The Washington Post ran this news item on August 2, 1995:

"'Escort services,' the Yellow Pages ad reads. "Discreet. Prompt. Major credit cards accepted." Sound like an ad for sex?
Apparently, more than a few men in the Washington area have thought so and hired an escort, only later finding out all they were getting was...talk. Some become so upset, they call the police to complain--and even leave their names.
Arlington police are so concerned about the potential for violence that they are considering asking the County Board to adopt an ordinance that would require the escorts to disclose upfront what services they are providing before money changes hands..."(Nakashima, 1995).

The problem involved in such transactions is similar to one confronting psychotherapists and their clients--the lack of a contract. Escort-service customers are misled to believe they're paying for intercourse. Instead, they get discourse. Psychotherapy-service customers are also often misled to believe they're paying for medical treatment of a disease. Instead, they get metaphorical intercourse, or "mind-fucking," as Fritz Perls once referred to it. Thus, while prostitutes, those who put their bodies to base use for gain, often masquerade as psychotherapists, many psychotherapists masquerade as prostitutes.

Since prostitution is generally illegal, any trade dispute must be settled through illegal means, e.g., extortion. What's amusing about the scenario above is the attempt to resolve a dispute regarding illegal activity through legal means. Psychotherapy is a legal enterprise, so trade disputes are settled through legal acts, e.g., attributing psychopathology to the metaphorical patient, malpractice lawsuits, etc. If psychotherapist-licensing organizations file litigation against prostitutes for practicing therapy without a license, will pimps go after therapists for infringing on their territory?

Therapists bemoan malpractice litigation--and much of that litigation is frivolous, to be sure. Too often it's a way of assigning responsibility where none belongs. Yet there are instances when malpractice litigation is appropriate though seldom resorted to for reparation. Those concern the various claims made by psychotherapists regarding their products. The most common misrepresentation is psychotherapists' claim to be practicing medicine when in fact they are engaged in secular ethics (Szasz, 1988a). Such a claim appears to constitute fraud, not to mention bad therapy.

FRAUD AND LICENSURE
Abolishing the prohibition against prostitution (which is different from legalizing it) would facilitate quality control for services rendered and give clients a means for legal redress. Abolishing the licensure of psychotherapists, e.g., psychologists, social workers, and counselors, would have similar benefits. Prostitutes and therapists could then both be held legally culpable for misrepresentation, i.e., fraud.

Fraud is "[a]n intentional perversion of truth for the purpose of inducing another in reliance upon it to part with some valuable thing belonging to him or to surrender a legal right" (Black, 1990). Fraud is deliberate misrepresentation. In trade, sellers cannot misrepresent their products. To do so constitutes fraud, an illegal transaction of commerce.

The notion of scientific validity, though not an act, is related to fraud. Validity refers to the extent to which something represents or measures what it purports to represent or measure. When diagnostic measures do not represent what they purport to represent, we say that the measures lack validity. If a business transaction or trade rested on such a lack of validity, we might say that the lack of validity was instrumental in a commitment of fraud. The Diagnostic and Statistical Manual (DSM-IV) published by the American Psychiatric Association and used by licensed psychotherapists throughout the country is notorious for low scientific validity. Yet it is instrumental in securing insurance reimbursement for psychotherapy services. Without DSM-IV diagnoses, insurance companies will not pay for psychotherapy. Without insurance reimbursement, most psychotherapists would be out of business. In licensing psychotherapists to practice and in effect requiring them to rely on DSM-IV diagnoses, the state sanctions the scientifically invalid claims made by psychotherapists regarding their patients. In this way, the state also sanctions fraud.

Fraud is exposed by examining a seller's claims concerning a product for trade. Psychotherapists sell a particular product--conversation and they make certain claims about that product. But claims are one thing, and outcomes are another: The result of psychotherapists' rhetoric speaks for itself. Does the psychotherapeutic product represent what it is purported to represent? Are product outcomes consistent with seller claims? Generally speaking, they do not appear to be.

A critical task in "good" therapy is differentiating fact from fiction. Fictions are invented. They're personal and social constructions. Facts are discovered. What is fact and what is fiction in terms of the product sold by psychotherapists? Consider the following:

Psychotherapists claim that licensure ensures quality control of psychotherapeutic service. That's fiction. The fact is that credentials do not equal competency (A. Gunsberg, personal communication, 1994).

Psychotherapists claim that licensure protects clients from bad therapists. That's fiction. The fact is that psychotherapists not their clients, are protected by licensure.

Psychotherapists claim that licensure protects the confidentiality of the psychotherapeutic relationship. That's fiction. The fact is that licensure facilitates insurance reimbursement for services--and reimbursement violates confidentiality.

Psychotherapists claim that licensure ensures accurate diagnosis and treatment of disease conditions with medicines. That's fiction. The fact is that psychotherapists are not medical doctors. "Mental illness" does not meet the nosological criteria for disease classification by pathologists.

Those fictions are the professional context within which most psychotherapists operate. Nobel laureate Milton Friedman wrote about the myths of occupational licensure more than thirty years ago:

"In the arguments that seek to persuade legislatures to enact such licensure provisions, the justification is always said to be the necessity of protecting the public interest. However, the pressure on the legislature to license an occupation rarely comes from the members of the public who have been mulcted or in other ways abused by members of the occupation. On the contrary, the pressure invariably comes from members of the occupation itself. Of course, they are more aware than others of how much they exploit the customer and so perhaps they can lay claim to expert knowledge" (Friedman, 1982, p. 140).

The rationalization for licensure is base rhetoric (Szasz, 1988a). It's a legal fiction created to protect the economic interests of therapists under the guise of protecting their clients. It ensures monopoly and monopsony of commerce (Szasz, 1994). Licensure doesn't protect psychotherapy clients--contracts do (Szasz, 1988b). A contract is "[a]n agreement between two or more persons which creates an obligation to do or not to do a particular thing" (Black, 1990). Although contractual therapy cannot guarantee good therapy, contracts can protect psychotherapy consumers against fraud. And good therapy is more likely to result when a contract is in place.

INEQUITY IN THERAPY
While some psychotherapists acknowledge the obvious inequities of the therapeutic relationship (e.g., the client's freedom of expression is unlimited while the therapist's is limited), there are other hidden inequities that constitute misrepresentation. Double- standards often exist. While they're embraced in the name of benevolent paternalism, they often occur at the client's expense. Moreover, they tend to decrease autonomy by encouraging dependency. If psychotherapy can help, then it can hurt.

For example, when therapists literalize metaphors, they're considered "insightful." When clients literalize metpahors, they're diagnosed as "psychotic." When therapists find fault in their clients, it's called "diagnosis." When clients find fault in their therapists, it's called "displacement." When therapists default on the commitment to psychotherapy, it's called "reality." When clients default on the commitment to psychotherapy, it's called "borderline" behavior.

Even with a contract, the inequities of the therapeutic relationship can persist. Here's an example of the double- standard which appears to constitute a breach of contract in couples therapy. The inequity operated to the therapist's advantage--and at the clients' expense: A couple sought therapy for assistance with conflicts apparently centered on career changes. A verbal contract was established for eight sessions. The therapist specified that the scope of therapy would be limited to decisions and adjustments associated with career decisions. Midway through the therapy, one of the clients asserted that resolution of the conflicts appeared to hinge on deeper analysis of the relationship. The therapist refused to comply, citing the terms of the contract. At the final session, the same client said that the therapy had failed because deeper issues had been avoided. The therapist responded by advising the couple to divorce. The clients accused the therapist of breach of contract. Although the therapist offered restitution in the form of continued therapy, the therapy was terminated at the clients' request.

In this case, the contract was established and broken. As a result, the clients were injured, the original contract unfulfilled and restitution obscured. The only person who benefited from the business transaction was the therapist, because she was still paid.

While prostitutes may feel and act like psychotherapists (the reverse is likely to be true, too), one difference between the two is clear: Prostitutes generally pretend to care about their clients, but their clients know they're pretending. Psychotherapists pretend to care about their clients, but their clients don't know they're pretending! Moreover, clients' belief that their therapists really care, i.e., love them, is considered a sign of psychopathology, e.g., "transference."

Which is the more confusing, knowing that someone is pretending, or not knowing that someone is pretending not to be pretending?

GOOD THERAPY IS CONTRACTUAL THERAPY
A contract implies voluntariness and consent. Thus, psychotherapy without contract implies an absence of consent or voluntariness. Because psychotherapy is essentially a moral confrontation with oneself, and necessarily implies truthfulness, no one can be coerced into successful psychotherapy or truthfulness. Psychotherapy without contract is not psychotherapy at all. It's coercion. Coercion has more to do with obedience and social control than with compliance and medicine. Contractual psychotherapy with coercion is a contradiction.

Contractual psychotherapy is never value free; i.e., the values of the therapist and the client are as integral a part of the conversation called psychotherapy as are the social, economic and political contexts within which all therapy occurs. If the primary goal of therapy is autonomy, then that goal can be achieved only through clarity of contract. Therapists cannot enforce the success of therapy or their clients' truthfulness. They must be prepared to prove the validity of their product claims. Clients must be aware of their rights to restitution when breach of contract occurs. Government should protect citizens in their right to free trade, not punish them by sanctioning the economic interests of a select few in the name of protecting citizens against bad therapy.

REFERENCES
Black, H.C. (1990). Black's law dictionary, 6th ed. St. Paul, Minn.: West Publishing Co.

Friedman, M. (1982). Capitalism and freedom. Chicago: University of Chicago Press.

Nakashima, E. (1995, August 2). Some customers are never satisfied. The Washington Post, D1.

Szasz, T. (1994). Cruel compassion: Psychiatric control of society's unwanted. New York: John Wiley & Sons, Inc.

Szasz, T. (1988a). The myth of psychotherapy. Syracuse, N.Y.: Syracuse University Press.

Szasz, T. (1988b). The ethics of psychoanalysis: The theory and method of autonomous psychotherapy. Syracuse, N.Y.: Syracuse University Press.

Jeffrey A. Schaler, Ph.D., teaches psychology and public policy at American and Johns Hopkins universities and is the listowner of NUVUPSY@sjuvm.stjohns.edu and co-listowner of SMARTREC@sjuvm.stjohns.edu. He lives in Silver Spring, Md. U.S.A. jschale@american.edu