Psychotherapy and Moral Culture: A Psychiatrist’s Field Report

A drug advertisement in a psychiatric journal depicts a psychiatrist’s office with a fireplace, white walls, large black leather chairs, a primitive soapstone carving on the mantel, and a photograph of Freud on the wall. It is an elegantly appointed office, even to the smoking pipe and the rosewood humidor beside the doctor’s chair. No people are pictured. During my training years at the Sheppard and Enoch Pratt Hospital, where such appointments were ubiquitous and taken for granted, I would have hardly noticed the ad or dismissed it as an appeal to snobbery and elitism, which no doubt it is. But after I began work at a mental-health center where I was seeing patients in a windowless room furnished with a steel desk and two straight-backed chairs, I became fascinated with the ad and unable to restrain the terror and alienation it inspired. It made me feel like an outcast, under siege, as though behind enemy lines or strayed from my own kind; disinherited; abandoned. It was like looking through time at a lost age or a forgotten language. Beyond the appeal to snobbery in the ad was a subtler, more menacing, appeal to nostalgia. The beautiful room represents a commonly shared and richly meaningful cultural milieu which creates the possibility, the “space,” for depth of meaning in what goes on between the doctor and the patient. For the purpose of the ad, this possibility is associated with the drug, as though giving this drug would make that kind of “space” available. What is implied by an image of a cultural milieu, the psychiatrist’s office, is a possibility of relationship which is not suggested, for example, by an ad showing a worried patient, in a work shirt, clutching the iron bedpost of a barracks-style bed while the doctor in the background looks on, concerned; or by an ad showing a patient standing with his suitcase ready to leave the hospital, in front of a table at which a doctor sits writing a prescription. In the latter two examples, the patient is a problem that the doctor worries about and feels vaguely threatened by. He seems to be a stranger to the doctor, personally and socially. There is no suggestion of a longstanding involvement with the patient. The doctor and the patient seem to meet across a social gap, either of class or “background.” There is no implication that the patient is invited to talk to the doctor or to express himself as an individual other than to make known his complaints. This is in contrast to the social closeness and comfort in the doctor-patient relationship implied in the image of the psychiatrist’s well-appointed office. That patient would appreciate the art on display, the good taste shown, and would recognize Freud’s portrait. The person in the easy chair opposite that doctor is the object of compassion and empathy, rather than worry. His relationship with the doctor is intimate, longstanding, and complex, and he is clearly invited to speak his mind fully and at leisure. It was the realization that these values could be represented in the furnishings of an office that focused my interest on the cultural milieu in which therapy takes place; and it was the move from an environment relatively rich in these cultural artifacts, the 80-year-old, 400-acre, Sheppard-Pratt Hospital, to a relatively more modern and impoverished environment, that showed me how much I had taken for granted. Once a patient had driven through the stone gatehouse of Sheppard-Pratt, and through its wooded property and over the expanse of well-kept lawns, to the dignified Gothic edifice of the hospital, and seated himself in the tastefully appointed office that had been provided for my use, a great deal had already been accomplished. The patient knew that he was entering an institution which placed a value on beauty, on dignity, and on the high purpose of its work, so that even before I spoke he could be fairly certain that I would treat him humanely, that I could be more or less trusted not to be brutal, and that he could regard me as an important person by virtue of my association with an institution which he could regard as important. In contrast, the patient who enters the mental-health center, a one-story cinder-block building, cold and functional, with a large sterile public waiting room and tiny offices partitioned off with prefabricated vinyl walls, is being treated to an entirely different kind of experience. His associations with what he sees are the social security office, the welfare office, or an army induction center. He has no reason to think that he will not be brutalized by me because the building is already brutalizing us both.

I recall sitting with a patient in a sunlit room at Sheppard-Pratt Hospital where the summer breeze carried sounds of splashing and shouting from the swimming pool outside. The patient, sprawled across a wicker couch smoking cigarettes and sipping coke, would attack and berate me mercilessly for my brutality and my insensitivity, and would rage against the hospital as though it were his prison. I would listen in silence, contemplating the toes of my shoes against the ceramic tiled floor; and eventually would begin to hear, through the attacks on me and the hospital, the cries of anguish at the deeper hurts that could not be expressed directly.

Had the same patient been sprawled across a wooden bench in the corner of a state hospital ward, and had he attacked me and the hospital over the sound of slamming steel doors, my silence would have been simply a tacit complicity with the brutality of the real situation. The psychotherapeutic event becomes possible only when the therapist can listen to the patient’s complaints in benign and compassionate silence, in the full knowledge that the patient has every reason to believe that he is held in regard by those who are treating him.

In the absence of a cultural milieu in which the values of personal dignity and respectability are consistently reaffirmed in the available artifacts, such as the Sheppard-Pratt gatehouse, or the sunlit room, or the leather chairs in the psychiatrist’s office, the affirmation of those values becomes a difficult, self-conscious, and time-consuming program in the psychotherapy itself.

I find myself sympathetic now as I never had been with the missionary in the first scene of The African Queen who doggedly finishes the last stanzas of “Rock of Ages” in his grass-hut church deep in the jungle despite the commotion and dispersion of most of the congregation at the sound of the whistle which signals the arrival of the mail boat outside. My new-found sympathy was for the missionary’s necessity, as he saw it, to be in his own person, and in isolation, the Church of England, in a cultural milieu in which no one could have imagined the existence of Canterbury Cathedral. The missionary feels that he has been exiled, and that his fate now is to be a church where there is no church; to be this church, he abandon’s who he is as a person and thinks of himself as an institution. He cannot permit himself to admit to his own excitement at the arrival of the mail boat. There is no choice for him but orthodoxy.

There are times when the psychotherapist in the modern-day situation feels a similar destiny, and tends to turn himself into an institution, but the missionary mentality is a trap because of the rigidity and orthodox devotion it demands. In fact, the missionary in The African Queen is an irrelevant appendage to the community life of his village because, by institutionalizing himself, he and his values remain aloof and detached; his attention is occupied with empty formality rather than the living reality around him, and his devotions become merely self-serving.

The values embodied in the traditions, the texts, the artifacts, and the conventions of an institution such as the Church, or the institution of psychoanalytic psychology, provide the context for meaningful personal responsiveness; but the institutionalized values are not and can never be the spontaneous and complex personal response itself. They only make such a response possible. Orthodoxy and tradition are never the substance of a creative exchange, whether religious or therapeutic. When the missionary finishes the last stanzas of “Rock of Ages,” or when I, to take another example, use a word like “symbiosis” or “sublimation” when I know that it will not be understood, we are each insisting that we will go on acting as though the context were still there. If the context were there, however, our own responses would certainly be more complex and richly personal. The missionary, if he were preaching in a little church in the English countryside, where he could assume that his congregation understood and respected the decorum of the service, could easily feel free to betray his own excitement upon the intrusion of a happy distraction such as the mail boat, and even to end the service early without fearing the collapse of tradition as a result. Similarly, if I were not, insanely, trying to recreate the hallowed halls of psychoanalysis in the busy traffic of a mental-health center, I would be less bound to the conventional language of psychoanalytic thinking and free to use more down-to-earth language.

To the extent that the values of the psychotherapist become increasingly alien to the values of the culture in which he practices, the problems and responsibilities of the missionary become increasingly relevant to him. To represent his values as a person requires of the therapist that he be much more personal with his patients, for example, by offering opinions about books, music, or art, not as a rejection of conventional psychoanalytic techniques but as a means of establishing that there are commonly held esthetic and moral values between them. I find that suggesting to a patient that he might be interested in a particular book or a movie is a way to communicate to him that I respect his intelligence and his sensitivity, and that in psychotherapy my object is to share my knowledge with him as an equal rather than to administer to him from above. This personal “offering” of the therapist is simply an attempt to create a common cultural space with the patient, a space which already exists and thus needs no special attention in the sunlit room at Sheppard-Pratt Hospital or in the psychiatrist’s office in the advertisement.

In some cases this need for a common cultural space becomes a major issue in the therapy. For a man who had been hospitalized for a suicide attempt at age thirteen in a state institution for the mentally defective, and had since been treated in other brutal and inhumane inpatient and outpatient programs, it look months of patient reassurance that I had respect for his mind, that I did not regard his perception of the brutality of his experience as “sick” or “psychotic,” before he could entertain the notion that I could consider him an equal. After weeks of silent procrastination and agonizing doubt, he trusted me with information given him by another patient that a professional colleague had engaged in obscene activity in this patient’s presence. The fact that I treated the information with respect, held it in confidence, and did not automatically dismiss it as insane raving helped him to feel that I did not regard his mind as “inferior” because he was a patient. It was only then I learned that he had always assumed that he would never be accepted into a medical school or graduate school in psychology because of his “record” as a mental patient, an attitude that would logically grow out of his previous “treatment” as a patient. He was initially totally incredulous about my suggestion that a school might consider his personal experience with mental illness and its treatment an asset rather than a disgrace. One day after I had given him a ride to his appointment, he said, sitting in my cramped office with noise outside the door, that he would just as soon have therapy in my truck as in this “goddamned office.” I felt that it was an essential part of his therapy to damn the office, as a repudiation of the degradation he had experienced, and that, to be effective as a therapist, I must accept his need to dissociate me from the mental-health establishment which had brutalized him by agreeing that the office was an insult to the importance of the work we were engaged in. This was my only way to give him some substitute for the stone gatehouse and well-kept lawns that were missing, to allow the emergence of a common cultural space in an otherwise alienated and culturally inadequate milieu.

To the extent that the Sheppard-Pratt situation is the more anachronistic and the mental-health center the more modern setting, we recognize the difference between the two as an historical development of sorts. Understanding that development means looking at psychotherapy in the context of the larger culture in which it is practiced.

Psychotherapy occurs in history. It exists and evolves in a specific time and place uniquely and in relation to the complex social and cultural forces of the changing scene. I t is not the hot-house flower of some pure intellectual pursuit, and one cannot assume that it is determined only by its own internally rational development.

We must not assume that a history of psychotherapy, with “advances” in therapy, new theories or techniques, represents a rational or progressive development in the sense that quantum mechanics represents a progressive development from Newtonian mechanics. It is possible for psychotherapy to develop in regressive or degenerate forms as well as progressive ones. Psychotherapy is a phenomenon of culture, with complex origins and relationships. It has ties to medicine in its primitive and its scientific traditions, to art and to religion as sources of meaning in culture, and to politics as an agency of social control and of social criticism. To assume that psychotherapy is any less complex than this, or that it can be studied in isolation and out of context of the culture in which it is practiced, is more an ideological assertion than a scientific premise.

A comparison of Freud’s office in Vienna, with its brocade, Persian rugs, and collection of primitive sculpture, to a modern mental-health center building of cinder blocks, steel desks, Muzak, and California landscape posters with mottos like “Today is the First Day of the Rest of Your Life,” reveals something relevant to what has happened in the history of psychotherapy from its original form as daily psychoanalytic sessions to present dispersion into the various tendencies and techniques of brief therapy, behavior therapy, desensitization therapy, transactional therapy, reality therapy, etc. The comparison of rooms is obviously one of esthetic values, yet it is in these that the culture which is the context of psychotherapy is represented and revealed.

Psychotherapy is a part of our cultural life. Developments and tendencies in therapy reflect and manifest similar tendencies in the morality and ideology of the time. To become conscious of this content the psychotherapist must be a self-conscious moralist who will not accept at face value the manifest therapeutic rationale of a therapy as the only moral content of the actual therapeutic exchange, but will analyze critically the therapeutic experience itself specifically for its “latent” moral content. For example, to tell a patient that his “illness” is caused by a “biochemical defect” over which the patient has no control is not only to present a scientific theory, but in the context of therapy is to advance a moral doctrine of predestination and human nonaccountability, and to deprive the patient of the moral option to regard himself as responsible for and potentially master of his fate. Even if it were to become empirically evident that patients improve when presented with this theory (presumably because they are given a release from the burden of responsibility), the moral issue could not be decided on the basis of empirical outcome alone.

To take another example, the use of first names by psychotherapists is usually justified by the rationale that it expresses the equality of the patient and the therapist, that it rejects the so called “medical model,” and that it is a way of being personally “open” with the patient. A critical look at examples will show that use of the first name can also be a means of evading responsibility and a subtle form of mystification.

My initial impression of the names on the row of mailboxes behind the receptionist’s head in the waiting room of the mental-health center (Wendy, Cindy, Rick, Rob, or Debbie, nicknames from a generation of “April Love,” Peter Pan, and South Pacific) was that it seemed more like roll call at a summer camp than the roster of a professional staff. I suppressed my impulse to take offense partly because it seemed an esthetic judgment merely, or worse, that I was feeling threatened with loss of status. Was it not after all more democratic to be Fred than to be Dr. Bloom?

My experience has shown since that informality, rather than making the patient feel more equal to the therapist, can instead be a subtle insult if the informality is not a mutual agreement to put aside the conventions of respect and respectability that are in common social use; and is rather an imposition by the therapist of an ideological stand on the patient and on the therapeutic relationship. A grey-haired gentleman from a conservative, religious, working-class community told me that his therapist walked into his group-therapy session on the first day without introducing himself, slipped off his shoes, put his feet on the coffee table, folded his hands on his chest, and treated the group to a broad grin. His communication is not that all are equal. Nobody else has his feet on the table, and if other members later add their feet to the table it is clearly under the therapist’s auspices and his mandate that they do so, not through a mutual agreement to suspend customary formality.

Insistence that people be immediately and uniformly on a first-name basis, or that they put their feet on the table, is a refusal to acknowledge that formal conventions of address and decorum constitute the social language by which people confer on one another the freedom to remain at a distance, that is, to decline intimacy. An ideology of intimacy and familiarity denies that choice, and defines anyone who refuses to accept it as rejecting health and wholeness of personality, when what is being offered and rejected is neither health nor wholeness, but a code of behavior which negates the difference between strangers and intimates, and a language of first names which obliterates that distinction.

A variation on this use of first names is the instance of a group therapist, let us call him Richard Smith, whose patients call him “Dr. Rick.” Dr. Rick, by insisting relentlessly on his equality through such devices as the first name, wearing Levis and leaving shirttails out, and justifying this insistence on ideological grounds (nonelitism, shared humanity, being a “real person”), also evades the uncomfortable fact that he exercises authority in the life of his patients; and insofar as this is not reciprocated (and to my knowledge none of our patients has ever invited one of our staff on “an adventure of self-discovery”) the situation is not equal. The patient puts his trust in someone he assumes to be a responsible professional who will accept authority for his treatment, but is told that for such authority to exist would be elitist undemocratic, etc. The professional person becomes just “Rick,” de-professionalized, and not accountable. Yet “Rick” no more accepts real equality with his patient than he expects to go out repairing televisions with him the morning after the group meeting, if real equality means that Rick and the patients make sense together out of what they are doing, and develop a common understanding and rationale of their task which would be open to criticism on both sides. To retain the title “Doctor” then serves, along with the rest of the paraphernalia and jargon, to mystify and impress so as not to have to answer and explain. Dr. Rick is a healer in short pants, a shaman in sneakers and football jersey. He is so intimidating with his degree and his jargon, and is such a down-to-earth nice guy, that he is invulnerable.

Therapies which operate on empty mystification and evasion of responsibility, in which the therapist indulges himself in cheap charismatic heroics, and in which the accepted forms of social interchange in the patient’s community are ridiculed, could easily be called anti-therapy on moral grounds alone, irrespective of the empirical outcome of treatment.

As technicians and specialists exercise increasing authority over the lives of individuals, the influence of technical ways of thinking on social relations and on the ways in which we conceptualize our experience correspondingly increases, so that not even the most technical procedure can be passed off as morally neutral. Technicians preempt the moral authority of tradition, church, family, and of the individual responsible person on the grounds of special expertise or technical competence. The social categories of health and sickness, for example, become defined by medical diagnostic and therapeutic technologies, so that health is measured in a laboratory profile rather than experienced by the individual as an internal state of well-being. Diagnostic technology in this case becomes the method of social certification to which the individual’s claims to health or sickness are subjected. The moral authority for the social definition of health and sickness becomes assimilated into a set of technical functions. Similarly, the social definition of knowledge and education becomes that which is taught in mechanized schools by technically trained teachers and which can be tested by mechanized examinations. The moral authority for the social definition of knowledge and folly becomes assimilated into the technology of schooling and testing.

The psychotherapist, in his modern role as the technical engineer of personality, also indirectly assimilates a social function. This is the crucial meeting point of psychotherapy and culture. The psychotherapist is the unique focus for the social expression of our changing notion of what constitutes human nature. The forces shaping our view of human nature achieve articulate social expression in the theory and practice of psychotherapy. The theories that psychotherapists use are the current cultural forum in which the issues of man’s essential nature are debated.

The transfer of this forum from religion and from the domain of social criticism (Marxism, utopian socialism, etc.) into the domain of psychotherapy is partially due to the ascendance of science and technology, the ideological mainstays we believe in, so that in our single-minded reliance on expertise we turn to the scientific psychologist to discover the nature of man. But it is also due to the relative decline of Judeo-Christian dogma as a metaphysical voice that can still be vital for us, and the relative absence of critical social theory in a society in which the thorough isolation of the individual from his archaic communal ties and his reintegration into the interdependent industrial world, always potentially unstable on a mass scale, creates the necessity for immediate accommodation to and neutralization of social criticism. What remains is the individual sick soul, the individual suffering person, who can only see himself as sick because he can no longer see himself as spiritually bereft, a lost soul, or damned, and can no longer see himself as socially or politically oppressed. The responsibility for sustaining a meaningful existence falls on this individual isolated personality and becomes redefined as the achievement of personal adjustment, which is now the domain of psychotherapy.

The emergence of psychotherapy in this century as the available mode of transcendence is associated with a specific narrowing of the conceptualizing of the transcendent possibility inherent in human nature. Transcendence in the religious sense is the integration and reconciliation of the individual with a total universe which is perceived to be alive with spiritual and moral meaning. It is the resolution of a state of alienation with respect to nature, to mankind, to the forces of creation, and to the spiritual order of the cosmos. In religious activity men bring themselves into harmony, into oneness, with the whole. The moral order within is continuous with the moral order on the scale of creation. Utopian social theory abandons the hope for total oneness with the universe but retains the vision of integration and reconciliation on the scale of the total human community. In psychotherapy we retreat further to an enclave in the individual personality and hope for the individual to achieve integration and reconciliation only with himself. In a sense it is a last stand. The moral ground of any psychotherapy is therefore not in its theory of psychopathology or its rationale of treatment, but in its vision of the best that the individual person can be.

This is not to say that therapy is simply a form of moralizing. It would be a rejection of psychology as such not to go beyond moralizing to an understanding of the determinates of behavior or character. Without such understanding there could be no rational therapy other than moralistic exhortation. Psychological analysis, whether it be of behavioral, social, biochemical, or psychodynamic “causes,” puts aside moral judgment in an attempt to explain personality. But whatever rationale is used, whether the “cause” of the patient’s difficulties is found in his infantile experiences or his biochemical endowment, the patient himself must retain the potential for authentic action and responsibility in the moral realm. That is, he must retain a potential for integrity. If therapy has any meaning it is in relation to that potential: to expand the domain of responsibility, authenticity, and integrity in the life of the patient. It is a process of unification and integration of the personality under the dominance of the responsible, authentic person.

A therapy which increases mastery over life’s trials, its crises, its daily events, even over the biochemistry or the behavioral conditioning of the individual, can only broaden the basis for responsibility and integrity in the adult. Whatever theory describes the pathological failure of responsibility, moral categories must be preserved as the psychological categories appropriate to nonpathological adult life. The end point of a psychotherapy of personal integration is personal integrity. A therapy which invites the patient to imitate a social role and thereby ignore his inner experience also betrays the possibility for an integration of that inner experience into an authentic life; it betrays the possibility of integrity. Mystification of the patient, even if it changes his behavior for the better or makes him feel better, still deprives him of his need to recognize in his therapist an authentic person and further alienates him from himself.

There are therapies then which undermine rather than affirm the authentic, integrated individual. Is this a degenerate form, a failure of therapy to meet its task, or do these therapies in reality fill a social role other than to foster the integration of the individual? Has the necessity for people to perform their various alienated social roles become so pervasive that personal integrity becomes a handicap rather than an asset to social adjustment? It may be that, as pseudo-intimacy becomes a general condition in society and life takes place more on the surface and out in the open, as the intimacy of the suburban living room becomes infused with the “intimate” talk of the Johnny Carson Show, the therapy of the time becomes the social pablum of a hopelessly content public. Is this therapy of sham and mystification, which obliterates integrity and substitutes glib and facile pretenses, more practical in an alienated world than a therapy of the authentic self?

A clinical example of a physician who had been practicing for many years prior to seeking therapy will illustrate the erosion of the cultural basis of a therapy of personal integration by the general acceptance of fakery and deceit as valid social forms. The patient sought treatment because he wanted to run away with a girlfriend, but found himself unable to leave his wife and son. I had a report from another psychiatrist who had seen the patient, prior to this affair, because of marital discontent, but felt that he had been unable to help him other than to reassure him that there was nothing wrong with him and that the circumstances of his unhappiness were certainly due to the wife’s infantile ways; her demanding, her petulance, etc. With me, as with the previous psychiatrist, he told tales of the miseries he suffered at the hands of his infantile wife and pleaded to know what he might be overlooking in his own behavior that would allow him to see his wife as less than totally to blame. What he was overlooking, of course, was that he had stayed with his wife through twelve years of this torment, and still would not or could not leave, even for a brilliant, beautiful, and understanding paramour, despite the fact that he obviously had no moral scruples about being unfaithful to his wife.

It was clear that the beginning of therapy would be in the recognition that he goes from psychiatrist to psychiatrist, to his colleagues and to his friends, asking to be reassured that there is nothing wrong with him. At the same time, he thinks that his life is a sham and a fraud, so when he succeeds in getting his reassurances, he is filled with contempt for the person he has fooled. While he is asking for insight, he covertly makes his alibis and rationalizations impenetrable. He consciously withholds self. incriminating information about how he baits and provokes his wife, partly not to be humiliated by self-exposure, but also simply to bamboozle; partly to enlist the psychiatrist as an ally, to be liked, but also to lead the psychiatrist through a matrix of fabrication and half truth, to reduce the therapy to triviality and pretense. Because the patient is looking for reassurance that irresponsibility and inauthenticity are general facts of life and not a personal moral failing, he must convince himself that therapy, his therapist, and the world at large have nothing to offer which is less trivial and less a pretense than he feels his own life to be.

The transference neurosis is a model of the patient’s disturbed view of the nature of the therapeutic process. Insofar as that model derives from the patient’s past experience in being reared, provided with growth and maturational or therapeutic experience, it is also a model of past relationships, but this only secondarily. First of all it is the disturbed aspect of a creative striving in the present for what the patient believes to be his cure, or more correctly, it is a consolidation of the contradictory unconscious programs the patient has invented for his cure.

For this patient, the “cure” consists of gaining the reassurance that to be the “bullshit artist” he believes himself to be is not essentially abnormal, and therefore that nothing is wrong with him. To do this he puts himself to the test of daring the psychiatrist to see through him, to call his bluff. He asks to be called to task on some deeper level than he presents himself, by a psychology that will penetrate beyond his own pseudo-psychological presentation of reality, which he knows is an empty fabric of rationalization. If the psychiatrist is fooled and the therapy reduced to triviality, the triviality of two people commiserating over the impossibility of one of their wives, the patient is reassured that all psychology is empty rationalization. There is no deeper reality or higher validity than appearance.

The compulsive need to bamboozle, to gain allies to his own illusions, derives from the patient’s need to convince himself that no one else is any more substantial than he is, that all men are fakes, and that nothing means anything. Whatever he can manipulate becomes immediately worthless and he is reassured that his sense of meaninglessness and fraudulence is a universal condition, not a personal failing. In this way, even though his life has little meaning, at least he is not missing anything. In contrast to the sociopathic personality, this for him is a moral struggle against his deeper need to confer respect upon his therapist, the object of his confidence game.

His persistent returns to treatment reveal this deeper contrary need, which corresponds to the wish that the therapy make possible for him a reality and an authenticity that he now lacks; and corresponds to the wish that the therapist be an incorruptible and unfoolable moral authority. So the patient’s dilemma over whether or not he can allow therapy to mean anything to him, to be real for him, reflects a basic conflict in his life between authenticity and façade.

At crucial points along the way he has clearly chosen to continue a fraud rather than to ask the ultimate questions, just as wo all choose to act with integrity or to capitulate at various crucial junctures. But can we really accept the notion that my patient must flee therapy because he has sold himself down the river too often? Perhaps a man can be too much corrupted or too much compromised by social expedience to be able to use a therapy of personal integration. But is therapy not the legitimate way out of that corruption and toward responsibility? The prohibitive social cost of his therapy and the reason he finally quits is not the necessary confrontation with his own corruption in the past; it is the pain and alienation of a life of integrity in the future. If his cure, instead of returning him to a station of respect in a community of honorable men, should make him a stranger to his colleagues and render his whole personal and professional life suddenly problematic, if he should awaken to moral responsibility, like Jonah, in a land and a time which has no use for it, then, like Jonah, he will flee his awakening.

In a sense psychotherapy presupposes the moral life of the patient and the therapist, in that they must each be striving after integrity and responsibility. But it also presupposes a certain integrity of the ambient cultural climate, in which the patient’s therapeutic gains can be seen as a cure of a corrupted and alienated state and a return to the moral community, rather than a climate in which therapeutic gains would be perceived as painful moral burdens to be borne in isolation and sorrow.

It makes sense, then, to ask what happens to therapy as culture moves toward 1984, that is, as integrity becomes more hollow, as contradictions become neutralized, as compromise and corruption become universal, as reality is identified with appearance. Under such circumstances therapy moves closer to theatre; not the theatre of the ritual enactment of sacred drama, but the theatre of entertainment, of diversion, of self-delusion, of illusion for its own effect, bedazzlement, mystification, delight, turn-on; theatre which is circus. Or else, in opposition to the reign of meaningless performance, therapy assumes the task of establishing meaning and moral certainty, which drives it toward a religious purpose.

Psychotherapy can be judged on a basis totally different from the empirical determination of outcome of therapy, and yet with criteria that are still perfectly objective; for example, in terms of the degree to which the therapy affirms or undermines the authenticity of the patient as a moral agent. Psychoanalysis could be objectively compared with transactional analysis or gestalt therapy in this respect. A therapy is valid when it preserves and enriches the cultural possibility of knowledge of ourselves as we are, in depth, and knowledge of ourselves as having depth; when it makes a position of honesty and integrity available to us. The alternative is one-dimensional man administered with Valium and a teaspoon of group therapy.

We have seen that the dynamics of the modern individual can be viewed as an elaborate defense against real experience; the frantic fabrication of pretense and façade protects the individual from confronting himself as compromised and sold out. In the mental-health industry—among the college youth studying social work, among medical students going into flashy psychiatric residencies, among high school students going into “mental-health technology”—precisely this same dynamics will invariably reject psychoanalysis in favor of transactional analysis, just as it would reject any serious psychotherapy in favor of any pretense to one. Our annihilation and our holocaust will not be imposed from without, but will arrive as an inner compulsion. The modern mind is bent on that final liberation and cultural death in which appearance equals reality. A professional psychologist signals our demise when he says to his students, in a lecture on transactional analysis, “Let me give you a quickie way to think about this . . .”

The scientific conceit that psychological theory and psychotherapy can be “objective” and morally “neutral” pursuits must give way to a recognition that social and cultural values are intrinsic to psychotherapies and, reciprocally, that a psychotherapy is an intrinsic feature of the moral structure of the society that adopts it.

In another instance, two psychotherapists plan to act as co-therapists in an experiential group of the “human growth movement” type. The group will operate on the premise that the leaders meet with the participants on an equal footing and together make a commitment to “complete self-disclosure.” Here the manifest purpose is the realization of the authentic individual by allowing the self to emerge in a group setting that will be tolerant to it. The social mask is to be stripped away by means of an ideological commitment to democratic nakedness in which the therapists no less than the participants must be “who they really are.” Apart from the dangerous equation such a therapeutic rationale makes between social reserve and dishonesty, there is the assumption that the alienation of the individual is enforced by no more sinister agency than social convention, so that by merely changing the ground rules of social exchange in the group, the deeper self will spontaneously emerge.

The two psychotherapists, a man and a woman, are in fact having an affair. Since each is married and has a family, they decide that their “self-disclosure” will include everything about themselves but the fact that they are lovers. Therapy is in this way reduced to theatrical performance and the authentic self degenerates into an empty social role. Simply leaving out the fact that the therapists are lovers on their lunch hour makes all manner of self-exposure and “deep” revelation immediately possible, even easy. But it is the intimacy of the husband who will tell his wife about everything but his mistress. The essential truth always escapes into the one detail withheld. In this case that essential truth is precisely that there are things that one does not easily expose. The “real self” exposed after first deciding to hide the one essential fact is in reality the highest expression of the real façade, the most successful hiding.

The decision to withhold information which could prove damaging from a group of strangers is in itself perfectly legitimate. It is the pseudo-commitment to “complete self-disclosure,” the implication that an intimate, chest-baring performance represents a valid strategy or ethic of therapy, or learning, or self-realization that is fraudulent. I t equates the appearance, acting the role of self-disclosure, with the reality, self-disclosure in fact. The need for secrecy and privacy and the difficult contradictions of the therapists’ lives are hidden from the group. The content of the therapists’ immediate experience is betrayed by the therapeutic performance. Similarly, for the participants, a loyal pretense of gallant self-exposure becomes inevitably a betrayal of immediate experience. Certainly no participant is any more prepared to abandon his refuge in privacy than are the two therapists. A compromise of integrity becomes a premise of the therapeutic activity.

If, from the outset, the therapists were to admit that there were some things that would not be revealed because they were too dangerous, the group would begin on a more authentic basis. The problem then of real self-disclosure, with its risks and dangers in the real social world, would be fairly confronted. What would be lost, however, would be the false glamour and charisma of the leaders. The mask of the drama would drop. The actors would find themselves on stage out of costume. The curtain would rise on real people.

As a substitute for integration of the personality we are presented in this type of therapy with the image of the “together” person, the person without conflict, without doubt or shame, with no need for secrecy or for reserve, for whom emotion and the drama of “gut feelings” are greeted with sporting good humor, in the same way that Playboy magazine turns eroticism into a sporting pastime for sophisticates and connoisseurs. In both cases an imago is being peddled. The reader of Playboy purchases not an idealized sexual object, but an image of himself, a persona in whom sterilized erotic fantasies can range conflict-free. The imago of the psychologically liberated man functions in a similar way in this therapy to advance an ideal character type for the conflict-free discharge of drives and pent-up feelings. Allowing the mask to fall from the Playboy image, to photograph a varicose vein or a soiled bedsheet, would dissolve the basis of its appeal. In a self-disclosure therapy group, to expose the conflict-ridden person behind the “together” persona would similarly dissolve the basis of the therapeutic impact.

Making therapy identical to learning a new social role undermines the conception of the potential in the human personality for experience which has depth and which carries the individual into irrevocable moral commitment. If therapy is the replacement of one social mask for another, there is no authentic person.

The experience of a person performing in a lie is qualitatively different from the experience of that person confronting his most immediate and direct experience and being understood and confirmed by others in that. Integrity in this context can be seen as a dimension of psychological experience. More than a moral position, integrity is a state of mind, a relationship between the self and inner experience different from the benign well-being of the compromised man. The description of that difference would require a metapsychology of the moral sense which could distinguish between a state of inspiration which derives from authentic action, from the willingness to live in an uncensored reality, and from the discovery of allegiance or commitment to some domain of responsibility outside the needs of the self, and a state of excitement which derives from the discharge of drives in association with release from commitment, with distraction from the uncomfortable complexities of reality, played out under assumed personae. Inspiration, on the one hand, is a source of energy, it increases attentiveness, it is satiating, self-limiting, and it carries with it a sense of commitment. Excitement, on the other hand, is energy draining, distracting (decreasing attentiveness), insatiable, addictive, and easily repudiated. These two dimensions of moral experience are made more or less available in a particular culture. It is in this sense that psychology can be viewed as a science of the internal structure of moral form, and it is in this sense that the meaning of the therapeutic event derives ultimately from the culture.

Sexual liberation, for example, which is perceived as a moral triumph in the modern world, would have been perceived as exactly the inverse, a spiritual debauch, in medieval times, not because psychology has changed, or because the medieval world was backward or ignorant psychologically while we moderns are smart and progressive, but because the internal moral structure of culture, from which the healthy personality derives, has become inverted.

The dilemma which faced my patient, the physician, was that I offered him a therapy of integrity for a life situation which demanded the flexible adaptation to numerous empty performances. My therapy would have made him that much more rigid, that much more unfit, for that life. He would either have had to reject the tenets of the therapy as such or effect a revolutionary moral transformation reaching every aspect of his life. In this sense what I offered him was not therapy but conversion. For the patient to proceed in therapy, large areas of autonomous, i.e., nonconflictual, nonproblematic areas of ego functioning would have had to become problematical, and would have had to submit to transformation. In fact, his therapy was characterized by a constant struggle on his part to limit its scope to the problematical, which meant that he constantly retreated from the logical extension of “the problem” into critical thinking about his facile self-assurance and his successful career. He came to treatment not because he was unable to make an authentic commitment to his marriage, but because he was not able simply to walk away from it. My treatment offered to make it only that much more difficult to walk away. A therapy like the self-disclosure group just discussed could teach him styles of self-deception that would solidify his alienation from his need for a moral standard, which he regards, to the extent that he is conscious of the need, as an archaic cultural remnant, like an appendix. In self-disclosure therapy he could disabuse himself of the moral relics of the Age of Reason which disturb his life. Authentic moral action would be transformed into role playing and performance. The need for commitment to some domain of moral authority, from which inspiration is derived, would be transformed into the indulgence in some domain of appetite, from which excitement is then derived. The Freudian attitude of acceptance and non- judgment as a strategy for the inhibited and guilt-ridden patient has subtly been transformed into a strategy of permission and license for the insatiable and nihilistic patient.

Psychotherapy is, more and more, an institution which sanctions direct satisfaction of appetites. It is becoming a training ground in inauthenticity, perverting the need for integrity and integration by the sanctioning of suprastimulation and ultraindulgence. The proliferation of game and play words in the theoretical language of psychotherapists reflects this development.

The strategy of this modernized psychotherapy is to invite the patient to adopt a role which he can act with impunity, because it is a role, because it is specifically sanctioned, and because it is in a therapeutic setting. When the patient attaches some affect to his performance, it is hailed as self-discovery, and the actor is sent away to play his part on the stage of life. I participated in a training session in which a medical resident played the role of the doctor, a hospital social worker played the role of the patient with a sexual problem, and the others observed through a one-way mirror. The resident launched with impunity into detailed questions about the patient’s masturbation techniques and the adequacy of her “vaginal lubrication” while the “patient,” with blithe disregard for the embarrassment a “real” person might have felt in the situation, answered him with the bravado of a GI, while confounding his efforts to understand her problem. In the discussion that followed, a “psychological analysis” was applied to the interchange as though it had been a real event, that is, as though a doctor and patient had been discussing a real problem. The discussion perpetuated the verisimilitude of the role-playing, as though we were all now to play the role of analysts of what we pretended was an event, as opposed to a pseudo-event. What insights does such an analysis produce? While it might make sense for one to play a role in order to elicit fantasy, one can hardly assume that in the role-playing the deepest self is represented or that the unconscious plays along in a supporting role. It is precisely that what is being “analyzed” is the persona of the role-player, rather than the person playing the role, that allows the discussion to flow so good-naturedly through the rocky psychological depths. Self-disclosure is easy so long as it involves only the persona and never the person. What remains “unconscious” is the immediately available reality that would appear if the personae were dropped: the medical resident anxious to appear well-informed and effective before his colleagues and teachers is facing a female social worker who too often feels inferior and subservient to male doctors and is anxious to show them that she is not to be outdone on her home territory, particularly, that she will not accept the role of the embarrassed woman receiving sexual aid from the male doctor. The interview thus becomes a covert competition to exhibit the most sexually liberated attitudes. Remarking on this in the discussion would be like turning on the house lights before the final curtain.

The discussion is a pseudo-analysis because it will not penetrate to the real event. Instead it remains a commentary on a prearranged and preconceived scenario. The resident was always expected to be anxious, so his anxiety is discussed; he is expected to have difficulty with the open discussion of sexual issues, so that is discussed, even though he has clearly demonstrated a willingness, indeed, a compulsion, to discuss everything. It is as though the one-way mirror had failed to allow a view into the other room, but instead reflected back to the observers only their own expectations.

We see in this role-playing exercise a fundamental betrayal of the analytical mind. The reality of the objective world is both serious and unknown, and the task of reason is to penetrate into that outer thing. When the other person ceases to remain essentially unknown to the observer of human behavior, the observer is then observing only his own system of persuasion. The mind, intent on the frontier of its understanding, is always aware that understanding has its frontier, beyond which the other person remains separate and objectively mysterious. When all things are categorizable and therefore “known,” human behavior becomes mail to be sorted rather than a text to be studied. It follows that an analytical mind preserves the authenticity of the observed person, his objective status as something separate from the system of observation. When the observer knows that he has nothing to discover, that it all comes down to “parent-adult-child” or some such thing, we have a system which is both functionally efficient because it simplifies and routinizes interaction, and murderous of the deeper person. The system of observation determines whether the observed person may discover himself through the eyes of the observer, or merely learn the set of social roles and personae he is expected to adopt.

The broader relevance of the role-playing exercise is that, in mistaking persona for identity, it obscures the essential task of identity formation, which is an integrative one: the synthesis of conflicting and incompatible fragments of identification and their integration with already established identity structures. Thus we train people to play the role of a doctor in preference to teaching them to be doctors. This preference derives from the culture.

The problem of identity must be circumvented in a culture which demands the ready adoption of numerous, fragmented, and contradictory social performances. The numerical order of hypocrisies must eventually overwhelm the integrative capacity of the isolated individual, so that integration itself begins to appear anti-adaptive, rigid, an unrealistically idealistic and saintly pursuit, while compromise and a “healthy” cynicism become the therapeutic virtues of a decadent modernity.

An integrative psychotherapy, one which addresses itself to the individual in depth, cannot be expected to survive the death of integrity as a social possibility. If psychoanalysis can be viewed as the social form of the nineteenth-century death of God, then the death of psychoanalysis in the therapeutic abandonment of reason and analytical thought, and the ascendance of the “new therapy,” would mark the twentieth-century death of moral culture, the replacement of the morally integrated individual of the Age of Reason with the totally adaptable psychological man.