In a rare psychoanalytic case history, Thomas Szasz presents Recollections of a Psychoanalytic Psychotherapy: The Case of “Prisoner ‘K'”. In it, Szasz gives us an opportunity to see how he actually practiced psychotherapy.
Szasz mentions in the first pages that his practice has since changed, but that he views the case as an adequate case study for psychoanalytic treatment. He goes on to say that no psychotherapy can be encapsulated by a specific technique, but that it can only adhere to certain rules of the game. Just as in a game of chess, only certain rules must be adhered to.
For Szasz, the rules are that the therapist must not interfere in the patient’s life outside of the office, and the patient must pay for therapy from his own pocket. Szasz viewed third-party payments as a corrupting influence on psychotherapy. He viewed voluntary payment as the only way to know for sure whether the patient found the therapy truly beneficial.
Szasz goes into detail about what exactly psychotherapy is, and how it relates to human affairs. He says that psychotherapy is more akin to analyzing great literature than doing medicine.
The most accurate method of rendering human relationships “public” is, of course, that of the novelist. Indeed, we regard it as his distinctive task to portray human relationships from the inside, as it were. Clearly, it is easier, psychologically, to do this with hypothetical people than with’ real ones, particularly when the “real person” is oneself. Nevertheless, some biographies, and also a few autobiographies, do manage to convey the human drama which is their subject with amazing fidelity.
It is important to note that Szasz did not believe in mental illness. He believed that so-called mental illness is a metaphor for problems in living. He says, so-called mental illness “is a myth whose function is to disguise and thus render more palatable the bitter pill of moral conflict in human relations.”
In this case study, Szasz writes:
I have found that considerations of “sickness” and “health” do not enhance clarity of thought in this area and I have made an effort in this exposition, much as I do in my practical work, to avoid slipping into cliches borrowed from the medical model of treatment.
Szasz chose to name the patient, Prisoner K, because he resembled the hero in Kafka’s novels, The Trial and The Castle. He says, “…the designation which Franz Kafka used for his hero in The Castle and The Trial The theme of these novels revolves around Kafka’s struggles with his introjected objects, mainly his parents.”
Prisoner K “suffers” from exhibitionism. Szasz does not go into too much detail, so as not to expose his patient’s true identity. Prisoner K sought relief from his problem after he was caught by police, exposing his penis in public. Prisoner K tells Szasz that he had wanted to be analyzed for a long time, but never made the effort until after he was caught.
Szasz is interested in understanding the most formative aspects of the relationships with important people in the patient’s life. In most cases, this is the relationship with one’s parents. Szasz finds it interesting that Prisoner K viewed his parents as having a completely benign effect on his life. He was unable to see any negative aspect of his parents. This was interesting because it represents a potential blind spot for the patient, which in this case it did.
One of the most salient features of Szasz’s writings is that he views all human behavior as having meaning. For Szasz, humans are meaning-making creatures with free-will who are responsible for their actions. The fact that Prisoner K could not see anything but good in his parents, presented Szasz with material for further exploration. Szasz notes, that while the patient could not speak ill of his parents, he was emotionally aloof towards them and separated himself from them by geographic distance.
Through the course treatment, Szasz finds out that Prisoner K’s view of his parents was due to some formative experiences involving his mother. It seems that everyone in the Prisoner K’s family, outside of his father and himself, viewed his mother as “crazy”, and would not visit the family home. Prisoner K’s mother was obsessed with her son’s sexuality. From the time he was a little boy, Prisoner K was told to sleep with his hands above his blanket, so as not to touch his penis. She would often read aloud, stories about “perverts”, in the newspaper and said that “she would die” if her son ever did something perverted. She also told him that a man once exposed his penis to her in public and was terrified by the ordeal. In addition, Prisoner K, as a young boy, once spoke ill of his mother, saying something like, “I hope you die”. After hearing this, his mother fainted as if she had actually died. His father told him to never speak ill of his mother again.
From these experiences, Prisoner K learned that touching his penis was to be avoided and that his words had great power over his mother. Szasz views behavior classified as “mental illness”, as a sort of enfeebled method of communication. Instead of Prisoner K acknowledging and rejecting his mother for her strangeness, he “acted-out” his rejection of her. For Prisoner K, it was too painful to acknowledge his mother as a corrupting influence on his life. Instead, he symbolically acknowledges this through his exhibitionism.
Seeing and touching his penis at least defined his sexual identity and role as clearly “masculine.” One of the meanings of the exhibitionism could thus be paraphrased as follows: “I am not a woman — I am not crazy like my mother.”
Szasz mentions that his interpretation angered Prisoner K. By accepting such an interpretation, Prisoner K could no longer hold the view that his parents were all good. He had to form a new view of his parents, after which he apparently found little desire to have much to do with them.
Szasz concludes the case study by writing that this was a successful treatment of psychoanalytic psychotherapy. He writes:
We had now been seeing each other four times a week for thirty months… with the extensive “mapping out” of his exhibitionism — its origin and its various meanings, old as well as recent — and the working through of his relationship with his parents and me, his interest in exhibiting himself disappeared. What gratified him even more, however, was that he did not have a fear of its recurrence. I mention this specifically because before treatment he could imagine that he would not exhibit himself as a result of therapy, but he could not imagine that he would not contemplate and fear its recurrence… Last, but not least, he felt free and enjoyed this feeling immensely. He read more widely, he enjoyed his daily activities more fully, and he was astonished at his freedom from feelings of “sinfulness,” “dirtiness,” and “badness,” which had always plagued him so much. He felt like a decent human being.
Reading this case study by Szasz was extremely enjoyable. It was fascinating to get a glimpse into the actual work of Szasz as a therapist. I liked how Szasz was able to help Prisoner K find meaning and resolution to his enfeebled responses to unacknowledged forces in his life.
If you’d like to read this case study, you can read it for free at archive.org, it starts on page 75 of a collection of case studies. You can also buy it on Amazon Kindle, which makes it much more readable. You can also view the embedded PDF of the book below; flip to page 75 to read this case study.
What do you think? Does psychoanalytic therapy make sense to you? Let me know in the comments below.