Tuesday, 11 August 2009
Dilemmas and Controversies of Traditional Psychiatry
Dilemmas and Controversies of Traditional Psychiatry
Chapter 5 of Beyond the Brain: Birth, Death and Transcendence in Psychotherapy
©1985 State University of New York Press
The Medical Model in Psychiatry: Pros and Cons
As a result of its complex historical development, psychiatry became established as a branch of medicine. Mainstream conceptual thinking in psychiatry, the approach to individuals with emotional disorders and behavior problems, the strategy of research, basic education and training, and forensic measures—all are dominated by the medical model. This situation is a consequence of two important sets of circumstances: medicine has been successful in establishing etiology and finding effective therapy for a specific, relatively small group of mental abnormalities, and it has also demonstrated its ability to control symptomatically many of those disorders for which specific etiology could not be found.
The Cartesian-Newtonian world view that had a powerful impact on the development of various fields has played a crucial role in the evolution of neuropsychiatry and psychology. The renaissance of scientific interest in mental disorders culminated in a series of revolutionary discoveries in the nineteenth century that firmly defined psychiatry as a medical discipline. Rapid advances and remarkable results in anatomy, pathology, pathophysiology, chemistry, and bacteriology resulted in tendencies to find organic causes for all mental disturbances in infections, metabolic disorders, or degenerative processes in the brain.
The beginnings of this "organic orientation" were stimulated when the discovery of the etiology of several mental abnormalities led to the development of successful methods of therapy. Thus, the recognition that general paresis—a condition associated, among others, with delusions of grandeur and disturbances of intellect and memory—was the result of tertiary syphilis of the brain caused by the protozoon Spirochaeta pallida was followed by successful therapy using chemicals and fever. Similarly, once it became clear that the mental disorder accompanying pellagra was due to a vitamin B deficiency (lack of nicotinic acid or its amid), the problem could be corrected by an adequate supply of the missing vitamin. Some other types of mental dysfunction were found to be linked to brain tumors, degenerative changes in the brain, encephalitis and meningitis, various forms of malnutrition, and pernicious anemia.
Medicine has been equally successful in the symptomatic control of many emotional and behavior disorders the etiology of which it has not been able to find. Here belong the dramatic interventions using pentamethylenetetrazol (Cardiazol) shocks, electroshock therapy, insulin shock treatment, and psychosurgery. Modern psychopharmacology has been particularly effective in this regard with its rich armamentarium of specifically acting drugs—hypnotics, sedatives, myorelaxants, analgesics, psychostimulants, tranquilizers, antidepressants, and lithium salts.
These apparent triumphs of medical research and therapy served to define psychiatry as a specialized branch of medicine and committed it to the medical model. With the privilege of hindsight, this was a premature conclusion; it led to a development that was not without problems. The successes in unraveling the causes of mental disorders, however astonishing, were really isolated and limited to a small fraction of the problems that psychiatry deals with. In spite of its initial successes, the medical approach to psychiatry has failed to find specific organic etiology for problems vexing the absolute majority of its clients—depressions, psychoneuroses, and psychosomatic disorders. Moreover, it has had very limited and problematic success in unraveling the medical causes underlying the so-called endogenous psychoses, particularly schizophrenia and manic-depressive psychosis. The failure of the medical approach and the systematic clinical study of emotional disorders gave rise to an alternative movement—the psychological approach to psychiatry, which led to the development of dynamic schools of psychotherapy.
In general, psychological research provided better explanatory models for the majority of emotional disorders than the medical approach; it developed significant alternatives to biological treatment and in many ways brought psychiatry close to the social sciences and philosophy. However, this did not influence the status of psychiatry as a medical discipline. In a way, the position of medicine became self-perpetuating, because many of the symptom-relieving drugs discovered by medical research have distinct side effects and require a physician to prescribe and administer them. The symbiotic liaison between medicine and the rich pharmaceutical industry, vitally interested in selling its products and offering support to medical endeavors, then sealed the vicious circle. The hegemony of the medical model was further reinforced by the nature and structure of psychiatric training and the legal aspects of mental health policies.
Most psychiatrists are physicians with postgraduate training in psychiatry—and a very inadequate background in psychology. In most instances, individuals who suffer from emotional disorders are treated in medical facilities with the psychiatrist legally responsible for the therapeutic procedures. In this situation, the clinical psychologist frequently has the function of ancillary personnel, subordinate to the psychiatrist, a role not dissimilar to that of the biochemist or laboratory technician. Traditional assignments of clinical psychologists are assessment of intelligence, personality, and organicity, assistance with differential diagnosis, evaluation of treatment, and vocational guidance. These tasks cover many of the activities of those psychologists who are not involved in research or psychotherapy. The problem to what extent psychologists are qualified and entitled to conduct therapy with psychiatric patients has been subject to much controversy.
The hegemony of the medical model in psychiatry has resulted in a mechanical transplantation of medical concepts and methods of proven usefulness into the field of emotional disorders. The application of medical thinking to the majority of psychiatric problems and to the treatment of emotional disorders, particularly various forms of neuroses, has been widely criticized in recent years. There are strong indications that this strategy has created at least as many problems as it solved.
Disorders for which no specific etiology has been found are loosely referred to as "mental diseases." Individuals who suffer from such disorders receive socially stigmatizing labels and are routinely called "patients." They are treated in medical facilities where the per diem expenses for hospitalization amount to several hundred dollars. Much of this cost reflects enormous overhead directly related to the medical model, such as costs for examinations and services that are of questionable value in the effective treatment of the disorder in question. Much research money is dedicated to refining medically oriented research that will eventually discover the etiology of "mental diseases" and thus confirm the medical nature of psychiatry.
There has been increasing dissatisfaction with the application of the medical model in psychiatry. Probably the best known and most eloquent representative of this movement is Thomas Szasz In a series of books, including his Myth of Mental Illness (1961); Szasz has adduced strong evidence that most cases of so-called mental illness should be regarded as expressions and reflections of the individual's struggles with the problems of living. They represent social, ethical, and legal problems, rather than "diseases" in the medical sense. The doctor-patient relationship as defined by the medical model also reinforces the passive and dependent role of the client. It implies that the solution of the problem depends critically on the resources of the person in the role of scientific authority, rather than on the inner resources of the client.
The consequences of the medical model for the theory and practice of psychiatry are far reaching. As a result of the mechanical application of medical thinking, all disorders that a psychiatrist deals with are seen in principle as diseases for which the etiology will eventually be found in the form of an anatomical, physiological or biochemical abnormality. That such causes have not yet been discovered is not seen as a reason to exclude the problem from the context of the medical model. Instead, it serves as an incentive for more determined and refined research along medical lines. Thus, the hopes of organically-minded psychiatrists were recently rekindled by the successes of molecular biology.
Another important consequence of the medical model is a great emphasis on establishing the correct diagnosis of an individual patient and creating an accurate diagnostic or classificatory system. This approach is of critical importance in medicine, where proper diagnosis reflects a specific etiology and has clear, distinct, and agreed-upon consequences for therapy and for prognostication. It is essential to diagnose properly the type of an infectious disease, because each of them requires quite different management and the infectious agents involved respond differently to specific antibiotic treatments. Similarly, the type of tumor determines the nature of the therapeutic intervention, approximate prognosis, or danger of metastases. It is critical to diagnose properly the type of anemia, because one kind will respond to medication with iron, another requires cobalt treatment, and so on.
A good deal of wasted effort has been poured into refining and standardizing psychiatric diagnosis, simply because the concept of diagnosis appropriate for medicine is not applicable to most psychiatric disorders. The lack of agreement can be illustrated clearly by comparing the systems of psychiatric classification used in different countries, for example in the United States, Great Britain, France, and Australia. Used indiscriminately in psychiatry, the medical concept of diagnosis is vexed by the problems of unreliability, lack of validity, and questionable value and usefulness. A diagnosis depends critically on the school to which the psychiatrist adheres, on his or her individual preferences, on the amount of data available for evaluation, and on many other factors.
Some psychiatrists arrive at a diagnosis only on the basis of the presenting complex of symptoms, others on the basis of psychodynamic speculations, still others on a combination of both. The psychiatrist's subjective evaluation of the psychological relevance of an existing physical disorder—such as thyroid problems, viral disease, or diabetes—or of certain biographical events in the past or present life of the patient can have a significant influence on the diagnosis. There is also considerable disagreement concerning the interpretation of certain diagnostic terms; for example, there are great differences between the American and European schools about the diagnosis of schizophrenia.
Another factor that can influence the psychiatric diagnosis is the nature of the interaction between the psychiatrist and the patient. While the diagnosis of appendicitis or a hypophyseal tumor will not be appreciably affected by the personality of the doctor, a psychiatric diagnosis could be influenced by the behavior of the patient toward the psychiatrist who establishes the diagnosis. Thus, specific transference-counter-transference dynamics, or even the interpersonal ineptness of a psychiatrist, can become significant factors. It is a well-known clinical fact that the experience and behavior of a patient changes during interaction with different persons and can also be influenced significantly by circumstances and situational factors. Certain aspects of current psychiatric routines tend to reinforce or even provoke various behavioral maladjustments
Because of the lack of objective criteria, which are so essential for the medical approach to physical diseases, there is a tendency among psychiatrists to rely on clinical experience and judgment as self-validating processes. In addition, classificatory systems and concerns are frequently products of medical sociology, reflecting specific pressures on physicians in the task imposed on them. A psychiatric diagnostic label is sufficiently flexible to be affected by the purpose for which it is given—whether for an employer, an insurance company, or forensic purposes. Even without such special considerations, different psychiatrists or psychiatric teams will frequently disagree about the diagnosis of a particular patient.
A considerable lack of clarity can be found even regarding such a seemingly important question as differential diagnosis between neurosis and psychosis. This issue is usually approached with great seriousness, although it is not even clearly established whether there is a single dimension of psychopathology. If psychosis and neurosis are orthogonal and independent, then the patient can suffer from both. If they are on the same continuum and the difference between them is only quantitative, then a psychotic individual would have to pass through a neurotic stage on the way to psychosis and return to it again during recovery.
Even if psychiatric diagnosis could be made both reliable and valid, there is the question of its practical relevance and usefulness. It is quite clear that with a few exceptions the search for accurate diagnosis is ultimately futile because it has no agreed-upon relevance for etiology, therapy, and prognosis. Establishing the diagnosis consumes much time and energy on the part of the psychiatrist, and particularly the psychologist, who must sometimes spend hours of testing to make the final decision.
Ultimately, the therapeutic choice will reflect the psychiatrist's orientation rather than a clinical diagnosis. Organically-minded psychiatrists will routinely use biological treatment with neurotics, and a psychologically-oriented psychiatrist may rely on psychotherapy even with psychotic patients. During psychotherapeutic work, the therapist will be responding to events during sessions rather than following a preconceived psychotherapeutic plan determined by the diagnosis. Similarly, specific pharmacological procedures do not show a generally agreed-upon relation between diagnosis and choice of the psychopharmacon. Frequently the choice is determined by the therapist's subjective preferences, the clinical response of the patient, the incidence of side effects, and similar concerns.
Another important legacy of the medical model is the interpretation of the function of the psychopathological symptoms. In medicine, there is generally a linear relationship between the intensity of symptoms and the seriousness of the disease. Alleviation of symptoms is thus seen as a sign of improvement of the underlying conditions. Therapy in physical medicine is causal whenever possible, and symptomatic therapy is used only for incurable diseases or in addition to causal therapy.
Applying this principle to psychiatry causes considerable confusion. Although it is common to consider the alleviation of symptoms as an improvement, dynamic psychiatry has introduced a distinction between causal and symptomatic treatment. It is thus clear that symptomatic treatment does not solve the underlying problem but, in a way, masks it. Observations from psychoanalysis show that intensification of symptoms is frequently an indication of significant work on the underlying problem. The new experiential approaches view the intensification of symptoms as a major therapeutic tool and use powerful techniques to activate them. Observations from work of this kind strongly suggest that symptoms represent an incomplete effort of the organism to get rid of an old problem—and that this effort should be encouraged and supported.
From this point of view, much of the symptomatic treatment in contemporary psychiatry is essentially antitherapeutic, since it interferes with the spontaneous healing activity of the organism. It should thus be used not as a method of choice but as a compromise when the patient explicitly refuses a more appropriate alternative or if such an alternative is not possible or available for financial or other reasons.
In conclusion, the hegemony of the medical model in psychiatry should be viewed as a situation created by specific historical circumstances and maintained at present by a powerful combination of philosophical, political, economical, administrative, and legal factors. Rather than reflecting the scientific knowledge about the nature of emotional disorders and their optimal treatment, it is at best a mixed blessing.
In the future, patients with psychiatric disorders having a clear organic basis may be treated in medical units especially equipped to handle behavior problems. Those in whom repeated physical checkups detect no medical problems could then use the service of special facilities where the emphasis would be psychological sociological, philosophical, and spiritual, rather than medical. Powerful and effective techniques of healing and personality transformation addressing both the psychological and physical aspects of human beings have already been developed by humanistic and transpersonal therapists.
Disagreements about Theory and Therapeutic Measures
Conflicting theories and alternative interpretations of data can be found in most scientific disciplines. Even the so-called exact sciences have their share of disagreements, as exemplified by the differences of opinion on how to interpret the mathematical formalism of quantum theory. However, there are very few scientific fields where the lack of unanimity is so great and the body of agreed-upon knowledge so limited as in psychiatry and psychology. There is a broad spectrum of competing theories of personality, offering a number of mutually exclusive explanations about how the psyche functions, why and how psychopathology develops, and what constitutes a truly scientific approach to therapy.
The degree of disagreement about the most fundamental assumptions is so phenomenal that it is not surprising that psychology and psychiatry are frequently denied the status of science. Thus, psychiatrists and psychologists with impeccable academic training, superior intelligence, and great talent for scientific observation frequently formulate and defend concepts that are theoretically absolutely incompatible and offer exactly opposite practical measures.
Thus, there are schools of psychopathology that have a purely organic emphasis. They consider the Newtonian-Cartesian model of the universe to be an accurate description of reality and believe that an organism that is structurally and functionally normal should correctly reflect the surrounding material world and function adequately within it. According to this view, every departure from this ideal must have some basis in the anatomical, physiological, or biochemical abnormality of the central nervous system or some other part of the body that can influence its functioning.
Scientists who share this view are involved in a determined search for hereditary factors, cellular pathology, hormonal imbalance, biochemical deviations, and other physical causes. They do not consider an explanation of an emotional disorder to be truly scientific unless it can be meaningfully related to, and derived from, specific material causes. The extreme of this approach is the German organic school of thought with its credo that "for every deranged thought there is a deranged brain cell," and that one-to-one correlates will ultimately be found between various aspects of psychopathology and brain anatomy.
Another extreme example at the same end of the spectrum is behaviorism, whose proponents like to claim that it is the only truly scientific approach to psychology. It sees the organism as a complex biological machine the functioning of which, including the higher mental functions, can be explained from complex reflex activity based on the stimulus-response principle. As indicated by its name, behaviorism emphasizes the study of behavior and in its extreme form refuses to take into consideration introspective data of any kind, and even the notion of consciousness.
Although it definitely has its place in psychology as a fruitful approach to a certain kind of laboratory experimentation, behaviorism cannot be considered a serious candidate for a mandatory explanatory system of the human psyche. An attempt to formulate a psychological theory without mentioning consciousness is a strange endeavor at a time when many physicists believe that consciousness may have to be included explicitly in future theories of matter. While organic schools look for medical causes for mental abnormalities, behaviorism tends to see them as assemblies of faulty habits that can be traced back to conditioning.
The middle band of the spectrum of the theories explaining psychopathology is occupied by the speculations of depth psychology. Besides being in fundamental conceptual conflict with the organic schools and behaviorism, they also have serious disagreements with each other. Some of the theoretical arguments within this group have already been described in connection with the renegades of the psychoanalytic movement. In many instances, the disagreements within the group of depth psychologies are quite serious and fundamental.
On the opposite end of the spectrum, we find approaches that disagree with the organic, behaviorist, or psychological interpretations of psychopathology. As a matter of fact, they refuse to talk about pathology altogether. So, for phenomenology or daseinsanalysis, most of the states that psychiatry deals with represent philosophical problems, since they reflect only variations of existence, different forms of being in the world.
Many psychiatrists refuse these days to subscribe to the narrow and linear approaches described above and instead talk about multiple etiology. They see emotional disorders as end results of a complex multidimensional interaction of factors, some of which might be biological, while others are of a psychological, sociological, or philosophical nature. Psychedelic research certainly supports this understanding of psychiatric problems. Although psychedelic states are induced by a clearly defined chemical stimulus, this surely does not mean that the study of biochemical and pharmacological interactions in the human body following the ingestion can provide a complete and comprehensive explanation of the entire spectrum of psychedelic phenomena. The drug can be seen only as a trigger and catalyst of the psychedelic state that releases certain intrinsic potential of the psyche. The psychological, philosophical, and spiritual dimensions of the experience cannot be reduced to anatomy, physiology, biochemistry, or behavior study; they must be explored by means that are appropriate for such phenomena.
The situation in psychiatric therapy is as unsatisfactory as the one just outlined in regard to the theory of psychopathological problems. It is not surprising, since the two are closely related. Thus, organically-minded psychiatrists frequently advocate extreme biological measures, not only for the treatment of severe disorders such as schizophrenia and manic-depressive psychosis, but for neurosis and psychosomatic diseases as well. Until the early 1950s, most of the common psychiatric biological treatments were of a radical nature—Cardiazol shocks, electroshock therapy, insulin shock treatment, and lobotomy.
Even the modern psychopharmacopeia that has all but replaced these drastic measures, although far more subtle, is not without problems. It is generally understood that in psychiatry drugs do not solve the problem, but control the symptoms. In many instances, the period of active treatment is followed by an indefinite period during which the patient is obliged to take maintenance dosages. Many of the major tranquilizers are used quite routinely and usually for a long period of time. This can lead to such problems as irreversible neurological or retinal damage, and even true addiction.
The psychological schools favor psychotherapy, not only for neuroses, but also for many psychotic states. As mentioned earlier, there are ultimately no agreed-upon diagnostic criteria, except for well-established organic causations of particular disorders (encephalitis, tumor, arteriosclerosis), which would clearly assign the patient to organic therapy or psychotherapy. In addition, there is considerable disagreement as to the rules of combining biological therapy and psychotherapy. Although psychopharmacological treatment may occasionally be necessary for psychotic patients who receive psychotherapy and is generally compatible with its superficial, supportive forms, many psychotherapists feel that it is incompatible with a systematic depth-psychological approach. While the uncovering strategy aims to get to the roots of the problem and uses the symptoms for this purpose, symptomatic therapy masks the symptoms and obscures the problem.
The situation is now further complicated by the increasing popularity of the new experiential approaches. These not only use symptoms specifically as the entry point for therapy and self-exploration, but see them as an expression of the self-healing effort of the organism and try to develop powerful techniques that accentuate them. While one segment of the psychiatric profession focuses all its efforts on developing more and more effective ways of controlling symptoms, another segment is trying equally hard to design more effective methods of exteriorizing them. While many psychiatrists understand that symptomatic treatment is a compromise when a more effective treatment is not known or feasible, others insist that a failure to administer tranquilizers represents a serious neglect.
In view of the lack of unanimity regarding psychiatric therapy—with the exception of those situations that, strictly speaking, belong to the domain of neurology or some other branch of medicine, such as general paresis, brain tumors, or arteriosclerosis—one can suggest new therapeutic concepts and strategies without violating any principles considered absolute and mandatory by the entire psychiatric profession.
Criteria of Mental Health and Therapeutic Results
Since the majority of clinical problems psychiatrists deal with are not diseases in the true sense of the word, application of the medical model in psychiatry runs into considerable difficulty. Although psychiatrists have tried very hard for over a century to develop a "comprehensive" diagnostic system, they have largely failed in their effort. The reason for this is that they lack the disease-specific pathogenesis on which all good diagnostic systems are based. Thomas Scheff (1974) has described this situation succinctly: "For major mental illness classifications, none of the components of the medical model has been demonstrated: cause, lesion, uniform and invariate symptoms, course, and treatment of choice." There are so many points of view, so many schools, and so many national differences that very few diagnostic concepts mean one and the same thing to all psychiatrists.
However, this has not discouraged psychiatrists from producing more and more extensive and detailed official nomenclatures Mental health professionals continue to use the established terms despite overwhelming evidence that large numbers of patients do not have the symptoms to fit the diagnostic categories used to describe them. In general, psychiatric health care is based on unreliable and unsubstantiated diagnostic criteria and guidelines for treatment. To determine who is "mentally ill" and who is "mentally healthy," and what the nature of this "disease" is, is a far more difficult and complicated problem than it seems, and the process through which such decisions are made is considerably less rational than traditional psychiatry would like us to believe.
Considering the large number of people with serious symptoms and problems and the lack of agreed-upon diagnostic criteria, the critical issue seems to be why and how some of them are labeled as mentally ill and receive psychiatric treatment. Research shows that this depends more on various social characteristics than on the nature of the primary deviance (Light 1980). Thus, a factor of great importance is the degree to which the symptoms are manifest. It makes a great difference whether they are noticeable to everybody involved or relatively invisible. Another significant variable is the cultural context in which symptoms occur; concepts of what is normal and acceptable vary widely by social class, ethnic group, religious community, geographical region, and historical period. Also, measures of status, such as age, race, income, and education tend to correlate with diagnosis. The preconception of the psychiatrist is a critical factor; Rosenhan's remarkable study (1973) shows that, once a person has been designated as mentally ill—even if actually normal—the professional staff tends to interpret ordinary daily behavior as pathological.
The psychiatric diagnosis is sufficiently vague and flexible to be adjusted to a variety of circumstances. It can be applied and defended with relative ease when the psychiatrist needs to justify involuntary commitment or prove in court that a client was not legally responsible. This situation is in sharp contrast with the strict criteria applied by the psychiatrist for the prosecution, or by a military psychiatrist whose psychiatric diagnosis would justify discharge from military service. Similarly flexible can be psychiatric diagnostic reasoning in malpractice and insurance suits; the professional argumentation might vary considerably depending on which side the psychiatrist stands.
Because of the lack of precise and objective criteria, psychiatry is always deeply influenced by the social, cultural, and political structure of the community in which it is practiced. In the nineteenth century, masturbation was considered pathological, and many professionals wrote cautionary books, papers, and pamphlets about its deleterious effects. Modern psychiatrists consider it harmless and endorse it as a safety valve for excessive sexual tension. During the Stalinist era, psychiatrists in Russia declared neuroses and sexual deviations to be products of class conflicts and the deteriorated morals of bourgeois society. They claimed that problems of this kind had practically disappeared with the change in their social order. Patients exhibiting such symptoms were seen as partisans of the old order and "enemies of the people." Conversely, in more recent years it has become common in Soviet psychiatry to view political dissidence as a sign of insanity requiring psychiatric hospitalization and treatment. In the United States, homosexuality was defined as mental illness, until 1973 when the American Psychiatric Association decided by vote that it was not. The members of the hippie movement in the sixties were seen by traditional professionals as emotionally unstable, mentally ill, and possibly brain-damaged by drug use, while the New Age psychiatrists and psychologists considered them to be the emotionally liberated avant-garde of humanity. We have already discussed the cultural differences in concepts of normalcy and mental health. Many of the phenomena that Western psychiatry considers symptomatic of mental disease seem to represent variations of the collective unconscious, which have been considered perfectly normal and acceptable by some cultures and at some times in human history.
Psychiatric classification and emphasis on presenting symptoms, although problematic, is somewhat justifiable in the context of the current therapeutic practices. Verbal orientation in psychotherapy offers little opportunity for dramatic changes in the clinical condition, and suppressive medication actively interferes with further development of the clinical picture, tending to freeze the process in a stationary condition. However, the relativity of such an approach becomes obvious when therapy involves psychedelics or some powerful experiential nondrug techniques. This results in such a flux of symptoms that on occasion the client can move within a matter of hours into an entirely different diagnostic category. It becomes obvious that what psychiatry describes as distinct diagnostic categories are stages of a transformative process in which the client has become arrested.
The situation is scarcely more encouraging when we turn from the problem of psychiatric diagnosis to psychiatric treatment and evaluation of the results. Different psychiatrists have their own therapeutic styles, which they use on a wide range of problems, although there is no good evidence that one technique is more effective than another. Critics of psychotherapy have found it easy to argue that there is no convincing evidence that patients treated by professionals improve more than those who are not treated at all or who are supported by nonprofessionals (Eysenck and Rachman 1965). When improvement occurs in the course of psychotherapy, it is difficult to demonstrate that it was directly related either to the process of therapy or to the theoretical beliefs of the therapist.
The evidence for the efficacy of psychopharmacological agents and their ability to control symptoms is somewhat more encouraging. However, the critical issue here is to determine whether symptomatic relief means true improvement or whether administration of pharmacological agents merely masks the underlying problems and prevents their resolution. There seems to be increasing evidence that in many instances tranquilizing medication actually interferes with the healing and transformative process, and that it should be administered only if it is the patient's choice or if the circumstances do not allow pursuit of the uncovering process.
Since the criteria of mental health are unclear, psychiatric labels are problematic, and since there is no agreement as to what constitutes effective treatment, one should not expect much clarity in assessing therapeutic results. In everyday clinical practice, the measure of the patient's condition is the nature and intensity of the presenting symptoms. Intensification of symptoms is referred to as a worsening of the clinical condition, and alleviation of symptoms is called improvement. This approach conflicts with dynamic psychiatry, where the emphasis is on resolution of conflicts and improvement of interpersonal adjustment. In dynamic psychiatry, the activation of symptoms frequently precedes or accompanies major therapeutic progress. The therapeutic philosophy based primarily on evaluation of symptoms is also in sharp conflict with the view presented in this book, according to which an intensity of symptoms indicates the activity of the healing process, and symptoms represent an opportunity as much as they are a problem.
Whereas some psychiatrists rely exclusively on the changes in symptoms when they assess therapeutic results, others include in their criteria the quality of interpersonal relationships and social adjustment. Moreover, it is not uncommon to use such obviously culture-bound criteria as professional and residential adjustment. An increase in income or moving into a more prestigious residential area can thus become important measures of mental health. The absurdity of such criteria becomes immediately obvious when one considers the emotional stability and mental health of some individuals who might rank very high by such standards, say, Howard Hughes or Elvis Presley. It shows the degree of conceptual confusion when criteria of this kind can enter clinical considerations. It would be easy to demonstrate that an increase of ambition, competitiveness, and a need to impress reflect an increase of pathology rather than improvement. In the present state of the world, voluntary simplicity might well be an expression of basic sanity.
Since the theoretical system presented in this book puts much emphasis on the spiritual dimension in human life, it seems appropriate to mention spirituality at this point. In traditional psychiatry, spiritual inclinations and interests have clear pathological connotations. Although not clearly spelled out, it is somehow implicit in the current psychiatric system of thought that mental health is associated with atheism, materialism, and the world view of mechanistic science. Thus, spiritual experiences, religious beliefs, and involvement in spiritual practices would generally support a psychopathological diagnosis.
I can illustrate this with a personal experience from the time when I arrived in the United States and began lecturing about my European LSD research. In 1967, I gave a presentation at the Psychiatric Department of Harvard University, describing the results achieved in a group of patients with severe psychiatric problems treated by LSD psychotherapy. During the discussion, one of the psychiatrists offered his interpretation of what I considered therapeutic successes. According to his opinion, the patients' neurotic symptoms were actually replaced by psychotic phenomena. I had said that many of them showed major improvement after undergoing powerful death-rebirth experiences and states of cosmic unity. As a result, they became spiritual and showed a deep interest in ancient and Oriental philosophies. Some became open to the idea of reincarnation; others became involved in meditation, yoga, and other forms of spiritual practices. These manifestations were, according to him, clear indications of a psychotic process. Such a conclusion would be more difficult today than it was in the late sixties, in light of the current widespread interest in spiritual practice. However, this remains a good example of the general orientation of current psychiatric thinking.
The situation in Western psychiatry concerning the definition of mental health and disease, clinical diagnosis, general strategy of treatment, and evaluation of therapeutic results is rather confusing and leaves much to be desired. Sanity and healthy mental functioning are defined by the absence of psychopathology and there is no positive description of a normal human being. Such concepts as the active enjoyment of existence, the capacity to love, altruism, reverence for life, creativity, and self-actualization hardly ever enter psychiatric considerations. The currently available psychiatric techniques can hardly achieve even the therapeutic goal defined by Freud: "to change the excessive suffering of the neurotic into the normal misery of everyday life." More ambitious results are inconceivable without introducing spirituality and the transpersonal perspective into the practice of psychiatry, psychology, and psychotherapy.
Psychiatry and Religion: Role of Spirituality in Human Life
The attitude of traditional psychiatry and psychology toward religion and mysticism is determined by the mechanistic and materialistic orientation of Western science. In a universe where matter is primary and life and consciousness its accidental products, there can be no genuine recognition of the spiritual dimension of existence. A truly enlightened scientific attitude means acceptance of one's own insignificance as an inhabitant of one of the countless celestial bodies in a universe that has millions of galaxies. It also requires the recognition that we are nothing but highly developed animals and biological machines composed of cells, tissues, and organs. And finally, a scientific understanding of one's existence includes acceptance of the view that consciousness is a physiological function of the brain and that the psyche is governed by unconscious forces of an instinctual nature.
It is frequently emphasized that three major revolutions in the history of science have shown human beings their proper place in the universe. The first was the Copernican revolution, which destroyed the belief that the earth was the center of the universe and humanity had a special place within it. The second was the Darwinian revolution, bringing to an end the concept that humans occupied a unique and privileged place among animals. Finally, the Freudian revolution reduced the psyche to a derivative of base instincts.
Psychiatry and psychology governed by a mechanistic world view are incapable of making any distinction between the narrow-minded and superficial religious beliefs characterizing mainstream interpretations of many religions and the depth of genuine mystical traditions or the great spiritual philosophies, such as the various schools of yoga, Kashmir Shaivism, Vajrayana, Zen, Taoism, Kabbalah, Gnosticism, or Sufism. Western science is blind to the fact that these traditions are the result of centuries of research into the human mind that combines systematic observation, experiment, and the construction of theories in a manner resembling the scientific method.
Western psychology and psychiatry thus tend to discard globally any form of spirituality, no matter how sophisticated and wellfounded, as unscientific. In the context of mechanistic science, spirituality is equated with primitive superstition, lack of education, or clinical psychopathology. When a religious belief is shared by a large group within which it is perpetuated by cultural programming, it is more or less tolerated by psychiatrists. Under these circumstances, the usual clinical criteria are not applied, and sharing such a belief is seen as not necessarily indicative of psychopathology.
When deep spiritual convictions are found in non-Western cultures with inadequate educational systems, this is usually attributed to ignorance, childlike gullibility, and superstition. In our own society, such an interpretation of spirituality obviously will not do, particularly when it occurs among well-educated and highly intelligent individuals. Consequently, psychiatry resorts to the findings of psychoanalysis, suggesting that the origins of religion are found in unresolved conflicts from infancy and childhood: the concept of deities reflects the infantile image of parental figures, the attitudes of believers toward them are signs of immaturity and childlike dependency, and ritual activities indicate a struggle with threatening psychosexual impulses, comparable to that of an obsessive compulsive neurotic.
Direct spiritual experiences, such as feelings of cosmic unity a sense of divine energy streaming through the body, death-rebirth sequences, visions of light of supernatural beauty, past incarnation memories, or encounters with archetypal personages, are then seen as gross psychotic distortions of objective reality indicative of a serious pathological process or mental disease. Until the publication of Maslow's research, there was no recognition in academic psychology that any of these phenomena could be interpreted in any other way. The theories of Jung and Assagioli pointing in the same direction were too remote from mainstream academic psychology to make a serious impact.
In principle, Western mechanistic science tends to see spiritual experiences of any kind as pathological phenomena. Mainstream psychoanalysis, following Freud's example, interprets the unifying and oceanic states of mystics as regression to primary narcissism and infantile helplessness (Freud 1961) and sees religion as a collective obsessive-compulsive neurosis (Freud 1924). Franz Alexander (1931), a very well-known psychoanalyst, wrote a special paper describing the states achieved by Buddhist meditation as self-induced catatonia. The great shamans of various aboriginal traditions have been described as schizophrenic or epileptic, and various psychiatric labels have been put on all major saints, prophets, and religious teachers. While many scientific studies describe the similarities between mysticism and mental disease, there is very little genuine appreciation of mysticism or awareness of the differences between the mystical world view and psychosis. A recent report of the Group for the Advancement of Psychiatry described mysticism as an intermediate phenomenon between normalcy and psychosis (1976). In other sources, these differences tend to be discussed in terms of ambulant versus florid psychosis, or with emphasis on the cultural context that allowed integration of a particular psychosis into the social and historical fabric. These psychiatric criteria are applied routinely and without distinction even to great religious teachers of the scope of Buddha, Jesus, Mohammed, Sri Ramana Maharishi, or Ramakrishna.
This results in a peculiar situation in our culture. In many communities considerable psychological, social, and even political pressure persists, forcing people into regular attendance at church. The Bible can be found in the drawers of many motels and hotels, and lip service is paid to God and religion in the speeches of many prominent politicians and other public figures. Yet, if a member of a typical congregation were to have a profound religious experience, its minister would very likely send him or her to a psychiatrist for medical treatment.
1. The term disease, or nosological unit (from the Greek nosos, "disease"), has a very specific meaning in medicine. It implies a disorder that has a specific cause, or etiology, from which one should be able to derive its pathogenesis, or the development of symptoms. An understanding of the disorder in these terms should lead one to specific therapeutic strategies and measures, and to prognostic conclusions. (back)
2. The principle of the intensification of symptoms is essential for psychedelic therapy, holonomic integration, and Gestalt practice. The same emphasis also governs the practice of homeopathic medicine and can be found in Victor Frankl's technique of paradoxical intention . (back)
3. Lobotomy is a psychosurgical procedure that in its crudest form involves severing the connections between the frontal lobe and the rest of the brain. This technique, for which the Portuguese surgeon Egas Moniz received the 1949 Nobel prize, was initially used widely in schizophrenics and severe obsessive-compulsive neurotics. Later, it was abandoned and replaced by more subtle microsurgical in terventions. The significance of irrational motifs for psychiatry can be illustrated by the fact that some of the psychiatrists who did not hesitate to recommend this operation for their patients later resisted the use of LSD on the premise that it might cause brain damage not detectable by present methods. (back)
4. A detailed discussion of the problems related to psychiatric diagnosis, definition of normalcy, classification, assessment of therapeutic results, and related issues is not possible here. The interested reader will find more relevant information in the works of Donald Light (1980), Thomas Scheff (1974), R. L. Spitzer and P. T. Wilson (1975), Thomas Szasz (1961), and others. (back)
Alexander, F. 1931. "Buddhist Training as Artificial Catatonia." Psychoanalyt. Rev., 18: 129.
Freud, S. 1924. "Obsessive Acts and Religious Practices." Collected Papers vol. 6, Institute of Psychoanalysis. London: The Hogarth Press and the Institute of Psychoanalysis, 1952.
— 1961. Civilization and its Discontents. Standard Edition, vol. 21. London: The Hogarth Press
Group for the Advancement of Psychiatry, Committee on Psychiatry and Religion. 1976. "Mysticism: Spiritual Quest or Psychic Disorder?" Washington, D.C.
Light, D. 1980. Becoming Psychiatrists. New York: W.W. Noroton &Co.
Rosenhan, D. 1973. "On Being Sane in Insane Places." Science 179: 250.
Scheff, T.J. 1974. "The Labeling Theory of Mental Illness." Amer. Sociol. Rev. 39: 444