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Anne Sexton: Controversy Surrounding the Biography

The Psychiatric News 6 September 1991

Psychiatrist Criticized Over Release Of Poet's Psychotherapy Tapes

By Ken Hausman

Psychiatrist Martin T. Orne, M.D., treated poet Anne Sexton for eight years. In 1974, a decade after her psychotherapy with Orne had ended, she committed suicide. Now a major biography of the deeply troubled poet is scheduled for publication, and Orne is mired in controversy over his decision to make tapes of his therapy sessions with Sexton available to her biographer, Diane Wood Middlebrook.

Orne's cooperation and the content of the therapy tapes were revealed in the July 15 edition of the New York Times, where Orne pointed out that he agreed to turn over the tapes only after Sexton's daughter and literary executor, Linda Gray Sexton, urged him to do so.

The flap over Orne's release of his former patient's therapy tapes, with or without her verbal permission, has forced a new round of discussions-both inside and outside of psychiatric circles--of ethics and patient confidentiality, patients' desires, and the needs of scholarship.

Among the psychiatrists who see no justification for Orne's action is the chair of the APA Ethics Committee, Jeremy A. Lazarus, M.D.

No matter how convincing a case a patient's relatives make for posthumous release of therapy notes or tapes, and in the absence of proof that the patient consented, without a court order there is no way to square such a breach of confidentiality with APA's ethical standards, Lazarus said in an interview with Psychiatric News. Death does not terminate a patient's right to expect his or her psychiatrist to keep therapy records confidential. In addition, he pointed out, the possibility is quite real that revelations of what was said in therapy could cause considerable pain for surviving relatives or even be manipulated by them for some type of gain.

Orne insists that Sexton would have wanted the content of the tapes made public and that she conveyed to him her consent to do so. Sexton's friends and relatives have come forward to back Orne's claim that it would be perfectly in keeping with Sexton's life that she would want the tapes available to someone telling the story of her troubled life.

Asked in what form had Sexton given permission to make the tapes public, Orne told Psychiatric News that he had offered to return the tapes to her. However, "she told me that she wanted me to keep the tapes and use them in any way that I saw wouldhelp others who were troubled .... There was definitely no ambiguity as to Anne's wishes" about the eventual use to which the tapes would be put, he emphasized.

Even if a seriously disturbed patient such as Sexton urges or gives consent to a psychiatrist to release tapes of their psychotherapy, a serious question arises of their competency to understand the nature and consequences of what could be disclosed, noted Elissa Benedek, M.D., a member of the APA Ethics Committee and immediate past president of APA. Confidentiality Survives Death

The issue of disclosing the content of a deceased patient's therapy is not addressed specifically in APA's ethics code, The Principles of Medical Ethics, With Annotations Especially Applicable to Psychiatry, but is addressed in a companion publication of ethics opinions written by the APA Ethics Committee.

The opinion related to revealing confidential information after a patient's death emphasizes that confidentiality survives death and that weakening this tenet "reduces our responsibility to living patients who trust us to protect their confidences including after their death. This is no less so if the deceased is a prominent person."

While some states have laws mandating that a psychiatrist disclose psychiatric records in child abuse cases or warn third parties of threats against them by a patient, Lazarus said he is unaware of any similar statutes delineating circumstances in which psychiatric records of a deceased person can be made public without that individual's consent.

Even though the issue of divulging the content of therapy is dealt with in the opinions volume rather than APA's official code of ethics, a complaint to APA or one of its district branches charging that a psychiatrist revealed this information without express permission from the patient would be handled through the standard ethics procedure with the same sanctions available if a violation is found, Lazarus noted.

The sanctions allow APA or a district branch to admonish, reprimand, suspend, or expel a member who has violated ethics.

The APA ethics opinions do allow for the possibility that an exception to the guidelines on posthumous disclosure of records could exist, but Lazarus pointed out that no permissible exception has yet been brought to the Ethics Committee.

Sexton Listened To Tapes

Orne recorded his therapy sessions with Sexton for three of the eight years he treated her. She often went into fugue states, and Orne played back the recordings for her so she could hear what she revealed while in one of these trancelike states.

Sexton, whose anguished poems often bared her mental torment and eventually won her a Pulitzer Prize, would not have objected to the content of her therapy being divulged, according to Middlebrook.

The biographer told the Times "I don't think Anne Sexton cared what was known about her private life. She just didn't want to be known as a bad artist." Sexton made no effort to soften or withhold painful or shocking aspects of her life, Middlebrook suggested.

She also said that the tapes Orne turned over to her provided little information she didn't already have, since she was in possession of notes the poet wrote about the tapes just after Orne played them for her. Among the grim details were Sexton's admission of incest with her daughter, but the daughter had previously volunteered that such a relationship existed, Middlebrook explained.

That Orne taped therapy sessions with Sexton at all has raised some psychiatric eyebrows as well.

"It's very, very unusual for a psychiatrist to tape-record sessions of a patient in individual therapy in private practice," emphasized Benedek. She explained that except for forensic psychiatric interviews and some teaching purposes, in which a patient or interviewee is informed of the lack of confidentiality and of their access to the recordings, it is difficult for a therapist to justify recording psychotherapy sessions.

Orne told Psychiatric News that the tapes "turned out to be a critical aid to [Sexton's] therapeutic progress." He explained that the tapes were made "to help Anne deal with feelings and integrate emotional events which she could not otherwise continue to work with after each therapy session was over. It was necessary for Anne to listen to the session at least once and sometimes twice or more to become able to integrate her feelings about the interactions that had taken place during the therapy session."

The poet kept a notebook in which she often wrote comments on the content of her therapy sessions, Orne pointed out. Sexton's biographer had access to these notes.

Orne rejects the notion that Sexton's fame played any part in his decision to tape her therapy sessions or keep the recordings after her death. When he began treating her in Boston in the late 1950's, he said, "she was a very troubled young mother who had finished high school but had no scholarly or literary achievements. I encouraged her to begin writing down her thoughts as an aid to her therapy .... When I suggested that other troubled individuals might be helped by her writing about her experiences in therapy, Anne became very involved in the process, and her first book of poetry was published within four years of our beginning therapy."

The reason he kept the tapes after her death was because Sexton had asked him to, he said. "Where the acclaim of her poetry played a role was in the likelihood that someone of stature might eventually be interested in her meteoric rise, which coincided with her early years in therapy," Orne told Psychiatric News. "Her life and poetry stand as a symbol of what a patient can achieve through commitment and the hard work of therapy."

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