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Much of Anne Sexton's poetry is autobiographical and concentrates on her deeply personal feelings, especially anguish. In particular, many of her poems record her battles with mental illness. She spent many years in psychoanalysis, including several long stays in mental hospitals. As she told Beatrice Berg, her writing began, in fact, as therapy: "My analyst told me to write between our sessions about what I was feeling and thinking and dreaming." Her analyst, impressed by her work, encouraged her to keep writing, and then, she told Berg, she saw (on television) "I. A. Richards [a poet and literary critic] describing the form of a sonnet and I thought maybe I could do that. Oh, I was turned on. I wrote two or three a day for about a year." Eventually, Sexton's poems about her psychiatric struggles were gathered in To Bedlam and Part Way Back which recounts, as James Dickey wrote, the experiences "of madness and near-madness, of the pathetic, well-meaning, necessarily tentative and perilous attempts at cure, and of the patient's slow coming back into the human associations and responsibilities which the old, previous self still demands."

This kind of poetry, which unveils the poet's innermost feelings, is usually termed confessional poetry, and it is the subject of much critical controversy. A Times Literary Supplement reviewer, for example, said of Live or Die that "many of Mrs. Sexton's new poems are arresting, but such naked psyche-baring makes demands which cannot always be met. Confession may be good for the soul, but absolution is not the poet's job, nor the reader's either." A Punch critic added, "When her artistic control falters the recital of grief and misery becomes embarrassing, the repetitive material starts to grow tedious, the poetic gives way to the clinical and the confessional." Many reviewers raised at least two questions. First, should her poetry be classified as confessional? Second, does her work consistently demonstrate the artistic control which many critics feel is an essential quality of good poetry?

Concerning the first question, Erica Jong objects to the classification: "Whenever Anne Sexton's poems are mentioned, the term 'confessional poetry' is not far behind. It has always seemed a silly and unilluminating term to me; one of those pigeonholing categories critics invent so as not to talk about poetry as poetry.... The mind of the creator is all-important, and the term 'confessional' seems to undercut this, implying that anyone who spilled her guts would be a poet." Sexton also often denigrated the term, but at times she applied it to herself. She told Berg that "for years I railed against being put in this category. Then ... I decided I was the only confessional poet." Moreover, in an interview with Patricia Marx, Sexton discussed the effect on her work of another poet often called confessional, W. D. Snodgrass, and acknowledged the confessional quality of her writing: "If anything influenced me it was W. D. Snodgrass' Heart's Needle.... It so changed me, and undoubtedly it must have influenced my poetry. At the same time everyone said, 'You can't write this way. It's too personal; it's confessional; you can't write this, Anne,' and everyone was discouraging me. But then I saw Snodgrass doing what I was doing, and it kind of gave me permission."

The second question is perhaps best answered in critics' specific responses to several of her individual books. Like many of Sexton's volumes, To Bedlam and Part Way Back received a mixed response. Dickey praised the subject of the work, but found that "the poems fail to do their subject the kind of justice which I should like to see done.... As they are they lack concentration, and above all the profound, individual linguistic suggestibility and accuracy that poems must have to be good." On the other hand, Melvin Maddocks believed that "Mrs. Sexton's remarkable first book of poems has the personal urgency of a first novel. It is full of the exact flavors of places and peoples remembered, familiar patterns of life recalled and painstakingly puzzled over.... A reader finally judges Mrs. Sexton's success by the extraordinary sense of first-hand experience he too has been enabled to feel." Barbara Howes thinks that many of the poems are flawed, but overall she judged Bedlam "an honest and impressive achievement."

All My Pretty Ones also garnered mixed reviews. Peter Davison found one poem, "The Operation," "absolutely superb," but he felt that none of the others are nearly as good. Dickey's critique was even stronger: "Miss Sexton's work seems to me very little more than a kind of terribly serious and determinedly outspoken soap-opera." Yet in an essay on both Bedlam and Pretty Ones, Beverly Fields argued that Sexton's poetry is mostly misread. She contended that the poems are not as autobiographical as they seem, that they are poems, not memoirs, and she went on to analyze many of them in depth in order to show the recurrent symbolic themes and poetic techniques that she felt make Sexton's work impressive.

Dissent among the reviewers continued with the appearance of Live or Die, Sexton's best known book. A Virginia Quarterly Review critic believed that Sexton was "a very talented poet" who was perhaps too honest: "Confession, while good for the soul, may become tiresome for the reader if not accompanied by the suggestion that something is being held back.... In [ Live or Die ] Miss Sexton's toughness approaches affectation. Like a drunk at a party who corners us with the story of his life,... the performance is less interesting the third time, despite the poet's high level of technical competence." Joel O. Conarroe, however, had a more positive view of Sexton's candor. "Miss Sexton is an interior voyager," commented Conarroe, "describing in sharp images the difficult discovered landmarks of her own inner landscape.... Poem after poem focuses on the nightmare obsessions of the damned: suicide, crucifixion, the death of others ..., fear, the humiliations of childhood, the boy-child she never had.... It is, though, through facing up to the reality (and implications) of these things that the poet, with her tough honesty, is able to gain a series of victories over them.... All in all, this is a fierce, terrible, beautiful book, well deserving its Pulitzer award."

Transformations, a retelling of Grimm's fairy tales, marked a shift away from the confessional manner of her earlier work, which several commentators found to be a fruitful change. Gail Pool, for example, contended that the tales provided Sexton with "a rich medium for her colorful imagery," a distance from her characters which allowed wit, an eerie realm "where she had always been her sharpest," and "the structure she needed and so often had difficulty imposing on her own work. At last she had found material to which she could bring her intelligence, her wit, all that she knew, and she created, in Stanley Kunitz's words, 'a wild, blood-curdling, astonishing book.'" Christopher Lehmann-Haupt echoed Pool's analysis, arguing that Sexton's earlier work tended to lack control, that perhaps she worked too closely with firsthand experience. Lehmann-Haupt continued, "by using the artificial as the raw material of Transformations and working her way backwards to the immediacy of her personal vision, she draws her readers in more willingly, and thereby makes them more vulnerable to her sudden plunges into personal nightmare." Similarly, Louis Coxe discovers a new objectivity and distance in Transformations, which he considers "a growth of the poet's mind and strength."

In The Death Notebooks, The Awful Rowing toward God, and 45 Mercy Street, the last two published posthumously, Sexton returned to the confessional method. While these books have been praised, they have also been more severely criticized than her early writings, many readers detecting a deterioration in quality. William Heyen remarked that Sexton's "poems went almost 'steadily downhill, became less intense, less dramatic, less interesting as one book followed another.... There were moments, occasional lines or even poems that wept or raged with her old power," but overall her voice became often "maudlin or patently melodramatic or simply silly." Heyen added that Awful Rowing continues the downward trend; it is touching, "but it's not very good." Robert Mazzocco seconded Heyen, commenting that while the early poems "depict intensely introverted states in highly extroverted style" and are well constructed, the later poems "seem to me less commanding, strike dissonant strains, chromatize the keyboard, or become programmatic." In like manner, Patricia Meyer Spacks argued that Sexton's poems become more and more sentimental in that they overindulge in emotion and fail to evaluate that emotion. The sentimentalism becomes "painfully marked" in Awful Rowing, "with its embarrassments of religious pretension.... The problem of internal division, the perception of divinity, the will to rebuild the soul: all alike register unconvincingly. The poetry through which these vast themes are rendered is simply not good enough."