BEHAVIOR THERAPY: A CRITICAL REVIEW OF THE MORAL

DIMENSIONS OF BEHAVIOR MODIFICATION

THOMAS S. SZASZ
State University of New York, Upstate Medical Center, Syracuse

I feel there’s something about the format of this that it is something good; “influencing” is a
symposium which calls for some explanation: I nice, neutral term; if you influence somebody
am neither “against” behavior therapy, nor am in a way that somebody else likes, then it’s
1 “for” it. As 1 understand behavior therapy, psychotherapy; if he doesn’t like it, then it’s
or behavior modification, it is a sequel to what psychonoxious, and the difference is entirely
used to be called “conditioning”. It thus partakes moral and political. My unqualified agreements
of what seems to me an elementary fact- with behavior therapy probably end right there.
namely, that human beings learn. There are My position on behavior therapy differs from
several different ways of learning, and probably that of most psychotherapists: I insist on distin-
the most important, in some practical sense, is guishing very sharply between voluntary and in-
learning by reward and punishment. In this voluntary interventions; between choice leading
sense, I am surely “for” behavior modification, to contract, and coercion leading to capitulation;
but that is like saying that I am “for” gravity, in short, between doing something for a person,
or “for” biology. That people learn in such and doing something to him, as that is defined
behavioral ways is a fact, and a very important by the client. That is my view. I can appreciate
one, because obviously I think there are other that the client may also be wrong; I am not
ways of learning, as exemplified by the symbolic, trying to ignore this.
conceptual ways of psychoanalysis. This does At this point, some behavior therapists might
not mean that one is preferable to the other. want to declare their allegiance to the principle
My aim in this presentation is to offer a sys- of informed consent for treatment, and their
tematic exposition of the moral dimensions of opposition to the use of psychotherapeutic
behavior therapy, to identify the actual activities technology for coercion and punishment. How-
of behavior therapists, and to indicate my accep- ever, it is not particularly important or interesting
tance of some of the behavioral interventions, what behavior therapists say about what they
my objections to others, and my justifications do; what is important and interesting is what
and reasons for these judgements. Let me begin they, in fact, do, and how they describe it, which
by registering my agreement with the contention is itself an act of doing. So examined, a great
of behavior therapists that, like all therapists, deal of what they do appears to be plainly coer-
they influence behavior. I very much agree with cive. Before illustrating this contention, let me
this-in fact, so much that I do not think there anticipate and try to rebut an objection that
is any such thing as psychotherapy. There is may arise-namely that, while among all be-
only influencing of behavior. “Therapy” implies havioral interventions there may be some that
Requests for reprints should be addressed to State University of New York, Upstate Medical Center, 766 Irving Avenue,
Syracuse, New York 13210.
From the symposium entitled Experimental Principles and Humanitarian Goals in Psychofheropy at the 2nd Annual Temple
Conference on Behavior Therapy and Behavior Modification, Philadelphia, 1975. A fuller version of this paper appears
under :he title The Ethics of Behavior Therapy in The Theology of Medicine by Thomas Szasz, Harper & Row, Publishers,
Inc.

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 200 THOMAS S. SZASZ

are coerced or involuntary, they represent a suggests that psychotic behavior is controlled to
small fraction of the total, and hence are not some extent by the reinforcing properties of the
representative of what “behavior therapy” immediate physical environment, and that the
really is. This may be a reasonable objection, effects of different schedules of reinforcement
but it is difficult to deal with. I will not deal upon the behavior of psychotics should be in-
with it because no one really knows whether vestigated further”. In the above passage,
more behavior therapy is conducted coercively Lindsley and Skinner put the word “normal”,
than contractually. But one thing is clear from with which they qualify rats, between quotation
a perusal of the published literature-that marks, but they do not do so with the word
behavior therapy is used routinely on patients “psychotic”, with which they qualify persons.
or clients who do not, or cannot, give full con- This means that they accept as obvious that,
sent to it. just as some individuals are diabetic of leukemic,
In language and law, cure and control are like others are psychotic. I consider this a fatal flaw
two banks of a river clearly separated by a body to everything that follows from this research.
of water-that is, they are clearly separated by Finally, that Lindsley and Skinner, and all those
a willingness to distinguish between the interests who subsequently refer to their work appro-
of two parties in conflict with each other. The vingly accept the moral legitimacy of incarcerating
word therapy-as in psychiatric therapy or psychotics, and then treating them against their
behavior therapy-is a bridge over the water; it will, is obvious; that this carries with it an ethical
unites the two parties in a fake cooperation and burden which, in my opinion, invalidates all
enables one or the other or both of them to subsequent work based on this model may be
declare the nonexistence of any difference less obvious, but is, I think, the case. Of course,
between cure and control, contract and coercion, I have the same objection against psychoanalysis
freedom and slavery. Let me give you some and psychiatry itself. I think it is a very important
documentation. Modern behavior therapy, I objection, and it applies to behavior therapy also.
am afraid, is tainted with a hereditary defect, During the past several decades a great deal
acquired from its own mother, out of whose of behavior therapy has been conducted in closed
womb it emerged. What do I mean by this? I institutions, i.e. in mental hospitals and prisons.
refer simply to the social context in which be- I emphasise this because I think it is very impor-
havior therapy, as we know it in America, was tant. I know that Dr. Wolpe has done most of
first carried out-namely, the state mental his own work, perhaps all of it, with neurotics.
hospital. The paradigmatic experiment was I want to make it clear that I have no objection,
originally performed by Lindsley and Skinner for the moment at least, to any of that work.
at the Metropolitan State Hospital in Waltham, However, many recipients of the “benefits” of
Massachusetts, with support from the Depart- behavior therapy have been and continue to be,
ment of Psychiatry at Harvard Medical School, persons whose status as patients was pro forma,
grants from the Office of Naval Research and de facto, or both, involuntary. For example,
The Rockefeller Foundation. Briefly summar- Lindsley (1956) writes, “The free-operant method
ized, Lindsley and Skinner (1954) studied fifteen can be used, with very little modification, to
male patients who had been hospitalized for an measure the behavior of any animal, from a turtle
average of seventeen years. Their conclusions to a normal genius. Since neither instructions
are best stated in their own words, and as I say, nor rapport with the experimenter are demanded,
words, speech and writing is behavior; please the method is particulariy appropriate in analy-
listen to it as such: “The similarity between the zing the behavior of non-verbal, lowly motivated,
performance of psychotic patients and the per- chronic psychotic patients”. Now, who are these
formance of ‘normal’ rats, pigeons and dogs on people described in this peculiar way? Here is
two schedules of intermittent reinforcement what Lindsley says about them . . . “We selected
 A CRITICAL REVIEW OF THE MORAL DIMENSIONS OF BEHAVIOR MODIFICATION 201

patients who were preferably not on parole, not report reveal close ties between coercive psy-
working in hospital industries, not receiving chiatry and the so-called conditioning therapies.
active therapy, not receiving visitors, and not “The early development of the token economy
going on home visits” (Ibid., p. 128). If they system took place almost exclusively within the
weren’t getting any of these things, why were context of the closed ward of psychiatric treat-
they locked up? Let’s go on: “We did this in ment centers, and was found quite useful in pre-
order to minimize extraneous variables and to venting or overcoming the habit deterioration . . .
facilitate patient handling . . . Our standard that accompanies prolonged custodial hospitali-
procedure is to go up to a patient, for the first zation, whatever the diagnosis.” This statement,
time, on the ward and ask him if he wants to I think, is extremely interesting and. self-
come with us and get some candy or cigarettes. incriminating. Behavior therapy is useful because
Those who do not answer are led, if they do not it enables psychiatric “wardens” to impose
follow us, to the laboratory. If at any time a prolonged custodial hospitalization on their
patient balks or refuses, he is left on the ward” victims, while sparing themselves the unpleasant-
(Ibid., p. 128). Evidently, Lindsley believes that ness of having to put up with the victims’
dealing with patients in this way is enough to “habit deterioration”. The Taskforce’s remarks
establish that they are not coerced. on the abuses of behavior therapy incriminate
I think this is absurd! He completely ignores this form of intervention still further! “Ther-
the fact that he is functioning as a member of apists must be on guard against requests for
an authority structure in a mental hospital. I treatment that take the form, ‘Make him behave,’
consider such work to be only slightly less odious in which the intention of the request is to make
than experimenting on inmates in prisons, con- the person conform . . . One safeguard against
centration camps, or prisoner-of-war camps. I this is to obtain the patient’s informed agree-
say this because I believe that it is the moral duty ment about the goals and methods of the therapy
of psychologists and psychiatrists, as human program whenever possible,” (Ibid., p. 100).
beings, not to mention as healers, to safeguard What does that mean? It means: “Whenever
first of all the dignity and liberty of people gen- possible” -and if it’s not possible, then, of
erally, and, as professionals, of those people course, it’s possible to use it without permission!
with whom they work. If instead they take pro- The use of behavior therapy in prisons,
fessional advantage of the imprisoned status of especially when its results ipfluence the judge-
incarcerated individuals or populations, they ments of the prison personnel and parole boards,
are, in my opinion, morally incriminated. If raises fundamental questions not only about
psychotic behavior is defined as a symptom, as infringemen@ on the prisoners’ rights, but also
if it were pneumonia, then you can call in be- about the nature-and limits of the penal system.
havior therapy and treat it, and then look upon In the United States, it would be &early uncon-
this treatment as analogous to penicillin. I think stitutional to demand as a condition of release
this is quite wrong. However, whether this is that a prisoner convert from religion A to reli-
wrong is not really the point here, because I have gion B. Evidently, it is not unconstitutional
no objection against voluntary behavior therapy. to demand that he convert from behavior A to
If somebody who wears fifty layers of clothing behavior B, especially when the conversion is
wants to have it so treated, that is fine. called behavior therapy. The APA Taskforce
In view of the support which behavior thera- says that aversive therapy also shouldn’t be used
pists lend to the principles and practices of without permission ‘which, I think, is disin-
institutional psychiatry, it is not surprising that genuous. I came across a widely publicized
the American Psychiatric Association Taskforce report a few years ago, involving the use of
of Behavior Therapy (1974) has issued a glowing aversive therapy on involuntary patients. If the
report about it. The following excerpts from this APA really believes that such an intervention
202 THOMAS S. SZASZ

is wrong then it should have done something either coercion or mock-coercion. You know
about it. I refer to psychotherapists at the what coercion is; mock-coercion is a little more
California Medical Facility at Vacaville, who complicated. If, for-example, the patient is a
used succinylcholine as an “aversive tool”, fee-paying client in a psychologist’s private office,
where this “therapy” was imposed on at least then behavior therapy is one of the countless
five inmates whose consent was explicitly sought, ways in which two persons enact scenes of mock-
and who refused it (Szasz, 1973). The fact that coercion, one of the participants pretending to
the therapist sought the consent proves that they control, the other pretending to be controlled,
considered the clients to be competent to give and both pretending to believe the other’s pre-
consent. tendings. Now whether we regard either, both,
I consider this to be five clearly documented or neither of these uses of behavior therapy as
cases of medical crime with aversive therapy, virtuous or wicked will depend in general on
and I’m not aware of the APA having com- our ethics and politics, and in particular, on our
plained about it. feelings about behavior therapy as a method
Let me summarize: it seems to me that be- and mystique. 1 would like to plead relative
havior therapists cannot easily escape from indifference; I believe that in the mental health
their own pragmatic strictures; in particular, field, no less than in medicine itself, our actions
from their own contention, with which I agree, should be informed and governed by an ancient
that what counts is not what clients or anybody Latin maxim, caveaf emptor (“Let the buyer
else says, but what they do. Judged by this beware”), and by a fresh extension of it, optet
criterion, behavior therapists are, again with emptor (“Let the buyer choose.“). This is an
appropriate qualifications, by and large con- ethical proposition, and this latter extension,
demned by their uncritical acceptance of the which I suggest, applies very rarely to patients
semantic and social consequences of the medi- in mental hospitals. My emphasis is thus on
calization of human problems; further, by their letting the client or patient choose, and benefit
self-serving imposition of behavioral interven- or suffer from the consequences of his choice.
tions on captive clients. Again, I say this not Thus, by autonomous psychotherapy, I mean
because I am against behavior therapy, but simply a situation in which the therapist must
because I am against therapeutic coercion. I not exert any power outside the consulting room
might explain this further by restating what I for or against the patient-hence the misunder-
think behavior modifiers actually do, and again, standing between what 1 mean by “real life”
I apologize if I offend some of you. Politically and what Leonard Ullmann (1969) says 1 mean
speaking, if behavior therapists have actual, by it. To say “let the buyer choose” is an ethical
legally legitimized and enforceable power over standard, not a technical one. Thus my views
a client, then behavior therapy relieves him of differ from those of Jonathan Cole (1975),
his symptoms in much the same way as a tax who states in a recent article, “The issue is not
collector relieves a citizen of his money. (I con- whether behavior therapy is bad, but whether it
sider any act “political” in which there is a works”. In my view, the issue is not whether it
significant element of force used by one person works, but whether the client wants it. As a rule,
or institution on another.) If, on the other hand, direct confrontation between the technical and
the behavior therapist has no such power, and the ethical approaches to human affairs is very
his authority over the client derives from the unproductive. The technicist wants to know
client’s own desire for dependency, or whatever, whether a certain intervention works or not; if
then the behavior therapist relieves him of his so, he considers it morally good, regardless of
symptoms in much the same way as a church how its recipient views it. From this posture,
relieves its members of their money. involuntary medical or psychiatric interventions
Practically speaking, behavior therapy is appear good and justifiable if they are for the
 A CRITICAL REVIEW OF THE MORAL DIMENSIONS OF BEHAVIOR MODIFICATION 203

benefit of the client. The ethicist, conversely, subtleties of psychiatric encounters than what
wants to know whether a certain intervention is I have discussed here, the positions I have por-
contracted or coerced. If contracted, he con- trayed point to two important and easily identi-
cludes that both parties benefit, although it is fiable social roles and pet>onal styles, and the
likely to be more desirable or necessary for the twain shall never meet!
party seeking the contract. If coerced, the ethicist
concludes that it helps the coercer and harms
the coerced. From this posture, involuntary REFERENCES
American Psychiatric Association Task Force Report No. 6
medical or psychotherapeutic interventions
(1974) Behavior Therapy in Psychiatry. Washington,, D.C.
appear bad and unjustifiable, as they subvert Cole J. 0. (1975) What’s in a word? Or guilt by definitton-
the moral mandate of the helping professions. I. Medicui Tribune, June 11, 22.
Lindsley 0. R. (1956) Operant conditioning methods applied
Furthermore, I insist that insofar as the therapist
to research in chronic schizophrenia, Psychiur. Res. Rep.
proposes to be a healer, he must be the agent of 5, 118.
his client; insofar as he proposes to be society’s Lindlsey 0. R. and Skinner B. F. (1954) A method for the
experimental analysis of the behavior of psychotic
agent (or that of any entity in conflict with
patients, Am. Psycho/. 9,419.
the ostensible patient), he ought to recognize Szasz T. S. (1973) The Age of Madness: The History of
and make explicit that he functions as the Mental Hospitalizarion Presented in Selected Texts.
Doubleday-Anchor Press, New York.
patient’s adversary, and not as his ally.
Ullmann L. P. (1969) Behavior therapy as social movement.
In conclusion, let me say that, although there In Behavior Therapy: Appraisal ond Status (Ed. by
may be, in actual practice, more to the moral Franks C. M.). McGraw-Hill, New York.