When the poet Anne Sexton began writing in the late 1950's, those intensely autobiographical poems about her mental breakdowns, erotic fantasies and preoccupation with death brought her overnight acclaim, and some criticism, as a "confessional poet." As Sexton said, rather proudly, at the peak of her popularity in 1969, "I hold back nothing."
Neither did her psychiatrist. "Anne Sexton," to be published by Houghton Mifflin in September, is the first serious examination of Sexton's life and work since her suicide, at the age of 45, in 1974. It is also the first known time a biography of a major American figure relies on material taken from the subject's private therapy sessions with a psychiatrist.
The author of "Anne Sexton," Diane Wood Middlebrook, was given medical records, unpublished early poems and more than 300 audiotapes of sessions the poet had with Dr. Martin T. Orne, a psychiatrist who treated her from 1956 to 1964 and who first encouraged her to write poetry. Details of Madness and Abuse
His action has caused far more consternation in literary and more particularly psychiatric circles than any other revelation in the book, which chronicles in sometimes harrowing detail Sexton's madness, alcoholism and sexual abuse of her daughter, along with her many extramarital affairs, including one with a woman and another with the second of her many therapists.
Dr. Willard Gaylin, a Columbia University psychiatry professor and an expert on medical ethics, said, "Doctors have no obligation to history and certainly should not act as a research assistant to a biographer." He described Dr. Orne's action as a betrayal of his patient "and his profession."
Though Sexton left no instructions about what should be done with the tape recordings of her therapy sessions, Dr. Orne as well as Sexton's children and friends have said she would have agreed to their release.
"I have no question that she would have jumped at the opportunity to share what we did," Dr. Orne said in a recent interview. The Philadelphia-based psychiatrist, who wrote a foreword to the biography explaining his cooperation, added, "I was often more concerned about her privacy than she was."
Yet even though Dr. Orne acted with the permission of Sexton's literary executor, her daughter Linda Gray Sexton, his decision has shocked many of his colleagues, who say they view it as an unconscionable breach of medical ethics.
"A patient's right to confidentiality survives death," said Dr. Jeremy A. Lazarus, the 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."
Until recently, families were better known for destroying private papers than for releasing them. Stephen Joyce, the grandson of James Joyce, burned letters written by Joyce's daughter, Lucia. Ted Hughes, the poet and husband of Sylvia Plath, has said he destroyed parts of Plath's diary to spare the feelings of their children.
But as even serious biographers show an ever-growing interest in uncovering their subjects' most private torments, or what Joyce Carol Oates has labeled pathography, relatives have begun taking it upon themselves to do the revealing. Linda Gray Sexton, who said she selected Ms. Middlebrook to write the book, did so for some of the same reasons that the children of John Cheever unveiled the secrets of their father's private life. "Our inclination is to let everything out," said John Cheever's son, Ben, who has prepared his father's journals for publication in the fall. "But we want to be in control of it." 'How Could I Cover It Up?'
Ms. Sexton said, "I retained the right to discuss and veto material if I felt I couldn't bear it." Though she said she found much of it "extremely painful," she said she concluded that full disclosure was necessary.
"I sometimes wonder if Mother is angry with me," Ms. Sexton said. "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?' "
Ms. Middlebrook, a professor of English at Stanford University, said she spent 10 years researching Sexton's life and work. After listening to the tapes, a task that took two years, she completely rewrote the manuscript, she said.
"I never thought they still existed," Ms. Middlebrook said of the tapes. "I was quite amazed when he offered to do this." The tapes, which Dr. Orne volunteered during an interview, did not provide her with vital new information, she said. Instead, Ms. Middlebrook said, she found "more confirming evidence than revelation." Sexton's incestuous behavior toward her daughter, which is among the more disturbing details in the book, was revealed by Linda Gray Sexton.
Ms. Middlebook said she had no qualms about using the tapes. "I don't think Anne Sexton cared what was known about her private life," she said. "She just didn't want to be known as a bad artist." Reserving Some Privacy
Among the heaps of letters and memorabilia she had carefully hoarded for posterity, Sexton placed only a few of her earliest poems off the record, in a folder marked, "Not to be seen by anybody." Ms. Middlebrook chose not to reprint any of those, though she did cite some of the early, tentative poems Sexton had written about therapy that she found in Dr. Orne's files.

Few of Sexton's close friends faulted Dr. Orne or Ms. Middlebrook. The poet Maxine Kumin said she found the biography of her close friend "very balanced and judicious." She described Dr. Orne's decision as "gutsy," and dismissed the objections of Dr. Orne's colleagues as "pietistic."
"Those same doctors would never have taken on a patient as demanding as Anne," she said scornfully. "They just want nice, mannerly depressives."
J. D. McClatchy, a poet and critic who edited "Anne Sexton, the Artist and Her Critics," said of Dr. Orne, "There is something a little sleazy about the way he has put himself forward as her Pygmalion." But Mr. McClatchy said he did not blame the biographer for using the material. "Imagine if we suddenly found tapes of the psychiatric sessions of Virgina Woolf," he said. "Who would not want to listen?"
Yet other biographers uneasily spoke of the conflict between a writer's need to gather all information about a subject and a doctor's duty to safeguard a patient's privacy. 'Like the Confessional'
When Winston Churchill's personal physician, Lord Moran, wrote a biography revealing the severity of the stroke Churchill suffered in 1953, his colleagues said they were appalled by what they regarded as a breach of the physician-patient relationship. "I used it," Anthony Storr, an English psychiatrist who has written about the creative process, said of Lord Moran's book. "It was very interesting. But I could never do it." Therapy, he said, "is like the confessional."
There have been other psychiatrists who have discussed their patients with biographers. A few psychiatrists who treated the artist Jackson Pollock, for example, spoke openly to the biographers Steven Naifeh and Gregory White Smith. Scott McDonald, who wrote an unauthorized biography of John Cheever, said he omitted a diagnosis propounded by one of the writer's psychiatrists, whom he described as "reckless."
Peter Gay, a Sterling Professor of History at Yale University who underwent psychoanalytic training to write a biography of Sigmund Freud, put it this way: "As a biographer, I was voracious and angry at anyone who withheld things, but I would despise any analyst willing to do this."
Barbara Schwartz, a psychiatric social worker who treated Sexton until her death, also discussed the poet with Ms. Middlebrook, but she did not release her notebooks or medical records. Ms. Schwartz said that she did not fault Dr. Orne, but added that she could not follow his example "because that was a private piece of the therapy." Psychiatrist Explains His Actions
Dr. Orne said he felt his insights about Sexton's therapy would inspire and help other troubled people. "Her life shows what can be done," he said of the uses of therapy. "How a gifted person who was nowhere could, with some help, become an outstanding poet."
When Sexton first came to see Dr. Orne, she was a deeply depressed suburban Boston housewife with suicidal tendencies. He persuaded her to write down her feelings as a way of helping other mentally disturbed people. Years later, Sexton described helping others as "my little reason to go on."
Because Sexton suffered severe memory lapses, states of fugue she called "trances," Dr. Orne took the unorthodox step of recording their sessions from 1961 to 1964 so Sexton could listen to them afterward to try to recall what she had revealed in therapy.
She turned into a successful poet almost immediately after beginning to write, becoming one of the most prominent and flamboyant members of a close-knit literary community in Boston that included Robert Lowell, Sylvia Plath, W. D. Snodgrass and Ms. Kumin. Sexton's poetry won a Pulitzer Prize in 1967; her lean good looks, theatrical despair and insatiable thirst for attention made her a cult figure.
"Mother was like wallpaper," her younger daughter, Joyce Ladd Sexton, said ruefully. "She plastered herself all other the walls."
Sexton never fully recovered from her mental illness, Ms. Middlebrook's book states. Dr. Orne, who moved to Philadelphia from Boston in 1964, said of Sexton, "When I left, she was in quite good shape." Bitterness About an Affair
Dr. Orne said he believed that the therapy Sexton received thereafter did her far more harm than good.
He said he was particularly bitter about the actions of Sexton's second psychiatrist, who he said had an affair with Sexton. The liaison is examined in some detail in the biography. Sexton's second psychiatrist, Dr. Frederick J. Duhl, is not named in the book.
Dr. Orne said when he learned of the affair, he intervened and instructed Sexton and the therapist to stop. He did not, however, denounce the therapist to the medical ethics board, he said. " I didn't want to ruin the career," Dr. Orne said. "Today, I might have done it differently."
Dr. Duhl, who now practices family therapy in Boston, refused to discuss the book's allegations, which were supported by Sexton's relatives and friends. "I am not going to comment," he said in a telephone interview. "You are dealing with an explosive subject: basically any doctor who has an affair with a patient loses his license in Massachusetts."
Ms. Schwartz, the psychiatric social worker, said that when she first began treating Sexton in 1973 the poet had asked her to accompany her to a conference the psychiatrist was to speak at. "She wanted to stand up there and say, 'J'accuse!' " Ms. Schwartz said. "I felt I could not go to that meeting and let her expose herself that way." 'Real Love in Imaginary Wagon'
This poem by Anne Sexton, written in 1957, was found in the files of her psychiatrist Dr. Martin T. Orne. 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?
Photos: Anne Sexton, whose biography is to be published in September (Thomas Victor); Dr. Martin T. Orne (David Fields for The New York Times) (pg. A1); Diane Wood Middlebrook, whose biography of Anne Sexton is to be published in September. (Margo Davis/Houghton Mifflin) (pg. C13)