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