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."[1] 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.[2]
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.
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.[3]
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.
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.[4] 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.
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