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VOLUME 2, ISSUE 7   THE INTERPSYCH NEWSLETTER      AUG-SEP, 1995
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                  SECTION D: THE FIFTH COLUMN

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| The following is the first installment of a regular,      |
| independent column written by Jeffrey Schaler, PhD.       |     
|                                                           |
| Opinions and comments are invited. Please send them       |
| to the IPN Mailbox  newsletter@fra.psych.nemc.org         |
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GOOD THERAPY
Jeffrey A. Schaler, Ph.D.

     The Washington Post ran this news item on August 2, 1995:
          "Escort services," the Yellow Pages ad reads.
     "Discreet.  Prompt.  Major credit cards accepted."
          Sound like an ad for sex?
          Apparently, more than a few men in the Washington
     area have thought so and hired an escort, only later
     finding out all they were getting was...talk.  Some become
     so upset, they call the police to complain--and even leave
     their names.
          Arlington police are so concerned about the potential
     for violence that they are considering asking the County
     Board to adopt an ordinance that would require the escorts
     to disclose upfront what services they are providing
     before money changes hands... (Nakashima, 1995).

    The problem involved in such transactions is similar to one
confronting psychotherapists and their clients--the lack of a
contract.  Escort-service customers are misled to believe
they're paying for intercourse.  Instead, they get discourse.
Psychotherapy-service customers are also often misled to
believe they're paying for medical treatment of a disease.
Instead, they get metaphorical intercourse, or "mind-fucking,"
as Fritz Perls once referred to it.  Thus, while prostitutes,
those who put their bodies to base use for gain, often
masquerade as psychotherapists, many psychotherapists
masquerade as prostitutes.

     Since prostitution is generally illegal, any trade dispute
must be settled through illegal means, e.g., extortion.  What's
amusing about the scenario above is the attempt to resolve a
dispute regarding illegal activity through legal means.
Psychotherapy is a legal enterprise, so trade disputes are
settled through legal acts, e.g., attributing psychopathology
to the metaphorical patient, malpractice lawsuits, etc.  If
psychotherapist-licensing organizations file litigation against
prostitutes for practicing therapy without a license, will
pimps go after therapists for infringing on their territory?

     Therapists bemoan malpractice litigation--and much of that
litigation is frivolous, to be sure.  Too often it's a way of
assigning responsibility where none belongs.  Yet there
are instances when malpractice litigation is appropriate though
seldom resorted to for reparation.  Those concern the various
claims made by psychotherapists regarding their products.  The
most common misrepresentation is psychotherapists' claim to be
practicing medicine when in fact they are engaged in secular
ethics (Szasz, 1988a).  Such a claim appears to constitute fraud,
not to mention bad therapy.

FRAUD AND LICENSURE
     Abolishing the prohibition against prostitution (which is
different from legalizing it) would facilitate quality control
for services rendered and give clients a means for legal
redress.  Abolishing the licensure of psychotherapists, e.g.,
psychologists, social workers, and counselors, would have
similar benefits.  Prostitutes and therapists could then both
be held legally culpable for misrepresentation, i.e., fraud.

     Fraud is "[a]n intentional perversion of truth for the
purpose of inducing another in reliance upon it to part with
some valuable thing belonging to him or to surrender a legal
right"  (Black, 1990).  Fraud is deliberate misrepresentation.
In trade, sellers cannot misrepresent their products.  To do so
constitutes fraud, an illegal transaction of commerce.

     The notion of scientific validity, though not an act, is
related to fraud.  Validity refers to the extent to which
something represents or measures what it purports to represent
or measure.  When diagnostic measures do not represent what
they purport to represent, we say that the measures lack
validity.  If a business transaction or trade rested on such a
lack of validity, we might say that the lack of validity was
instrumental in a commitment of fraud.  The Diagnostic and
Statistical Manual (DSM-IV) published by the American
Psychiatric Association and used by licensed psychotherapists
throughout the country is notorious for low scientific
validity.  Yet it is instrumental in securing insurance
reimbursement for psychotherapy services.  Without DSM-IV
diagnoses, insurance companies will not pay for psychotherapy.
Without insurance reimbursement, most psychotherapists would be
out of business.  In licensing psychotherapists to practice and
in effect requiring them to rely on DSM-IV diagnoses, the state
sanctions the scientifically invalid claims made by
psychotherapists regarding their patients.  In this way, the
state also sanctions fraud.
     Fraud is exposed by examining a seller's claims concerning
a product for trade.  Psychotherapists sell a particular
product--conversation and they make certain claims about that
product.  But claims are one thing, and outcomes are another:
The result of psychotherapists' rhetoric speaks for itself.
Does the psychotherapeutic product represent what it is
purported to represent?  Are product outcomes consistent with
seller claims?  Generally speaking, they do not appear to be.

     A critical task in "good" therapy is differentiating fact
from fiction.  Fictions are invented.  They're personal and
social constructions.  Facts are discovered.  What is fact and
what is fiction in terms of the product sold by
psychotherapists?  Consider the following:

     Psychotherapists claim that licensure ensures quality
control of psychotherapeutic service.  That's fiction.  The
fact is that credentials do not equal competency (A. Gunsberg,
personal communication, 1994).

     Psychotherapists claim that licensure protects clients
from bad therapists.  That's fiction.  The fact is that
psychotherapists not their clients, are protected by licensure.

     Psychotherapists claim that licensure protects the
confidentiality of the psychotherapeutic relationship.  That's
fiction.  The fact is that licensure facilitates insurance
reimbursement for services--and reimbursement violates
confidentiality.

     Psychotherapists claim that licensure ensures accurate
diagnosis and treatment of disease conditions with medicines.
That's fiction.  The fact is that psychotherapists are not
medical doctors.  "Mental illness" does not meet the
nosological criteria for disease classification by
pathologists.

     Those fictions are the professional context within which
most psychotherapists operate.  Nobel laureate Milton Friedman
wrote about the myths of occupational licensure more than
thirty years ago:

     In the arguments that seek to persuade legislatures to
     enact such licensure provisions, the justification is
     always said to be the necessity of protecting the public
     interest.  However, the pressure on the legislature to
     license an occupation rarely comes from the members of the
     public who have been mulcted or in other ways abused by
     members of the occupation.  On the contrary, the pressure
     invariably comes from members of the occupation itself.
     Of course, they are more aware than others of how much
     they exploit the customer and so perhaps they can lay
     claim to expert knowledge (Friedman, 1982, p. 140).

     The rationalization for licensure is base rhetoric (Szasz,
1988a).  It's a legal fiction created to protect the economic
interests of therapists under the guise of protecting their
clients.  It ensures monopoly and monopsony of commerce (Szasz,
1994).  Licensure doesn't protect psychotherapy
clients--contracts do (Szasz, 1988b).  A contract is "[a]n
agreement between two or more persons which creates an
obligation to do or not to do a particular thing" (Black,
1990).  Although contractual therapy cannot guarantee good
therapy, contracts can protect psychotherapy consumers against
fraud.  And good therapy is more likely to result when a
contract is in place.

INEQUITY IN THERAPY
     While some psychotherapists acknowledge the obvious
inequities of the therapeutic relationship (e.g., the client's
freedom of expression is unlimited while the therapist's is
limited), there are other hidden inequities that constitute
misrepresentation.  Double- standards often exist.  While
they're embraced in the name of benevolent paternalism, they
often occur at the client's expense.  Moreover, they tend to
decrease autonomy by encouraging dependency.  If psychotherapy
can help, then it can hurt.

     For example, when therapists literalize metaphors, they're
considered "insightful."  When clients literalize metpahors,
they're diagnosed as "psychotic."  When therapists find fault
in their clients, it's called "diagnosis."  When clients find
fault in their therapists, it's called "displacement."  When
therapists default on the commitment to psychotherapy, it's
called "reality."  When clients default on the commitment to
psychotherapy, it's called "borderline" behavior.

     Even with a contract, the inequities of the therapeutic
relationship can persist.  Here's an example of the double-
standard which appears to constitute a breach of contract in
couples therapy.  The inequity operated to the therapist's
advantage--and at the clients' expense:  A couple sought
therapy for assistance with conflicts apparently centered on
career changes.  A verbal contract was established for eight
sessions.  The therapist specified that the scope of therapy
would be limited to decisions and adjustments associated with
career decisions.  Midway through the therapy, one of the
clients asserted that resolution of the conflicts appeared to
hinge on deeper analysis of the relationship.  The therapist
refused to comply, citing the terms of the contract.  At the
final session, the same client said that the therapy had failed
because deeper issues had been avoided.  The therapist
responded by advising the couple to divorce.  The clients
accused the therapist of breach of contract.  Although the
therapist offered restitution in the form of continued therapy,
the therapy was terminated at the clients' request.

     In this case, the contract was established and broken.  As
a result, the clients were injured, the original contract
unfulfilled and restitution obscured.  The only person who
benefited from the business transaction was the therapist,
because she was still paid.

     While prostitutes may feel and act like psychotherapists
(the reverse is likely to be true, too), one difference
between the two is clear:  Prostitutes generally pretend to
care about their clients, but their clients know they're
pretending.  Psychotherapists pretend to care about their
clients, but their clients don't know they're pretending!
Moreover, clients' belief that their therapists really care,
i.e., love them, is considered a sign of psychopathology, e.g.,
"transference."

     Which is the more confusing, knowing that someone is
pretending, or not knowing that someone is pretending not to
be pretending?

GOOD THERAPY IS CONTRACTUAL THERAPY
     A contract implies voluntariness and consent.  Thus,
psychotherapy without contract implies an absence of consent or
voluntariness.  Because psychotherapy is essentially a moral
confrontation with oneself, and necessarily implies
truthfulness, no one can be coerced into successful
psychotherapy or truthfulness.  Psychotherapy without contract
is not psychotherapy at all.  It's coercion.  Coercion has more
to do with obedience and social control than with compliance
and medicine.  Contractual psychotherapy with coercion is a
contradiction.

     Contractual psychotherapy is never value free; i.e., the
values of the therapist and the client are as integral a
part of the conversation called psychotherapy as are the
social, economic and political contexts within which all
therapy occurs.  If the primary goal of therapy is autonomy,
then that goal can be achieved only through clarity of
contract.  Therapists cannot enforce the success of therapy or
their clients' truthfulness.  They must be prepared to prove
the validity of their product claims.  Clients must be aware of
their rights to restitution when breach of contract occurs.
Government should protect citizens in their right to free
trade, not punish them by sanctioning the economic interests
of a select few in the name of protecting citizens against bad
therapy.

REFERENCES
Black, H.C.  (1990).  Black's law dictionary, 6th ed.
     St. Paul, Minn.:  West Publishing Co.
Friedman, M.  (1982).  Capitalism and freedom.  Chicago:
     University of Chicago Press.
Nakashima, E.  (1995, August 2).  Some customers are never
     satisfied.  The Washington Post, D1.
Szasz, T.  (1994).  Cruel compassion:  Psychiatric control of
     society's unwanted.  New York:  John Wiley & Sons, Inc.
Szasz, T.  (1988a).  The myth of psychotherapy.  Syracuse,
     N.Y.:  Syracuse University Press.
Szasz, T.  (1988b).  The ethics of psychoanalysis:  The theory
     and method of autonomous psychotherapy.  Syracuse, N.Y.:
     Syracuse University Press.

Jeffrey A. Schaler, Ph.D., teaches psychology and public
policy at American and Johns Hopkins universities and is the
listowner of NUVUPSY@sjuvm.stjohns.edu and co-listowner of
SMARTREC@sjuvm.stjohns.edu.  He lives in Silver Spring, Md.
U.S.A.     jschale@american.edu