal bias and arguments hinged on misperceptions.
A number of studies have adopted a critical reading of Szasz's texts but have limited their analyses to his better known works (cf Wynne, 2006; Cresswell, 2008). Consequently, a significant portion of Szasz's texts still require a critical reading. One such work is The Ethics of psychoanalysis (1988a) in which Szasz explores his approach to psychotherapy. Although his views on therapy have been overlooked in favour of his postulates on mental illness (Wyatt, 2000, 2004), his interest in psychotherapy was actually the precursor and motivating factor for him to pursue a career in psychiatry. Szasz (as cited by Wyatt, 2004: 80) states that "I was never interested in becoming a psychiatrist and never considered myself a psychiatrist. Psychiatry was a category I had to operate in, given the society in which we live. I was interested in psychotherapy...". In particular, his interest in psychotherapy is in its potential to increase a person's autonomy. In this regard, The ethics of psychoanalysis (1988a), is an outline how Szasz works with his patients to increase individual autonomy.
However, in forwarding his thesis, a number of statements regarding social class are raised. In order to reveal and investigate such statements, the paper examines The ethics of psychoanalysis (1988a) through the following methods. First, through an intertextual reading of Szasz's seminal text The myth of mental illness (1961). One of the pillars of Szasz's theoretical edifice is defined as The myth of mental illness (cf Sedgwick, 1982: 149). As such, in order to interpret and understand Szasz's theories, reference to the aforementioned text needs to be made. To substantiate further, both texts deal with similar themes and a number of his notions forwarded in The ethics of psychoanalysis (1988a) are based on the reasoning and evidence presented in The myth of mental illness (cf Szasz, 1988a: 3; 47). Nonetheless, The ethics of psychoanalysis (1988a) displays a number of developments and transformations from Szasz's seminal text. It will be argued that these changes forefront the delimiters of social class in psychotherapy. Second, a discursive analysis of The ethics of psychoanalysis (1988a) is offered in order to explore the attitudes, beliefs and tendencies that become evident in Szasz forwarding his central thesis.
An intertextual reading.
Szasz (1988a: xv) defines psychotherapy as the name of a particular kind of personal influence "... by means of communications, one person, identified as 'the psychotherapist', exerts an ostensibly therapeutic influence on another, identified as 'the patient' ". This definition allows for Szasz (cf 1988a: xv) to view psychotherapy in the same class as virtually all human interactions - from advertising, education, friendship and marriage - in which people try to influence one another. For Szasz, (1988a: xv) people try to influence each other constantly, so much so that he deems that "[t]o control and be controlled are the warp and woof of the fabric of human relations". Yet, in psychotherapy, the personal influence and interaction is premised to be therapeutic for the patient (cf Szasz, 1988a: xv). Rather than following in the same act of prejudging, Szasz (cf 1988a: xv) urges one to reconsider whether such interactions are really helpful or whether they are actually harmful. In the most part, the dominant markers of psychiatry and psychotherapy are based on control, coercion and influence (Szasz, 1988b).
To overcome such dominant markers of psychiatry and psychotherapy, Szasz (1988a) advocates a form of psychotherapy that he terms "Autonomous psychotherapy".3 The concept of autonomy and contract are crucial for autonomous psychotherapy (cf Szasz, 1988a: 190). The underlying motivation for these aspects rests on the principle that both the patient and psychiatrist must retain autonomy. As such, the psychotherapist must not have any direct control, or power over, the patient's life outside the consulting room, and neither must the patient over the psychotherapist (cf Szasz, 1988a: x). Furthermore, it is a fundamental tenet his approach that the patient is not sick in the medical sense of the term, and that the psychotherapist is not treating the patient in medical terms (cf Szasz, 1988a: x). Instead, the aim of psychotherapy is "... to increase the patient's knowledge of himself and others ..." (Szasz, 1988a: xvi-xvii). This aim also informs the psychotherapist's attitude toward the patient - the therapist must help the patient to make an informed choice for the specific problems in living (cf Szasz, 1988a: 89). The therapist can do this by keeping in mind that the task is, "... first, not to diagnose the patient, but to engage him in a meaningful dialogue and, second, not to try and collect data from the patient, but to relay appropriate information to him" (Szasz, 1988a: 89).
In autonomous psychotherapy, the materialisation of autonomy is hinged upon an analytic contract which is defined as "... an explicit and mutually accepted set of promises and expectations" (Szasz 1988a: 130).4 The analytic contract acts to reduce the inequality of the client while simultaneously protecting the client from the analyst's influence (cf Szasz, 1988a: 130). Such potentials are however not inherent in the analytic contract but actively constructed by delimiting the psychotherapist-patient relationship to individuals of the same socio-economic profile and social class. This point is evident in him stating that contracts require two almost equal participants.5 Two reasons for this requirement are forwarded. First, if either party feels much weaker or much stronger than the other, the contracting may fail (cf Szasz, 1988a: 199). This is most clearly evident in poor or helpless patients who run the risk of being exploited by their psychotherapist. According to Szasz (1988a), the lowly status of the patient calls for the psychotherapist to adopt a superior position and command the patient's full submission.6 Second, they must be approximately equal in their willingness and ability to assume responsibility for themselves and toward each other (cf Szasz, 1988a: 200). For Szasz, this means that the patient needs and wants psychotherapeutic help and, in return, offers the therapist money and responsible cooperation. In regard to the therapist, this entails the need for money and opportunity to work and, in return, the therapist offers the patient analytic knowledge and skill. On this foundation, meaningful negotiation and contracting can occur in the psychotherapist-patient coupling (cf Szasz, 1988a: 200). Yet, of the therapist's two needs, money and the opportunity to do work, Szasz (1988a) states that it is the patient's payment of a fee that above all enables the patient to be a responsible, negotiating party to a contract with the therapist. Additionally, if the therapist did not need the patient's money it would complicate what the patient could give the therapist in order to maintain the contracting relationship (cf Szasz, 1988a: 200).
From the abovementioned points, it is clear that the positive therapeutic ideals of autonomous psychotherapy can be only attained through contracting. Owing to the fact that the poor are unable to meet the requirements of contracting, namely the payment of a fee, they are excluded as candidates for autonomous psychotherapy. In this regard, Szasz may be critiqued for excluding the poor. However, Szasz (1988a: 200201) does not deny that it is impossible for a therapist to "treat" a non-paying patient "... but such therapy would be neither contractual nor, in our terms, analytic". In this statement, he excludes the poor from autonomous psychotherapy but not from other psychotherapeutic methods. Szasz, much like Jung, can be argued in this sense to be forefronting the limitations of his approach to psychotherapy.
Even though Szasz may be argued to be conceding to the delimiters of his therapy, he is still not clear from critique. For Sedgwick (cf 1982: 138) a notable absence in Szasz's argument is that he does not provide any indication of the kind of therapy suitable for the poor that he excluded. One reason for this absence is that Szasz believes that the poor may not necessarily need the treatment offered by psychoanalysis. This opinion is evident in Szasz's response to Freud calling for the development of a psychotherapy that could be suitable for treating the poor and the uneducated (cf Szasz, 1988a: 27). Szasz (1988a: 28) is resolutely opposed to such an envisaging:
"But what kind of help, or therapy, does a 'considerable mass of the population' need? The poor need jobs and money, not psychoanalysis. The uneducated need knowledge and skills, not psychoanalysis. Furthermore, the poor and the uneducated are also often politically disfranchised and socially oppressed; if this is the case, they need freedom from oppression. The kind of personal freedom that psychoanalysis promises can have meaning only for persons who enjoy a large measure of economic, political, and social freedom".
This statement is the most severely critiqued by reviewers of Szasz's text (Cioffi, 1969; Goldstein, 1980; Stillman, 1983; Clarke, 2007). In particular, Cioffi (cf 1969: 189) characterises Szasz in terms of the "YAVIS syndrome": a preference among therapists for patients who are Youthful, Attractive, Vocal, Intelligent and Successful. Beyond such critiques, Szasz's statement also shows a link to identified classist attitudes, assumptions and biases in psychotherapy. One such classist bias is the widespread assumption that the poor's need for the material necessities of life need to be met before any psychotherapeutic assistance can be offered (Smith, 2005; Kumar, 2012). In this line of reasoning, the poor do not require a psychotherapist but need economic opportunity and social justice (Smith, 2005). Yet, this reasoning is a dismissal of the fact that life for the poor exposes them to a greater burden of stress, loss, trauma, and of consequence, mental suffering (Silver, 2009; Altman, 2010). Apart from treating such ensuing mental suffering, the psychotherapist can also offer the poor the opportunity, like the other social groups frequenting the therapist, to: visualise and reach their goals; and to become more fully conscious of feelings and actions (Smith, 2005).
For the purposes of this paper, the statement in question will be investigated through an intertextual reading of The myth of mental illness (1961). It will be argued that the development of ideas in the two books is not a mere continuation of similar themes. Rather, the ideas presented in The ethics of psychoanalysis (1988a) become focused on the exclusions and limitations of psychotherapy based on social class.
In The myth of mental illness, Szasz (1961: 61) does not reject patients based on social class but acknowledges that a "better education and economic security favor the conditions necessary for a two-person therapeutic contract". In this regard, Szasz (1961: 59) cautions psychotherapists "... not be influenced by socially distracting considerations concerning [the] ... patient. This condition can be met best if the relationship is rigidly restricted to the two people involved in it". By this, he means that psychotherapists should not function as "attorneys for the poor" - to be their representatives and protect them against social injustice (cf Szasz, 1961: 70). Conceptualised as such, psychotherapists are to be the patient's agent and not an agent for society (cf Szasz, 1961: 72).7 Thus, Szasz places emphasis on the importance of the psychotherapist to be mindful of assuring a two-person therapeutic contract - restricting the relationship solely in terms of the psychotherapist-patient. The purpose of which is neither to protect nor to medically 'treat' the patient but to foster "... certain values and types of learning" (Szasz, 1961: 297).
From the above outline, The myth of mental illness (1961) defines the conditions of contracting less in terms of social class than in the role of the psychiatrist to: assure a two-person relationship; and to act as the patient's agent. Besides for which, the only other reference to contracting is that it is based on confidentiality - an aspect that for Szasz is indispensable in protecting both parties of the psychotherapist-patient relationship (cf Szasz, 1961: 66-67). However, in The ethics of psychoanalysis (1988a) the aspects of contracting are conditioned by parameters and delimiters of social class.
One reason for Szasz's transformation of the themes - originally identified in The myth of mental illness (1961) but modified in The ethics of psychoanalysis (1988a) to be focused on delimiters of social class - is found in the significance that he accords to psychoanalysis. For Szasz (1988a: 17-18), the importance of the psychoanalytic situation is that it "... is a model of the human encounter regulated by the ethics of individualism and personal autonomy". However, individualism for Szasz is only possible if one has attained and is secure in their collectivist freedom - which includes freedom from political oppression, economic exploitation, slavery, colonisation, and persecution based on religion, race and culture (cf Szasz, 1988a: 20). As such, he believes that psychotherapy holds the possibility of enlarging a patient's freedom (individualism and personal autonomy) but not in generating the freedom (collectivist) (cf Szasz, 1988a: 116). In cognisance of this, his argument that the poor do not require psychoanalysis is qualified by indicating that psychoanalysis only offers personal freedom. In doing so, the critique against Szasz for presenting an attitudinal bias or belief against the poor and uneducated proves to be unfounded. Although such critique may be unsubstantiated, the subsequent section of the paper argues that Szasz's text still reflects attitudinal biases. This is evident in his disapproval of the collectivist values promoted in the psychotherapy of Freud.
A discursive reading.
In this section of the paper, Szasz's idea that psychoanalysis only offers personal freedom is neither validated nor invalidated within the epistemology of psychotherapy.8 Instead, this paper offers a discursive investigation of Szasz's aforementioned idea within The ethics of psychoanalysis (1988a). The main reason for conducting a discourse analysis is not to uncover the truth of a statement but rather to discover how its 'claim to the truth' is constructed and produced. This process includes the denial and disregard of statements that counter the dominant discourse. In other words, one statement through a wide range of strategies is legitimated and produced as the dominant discourse, whereas the other is treated with suspicion and either marginalised or denied. As such, it will be argued that Szasz constructs the individualism of psychoanalysis as valid and justifiable through the process of disapproving of Freud's expressions of collectivist values in psychotherapy.
Szasz argues that Freud's greatest contributions include: providing the foundations for a therapy that seeks to enlarge the patient's freedom and responsibility (cf Szasz, 1988a: 16); and establishing the role of the psychiatrist as the agent for the patient (cf Szasz 1988a: 21). Additionally, he allots an elevated importance to Freud for stating that the aim of psychoanalysis is to help patients achieve personal autonomy (cf Szasz, 1988a: x-xi). However, on reflecting on which position Freud had concerning the two kinds of freedom - individualism and collectivist - he finds that Freud did not recognise the necessity of making the psychiatrist's position on these matter explicit (cf Szasz, 1988a: 20-22). For Szasz this is one of the imperfections of Freud's approach to therapy and the basis for its improvement (cf Szasz, 1988a: 95).9 In this process, Szasz (1988a: 113) does not just present autonomous psychotherapy as "... a fully contractual type of psychotherapy" but refutes and devalues the instances that Freud expresses collectivist values in psychotherapy. For example, and most important for this paper, is Szasz's dismissal of Freud in his postulation for a therapy to treat the poor and uneducated.
In cognisance of the above, the process by which Szasz constructs autonomous psychotherapy as a reasonable development from Freud (cf Szasz, 1988a: 6) is not a neutral process of advancement but is hinged upon a number of attitudes and beliefs towards Freud. In particular, such tendencies include: the recognition of Freud for providing a therapy based on enlarging a patient's freedom and autonomy; but also a disapproval of Freud's expression of collectivist values in psychotherapy. In doing so, it appears as if Szasz constructs a rigid binary of individualist versus collectivist values in psychotherapy. In this binary any expression of collectivism is deemed as negative. As a result, Freud's move towards offering the poor and uneducated access to psychoanalysis becomes regarded as unhelpful. Furthermore, any further investigation into Freud's development of a psychotherapy for the masses is deemed to be unwarranted. To offer a counterpoise to Szasz's negative descriptions and the absence of any ensuing investigation, the following paragraphs aim to indicate the tacit attempts and recorded practices offered by Freud to incorporate a more representative socioeconomic profile of patients for psychotherapy.
As already indicated, in 1919, Freud (1955: 166) acknowledged that psychoanalysis has become a treatment for the "well-to-do classes". However, Freud (1955: 167) had a vision of a day when:
"it is possible to foresee that at some time or other the conscience of society will awake and remind it that the poor man should have just as much right to assistance for his mind as he now has to the life-saving help offered by surgery; and that the neurosis threaten public health no less than tuberculosis, and can be left as little as the latter to the impotent care of individual members of the community. When this happens, institutions or out-patient clinics will be started, to which analytically-trained physicians will be appointed ..."
Freud looked forward to the day when clinics would be built for psychoanalysts to offer free treatment (cf Freud, 1955: 167). Freud was also not overwhelmed by the prospect of working with people from different socio-economic or cultural backgrounds, for he wrote, "I have been able to help people with whom I had nothing in common, neither race, education, social position, nor outlook upon life in general" (Freud, as cited by Altman, 2010: 33). From the above evidence, Freud has been revealed to express a social conscience (Danto, 2005), a democratic sensibility and a discomfort regarding psychoanalytic treatment restricted to well-to-do patients (Altman, 2010).
Yet, Freud's 1919 statement was not an intangible momentary postulation that was never taken seriously by the community of psychoanalysts. Rather, as Elizabeth Danto (2005) has recently documented, Freud's comment were taken as a direct instruction by the analysts of Europe between 1920 and 1938. Analysts responded to Freud's call by establishing free clinics throughout Europe in which analysts took on at least one free case or dedicated a part of their income from private practice to the maintenance of the clinic. Even the most senior analysts saw one-fifth of their patients free. Freud was no different as he saw some of his own patients without charge (Altman, 2010). As such, the psychoanalysts of this period resolutely believed that they had a social obligation to donate a portion of their time to people who could not otherwise afford psychoanalysis. Moreover, the majority of the psychoanalysts did not even consider weighing the effectiveness of treatment against the financial burden imposed by the patient (Danto, 2005). Therefore, the classical analysts of Europe, under the direction of Freud attempted to make psychoanalytic therapy available to as many people as possible through the establishment of free clinics (Danto, 2005).10
From the above discussion, the paper has identified certain attitudes and prejudices adopted by Szasz in his references to Freud. In particular these attitudes are informed by Szasz's position regarding individualism in psychotherapy. Szasz commends and even builds upon the expressions of individualism in Freud's therapy. However, Szasz's focus on individualism becomes a rigid framework for framing the goal of psychotherapy. Consequently, Freud's expressions of collectivist values are deemed unnecessary and devalued. In this process, the contributions and influence of Freud towards the establishment of a psychotherapy for the poor and uneducated are not only denied but deemed an unnecessary exploration. To substantiate further, his response to Freud calling for a psychotherapy for the people is met only with pronouncements concerning how it is at odds with the goals of individualism. What is missing is an evaluation of the tacit attempts and recorded practices offered by Freud to incorporate a more representative socio-economic profile of patients for psychotherapy. Thus, as a counterpoise to the exclusion of such historical details, the paper has indicated Freud's influence in developing a social-conscience in psychotherapy.
Szasz's The ethics of psychoanalysis can be regarded less in terms of professing a social bias in psychotherapy and more in terms of expressing the nature of psychotherapy (to enlarge a patient's individualism and personal autonomy) and its limitations (a patient needs to be have already achieved collectivist freedom). In this reasoning, the majority of the critiques of classism in Szasz can be argued to be tenuous - their claims are based on a generalised reading of Szasz that fails to account for the limitations and qualifiers of personal freedom evident in his pronouncements. Yet, the paper has argued that Szasz's text still reflects attitudinal biases through the disapproval of the collectivist values promoted in the psychotherapy of Freud.
Even though Szasz (1988a: xi) states that Freud would reject "... the 'therapeutic' ends and means I have made my own. Thus, the qualification I mention ... place my approach outside the bounds of psychoanalysis and other recognized methods of psychotherapy", a number of attitudes, beliefs and tendencies in Szasz's references to Freud can still be deduced. These include affirmations of Freud in terms of personal autonomy but also the denial and disregard of Freud's collectivist values in psychotherapy. Evident in this process is that he forwards his thesis by repudiating Freud for his lapses and breaches of individualism. Thus, the collectivist values in Freud are regarded as negative. Subsequently this leads to Szasz disregarding the place of these collectivist values in Freud's approach or theoretical development.
In sum, one can argue that Szasz forwards individualism in psychotherapy by casting collectivism in the negative. However, this statement is not an argument for collectivism in favour of individualism. Instead it serves only to reveal the process in which Szasz disregards collectivist values. One consequence of which is that Freud's recorded history of engaging with social class is excluded from discussion. Therefore, the paper has revealed that Szasz might not be guilty of presenting a class basis in psychotherapy but does regard collectivist values in psychotherapy as negative. This in turn leads to Szasz neglecting an exploration and investigation into the efforts made by Freud to make psychotherapy available to all people.
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1 This is not necessarily a critique but a limitation of Jung's approach. The method used in Jung's cases cannot be applied to all patients, nor did Jung think that it could (Fordham, 1978). To elucidate further, Jung advocated a particular psychological theory for a designated type of person. Additionally, Jung (2010) believes that psychological theories and approaches to psychotherapy should be based on the context and position of the patient. Thus, according to Jung (2010: 60): "... it is a blunder in technique to treat from the Freudian standpoint a patient of the type to whom the Adlerian psychology applies, that is, an unsuccessful person with an infantile need for self-assertion. Conversely, it would be a gross error to force the Adlerian viewpoint upon a successful man whose motives can be understood in terms of the pleasure principle".
2 This fact is confirmed by older literature such as Hollingshead and Redlich (1958) which has been described as a classic study focusing on social class (Busfield, 2011). Hollingshead and Redlich's study details the inequalities of treatment accorded to the psychiatrically ill of different classes. The unskilled and semi-skilled workers of poor education were much more likely than the members of superior social rankings to receive organic treatments (ECT, insulin coma, brain surgery, drugs). If they were given any psychotherapy it was brief or of a directive kind.
3 Szasz (cf 1988a: 6-7) also hesitates to term his approach to psychotherapy as Autonomous psychotherapy. In particular, this is because Szasz (cf 1988a: 6) deems his approach as inherently indicative of psychoanalysis. To support his claim, Szasz (1988a: 6) outlines a number of shared similarities: firstly, the aim is the same, in psychoanalysis the aim is to "... extend the control of the ego over certain areas of the id" or in Szasz's approach "... to augment the client's capacity for self-determination and making choices" (Szasz, 1988a: 6). Secondly, in terms of common methods, "... in classical psychoanalysis as well as in autonomous psychotherapy, the therapist's sole task is to 'analyze' " (Szasz, 1988a: 6). In this regard, Szasz is cautious to name his approach by a new term, as he would risk being criticised for using a new term to describe psychoanalysis as defined and intended by Freud (cf Szasz, 1988a: 6).
4 For a critique of Szasz's construction of the positive potentials in contracting, please see Stillman (1983). In particular, Stillman (1983) indicates that free contracting is not necessarily a sufficient condition for individual autonomy.
5 In addition to equal participants, another essential ingredient of contracts is freedom. For Szasz (1988a: 116), "in proportion as either therapist or patient is not free - in particular, not free with respect to the conduct of their relationship with each other - there is an external, situational limit on psychoanalysis. This limit is insurmountable regardless of the professional qualifications of the therapist and the psychological make-up of the patient". According to Szasz (cf 1988a: 115-116), patients that lack freedom include the poor who cannot pay for the services of the analyst.
6 To explain further, when the patient is defined as dependent, helpless and sick, the analyst assumes the role of the patient's "protector" - and of consequence its association with exploitation and oppression. Alternatively, when the analyst considers the patient autonomous and self-responsible, protection is not legitimate. Therefore, by relinquishing the "duty" to protect the patient, psychiatrists abandon their control of the patient (cf Szasz, 1988a: 184).
7 The role of the psychotherapist as the patient's agent continues in The ethics of psychoanalysis. Primarily this is evident in Szasz (cf 1988a: 21) accounting for the contribution of Freud who established the role of the psychiatrist as the patient's agent. Szasz (cf 1988a: 21) describes that when Freud became a physician, two roles had been established for the psychiatrist. One was the role of society's agent evident in the state-hospital psychiatrist. Although attempting to serve and support the patient, the psychiatrist in this role actually protects society from the patient. The other role was being an arbiter of the conflicts between patient and family, patient and employer, and so forth. In this role, the psychiatrist's allegiance is to whoever pays him or her. In contrast, Freud refused to take part in either of these roles. Instead he forged a new one - the role of agent of the patient. In this way, Freud assisted the individual patient while declining any obligation to the patient's family and society (cf Szasz, 1988a: 21).
8 Further information on liberation from oppression as the minimum requirement for the practice of psychoanalysis is discussed by Kumar (2012).
9 According to Szasz, the other inadequacies in Freud's approach include amongst others that it retains too many of the status aspects of the medical game and it is not sufficiently contractual (cf Szasz, 1988a: 113).
10 However, in the United States (US), the idea of psychoanalysis for all people did not take hold to the extent that it did in Europe (Altman, 2010). In the US, psychoanalysis became more and more a treatment reserved for the highest social classes. Poor people, working-class people and people seen in the public sector came to be viewed as unsuitable candidates for psychoanalysis. One reason for this was the prominence of the capitalism in American life. Thus, rather than being unsuitable candidates for psychoanalysis, the poor and uneducated were not aligned with the business aspect of the private practices of psychoanalysis (Altman, 2010).