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 Scheft (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-gard 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.