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