The Psychiatric Times September 1991

Release of Psychotherapy Tapes to Biographer Raises Ethics Questions

The issue of whether the psychiatrist who treated Pulitzer Prize-winning poet Anne Sexton should have released tapes of her therapy sessions to her biographer, even with family approval, has become a medical ethics question that has drawn national media attention. Many of Sexton's poems were autobiographical and described her mental breakdowns and preoccupation with death before her suicide in 1974. Her biography, written by Stanford English professor Diane Wood Middlebrook, is scheduled for release this month by publisher Houghton Mifflin.

Martin Orne, M.D., professor of psychiatry at the University of Pennsylvania, treated Sexton from 1956 to 1964. He was criticized in a July 15 article in The new York Times by several psychiatrists, who disagreed with his decision to release the tapes. Jeremy A. Lazarus, M.D., chairman of the American Psychiatric Association's ethics committee, said in the article: "Our view is that only the patient can give that release. What the family wants does not matter a whit." In a lengthy response on the July 23 Times' op-ed page, Orne said that the family's permission to release the tapes was important because before her death Sexton had clearly expressed to him her permission for release of information from the therapy sessions. After studying the tapes, Orne said, Sexton told him he should "keep them to use as I saw fit to help others." He said the disclosure was in keeping with her work as a "confessional poet" but said he would not have released them had her family objected.

But the issue is not whether Orne correctly perceived that the patient, when she was alive, implied approval of his disclosure, Josef H. Weissberg, M.D., president of the American Academy of Psychoanalysis, said in a letter to the editor on July 26. The question is "whether or not a psychiatrist is ever justified in disregarding confidentiality without the patient's explicit, freely given permission," he said. If such action is condoned, "no patient would have any basis for trusting any psychiatrist, since the decision to disclose could be made unilaterally" for any number of worthwhile purposes.

Sexton's son-in-law and her biographer, in separate letters in the same issue, defended Orne's actions. Son-in-law John G. Freund claimed that when Sexton assembled her archives near the end of her life, she marked those that were not to be published, and her daughter and literary executor, Linda Gray Sexton, honored her request. But the audiotapes she had kept from several of Orne's sessions as well as her "detailed notes from hundreds of other such tapes were not so marked," Freund said. He also pointed out that Orne was not alone in releasing information about Sexton's treatment. The psychiatric institutions where Anne Sexton was treated also complied with her daughter's request to release information to her biographer; only one requested and received a court ruling, he said.

Middlebrook described the tapes in her letter as "a historical record of the processes by which a human being had survived a mental illness by turning her treatment into an education in the service of art." In Sexton's biography, she depicts Orne as a caring psychiatrist who encouraged a 28-year-old suicidal patient to resume her education and begin writing poetry, which led to a successful career and a Pulitzer Prize. Middlebrook points out in her letter that she had already been compiling information for six years when Orne turned the tapes over to her and that they corroborated information she had found in Sexton's therapy notes or received from the poet's family. In an interview published in the July 29 Newsweek, however, Middlebrook said that while she did not use many direct quotations from the tapes, they prompted her to rewrite "most of the book."

Robert Hopkins, M.D., chair of the Massachusetts Psychiatric Association's ethics committee, said in the same article that the tapes' existence after Sexton's death presents an ethics problem. Orne said Sexton suffered memory lapses, so he made the tapes for her to hear to fill in her memory gaps. But Hopkins said that after Sexton's death, there was no chance of future treatment and therefore no further reason to keep the tapes.