Hughes, S. M. The Sexton Tapes. The Pennsylvania Gazette, December 1991, 90(3) 20-28, 39.

THE SEXTON TAPES

Dr. Martin Orne called the predicament he found himself in after giving a biographer tapes with poet Anne Sexton of his psychiatric sessions "a peculiar situation." Another way of putting it is that all hell broke loose.

By Samuel M. Hughes

DR. MARTIN T. ORNE, professor of psychiatry and adjunct professor of psychology, presses a button and the tape begins to wind. It's one of those big old reel-to-reel machines that almost nobody uses anymore, and for the first few minutes of the interview, I am vaguely aware of its faint, rhythmic thwick ... thwick ... thwick, which gradually fades into the background of his office in the Unit for Experimental Psychiatry at the Institute of Pennsylvania Hospital. Sitting beside him on a pea-green couch is his wife and fellow scientist, Emily Carota Orne. He apologizes in his deep, Viennese-accented voice for the carefully controlled set-up of the interview: Any quotes which I use -- since I am tape-recording this interview too -- are to be FAXed to Orne for his approval.

"You know," he says, "it isn't something which under normal circumstances would bother me so. But it is a peculiar situation."

It is indeed. Life has not been quite the same for Orne since the middle of July, when the world learned that he had allowed biographer Diane Wood Middlebrook to use some 300 audiotapes of his psychotherapy sessions with Anne Sexton, the troubled, flamboyantly confessional poet whom he treated from 1956 until 1964 and who died by her own hand 10 years later. It was an unorthodox move, as layered with complexities as Sexton herself, and he knew that it would be a controversial one. But he could not have anticipated the depth of passions it would unleash: in psychiatrists, patients, the public at large, and, of course, the press. The thought of a psychiatrist releasing the records of his patient's innermost thoughts and feelings touched something very tender in the country's collective subconscious -- and consequently made for great copy. Some vilified Orne for breaking a sacred trust; others, including Sexton's friends and daughters (one of whom is her literary executor), defended him with equal passion on a variety of grounds, including the almost unanimous opinion that it was what the poet herself would have wanted. The controversy also sparked brisk sales of Anne Sexton, Middlebrook's biography, which was released in September.

It has not been an easy time for the 64year-old Orne, a Harvard-educated psychiatrist who, five years ago, won the Distinguished Scientific Award for the Applications of Psychology, given by the American Psychological Association. "No

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one better exemplifies the theoretical and practical advanages of transcending boundaries in the pursuit of our common goals," said the accompanying citation, which added that his style "reflects a healthy disregard for artificial dichotomies, and his accomplishments suggest the value of intellectual curiosity unfettered by disciplinary boundaries."

Orne was, until recently, best known to the general public for his work as an expert witness for Patricia Hearst and for his pivotal testimony that led to the Hillside Strangler pleading guilty. Now he is known to readers of The New York Times as the man who "dishonored his profession by releasing the tapes to a biographer. It is not surprising that he is chary of the press -- even though he holds no grudges against Middlebrook.

"I think that the book should have been written," he says, "and I know that Diane Middlebrook worked very hard on it. It is not a sensationalist book, but it is a book that Anne would have been proud of. I'm pleased that I could contribute to it. I figure more in the book than a psychiatrist would ordinarily, perhaps because she might not have been there if we hadn't worked together and because her therapy was so intertwined with her poetry.

"I'm willing to talk about Anne because she expressly wanted her therapy to be talked about," he adds; "I don't talk about my other patients because they would not want to be talked about. I don't have the right to talk about them. And that's a very important difference."

It is not hard to sense, when Orne does talk about Anne Sexton, how much his former patient affected him.

"One of Anne's more charming comments," he recalls, more than a quarter of a century after he stopped treating her, "was that psychotherapy is really one of the 'minor arts.' That is so typical. And it was something that we could both enjoy. And in a sense, she's right. When you think about it, a great artist gives more to the world than a psychotherapist, no matter how good the psychotherapist may be. The only way we can manage to beat that is to help patients develop their own resources and be as great as they can."

"And you know," he says with a small smile, "it never really bothered me to be a minor artist."

Orne even wrote the foreword to Anne Sexton; in it, he discussed his work with Sexton and his reasons for turning over the therapy tapes to Middlebrook. He also offered his own view of the events that led to Sexton's death, which amounts to a blunt condemnation of the two psychiatrists who treated her after he left Boston for Philadelphia. The criticism hardly seems unwarranted: the first allegedly had an affair with her while he was treating (and charging) her, a blatant violation of ethics that, Orne believes, undermined her "vital" relationship with her husband, Alfred "Kayo" Sexton; the second, who had forbidden her from seeing Orne anymore on the grounds that it would interfere with her therapy, abruptly decided to stop treating her and would not help her find a new therapist: nine months later, Sexton was dead. But Orne's suggestion that Sexton might still be alive had she not been led astray by her new therapists prompted more angry adjectives in the press, including "repulsive," "arrogant," and "sleazy."

He looks puzzled and a little sad when I mention some of the more vituperative comments made about the foreword.

"I don't know," he says, referring to his critics; "I am not one of those psychiatrists who makes diagnoses without knowing the patient. Some of my colleagues did, unfortunately."

"I felt that the book would be a way of showing the public what psychotherapy can do," he adds: "You know, Anne was someone who was difficult. But she gave tremendously to her therapists, provided they met her not halfway but even just a quarter of the way. …There's nothing that makes a therapist more pleased than to be able to help some-

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one. And if anybody ever benefited from therapy, it was Anne Sexton. That's what I find most sad. And I guess I still am angry at what happened to her, because I wish she were alive today. She had very much to give. And she was a suicide that was not necessary."

On May 29, 1957, Anne Sexton -- then 28 years old, a housewife in the Boston suburb of Newton Lower Falls, and the mother of two little girls -- tried to take her own life. She probably swallowed sleeping pills -- even Orne doesn't remember now -- but she didn't succeed in killing herself. It was not the first time that she tried, as she put it in one of her poems, "to thrust all that life under the tongue," and it certainly would not be the last. She later claimed that, just as tobacco and alcohol could be addicting, so, too, can suicide. Over the next 17 years, she carried on a running flirtation with death, finally consummating the relationship, by asphyxiation, in the front seat of her red Cougar.

But something else happened on that spring night in 1957, when she was sent to Glenside Hospital by Orne, who had decided to put her there because its "no-nonsense" atmosphere helped convince her family that "this was a girl who wasn't playing games." (On other occasions, she went to Westwood Lodge, a more comfortable facility run by Orne's mother, Dr. Martha Brunner-Orne, who treated her just before he did.) Orne, who had been caring for her for less than a year, met her at the hospital.

"I was angry with her for not caring about herself," he recalls; "I can't say I wasn't. There's nothing wrong with that, as long as it's honest. But then we had to pick up the pieces and take it from there. You see, instead of thinking so much about pathology, a therapist has to try to understand what's going on with the patient's life. I've always argued that a therapist has to focus on the resources that an individual has. And by doing that, you grow -- and help the patient grow."

It was sometime that night, Sexton later told an interviewer, that Orne gave her the message that was to change her life: " 'You can't kill yourself; you have something to give. Why, if people read your poems' (they were all about how sick I was) 'they would think, "There's somebody else like me!" They wouldn't feel alone.' "

At that point, she told the interviewer, "I had found something to do with my life.''

It was Orne, in fact, who had urged her to write poetry in the first place. During Sexton's first meeting with him in 1956, Middlebrook relates, he told her that his diagnostic tests indicated that she had "good deal of undeveloped creative potential, and he later proposed that she might try to do some writing about her experiences in treatment. This might help others with similar difficulties to feel less alone, he suggested. Sexton subsequently singled out that conversation as the first encouragement she had ever received to think of herself as a capable person."

"It is difficult to communicate fully how pervasive Anne's profound lack of self-worth was and how totally unable she was to think of any positive abilities or qualities within herself," Orne recalled in his foreword; "when I pressed her to think hard about what she might be able to do, she finally revealed that there was only one thing that she might possibly be capable of doing well -- to be a good prostitute and to help men feel sexually powerful."

But soon, he added, "she herself returned to my original, almost offhand comment, 'How about writing?' and she began to bring poems to our sessions."

She did not dabble. She wrote prolifically and with a tough, self-editing eye, which was soon aided by the poetry workshop she joined, where she met Maxine Kumin, the poet who was to become her best friend. The man who ran the workshops, John Holmes, encouraged her to publish, though he eventually told her that he distrusted "the very source and subject of a great many of your poems, namely, all those that describe and dwell on your time in the hospital. ... Don't publish it in a book. You'll certainly outgrow it, and become another person, then this record will haunt and hurt you. It will even haunt and hurt your children, years from now."

Between January and December of 1957, despite her desperately brittle mental health, she brought Orne over 60 finished poems, carefully typed and usually dated. In less than three years, her first book of poetry -- To Bedlam and Part Way Back -- would be published and, soon thereafter, nominated for a National Book Award. Its opening work was titled "You, Doctor Martin," which begins with the lines "You, Doctor Martin walk/from breakfast to madness. ..."

But "Doctor Martin" makes it very clear that he kept a respectful distance from her poetry.

"She brought all of her poems to me," he acknowledges, "but I never commented. All I said was, 'They're very interesting. They should help people.' I was very careful about that. Because, you see, I learned that her mother took up poetry as soon as Anne was doing poetry. Given that history, the therapist does not get involved. I did not discuss her poems with her as a source of insight into psychological problems, because if that had been done, she would have rationalized all kinds of things. ... And I believed it was very important that she owned the poetry.

"By the way," he adds, "one of the two psychiatrists after me tried to write poetry, which was very bad for Anne. I couldn't not listen to her 'You, Dr. Martin.' But I went out of my way not to discuss poetry."

Orne also dissuaded her from dedicating a long poem titled "The Fortress" to him in her second book, All My Pretty Ones, quoting advice given to him by one of his own mentors: "Unlike other doctors, psychiatrists are entitled to only one form of currency: money. Everything else costs the patient too much."

Somewhat later, Orne encouraged her to continue her education, since she had barely graduated from high school, and when she was accepted in a special program for "intellectually displaced women" at Radcliffe, she wrote him a deliriously happy letter: "Both you and Dr. Brunner [Orne's mother] said I could do this; I'm trying to say you were right even though I didn't think so." Sexton's academic career eventually led to her becoming a professor of English at Boston University, where she taught poetry.

Although she never completely lost her dangerous fascination with death, Sexton nonetheless evolved, in a remarkably short

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period of time, from suicidal housewife and emotional basket case to that rarest of breeds: the commercially and critically successful poet. In 1967, she won the Pulitzer Prize for poetry, years after she told Orne that she wanted it "just as much for when I'm dead as when I'm alive."

"I am convinced that poetry kept Anne alive for the 18 years of her creative endeavors," said Maxine Kumin, in the foreword to Sexton's Complete Poems: "Without this rich, rescuing obsession, I feel certain she would have succeeded in committing suicide in response to one of the dozen impulses that beset her during the period between 1957 and 1974."

One does not need to have read Anne Sexton to discover Orne's benignant presence, which surfaces repeatedly in her work. Take, for example, her long poem "Flee On Your Donkey," which she wrote after passing out in Orne's office:

But you, my doctor, my enthusiast were better than Christ. You promised me another world to tell me who

I was....

Once,

outside your office,

I collapsed in the old-fashioned swoon

between

the illegally parked cars. I threw myself down,

pretending dead for eight hours.

I thought I had died

into a snowstorm.

Above my head

chains cracked like teeth

digging their way through the snowy street.

I lay there

like an overcoat

that someone had thrown away.

You carried me back in,

awkwardly, tenderly,

with the help of the red-haired secretary

who was built like a lifeguard....

You taught me

to believe in dreams;

thus I was the dredger.

"In Dr. Orne," argues Middlebrook, "Sexton had found an intelligent and responsive nurturer of her humanity."

And Sexton adored him, as a previously unpublished poem that appeared in the biography -- "Real Love in Imaginary Wagon"-- shows:

Well Doctor -- all my loving poems

write themselves to you.

If I could channel love,

by gum, it's what I'd do.

And never pen another

foolish freudian line

that bleeds across the page

in half-assed metered rhyme.

If all this bother and devotion

is not, in truth, for you --

(since you're the expert on emotion)

tell me Doctor -- who?

"Anne viewed psychotherapy as a kind of fraud, which she called 'the big cheat,' " Orne told Middlebrook, "because the powerful feelings aroused could never be consummated. The patient's improvement, rather than the patient's gratification, were the goals of treatment."

Unlike the psychiatrist who treated her after Orne moved to Philadelphia -- pseudonymously referred to in the biography as "Dr. Zweizung" (the name means "forked tongue" in German) -- Orne made sure that his treatment of Sexton remained "the big cheat."

"Let me be quite clear," he says: "Anne Sexton was a very difficult patient to treat. She was very seductive. But you know, if you can't deal with that, you should not be a psychiatrist."

It was not just male psychiatrists who found Sexton to be, as one friend put it, a "seducing sort of woman." She once described herself as "so oversexed that I have to struggle not to masturbate most of the day," and she carried on wildly passionate affairs with many men and at least one woman -- making little effort to conceal them from her husband, whom Orne regarded as a vital source of stability for his wife, even though he occasionally lost his temper and hit her. Ironically, says Middlebrook, Kayo Sexton often resented Orne during the years he was treating her, partly because Kayo felt like an "unwanted third party" and partly because he thought some of Orne's advice was meddlesome -- especially when he warned her about the dangers of her drinking and pill-taking.

So when Sexton finally told Orne that she was having an affair with "Dr. Zweizung" (identified by The New York Times as Dr. Frederick J. Duhl), Orne -- who had helped arrange for Sexton to begin seeing him in the first plac -- was outraged.

"That was a devastating thing," he says now: "I can't overemphasize it. Because, you see, the first time I saw Anne -- and there is something very important about the initial interview -- when I asked her to tell me, 'When do you feel better or worse,' there was no hesitation. Her immediate response was, 'Well, when my husband is away, I fall apart.' Now that was a very significant statement. It became very clear to me that here was a life-giving force, because, for Anne to be good and whole, she needed Kayo.

"The trouble was," he explains, "the therapist not only started an affair with Anne, but he also began to chip away at Kayo, and tried to get Anne to leave him. And that was devastating. She finally left Kayo when she was already with the third therapist, but the erosion of the relationship began much earlier."

Although Orne demanded that Zweizung and Sexton end their affair, he stopped short of denouncing Zweizung to the medical ethics board. "I didn't want to ruin the career," he told The New York Times; "today, I might have done it differently."

Apart from the Zweizung affair, some of the most disturbing revelations in the book involve allegations of incest, a theme that repeatedly surfaces, like a dark fin, in Sexton's work. One episode is her alleged sexual abuse of her daughter Linda, which is said to have occurred after Orne moved to Philadelphia and which Linda herself disclosed to Middlebrook. And Anne Sexton sometimes believed that she had been molested by her father, Ralph Harvey, and by her great-aunt, Anna Ladd Dingley ("Nana"). The publication of her trancelike musings on the subject in Orne's office greatly offended Sexton's nieces, Lisa Taylor Tompson and Mary Gray Ford.

"Aside from some very serious ethical and moral issues," they wrote in a letter to the Times, "we find it especially sadden-

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ing that Anne's remarks, made in some sort of hypnotic trance, are treated as statements of truth rather than what they are -- the perceptions of a seriously troubled woman who saw ominous undertones in every kind word, and peril in the most innocent remark. ... We don't know what made Anne the way she was, and never will. ... All of the speculation in the world, including the wild speculation and completely unwarranted conclusions in Diane Wood Middlebrook's book, won't answer the question. But one thing is certain: this puerile, psychobabble attempt to explain the roots of Anne Sexton's poetic creativity does a severe disservice to people who never did her a moment's harm by thought, word, or deed. ... Her great-aunt Nana -- a woman then in her 80s -- may have given Anne a back rub, but it is patently ridiculous to suggest that she did so with salacious intent. ... Similarly, our grandfather Ralph Harvey most certainly did not abuse Anne, sexually or otherwise. ..."

In the book, Orne himself casts doubt on some of the alleged advances, including those attributed to Sexton's father. "I dealt with it in therapy as a real event," he told Middlebrook, "because there were times that it was real to her. ... If you ask me either as a psychiatrist or as a scientist, however, I would have to say I am virtually certain that it never occurred. It's not plausible the way she described it, and it wasn't the father's style when he was drinking. But it fit her feelings about her father having abused her, and since she sexualized everything, it would become the metaphor with which [she'd] deal with it."

Sexton herself knew that her veracity on such matters was not unimpeachable, and according to Middlebrook, she often condemned herself for " 'truth crimes'-- 'lies' that she had been dealing with as 'memories' in trance." In 1958, she told Orne a story about being molested by a family friend that, according to Middlebrook, "she knew she had made up on the spot. Leaving the doctor's office chagrined at having told such an outrageous lie, she vowed to work from then until [he went on research leave that summer] on a 'personal record' that would establish a baseline of truth."

Though the question of whether or not this material should have been published is certainly debatable, Middlebrook's own conclusions about the allegations of incest are cautiously phrased. "For Sexton the artist," she wrote, "the developmentally layered and conflicted love of a girl for her father was a source of insight into the psychological and social complexity of living as a woman. ... [T]he veracity of the incest narrative cannot be established historically, but that does not mean that it didn't, in a profound and lasting sense, 'happen.' "

Happen or not, this sort of dirty laundry is not the sort of thing that most families want the world to see.

"You have written a great deal that is painful," Linda Sexton wrote in a letter to Middlebrook in July of 1990: "This has been very difficult for me to read, more so than at any other time. No family member will ever like this book. You must not care about that any longer; it is an impossible task. We are all hurt by it. We were all hurt by having lived through her life beside her, behind her, in her shadow, holding her hand: that is reality. Of the joy we have also spoken. The only way to transcend the hurt is to tell it all, and to tell it honestly."

And, as she was to argue again and again, the idea of concealing anything would have been anathema to her mother, who made a career out of self-exposure.

"She was a flamboyant woman, and she was never ashamed of her mental illness," Linda told People magazine: "I remember once, when there was a gasoline shortage and she still had the name band on her wrist from a suicide attempt, she went to the head of an hour-long line at a gas station, held out her arm, and said: 'I'm Anne Sexton and I have to go to the hospital because I just swallowed pills, so you'd better give me some gas!' "

Although it can be argued that her addiction to self-revelation did not always result in first-rate poetry -- what some call the Confessional School of poetry, others call the School of Gabby Agony -- there is no question that her experiences made her a powerful witness to the strange terrors of the human psyche.

"She wrote openly about menstruation, abortion, masturbation, incest, adultery, and drug addiction at a time when the proprieties embraced none of these as proper topics for poetry," noted Maxine Kumin in the foreword to Sexton's Complete Poems: "If it is true that she attracted the worshipful attention of a cult group pruriently interested in her suicidal impulses, her psychotic breakdowns, her frequent hospitalizations, it must equally be acknowledged that her very frankness succored many who clung to her poems as to the Holy Grail."

The notion of helping others was, in fact, the leitmotif of Sexton's work. "If my life is a wreck, at least let my art help other people," she once said to Linda, while to an interviewer, she put it another way: "Poetry led me by the hand out of madness. I am hoping I can show others that route."

And, as the poems were published, the readers responded. "One by one, the letters arrived at Sexton's door," relates Middlebrook, "each from a reader who felt spoken to directly, almost spookily, by [All My Pretty Ones, Sexton's second book]. ... And many of these readers sought personal contact with Sexton as someone who spoke for the mentally ill."

"She had -- incredible! -- stacks and stacks of letters from readers that she would answer, every one," says Orne: "She must have answered well over two thousand."

For all her generosity, she was not an easy patient to treat. But Orne, who admits to liking a challenge, says: "I can see only a very few people. If I have a choice between a patient who is a pain in the neck but is willing to work with me, and does me the favor of improving, I vastly prefer that person to another who is a nice patient who always comes on time yet does not do the work necessary for progress."

He is also quick to admit that he made mistakes with Sexton. "We had a relationship which tolerated my mistakes and could tolerate her being impossible," he told Middlebrook: "I had a temper, and I lost it with her more than once. I learned from her that it didn't matter what mistakes I made -- only what I could do to help her."

"In a sense," he explains, "the difference was that when the third psychiatrist got

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angry with her, she -- the psychiatrist -- dropped her. I got angry, but I got over it, and I continued to work with her. That was what counted. You see, many young psychiatrists take the view that they mustn't make mistakes. That's nonsense. You can't not make mistakes. What is devastating is when you cannot understand your mistakes and allow your patient to learn from them. In treatment, both the patient and the therapist have to have the room to make mistakes."

One of the most challenging aspects of their relationship was the way she behaved -- or didn't behave -- in his office. Not only did she often lapse into trancelike states during their sessions, but she could remember almost nothing about what was said during the previous session.

"While to some extent each of us is selective in what we remember," wrote Orne in his foreword to the book, "Anne's selectivity was extreme in the sense that she literally remembered almost nothing of relevance from one session to the next."

That "severe memory problem," he added, "was eventually to lead to an impasse in her therapy. That is, although within an individual session she was able to work effectively during treatment, it emerged over a period of months that each therapy session had the quality of having a beginning, a middle, and an end -- which gave both therapist and patient the feeling that something meaningful was being accomplished. Yet, in looking back over the work of the sessions, I gradually realized that each session was a vignette unto itself, with very little progress being made across therapy sessions."

At first, Orne tried to jog Sexton's memory by taking extensive notes himself, but he soon came to the conclusion that it was "necessary for Anne herself to become the one responsible for remembering what we were doing together." When her efforts at note-taking failed, Orne suggested that they use a tape recorder.

"First, we would audiotape the therapy session," he explained in the foreword, "and afterward, Anne was asked to make extensive notes about everything she could remember from the session. The next day, she would come to the office, and my secretary would put the tape on the recorder and leave her alone to listen to the session. She was asked to note particularly the discrepancies between her memories, her notes from the previous day, and what actually happened on the tape. In the beginning, it was necessary for Anne to listen to the audiotape twice before she was able to recall on her own what we had dealt with during the session. This tedious approach demanded a great deal of Anne, but its consequences were profound. For the first time in her life, she was able to recall why she had been upset about something someone had said, or why she had been angry at me. . . . In other words, Anne could really remember and learn about her feelings, whereas, in the past, she had been unable to recall more than fragments of what occurred -- many of which she recalled incorrectly. ... "

Orne acknowledged that this procedure had led to some "embarrassing moments for me as the therapist -- since Anne was able to point to errors in my memory of prior sessions," but he said that "it was a unique experience for Anne to know more about what transpired in her treatment than her therapist did. ... Whereas the therapist usually holds all the cards, the patient now could know more about what was happening in treatment than the therapist did. Indeed, Anne made a major step forward when she was first able to show me that I was wrong!"

One can only speculate, as Orne has, about what might have happened had he not left Boston in 1964 to move his experimental-psychiatry laboratory from Harvard to West Philadelphia, at the invitation of Penn and the Institute of Pennsylvania Hospital on 49th Street. Before leaving, he arranged to see her periodically and helped her to find another psychiatrist -- Dr. Zweizung -- with whom she did well, until the relationship took on a sexual dimension. But at the time of Orne's departure, no one knew what lay ahead. She was, he says, in "relatively good shape."

"Despite her grief at separating from this fatherly, motherly man," wrote Middlebrook, "she shared his confidence that the gains of therapy were real and permanent."

Real, yes; permanent, no. The siren song of suicide never completely faded from her ears, and after she divorced her husband in 1973, she went downhill fast, marinating her fears and her muse in alcohol. When she killed herself in 1974, after priming herself with vodka, it seemed that the book of her life with Martin Orne was finished, except for his lingering emotions: sadness at her death and bitterness at those whom he felt betrayed her.

But it is important to remember that Anne Sexton was a woman who, on one level, viewed suicide as a "career move," to use Middlebrook's phrase. For a woman like that, new chapters are always a possibility.

On July 15, 1991, the new chapter exploded into print. "Poet Told All; Therapist Provides the Record" announced the frontpage headline in The New York Times. Orne's decision to release the 311 hours of audiotapes to Middlebrook "has shocked many of his colleagues, who say they view it as an unconscionable breach of medical ethics," wrote reporter Alessandra Stanley, who quoted several disapproving psychiatrists. One, Dr. Willard Gaylin, a professor of psychiatry at Columbia University who is considered to be an "expert on medical ethics," said that "doctors have no obligation to history and certainly should not act as a research assistant to a biographer."

"A patient's right to confidentiality survives death," added Dr. Jeremy Lazarus, chairman of the ethics committee of the American Psychiatric Association: "Our view is that only the patient can give that release. What the family wants does not matter a whit." Lazarus later told Clinical Psychiatry News, a monthly newspaper for psychiatrists, that the very fact that the story made the front page of the Times was a reason for the whole issue to be investigated by the ethics committee. (By then, he had also tempered his remarks slightly, suggesting that "the ethicality of Dr. Orne's behavior would depend on the facts and details of what happened.")

The story acknowledged that Orne had "acted with the permission of Sexton's literary executor, her daughter Linda Gray Sexton," and quoted Maxine Kumin as dismiss-

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ing as "pietistic" the psychiatrists' censure: "Those same doctors would never have taken on a patient as demanding as Anne. They just want nice, mannerly depressives." But on the whole, the story came down heavily on Orne.

"I sometimes wonder if Mother is angry with me," Linda Sexton is quoted as saying: "She might have preferred to be seen as a tragic victim. My feeling was: 'Look, Mom, you wrote about this stuff. You lived it in public. How could I cover it up?' " That comment, in the eyes of Newsweek magazine, sounded more like "settling a score" than "serving the needs of biography."

On July 16, Dr. Josef H. Weissberg, president of the American Academy of Psychoanalysis, wrote a letter to the Times (published on July 26) condemning Orne's action. "The question is not if Anne Sexton's wishes were correctly perceived," he charged, "but whether or not a psychiatrist is ever justified in disregarding confidentiality without the patient's explicit, freely given permission. If Dr. Orne's action were condoned, no patient would have any basis for trusting any psychiatrist, since the decision to disclose could be made unilaterally if it furthered the goals of scholarship or any other ostensibly worthwhile purpose. No scholarly insight can be worth the sacrifice of the integrity so essential to the psychotherapeutic endeavor."

On July 20, the Times ran an editorial titled "Betrayed: The Poet and the Public," opining that Orne had "dishonored" his profession by offering the tapes to Middlebrook and that "Anne Sexton likely assumed that the relationship between psychiatrist and patient was as confidential as that between priest and penitent."

The suggestion that she regarded the relationship between psychiatrist and patient as "confidential" raised some eyebrows among the people who knew Sexton. In a letter to the Times published on July 26, her son-in-law, John G. Freund, pointed out that "to Anne Sexton, who made a career of what quickly and quite aptly became known as confessional poetry, neither the doctor-patient relationship, the priest-penitent relationship, nor anything else of literary value was in the slightest way confidential." (Her friend and fellow poet C. K. Williams, '59 C, had already been quoted by Middlebrook as recalling how, in the early stages of their friendship, he had been "surprised by how much she would talk about her therapy when our relationship was not very intimate. But then, it wasn't a very intimate subject to her.")

Not surprisingly, writers and journalists all over the country had opinions on the matter. "Though Dr. Orne emerges as a model of compassion and insight," wrote author Joyce Carol Oates in The Washington Post, "and though Anne Sexton herself adored him, one wonders -- is this a dangerous precedent? Or is it merely another symptom of our era, in which the very nature of 'privacy' seems to be undergoing a radical reassessment?"

In a stinging critique in The Wall Street Journal, writer Raymond Sokolov described Orne's foreword in the book as "repulsive" and "arrogant" but ultimately defended his release of the tapes on the grounds that "Sexton's poetry was, in a concrete sense, caused by her therapy and, as Ms. Middlebrook so sensitively shows again and again, it was written in reaction to her sessions with Dr. Orne as well as to her blood-hot bouts with life." He concluded by saying that if "these would-be suppressors had actually read the poems and the passages that stem from the Orne tapes in 'Anne Sexton,' they probably would have gone about their business with some real things to think about instead of pondering the basically empty question of whether Dr. Orne should have kept mum about his wretched tapes."

Nancy Milford, whose biography of Zelda Fitzgerald also benefitted from access to psychiatric records, was openly scornful of those who condemned Orne: "Nuts!" she said in New York Newsday: "These are not sacred confessions in which sins are told and atoned for. These are modern sessions ... shaped by our own needs and the therapist's skills, in which there is an exchange between the patient and her doctor. ... Why shouldn't those who outlive Sexton learn from that splendid analysis, share in witnessing the benefit of that able assistance?"

The New York Times's book reviewers came to different conclusions about the release of the tapes. In her column in the daily Times, Michiko Kakutani wrote that "it's impossible to condone Dr. Orne's decision to violate his former patient's confidentiality, whatever the stance of the estate's executors. Sexton made no mention of releasing the tapes in her will, and contrary to what both Ms. Middlebrook and Dr. Orne suggest, there is evidence -- in this very volume -- that she valued and tried to hold on to at least a measure of privacy in her life."

But in a front-page review in the Sunday Book Review section, poet Katha Pollitt, while suggesting that "there is a case to be made that Dr. Orne violated professional standards by letting the tapes see the light," went on to say that "as readers we must surely be grateful for his disclosures." And, she added, she could not "work up much indignation over the release of the tapes as an issue of medical ethics. The posthumous revealing of Sexton's confidences seems a peccadillo compared to what some of her therapists did to her while she was alive. ... Clearly, Sexton would have given her blessing to [the tapes'] release. She had absolutely no regard for her own privacy -- or, for that matter, anyone else's."

Pollitt also observed that this was "one of the few biographies I have ever read that was written with the cooperation of the subject's family, but is not, in one way or another, compromised by the suppression of information, a literary practice that almost never attracts much attention."

Linda Sexton, who had asked Middlebrook to write the biography and cooperated fully with the project, defended her own actions -- and Orne's -- in a lengthy rebuttal for the same issue of the Book Review: "Concealing negative aspects of her life would be contrary to the standard of relentless self-inquiry my mother had held herself to in her work," she wrote; "moreover, these aspects would be critical to understanding her poetry, so clearly inspired by the events of her life. ..:.

Linda's husband, John Freund, explained in his letter to the Times how "late in her life, when she assembled her archives and appointed her daughter Linda Gray Sexton literary executor, Anne Sexton clearly marked the items she wanted never to be

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published; Linda abided by those wishes. Audiotapes from psychiatric sessions with Dr. Orne in the poet's possession, as well as her detailed notes from hundreds of other such tapes, were not so marked; they were in a category that allowed Linda to use her best judgment."

In an Op-Ed piece in the Times, published on July 23, Orne described the events that had led to turning over the tapes to Middlebrook:

"In 1964, when I left Massachusetts, I offered to return all of the therapy tapes to Anne. She asked that I keep them to use as I saw fit to help others, though she retained a few for herself. Anne knew what she was consenting to disclose because she had studied the tapes and taken extensive notes on them outside of therapy. Those notes were given to Professor Middlebrook as part of the estate that the biographer gained access to before the request to me for release of the tapes. Listening to them allowed Diane Middlebrook to be there while a young mother struggled in the early 1960s to achieve the role of poet."

There was, he told Psychiatric News later, "definitely no ambiguity as to Anne's wishes" about the eventual use to which the tapes would be put.

Linda Sexton wrote in the Times that both the tapes and the notebooks "would have been mere objects of prurience had they not revealed the roots of her poetic style-the unconscious associative process employed in analysis, which was to become the trademark of her poetry. And, perhaps unlike therapy tapes from any other author, these were almost uniquely relevant to any searching analysis of her poetry: her work examines her mental illness and psychiatric treatment, masturbation, elimination, copulation, adultery, and incest -- and she wrote about these aspects of her life in the first person."

Orne, she said, "did not stand alone when he made the records from his therapy available: all but one of the many psychiatric institutions that held my mother's medical records -- including the prestigious McLean Hospital in Belmont, Mass., closely affiliated with Harvard Medical School -- released those records at my request, complete with detailed notes taken from psychiatric sessions during her hospitalizations, for the express purpose of providing information to the biographer.

"The only institution that did not release records to us was Massachusetts General Hospital," she added, "which maintained that Anne Sexton's records could not be found. McLean requested a court ruling before turning over the record; I applied for such a ruling and the court awarded it. Had Dr. Orne revealed that he had the tapes but refused to make them available, I would have gone to court for them. It is germane to point out that Dr. Orne receives no royalties from the book, nor did he receive any remuneration for writing his introduction."

Orne scoffs at the notion that he should have protected himself by forcing Linda Sexton to get a court order: "It's very interesting, if you think about it. If I had gone ahead and said to Linda Sexton, the executor, 'Please go and get me a court order,' then nobody would have said anything! Now why is that ethical? That is a kind of game that is played. Either I have the right -- with Anne's permission -- to provide her tapes to the public, or I don't."

And despite the impression given by some news accounts, Orne was originally less than forthcoming. For the first four years of Middlebrook's research, he ignored her requests for an interview.

"I simply didn't want any part of it," he explains, "because I didn't want to see a sensationalist kind of book. In a sense, Anne was one of my children, though we were almost the same age. I just didn't feel that I wanted to take a chance on a biographer using the tapes in an inappropriate way."

Eventually, a colleague in the psychology department at Stanford University -- who had heard Middlebrook discuss the work in progress and knew of the Sexton estate's cooperation on access to medical records -- convinced Orne that she was a serious and responsible scholar and arranged an interview. In a letter to the Times, Middlebrook described the events by which the transaction took place:

"We met in August, 1985, after I had drafted an account of Sexton's treatment based on materials to which the family had given me access. These included hospital records, the personal journals in which Sexton had kept notes on her 1961-64 therapy tapes, and transcripts I had made of four tapes that remained among her papers at her death in 1974. These materials had been placed by the Sexton estate at the Harry Ransom Humanities Center at the University of Texas in Austin, under restriction.

"At this interview," she explained, "Dr. Orne told me that Sexton had left most of the tapes in his possession for whatever use they might prove to be to others. ... However, it was not until October, 1986, after discussions establishing procedures for their use, that Dr. Orne sent me the tapes and clinical notes on which I based my discussion of Sexton's treatment and its part in her development."

"Although I had many misgivings about discussing any aspects of the therapy," wrote Orne in the foreword to Anne Sexton, "I also realized that Anne herself would have wanted to share this process -- much as she did in her poetry -- so that other patients and therapists might learn from it. After much soul-searching, and after being assured that Anne's family had given their encouragement and approval, I allowed Professor Middlebrook to have access to the audiotapes and my therapy file, including the early unpublished poems Anne brought to therapy...."

Apart from the foreword, that front-page article in the Times (which he claimed used some of his quotes out of context) and a few comments in psychiatric journals such as Clinical Psychiatry News, Orne's only significant public self-defense came in his Op-Ed piece for the Times. In it, he directly addressed the issue raised by Dr. Lazarus that "confidentiality survives death."

"I would suggest that the patients' right to disclose the details of their therapy also survives death," he wrote, "but here the issue is more complex. I believe that a patient's desire for disclosure must be weighed against the rights of the family executor not to release such records in order to protect the privacy of the remaining family members if that is an issue for them....

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"Some may view a biographer's access to therapy tapes as further evidence of the erosion of privacy in an increasingly transparent society," he added: "But decisions about disclosure properly rest with the patient -- whose autonomy therapists must hold paramount -- not with therapists or colleagues. After the death of a patient who advocated disclosure and gave consent to it, the consent of the family, in my opinion, is foremost.... Anne Sexton's case was unique. She fully recognized that disclosure would result in an enduring loss of confidentiality for her and her family."

Over the next few months, several prominent psychiatrists would speak to the complexities of the issue.

"Psychiatrists certainly cannot claim that the general public interest in biography requires the disclosure of confidences," wrote Dr. Alan A. Stone, professor of law at Harvard Law School and professor of psychiatry at Harvard Medical School, in the November 14 issue of The New England Journal of Medicine: "But when a patient is sexually exploited by her psychiatrist, when she readily obtains prescriptions for drugs she is known to abuse, and when she commits suicide after a psychiatrist is unwilling to continue treatment, then issues of substantial public interest have been raised. Under such circumstances, psychiatrists have a responsibility not to bury their mistakes or those of their colleagues and perhaps not to cover them up in the name of confidentiality."

Maxine Kumin, Stone argued, "puts her finger on an exposed nerve when she suggests that the pietistic critics who condemn Dr. Orne are the kind of psychiatrists who would never have put up with Anne Sexton as a patient. She is certainly correct that most psychiatrists would not have been willing or able to help Anne Sexton in the ingenious and caring way Orne did.

"Even more important is Kumin's testimony that Orne's decision was what Sexton would have wanted," he added: "No one who knew Sexton, including those who have been offended by the book, dispute this. Most of us would never ask to have our souls bared in public, but most of us do not become confessional poets. If I had been Anne Sexton's psychiatrist, I would have urged her to allow me to destroy the tapes, but if she had refused, I hope I would have used them according to her wishes."

In a telephone interview, Stone offers some thoughts on the vehemence of the reaction to Orne's move.

"There isn't any doubt that Dr. Orne has crossed a boundary that no psychiatrist that I know of has ever crossed before," he says, "and because ethics is so entangled with tradition, it immediately seemed that Dr. Orne had done something obviously and clearly unethical. ... The vehemence is a direct result of the break with traditional practice. Any radical break with traditional practice is seen as unethical. But in fact, the whole last 20 years of medical ethics has been devoted to giving patients more autonomy and more control vis-a-vis their doctor. Twenty years ago, doctors wouldn't even let patients look at their own medical records, on the notion that we knew that it wasn't in their best interest. Now, it's quite clear that the patient has the right to look at their own records. Therefore, Anne Sexton's wishes in this matter are really crucial. And Dr. Orne claims that she gave him permission to use these tapes. My view is that if you believe Dr. Orne, then what he did was a judgment call -- but, I think, ethical."

Dr. Carola Eisenberg, a psychiatrist at Harvard Medical School, offered an opposing viewpoint in a companion piece to Stone's New England Journal of Medicine critique. She did not question Orne's motives -- he was, she felt, "unusually diligent" in his care of Sexton and "employed innovative and imaginative treatment techniques"-- and she acknowledged that "there is not a great deal in the transcripts that is not already evident in the poetry (but if that is so, why release the tapes?)." But she still found herself "troubled about the propriety of making privileged information available to a biographer, and hence the legions of readers, in the absence of explicit permission from the patient ...

"If Sexton had ever explicitly given permission for the release of this material to her biographer," she wrote, "I would not protest, even though I might well question her judgment. That permission was never given, however; Orne would not withhold such news from us if he had it. He infers Sexton's acquiescence in the release of the tapes from her willingness to have him use them in therapeutic and didactic settings. I disagree; the two situations are not comparable. Sharing therapeutic material with students or other patients, when permission has been given, lifts the curtain of confidentiality only partially and briefly. It is understood by the participants that neither students nor patients will talk with others about the material. In contrast, once published, these privileged communications are open to the public at large without controls on the way they are used, understood, or gossiped about. Furthermore, they are available to those who find themselves in the book, and this may be extremely wounding.

"The therapeutic contract with physicians -- and with psychiatrists in particular -- is based on confidentiality," Eisenberg added: "What the patient says belongs to the patient, not to the doctor. Its disposition is the patient's prerogative. The full confidence that such is and will remain the case is what allows patients to discuss their most intimate concerns, matters they cannot share with family or friends. Once patients begin to doubt the fidelity of therapists, the context for effective treatment is destroyed. ... Anne Sexton is dead and beyond harm. The legions of other patients who will learn of Dr. Orne's action are not, and erosion of trust in the profession is irreversible. ...

"It is only the patient who could speak for herself," she concluded, "but Anne Sexton can no longer do so. Precisely for that reason, her silence on the matter should have been respected."

"You can regard confidentiality either as the most cherished principle in psychiatry, or as kind of a shibboleth, by which I mean that it may not be quite so absolute as some people make it," says Dr. Paul E. Chodoff, '34 C, the psychiatrist at George Washington University School of Medicine and Health Sciences in Washington who coedited the book Psychiatric Ethics, published by Oxford University Press.

Continued on page 39

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"There's no doubt that it's extraordinarily important, in that the basis of the relationship is the ability to promise that nothing that he or she says is going to be exposed," he acknowledges, "but there are exceptions, and I think this may be one of them. ... It seems to me that there's something a little bit paternalistic about the notion that the psychiatrist always knows better, and that even if the patient says, 'Well, go ahead and use this stuff,' the psychiatrist can stand behind the belief that 'I know better than you, and you're not an autonomous person, so you can't make your own decision.'

"While I don't want to be quoted as saying I don't think confidentiality is terribly important," Chodoff adds, "I don't think it's an absolute. And, in this case, I think Martin Orne is an honorable person, which there's no reason to think he isn't, and if he really believed that Anne Sexton wouldn't have objected to doing this, then I think you can make a case that it's O.K. "

"I wish that Dr. Orne would have gotten a written permission," says Stone, "and the only thing I can say about that is that 20 years ago, psychiatrists and other physicians rarely obtained written consent for such things. It just wasn't done. Certainly almost no psychiatrists got written consent when they gave patients drugs, antipsychotic drugs. That whole area of law and ethics, of informed consent, is a product of the last 20 years. Doctors did all sorts of things without getting the written consent of their patients."

"In 1964," says Orne, "Anne and I discussed what should be done with the tapes. Anne expressly gave me permission to use the tapes in any way that would be beneficial to others. Her permission to disclose could not have been clearer, and it was intended to cover any matter we discussed in psychotherapy. I did not ask Anne for written authorization because at that time it was neither required nor customary.

"But you know," he adds with a certain exasperation, "when people talk about it, it's as if I got these tapes and held on to them for my purposes, rather than at the patient's request. I certainly didn't ask for or get any money. The point is that, if a patient really works hard in therapy, important gains can be made in his or her life. If that patient then wants the work of therapy to become known in order to help others, I believe that the patient and family executor have the right to make the decision for public disclosure."

Diane Middlebrook is standing before a large crowd of poetry fans and literary voyeurs at Borders, the hip, tony book store and espresso bar near Rittenhouse Square in Philadelphia. She is 51 years old, a professor of English at Stanford University, and she looks a lot younger and more wholesome than she has any right to, considering that she has just spent almost 11 years writing about a dead poet's mental breakdowns and obsessions with incest and suicide. A poet herself and a scholar who published five books before this one -- among them, the Selected Poems of Anne Sexton, which she co-edited -- she does not strike the casual observer as flamboyant or exhibitionistic. But as she begins to read "Her Kind," Sexton's haunting poem about the witch within, one senses that she is enjoying stepping into the "bad witch's" shoes, if only for a moment.

She has a number of fantasies about Sexton, she tells the audience. One is a "rescue fantasy" about preventing her death, but then, she suggests, "everyone has a rescue fantasy" about Sexton. Another is a literary one, in which she conjures up Sexton's ghost, reading over her shoulder and coming to some particularly juicy revelation in the biography.

"Very nice," Sexton says to her in her vision: "How did you find that out?"

Middlebrook's answer is cheerfully disingenuous: "I guess it's because I'm such a good girl -- and such an effective snooper."

It was partly because she had already proven to be such an effective snooper that she was able to convince Orne of her seriousness. Linda Sexton had already provided her Anne's extensive notes on the therapy sessions and the four tapes that she had left in her files.

"If you look at the book," says Orne, "you'll see all these citations to the tapes. Dr. Middlebrook is a scholarly biographer, so she cited the most reliable source, which was what Anne said directly. She would look at material in Anne's therapy notebooks, then she would find the tape where it was discussed and would cite the tape in the biography, as if she got the information from the tape rather than the therapy notebook. In fact, the biographer received the tapes more than five years after the executor gave her Anne's therapy notebook. But because the biographer cited everything back to the tapes, there is the assumption that I gave away all these secrets. There aren't any in the book that weren't already there in the possession of the biographer before she listened to the tapes. What Dr. Middlebrook did get from the tapes was a sense of the real person -- the personal self -- of Anne Sexton, that is, the doubts, the anguish, the caring, and the drive to express herself via her poetry."

Stone, too, argued in The New England Journal of Medicine, that Orne believed Middlebrook should hear the tapes "because, despite all her research, she did not have a convincing sense of the person Anne Sexton. He thought the tapes might give her the empathic connection she still lacked."

"I was there, and Anne was there, and the biographer was in the middle," Orne says now, "and that changed dramatically how Dr. Middlebrook felt about Anne. I guess that, since I still think Anne's somewhat part of me, I'd like her to be understood."

Middlebrook does, in fact, say that listening to the tapes helped her immensely. "Though I eventually quoted them sparingly," she wrote in the preface, "listening to them changed my view of Anne Sexton very much. I abandoned the book I had been writing and started over."

"For me, listening to the tapes provided immeasurably valuable insight into the person Sexton had been during the most important period of her creative life," she said in a letter to the Times: "I could not talk to her, but on the tapes she spoke for more than 300 hours -- as if to me, or so it often felt. ... The tapes made me privy not only to anguish but also to thousands of homely particulars."

"As I listened," she told Clinical Psychiatry News, "I thought, 'In the history of biography, which goes back as far as Plutarch, this is a first.' "

Whether it will also be a last is another matter. There will never be a case exactly like this one, but the gasps that greeted the opening of this Pandora's box will probably cause the next psychiatrist to think long and hard -- as Orne undoubtedly did -- about opening up another.

"If I had to do it over again, I don't know what I would do," says Orne, as the tape reels in his office slowly turn: "I kind of hope I would have done the same thing, because that's what I was asked to do. By Anne."

END

The preceding paper is a reproduction of the following article (Hughes, S. M. The Sexton Tapes. The Pennsylvania Gazette, December 1991, 90(3), 20-28, 39.). It appears here with the kind permission of the author, Samuel M. Hughes, who is also the Senior Editor of The Pennsylvania Gazette.