Spirituality and the Healthy Mind: Science, Therapy, and the Need for Personal Meaning

Spirituality and the Healthy Mind

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Spirituality and the Healthy Mind Science, Therapy, and the Need for Personal Meaning

MARC GALANTER, M . D .

OXPORD UNIVERSITY PRESS

2005

OXFORD UNIVERSITY PRESS

Oxford University Press, Inc., publishes works that further Oxford University's objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright © 2005 by Marc Galanter Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Galanter, Marc. Spirituality and the healthy mind : science, therapy, and the need for personal meaning / Marc Galanter p. cm. Includes bibliogrpahical references. ISBN-13: 978-0-19-517669-8 ISBN-io: 0-19-517669-3 i. Psychotherapy—Religious aspects. 2. Spiritual healing. 3. Spirituality. [DNLM: i. Psychotherapy—methods. 2. Spirituality. 3. Spiritual Therapies—methods. 4. Spiritual Therapies—psychology. WM 420 &47S 2005] I. Title. RC489.S676G34 2005 6i6.89'i4—dc22 2004025222

9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper

In Memory of Wynne

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Prologue

One man tells me that he used a meditation technique taught him by an Indian guru in a "knowledge session" some 30 years before. He said that "the knowledge gives you a kind of consciousness that frees you from the drama of everyday life. You're in life, but not affected by everything that goes on around you." A woman was a falling-down drunk 20 years ago, and despite a bout of psychotherapy felt humiliated and depressed. On the advice of a friend she went to an Alcoholics Anonymous (AA) meeting. Now, long abstinent, she is at peace with herself and explains that "I have a hard time with organized religion. But I feel that's a very different thing from AA's spiritual connection with a higher power." These are two of the people whom I have spoken with who reported the role of spirituality in their lives. Clinicians may employ spiritually related issues in their practices as well. One teacher of psychiatric residents explained how he tries to generate a sense of purpose in his patients: "Very often people with depression come in one way or other expressing 'What's the point?' My response is 'Wonderful question. What is the point? Let's find out. Let's talk about it. Let's understand what endows your life with some meaning.' Spirituality can offer these people a sense of purpose and a reason to move forward in life." Another psychiatrist was less sensitive: A woman who had suffered

from chronic and unabating depression committed suicide, and her father was first told of her death by her psychiatrist. In his despair, the only response the father could give at the moment was, "This must be God's will," to which the psychiatrist replied, "It's magical thinking like that that led to your daughter's suicide." In the last half century there have been remarkable advances in medications and in brief, structured psychotherapies to treat psychiatric problems. In a way previously unimaginable, these have helped to allay specific symptoms that cause many people distress. But over the same period there has also been something of a cultural revolution—one that might be considered spiritual in nature—in the way many people come to feel why they are here in the world and what they want beyond the material and practical. These people may turn to their religious roots to find out how a spiritual orientation can help them gain relief from their emotional problems. Others turn to philosophies from the East, to humanistic traditions, and even to upstart therapies. Both trends, one research-based and the other spiritual in nature, bear directly on problems that the mental health profession is meant to address. These trends may move in parallel, or they may diverge, even coming into conflict with each other. In either case, there is a gulf between what scientifically grounded treatments do to allay specific symptoms nowadays and what imagination, compassion, and belief can offer in making people's lives worthwhile. This is why psychiatry, which benefits from empirical research, and spirituality, which expresses people's existential needs, are at a crossroads. They can exist apart from each other or they can be integrated in a way to help people better find relief from unhappiness and achieve a life that is meaningful to them as well. Since there is no single way to look at the possibility of reconciliation between these two perspectives, it seemed reasonable to begin this book by describing how my own interest in the issue emerged. My psychiatric training and a stint at the National Institute of Mental Health (NIMH) some decades ago made it clear that research into the physiology of mental function is a potent tool for developing ways to allay people's emotional problems, but around that same time the counterculture was in full swing. Young people were turning against traditional political, social, and religious values, and this was transforming the way a generation of Americans was coming to understand what might be meaningful for viii

Prologue

them. Many were searching for something to transform or replace the personal commitments they had been raised with and had lost track of. I decided to study one aspect of this transformation while at the NIMH, the way marijuana, the elixir of that generation, affected people's thinking. Along with colleagues, I measured physiologic responses in the lab and social interactions in a group setting.1 As this work progressed, it became clear that one could systematically research the encounter between the science of the brain and people's need to find entry into their own personal worlds. Psychiatry at that time was awakening to the need to treat alcohol and drug problems, and under a grant from the NIMH designated for teaching about addiction treatment, I began to study the nature of consciousness in relation to drug intoxication.2 But when more practical needs intervened it became clear that the spiritual fellowship of AA was the only tool available at the time to help alcoholic people sustain their recovery. While I was doing this teaching, a friend suggested I look into the nature of one of the cultic youth movements that had recently come to public attention. The results of a series of studies made clear that these groups drew on recruits' needs for something they could believe in at a time when they were in a transition that was undermining their traditional family ties and religious roots. In one study it emerged that the likelihood of adopting the spiritual philosophy of such movements was directly proportional to the alienation and unhappiness potential recruits reported before entering the group's workshops.3 In applying a similar methodology to AA members, my colleagues and I found out how a benign and thoughtfully constructed social movement could also achieve a degree of transformation in turning around alcoholics' denial of their addiction.4 It became clear that when distressed, people have an innate inclination toward accepting some sort of ideologic or spiritual commitment, one that can transform them in ways that could be studied in a systematic way. So with colleagues at New York University (NYU) and its affiliate Bellevue Hospital, I went on to see if these wellsprings of spirituality and personal meaning could be drawn on to develop an organized treatment approach to help rehabilitate our indigent, addicted patients. We were able to frame a treatment system in which the commitment seen in AA was infused into our secular hospital-based services for mentally ill addicted patients.5 Prologue

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We then evaluated these patients , the folks who you could see panhandling on the street or dealing drugs to buy whatever alcohol, cocaine, or heroin they could garner. The results were quite striking.6 The patients rated spiritual issues more highly in their potential to help them achieve recovery than they did the practical ones, such as medical, rehab, and social services. Our staff, on the other hand, whom we studied at the same time, indicated in their responses that the practical options, not the spiritual ones, were the most important and thought that the patients would answer that way as well. It was becoming clear that psychiatry might be missing the mark on what people wanted from us. It was as if we were doling out aspirin to people who wanted redemption. An irony became evident in the direction psychiatry was going. A national leader in the mental health field7 had just documented how psychotherapy of any kind had fallen into a marked decline in psychiatric residencies over recent decades. There was even an ongoing debate over the merit of providing any training at all on how to help psychiatrists understand and work with their patients' personal conflicts.8 Furthermore, in my division at NYU we were studying how insurance companies were undermining the provision of all but the most limited rehabilitative services: in the 1990s there had been a 52% cutback in available insurance funding for general mental health treatment and a 75% decline in support for addiction rehabilitation.9 It seemed that psychiatry was moving away from its traditional healing and caring role and becoming increasingly committed to the pharmacologic advances and brief therapies it had developed. These latter options were beneficial in their own right, but they did not necessarily help people rebuild lives that had been compromised by the very problems the profession was supposed to address. People were now spending more money on alternative medicine—treatments based on a personal, often spiritual, commitment to medically unproven techniques—than on traditional ambulatory medical care.10 Could some rethinking of this divergence of two important ways of dealing with people's distress—symptom relief and the pursuit of what is personally meaningful—be achieved? Could psychiatry reclaim some of the immediacy of the healer's relationship with the healed that physicians had so long employed? This seemed to be an issue worth considering. x

Prologue

Acknowledgments

This book benefited from the opportunity to videotape extensive interviews with a variety of mental health professionals, clerics, patients, and lay people. Particular appreciation is due Shridhar Sharma, Nimesh Desai, Peter Geerlings, Tarek Gawad, Edward Hanzelik, and Paul Steinke, who were kind enough to help in making these arrangements. I have changed the names and identifying information of all of the parties whose personal lives are discussed in this book. At the Albert Einstein College of Medicine Drs. Jack Wilder and Byram Karasu directed the facilities I worked in. At New York University Drs. Robert Cancro, Steven Katz, and Manuel Trujillo were likewise responsible. My work was carried out because of their having contributed to these academic settings. To these leaders in American psychiatry I owe appreciation. Dr. Helen Dermatis and my fellows and academic colleagues collaborated with me on the research conducted. Kristin Frillmann played an invaluable role in preparing this manuscript, and appreciation is due Fiona Stevens, my editor.

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Contents

PART I WHAT IS SPIRITUALITY? 1. Spirituality Emerges 5 2. A Psychological Perspective 12 3. Spirituality and the Brain 31 PART II THE IMPACT OF CULTURE 4. The Apparent Conflict 49 5. Problems with Spirituality 68 6. When Something Is Missing 94 PART III VARIETIES OF SPIRITUAL EXPERIENCE 7. Christian Psychiatry 113 8. Spirituality in India 128 9. Liberal Islam 143 10. Hospital Chaplaincy: Confronting Illness and Death 149 PART IV SPIRITUAL RECOVERY MOVEMENTS 11. Alternative Medicine 159 12. Alcoholics Anonymous 171 PART V THERAPY OF A DIFFERENT KIND 13. Rethinking Care of the Mentally 111 189 14. A Shaman in the Halls of Medicine 214

15- Meditation 223 16. Psychotherapy for Personal Meaning 232 Epilogue 247 Notes 253 References 263 Index 279

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Spirituality and the Healthy Mind

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PART I

What Is Spirituality?

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eople in all cultures seek out meaning beyond the material, usually within the context of religious practice, but when longstanding religious traditions are found to be unfulfilling, marked changes in belief and practice may come about. In the eighteenth century the Great Awakening heralded the emergence of Baptist revivalism throughout the American colonies, as the traditional churches of Europe came to be seen as lifeless and impersonal. In the early twentieth century a reaction to the prevailing Christian theology led to a Fundamentalist revival that embodied the belief that people could be "born again" in anticipation of the Second Coming. We may now be in the midst of another transformation, the emergence of spirituality as a way for many people to meet their need for a meaningful life. The following chapters describe how and why this cultural transition has taken place. This is considered from a psychological perspective, since this development has been intertwined with evolving models of mental function and psychotherapy. And since mind and brain are not unrelated, it will also be considered in light of emerging research that sheds light on the neurophysiology that underlies spiritual experiences. It might come as a surprise to many psychiatrists that a large majority (84%) of Americans believe that prayer for others can have a positive effect on their recovery from illness. Many of the "disorders"

that psychiatry has described in its lexicon would be considered by these people to reflect a spiritual deficit as much as a problem in the mental health profession's domain. One psychiatrist, on the other hand, described for me how he is able to bridge the spiritual and biomedical in his work. He said "You might conclude that some larger hand is operative that makes sense of the mystery of the universe. I don't necessarily conclude that, but instead I find a pervasive and profound sense of the spiritual in things. That way I can respect the meaning of a person's experiences, as opposed to just saying they're a symptom of mental problems, and all we have to do is give some medicine to get rid of it."

4

What Is Spirituality?

1

Spirituality Emerges

S

o you're writing a book on spirituality. What is spirituality?" my friend asked. He is a psychiatrist steeped in the science of the mind, and the word spirituality seemed too vague to him for a serious undertaking. But as we spoke further we agreed that our patients needed something to give meaning to their troubled lives. For many of them, this could be worldly, such as a fulfilling relationship, a better job, or just relief from chronic depression. But spirituality transcends this. The dictionary defines it with phrases such as "not tangible or material," "concerned with or affecting the soul," and "pertaining to God." We can think of it as a search for existential or transcendent meaning. It can be achieved through religious affiliation, or independently of one as well. It is compatible with the religious pluralism that has emerged in recent decades, as tolerance for diverse beliefs has become part of our common culture. Even many people who are committed to formal religious practice are open to those who are not. Spirituality is a highly personal issue, and each person is his or her own expert on its definition. Because of this, we should attend to what people say for themselves, and here is what three of them, of the many I have asked, have said of it. Dominic was born in a small Catholic enclave in Pakistan, where his forebears were converted to Christianity by Portuguese missionaries. He was ordained a priest in a seminary in Lahore and first encountered "

5

the term spirituality in the class of an American professor in Rome while studying for a doctorate in canon law. He pointed out the personal nature of the word: Spirituality is a way of life. Actually, there's no definition, and it's different for each person. The way you have experience, the way you study, the way you live, the way you understand, and the way you act; that is called spirituality. Naomi, a Conservative Jewish rabbi, had served as a chaplain in a hospice for terminally ill patients and was now apprenticed to train other chaplains. She thought for a few moments when asked for a definition and said: Spirituality is wrestling with and creating meaning in one's life, and that meaning can be broken at times, or can have a sense of wholeness at other times. I guess it's kind of existential, and feeling connected to others. If that happens to connect to a belief or an experience of a transcendent one, that's fine too, but that's not necessarily better. . . . It's like a community of people all wrestling together but not necessarily having the same answer. Members of Alcoholics Anonymous (AA) call their movement a spiritual fellowship, and in AA's Second Step they say they have come "to believe that a Power greater than ourselves" will help them stop drinking. So I asked Ann, a 20-year member, what AA's spirituality meant to her. She pointed to herself and said: Don't think that it's out there. That if you're good enough, if you're smart enough, if you do well enough, if you talk loud enough, you'll feel it because it's in here. I feel like I see things in life now that I didn't when I was a kid. I'm finding joy with people—that's something I think I probably feel more than almost anything. I have a hard time with a lot of organized religion. But I feel that that's a very different thing from a spiritual connection to a Higher Power. For these three people, experts in their own right, spirituality is allied to religion, but it is a thing apart, allied to other people but it is also

6

What Is Spirituality?

apart from everyday relationships. Although it was different for each of them, each knew what it meant to him or her personally. Clearly, spirituality is not easily encompassed by a singular definition, nor is it easily parsed and subjected to research, but it is very real for those who experience it. Spirituality and religion are deeply rooted in the American ethos. Fully 95% of people respond positively when asked if they believe in "God or a universal spirit," and this figure has remained almost constant since Gallup began polling on the issue more than 6 decades ago. A followup question suggests that this belief is an active one that affects the daily lives of the majority (51%) of Gallup's respondents, who said they had talked to someone about God or some aspect of their faith or spirituality within the past 24 hours.1 In addition to this longstanding orientation of the American public, there has been considerable interest in spiritual approaches to medical illness in recent years. Attention to Eastern healing practices, such as acupuncture from China, now entering into the mainstream of medical practice, and to Ayurvedic medicine from India, which espouses meditation and exotic diets, are examples of this. Holistic medicine reflects this trend as well, encompassing a variety of spiritually oriented approaches to the person as a whole, rather than just the carrier of a particular illness. Spirituality is illustrated as well in the healing of Twelve-Step programs such as AA. The commitment to espouse these latter spiritual fellowships has had a major impact on the way people have come to view illnesses of compulsive behavior.

Where Did the Idea Come From?

T

he term spirituality has now gained considerable currency in American culture. Celebrities avow their spiritual orientation, politicians justify their actions on spiritual grounds, and booksellers stock their shelves with little volumes of "daily affirmations." But use of the term has only recently become part of popular parlance, and only in relation to our contemporary pluralistic culture. In previous generations people found transcendence in the sectarian religious denominations into

Spirituality Emerges

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which they were born. The trappings of other religious groups were dismissed as misguided, even dangerous. "Spirits" were associated with seances, ghosts, and the netherworld. Nor does spirituality appear in anthropologic studies. "Spirits" are conjured up as ancestral figures that wield power in what some might call "primitive" societies. They are associated with shamanistic practices that we see as being quite different from our own. The contemporary perspective on spirituality became evident following the radical cultural transitions that took place in the United States over the latter part of the twentieth century. Traditional social moorings were shaken and dislodged, and people's need for transcendence emerged in new form. This took place decade by decade following the halcyon days of the "Eisenhower Era," on through the dramatic social changes of the counterculture, and then toward a tentative resolution on what is meaningful to people in the domain of personal belief. Consider the changes that disrupted established attitudes over this period in relation to religion, race, and ethnicity. In the 19505 people typically identified with their respective religious denominations and their own ethnic groups. They went to the church of their own historically defined denomination, almost always segregated by race. The religious divide between American Protestants and Catholics was clearly demarcated, and anti-Semitism was embedded in social practice. The longstanding culture of religious and racial segregation began to fall apart with struggles to assure the integration of public education and the voting rights of minorities. In the popular media movies such as Gentleman's Agreement and Guess Who's Coming to Dinner came to reflect a challenge to established religious and ethnically grounded biases. The American political consensus was falling apart as well. While the Korean War was being fought to prevent Red Chinese hegemony in Asia, the legitimacy of anti-Communism was not questioned. The nation's commitment to anti-Communism, caricatured in the witch hunts of the McCarthy era, abated. Opposition to the war in Vietnam was now tearing the country apart. The military draft was called into question by many American youth, and the collapse of Lyndon Johnson's presidency was followed by antiwar riots at the ensuing Democratic National Convention.

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What Is Spirituality?

Gender roles and sexual behaviors were also dramatically transformed. Widespread access to contraceptives led to the acceptance of premarital sexual intercourse. The women's movement began to erase distinctions between the sexes that had defined home life and work life for generations. The Stonewall Riots in New York's Greenwich Village presaged the acceptance of diversity in sexual orientation. The very definition of mom and dad and their kids, Dick and Jane, was now gone. Another dramatic change had taken place in how people assumed their identities of mature adults, as the developmental norms for adolescence were evolving. When the twentieth century began, people ended their education to begin work at a relatively young age. By the latter part of the century, adolescence was prolonged as parents ceded their children to liberal educational institutions where youths could devote themselves to contemplating their direction in life, even their life's very purpose. The demands of marriage and child rearing were deferred. Young people could now take advantage of these opportunities to move away from their families to other parts of the country and to find cultural relativism as they traveled across any continent they chose. Alcohol, America's drug of choice, had previously allowed people to escape by dulling their senses. Marijuana and the psychotomimetics now came into widespread use, allowing users to question the nature of their own perceptions. Drug use validated young people's giving up the accepted concepts of normalcy, even reality, that their parents had adhered to. They could now "tune in, turn on, and drop out." All this allowed them to participate in the social and personal transitions just described, to reflect on them, and to question personal values that had previously been accepted as a matter of course. This was also embodied in transitions in popular music, which now became noisy and socially disruptive. Bob Dylan's paean to ending the separateness among diverse peoples that could lead to war heralded an initial change: "How many seas must a white dove sail before she sleeps in the sand. . . . The answer, my friend, is blowin' in the wind." He soon relinquished his acoustic guitar to accept the electric amplification of the new rock music, itself derived from the collapse of traditional barriers between blacks and whites. His words would now convey the consequences of these cultural transitions for many youths who

Spirituality Emerges

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were spiritually bereft, whose emergent birthright of "finding oneself" created an anomie that left them adrift: You used to laugh about everybody that was hangin' out, but now you don't talk so loud; now you don't seem so proud. . . . How does it feel? How does it feel to be on your own with no direction home, a complete unknown, like a rollin' stone.

The Beginning of Cultural Reintegration

A

s is often the case, the leading edge of a cultural transition can be highly deviant. The cultic movements of the 19608 and 19705 emerged as early signs of reintegration around spiritual commitment. They benefited from the fact that their newly minted religious norms could generate relief from the anomie of the counterculture. Members of groups such as the Moonies, the Hare Krishnas, and—for their elders—Scientology reflected the aberrant consequences of a need to find definition, clarity, and strong and binding ties, which had been lost over the preceding decades. Intensity of commitment was based on deification of dubious leaders who laid claim to people's material assets, to their option to live as they chose, and even to their choice of mate; this was a radical response to the loss of family ties and traditional values. These new communities of belief, or ad hoc families, constituted by severing ties with the members' families of origin, gave expression to the need to feel a sense of rootedness. This initial radical response was soon superseded by the search for adaptations more consonant with traditional religious culture. For some this meant a return to Christian beliefs, in large and zealous congregations in megachurches with thousands in attendance, mainly in middle America. Fundamentalist belief offered both social stability and a relationship with a religious format that many of the maturing baby boomers' parents would have understood. For others it was a less well-defined disposition, one that drew on a variety of spiritual traditions and religions, one that reflected a desire to integrate diverse beliefs in a world made smaller by electronic media and international travel, and one that reflected the liberal education

10

What Is Spirituality?

that had framed the world view of many who were now seeking some sense of transcendence. Children of the counterculture generation could no longer sustain sectarian enmity as a cultural norm; they had seen and experienced too much. Now they would encompass an ecumenical view of life's purpose, one that legitimated the diversity their country now sanctioned. Spirituality, a seemingly vague term for the pursuit of personal meaning, fit the bill. It became a catchword to embody the psychological needs that previous generations had addressed under the banner of traditional religion. It even allowed for mutual respect, or at least guarded acceptance, of discourse between fundamentalists and secularists. It thereby provided a large tent that could house diverse views of transcendence and allow acknowledgment of a certain commonality across the country's many subcultures.

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2

A Psychological Perspective

M

ainstream psychiatrists are, to say the least, reluctant to consider a role for spirituality-oriented healing for their patients. The American Psychiatric Association's 1,070-page Essentials of Clinical Psychiatry1 makes no mention of it. The term spirituality actually did make its way into the organization's nomenclature, but only "when the focus of clinical attention is a religious or spiritual problem,"2 hardly a positive view on the matter.

Spirituality as an Intense Personal Experience

S

piritual renewal clearly has a resonance for many people as important, even central, to their psychological well-being. For some it may be felt as members of a church, as part of their lifelong religious affiliation. For others it may emerge later in life with an intensity that yields a new look on their place in the world. St. Paul saw a blinding light while on the way to Damascus and then underwent baptism, embarking on years of learning about the nascent Christian faith and preaching to its converts. The psychological issues we will consider here can be highlighted by such intense, sometimes spontaneous, personal encounters, and experiences like his, of course, abound throughout history. They are regularly recounted by people "born again" into faith for whom

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an intense spirituality becomes a central part of their religious life. In fact, fully 40% of Americans consider themselves born-again Christians.3 Descriptions of religious intensity in the psychological literature date back to 1902, when William James, considered the father of modern psychology, derided a simplistic medical view of these revelatory phenomena: Medical materialism finishes up St. Paul by calling his vision on the road to Damascus a discharging lesion of the occipital cortex, he being an epileptic. It snuffs out St. Teresa as a hysteric, St. Francis of Assisi as a hereditary degenerate.4 James drew on these awakenings and those of his students as evidence of the psychological validity of religious faith in his seminal work, The Varieties of Religious Experience. He posited that introspection into religious experiences could provide evidence of the way the mind operates. In doing this, he legitimated these phenomena as a valid dimension of his academic discipline. The intensity of such spiritual experiences was dramatized for me early on when I began to do research on cultic youth movements in the 19708.1 encountered converts to a sect that had emerged from India and met a young, sensible American-born physician who had joined the group. As is often the case, his intense experience came as a surprise to him at the time. As he said, "I realized that something had happened to me that I couldn't dismiss." While working at a small-town clinic far from the urban setting he came from, he began to question the direction he was pursuing in life and was becoming disillusioned with his work. He accepted an invitation from a friend to attend a satsang, a religious sermon of the Divine Light Mission. The group consisted mainly of young adults, followers of an Indian guru who had come to the United States not long before. The young doctor found himself sitting among a dozen people listening to a woman convert extolling the guru's wisdom. As he was somewhat cynical himself, he paid little attention to what she was saying but glanced up at one point and saw a bright light forming a halo around her. Members of the group had spoken about the "Divine Light," but it had not occurred to him that this referred to an actual vision. He told me that he did a double take, but the vivid halo remained. A Psychological Perspective

13

As he left the satsang, he turned back and found the illumination still there. At that moment he decided that the experience could not be dismissed and that it would somehow influence the course of his life. He soon joined the movement and began to build his life around its spiritual orientation. At first he tried to recruit new members in his medical clinic. He got little response, as people thought his pleas reflected a measure of derangement more than a spiritual awareness. He then decided to keep his experience to himself but still kept close ties to the sect, living close to other converts but giving no indication to coworkers of the experience that had changed his life. The work of psychologist Abraham Maslow,5 who wrote in the midtwentieth century, a more secular era than James's, might be drawn on to shed some light on this physician's experience. Maslow spoke of a hierarchy of needs that people have, and it is only after safety, belongingness, and self-esteem are achieved that self-actualization, the highest of these needs, is addressed. This follower of the guru was apparently seeking such actualization, and his vision (as it were) of the Divine Light set him along such a course. Maslow considered the intense phenomena described by James and associated them with "peak experiences," ones which may be unrelated to formal religious affiliation but are nonetheless marked by feelings of wholeness of an almost mystical nature. Like James, he related how these experiences were reported by historical figures who spoke of their personal illumination, and also interviewed people who he felt had attained an exceptional degree of self-actualization. He lent a more contemporary credibility to the perspective that intense spirituality need not be characterized by visions or paranormal phenomena, but more by a heightened sense of fulfillment. He was also quite comfortable with a secular humanism that many contemporary devout Christians now find unappealing.

Evolution of a Psychoanalytic Perspective

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sychoanalysts with a positive attitude toward spirituality have had to work their way around the views of their progenitor, Sigmund Freud. Around the same time that William James championed the mean14

What Is Spirituality?

ingfulness of religious experience, Freud, himself experienced in physiologic research, was inclined to invalidate spirituality and religion as having no part in a healthy and mature adaptation. He ascribed religion to a neurotic perspective rooted in unresolved childlike fixations.6 We can only speculate as to why he was adamant on this issue: perhaps because of his orientation toward biologic science, perhaps because of his reaction to the anti-Semitism he encountered in his native Vienna, or maybe because of the antireligious philosophical writings of Central European philosophers such as Hegel and Schopenhauer. In any case, he spoke of religion as an illusion that operated outside empirical observation, even as a mass delusion, and his strongly held views were instrumental in the disavowal of religious experience within the psychoanalytic movement. Early on, however, views were expressed within the psychoanalytic mainstream that ran counter to Freud's bias. Oskar Pfister, a Lutheran pastor and psychoanalyst, was a longtime friend of Freud's. He emphasized the meaningful nature of religion as a unifying vision of the world, one that transcended the uncertainties of life and encouraged ethical responsibility.7 But the most elaborately thought out and well-developed psychoanalytic alternative to the established Freudian view emerged in the writings of Carl Gustav Jung. Jung was the son of a parson in the Swiss Reformed Church and studied psychiatry so that he could combine both his spiritual and scientific interests. He was 19 years Freud's junior and was allied with him early in his career, even becoming a leader among Freud's followers. He later parted ways with Freud, having come to differ with his mentor's stark empiricism and emphasis on sexuality rather than people's higher spiritual values. He accepted the concept of an irrational personal unconscious but came to believe in a collective unconscious, positing the existence of innate mental constructs, archetypes—primordial images that existed in all individuals. These serve as the basis for elaborating the diverse religious imagery and myths that arise across different cultures.8 Jung did not ascribe validity to a particular creed or to membership in any specific organized religion, but instead believed that his perspective took into account the full range of spiritual experiences, including people's acceptance of a godhead. He viewed the self as lying midway between the unconscious and consciousness and pointed out A Psychological Perspective

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that a person has to make peace with his or her spiritual nature in order to establish meaning and find comfort in life. Both Freud and Jung considered spirituality relative to people's psychological makeup. For Freud this was based on instinctually grounded, infantile drives that were biologically based. A person had to overcome these drives with the competency acquired during maturation and with the acquisition of the civilizing values of a culture that governs behavior. Psychoanalysis would liberate people from the neurotic views fueled by these drives. Jung's model, on the other hand, posited a collective unconscious that could mature into a constructive spiritual orientation. He saw psychotherapy as the means of helping people achieve this enlightenment. Another perspective, one that emerged in the second half of the twentieth century, emphasized the role of interpersonal relationships in shaping human experience. These object relations were understood to originate in the interaction between infant and mother and eventually evolve into the basis of relating to other people in an independent way. D. W. Winnicott, a psychoanalyst who began his medical career as a pediatrician, spoke of transitional objects, such as a baby's security blanket, that bridge the infant's fixation on the maternal breast to an engagement with the world at large.9 Such transitional objects embody the magical relationship between infant and feeding mother, given an implicit understanding that the literal breast will be there when the infant needs fulfillment. In coping with the demands of adaptation, the infant, and later the adult, subjects his or her perceptions to reality testing, logic we define as objective and valid. This entails measuring distances, obtaining material needs, even judging other people's motives. For Winnicott, another domain emerges in the infant and is later transformed in adult life. It is in the transitional divide between reality and subjectivity where the objectivity of photographs and micrometers do not apply. An artistic image—a floating angel, the spirit of a voodoo mask—these have reality in this domain, even if they are not seen in nature. This transitional divide, Winnicott wrote, matures into the domain in which the arts and creativity—as well as religion—emerge. Winnicott's conception was later elaborated on in a way that is relevant to our thinking about spirituality by Ana-Maria Rizzuto, a psycho16

What Is Spirituality?

analyst and a religious woman as well.10 She focused on qualities in this transitional realm, pointing out that people's conception of God and spirituality emerged from that transitional domain. She emphasized that the acceptance of this perspective implies neither the existence nor the nonexistence of an actual deity, but only a psychological realm in which people's spiritual nature operates. One of her case histories illustrates this well. She described her psychoanalysis of Laura, who grew up in an entirely nonreligious family and suffered greatly from a troubled relationship with her parents. Her mother humiliated her, deriding her appearance and poor school performance. Her father slighted her and was involved mainly with her mother in a glamorous social milieu. Although Laura was 2i-years-old when she entered analysis, the parents tried to control the treatment, even to the point of hiring an investigator to ferret out anything that might be compromising to Rizzuto herself. As Laura progressed in her treatment, she was able to resolve the stormy parental transference she felt toward Rizzuto and achieved an emotional distance from her parents. At the same time she began to declare a belief in God, something that had been alien to her and her family before, and started practicing rituals from her family's Jewish background. Rizzuto pointed out that Laura's case illustrated the opening up of the "transitional space" created upon Laura's separation from her parents, into which a belief in God as a vibrant force could find its way. This space had been created within her much as the infant experiences a space for nascent illusionary experience in separating from its mother.

A Values Orientation

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pirituality can be experienced from either a secular or religious standpoint. The secular is manifest in an emphasis on the place of values in a spiritual orientation, rather than theistic or formally religious beliefs. One early presentation of this secular option was made by William James in his Varieties of Religious Experience, in which Walt Whitman is described as "the restorer of the eternal natural religion." James was deeply impressed by Whitman's classic work "Song of Myself," in which the poet declared himself the symbolic representative of the common man: A Psychological Perspective

17

I could turn and live with animals, they are so placid and selfcontained, I stand and look at them long and long; They do not sweat and whine about their condition. They do not lie awake in the dark and weep for their sins. Not one is dissatisfied, not one is demented with the mania of owning things, Not one kneels to another, nor to his kind that lived thousands of years ago, Not one is respectable or unhappy over the whole earth. James goes on to cite R. M. Bucke, an early biographer of Whitman, to clarify the nature of the poet's "natural religion": The only sentiments he allowed himself to express were of the expansive order; and he expressed these in the first person, not as your mere monstrously conceited individual might express them, but vicariously for all men, so that a passionate and mystic ontological emotion suffuses his words, and ends by persuading the reader that men and women, life and death, and all things are divinely good.11 In Whitman's time a puritanical American society found him highly controversial for his exaltation of the body and sexual love. He was, in fact, discharged from a job he had held for a time as a clerk in the U.S. Department of the Interior, as many people considered his work immoral. But Whitman's humanistic brand of natural religion came to be much more acceptable as the twentieth century progressed, when it was understood by many that spirituality need not be rooted in denominational religion dominated by doctrine. Two examples of this trend emerged in rather different contexts. One is illustrated in the approach of Eric Fromm, a psychoanalytic writer, and the other in the empirically driven, quantitative research of Gordon Allport, a university-based psychologist. Fromm was born into an orthodox Jewish family and witnessed World War I as a young man in his native Germany and World War II as a philosopher and psychoanalyst in the United States. These experiences and his understanding of existentialism and social psychology led him to a secularized view of

18

What Is Spirituality?

religion as a way of life.12 He described two types of religious orientation. The first promotes a respect for humanity, allowing the individual to achieve self-realization. It stands in contrast to an authoritarian religious outlook that demands obedience to achieve its politically oriented goals. Fromm supported the importance of a meaningful life imbued with the first of these orientations, one that allows a person to overcome the limitations of egotism and thereby feel love and exercise humility. This clearly brought him close to a humanistic spiritual view. Around the same time, Gordon Allport, respectful of the introspective approach of William James, tried to infuse his scientific approach to the measurement of personality traits with an understanding of the role of personal values in shaping the diversity of people's beliefs. Allport came from a Midwestern Protestant background and drew on both his deeply felt religious background and the academic psychology he espoused while teaching. Allport was critical of the psychological model based only on observed behavior that had taken hold among academics but avowed that research based on standardized questionnaires and statistical analysis could yield a valid way of understanding people's spiritual or religious values.13 He was able to demonstrate that his students at Harvard maintained a lasting religious orientation that reflected their family backgrounds. He measured the distinction between an intrinsic religious orientation, in which the individual employs internalized beliefs to achieve personal fulfillment, and an extrinsic one, whereby religion is employed to accomplish more practical ends, such as providing self-justification and social acceptance. For him, the mature individual has incorporated religious values and diverse elements of human experience into an intrinsically felt sense of purpose, one that that lends meaning to life. Allport observed that individuals' values are inevitably expressed in their respective approaches to treatment. Allen Bergin carried this further while teaching psychology at Brigham Young University, an institution affiliated with the Mormon Church. He has called for a restoration of a spiritual, or theistic, orientation in psychotherapy. He emphasizes the importance of recognizing that psychotherapy is not value-free and points out that acknowledgment of this can free psychology from a historic bias against religious and spiritual

A Psychological Perspective

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values. In this manner, he writes, an acknowledgment of the importance of issues such as people's spiritual needs can be used as a resource for psychotherapy.14 Airport's values-oriented view has been extended into a biological model by Daniel Batson,15 who had formal training in both theology and psychology. He writes of the pursuit of existential meaning leading people to join in religiously grounded communities, thereby supporting mutuality and altruism. He points out that this aspect of altruism is adaptive for the survival of a social group and has therefore been sustained over the course of evolution. This relates to the sociobiological model we shall consider soon, which posits that many behavioral traits are rooted in biology. This extension of the psychological perspective is quite important, because if there is a biological basis for humans' spiritual quest, we may then ask how it relates to the brain's operation. For now, it leads us to look at some aspects of group psychology.

Acquiring a Group's Spiritually Oriented Perspective

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ertain group settings are quite effective in drawing people into a spiritual orientation. In order to understand how this takes place, we can turn to a dramatic experiment of nature, one seen in the various cultic movements that have emerged in recent decades. Examples of these range from sects protected by their status as religions, such as the Unification Church (the Moonies) and the Hare Krishnas; small, highly sinister groups such as the Branch Davidians (who were immolated in Waco, Texas); Aum Shinrikyu (who spread poison gas in the Tokyo subways); and politically oppressed, spiritually oriented organizations, such as Falun Gang in China. What they have in common is their ability to bind people together with transcendental philosophies that run against the cultural mainstream and lead their members into long-term conformity with ritualized behavior. They are, one might say, spiritual movements in the extreme. In understanding them, however, we can also shed light on the way induction takes place in less intensive spiritual recovery movements. Some years back, I was able to study a cultic group that had attracted a large following of young adults, the Divine Light Mission. It offered a 20

What Is Spirituality?

remarkable opportunity to learn about the impact of a spiritual subculture on people's thinking. In the mid-1970s and 19808 cults that attracted teenagers and young adults were much in the public eye and highly controversial. People could not understand how they could engage these youths, typically drawn from the American mainstream. Furthermore, the tenacious commitment that the inductees sustained was inscrutable to their parents, who would usually grieve the loss of their children to what appeared to be a bizarre and alien culture. For me, access to this group represented a unique opportunity to study how social influence was generated in the context of a group's system of beliefs. This venture began when Beth, a physician friend of mine, called me one day while I was working at the National Institute of Mental Health in Washington. She invited me to go to a public event to hear a lecture from a 13-year-old guru she had adopted as a sacred teacher. After emigrating from India some years before, the guru had established the U.S. branch of the Divine Light Mission, a sect that his father led back home. Beth was unusually enthusiastic and said that the group's work would be of great relevance to psychiatry, so I decided to go. Although some of the guru's lieutenants spoke at the conclave, Maharaj-ji, the guru, did not appear. It was later reported that he had overslept while he and his mother were staying in a Washington suburb. A year later I had moved back to New York, and Beth again tried to enlist my interest. She invited me to one of the group's ashrams, or ritual residences, which was actually in a Manhattan apartment not far from my home. She was now serving as the guru's physician, and because she had issued the invitation, I was warmly received. At the ashram the intensity of the members' involvement was striking. One person, Janet, was most intriguing. She had been hospitalized a number of times for schizophrenia and had a history of agitated and disruptive behavior. On one occasion before encountering the mission she had actually blinded herself with her own hands. In the ashram she was sitting quietly next to some of the members, with her sunken eyes quite apparent. One member was engaged in quiet conversation with her while holding her hand as if to console her. Janet described how the group had been successful in steadying her over the course of her membership. I was later told other stories of disturbed and addicted young people responding to the beneficial influence of the mission and was able to A Psychological Perspective

21

interview a number of very troubled people who supported these observations. It did seem, as Beth had said, that there were psychological forces operating within this spiritually oriented group that could have a material effect on the distress members had experienced before joining. Given my interest in social psychology, it was appealing to consider how the phenomena that took place in this group might be examined in a systematic way. I wanted to test two hypotheses. The first was that there would be a measurable decrease in both distress symptoms and ongoing substance abuse when people became engaged in this movement. The second was that the intensity of a given member's ties to the group would be correlated with the degree of improvement that they experienced. After some time in the library dedicated to developing a battery of appropriate psychological measures, I was able to frame a structured questionnaire designed to test these hypotheses. Beth secured an agreement with the mission's hierarchy so that, along with a colleague, Peter Buckley, I could apply the questionnaire to a sample of the sect's members who were meeting at its national conclave in Orlando, Florida.16 After some lengthy negotiations, I selected 137 members at random at the Orlando site to complete the questionnaire. Their responses were compelling. Most members used alcohol and marijuana before they joined, and about half of them had stopped since then. Heavy use of alcohol and marijuana was also assessed, and it had gone down dramatically. I was well aware that treatment programs were having trouble achieving a high level of success with young people at that time. In addition, the number of respondents who reported symptoms of psychological distress, such as anxiety and depression, had also declined by half since they had joined (from 71% to 37%). The degree of improvement in substance use and distress was significantly correlated with the respondents' scores on a scale for social cohesiveness in the questionnaire. For example, their scores on this scale accounted for 37% of the variance (statistical variability) in their decline in distress symptoms, a high figure for a psychological study. Apparently, the closer a given member felt to the group, the more relief they achieved in these symptom areas. This cultic movement appeared to be effective in curbing distress and substance abuse insofar as it succeeded in engaging recruits into close ties to other members.

22

What Is Spirituality?

A colleague, Richard Rabkin, was later approached by members of the Unification Church (the "Moonies") after giving a lecture on cults at a local church. They apparently hoped to reach out to professionals in the mental health field to try to soften their public image. This initial contact served as a basis for my later negotiating a relationship with the group to study the psychology of membership. In time, several studies ensued. Some of the Moonie recruitment took place in informal ways, such as meetings on college campuses, often under the guise of generic causes including ecology and the pursuit of world peace. Other techniques were carried out in well-structured, systematic workshops, providing an unusual opportunity to study the psychology of engagement at such a group. After a lengthy negotiation, I was allowed to evaluate the progress of young adults as they passed through a series of the group's recruitment workshops at a remote California site. These reflected a sophisticated technique for framing communication in the groups they ran and maximizing its psychological impact on potential recruits. The series began with a weekend-long retreat, followed by an invitation to stay for further enlightenment, a process that ultimately extended over three weeks.17 Of 109 young people who began the series I studied, seventy-seven left after the first weekend, having rejected offers to remain longer. Of the remaining thirty-two, seventeen left after a week, and of those who remained through the entire 3-week sequence, nine agreed to join. All members who stayed beyond the first weekend responded with high scores on both cohesiveness to the attendees and belief in the Moonie ideology. I had applied a measure of psychological well-being to all parties at the outset of the induction sequence. Their responses were highly predictive of who would actually stay on through each of the stages. Those who felt most comfortable with their lives left first, and those who scored lower on well-being stayed on through the first week and the following weekend. The nine who actually remained for 3 weeks and agreed to join were highly distressed in comparison to all the others who had left before them and to a matched sample from the population overall. The need for relief from emotional distress clearly provided pressure for affiliating. Significantly, once established in membership, general well-being scores moved up, back toward those of a nonmember

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sample from the general community.18 These latter scores were not based on retrospective self-assessments, so they were not subject to the distortion that might take place when answers to before and after items were given at the same sitting.

The Relief Effect

O

ne answer to the question of how people become engaged in such groups derives from their experience of a "relief effect,"19 that is, a relief in distress that could be measured when people were inducted into the group. This was apparent as people were put through the recruitment process, as it gave them answers to uncertainties they were confronting. Engagement in the church's beliefs and the emotional support it offered them resulted in a lightening of malaise and depressive feelings, a "relief" that these young people were feeling. This relief in distress was also important in understanding why people would accept a significant change in their established personal habits and considerable privation as well. In order to support the validity of the relief effect, three criteria had to be met in the findings that emerged from the studies on the Divine Light Mission and augmented by the research on the Unification Church.20 Here are the criteria: i. Affiliation with a highly cohesive group should yield a significant decline in distress or, conversely, an improvement in general well-being. At the time they were surveyed, members of the Divine Light Mission had scored themselves on neurotic distress symptoms and also scored themselves in retrospect on their status before joining. Their responses reflected a significant relief in their symptoms. Only 14% of the respondents rated themselves as "not at all" anxious before joining, but 38% did so for the two months after they had joined. As noted above, among members of the Unification Church, the general well-being scores of workshop members who decided to join the church were significantly below those of members who had already been in the group for 2 years.21

24

What Is Spirituality?

2. There should be a direct relationship between affiliation with the group and the degree of symptom relief. This finding emerged in both sects. It is clearly illustrated among the Moonies, where members' scores on the general well-being scale were highly correlated with the degree of their religious belief and their cohesiveness toward church members. Items that were most highly correlated with general well-being were "my religious beliefs give me comfort," and "I like being part of their [the members'] activities." 3. The relief effect should not depend on a poor adaptation to life's tasks, because this would operate against the survival of this trait over the course of evolution. That is to say, if this trait were associated with maladaptive behavior, people who had it would be less likely to survive and reproduce, and the trait would not have persisted in subsequent generations. So what actually was the case? When Divine Light respondents were asked whether emotional problems had interfered with their adjustment to life, 39% responded that they had. The degree of symptom relief and the likelihood of experiencing cohesive feelings toward the group were, however, the same for members who reported disruptive emotional problems and those who did not. Now here is an analogy that can be drawn to movements that promote spiritually oriented healing. People suffering from frightening mental or physical illnesses are acutely in need of emotional relief and are therefore open to accepting an outlook on life that leaves them feeling better. They may therefore be candidates for responding to spiritually oriented healing that would buoy their spirits and then for affiliating with other adherents. As with the Moonie recruits, acceptance of a spiritual recovery philosophy could provide them relief. This applied in particular if they were unsure of the ability of conventional care to cure their illness. In order to clarify further how engagement into cultic groups and spiritually oriented recovery takes place, we can turn to a body of social psychology research that has informed psychological research on group influence. One such model relates to the way people attribute meaning to their experiences. "Attribution theory" embodies a large number of A Psychological Perspective

25

studies and posits that people are most likely to adopt a new or unusual explanation for their situation (such as an illness) when they encounter problems they cannot solve, feel they are not getting enough support, or lose confidence in themselves.22 After this takes place, they undergo a reordering of how they attribute meaning to later experiences. They will then explain new observations by recourse to the explanatory model they adopted, thereby placing them in a coherent, internally consistent perspective. A patient with an anxiety disorder due to a general medical condition may feel helpless and may despair of receiving help from her physicians. Because of this distressed state, she may be open to considering an alternative spiritual explanation for her illness and a related "treatment" regimen. On adopting this explanation, she will be inclined to accept a whole constellation of ideas related to the new perspective and will attribute the meaning of future health issues to the associated "spiritual" explanation. Sometimes this engagement into a new perspective and set of beliefs can occur quite rapidly. This is evident in the dramatic conversion experiences that take place among distressed people exposed to Fundamentalist religious preaching.23 Cognitive dissonance theory is relevant as well. This perspective was popularized by the social psychologist Leon Festinger, who sent his graduate students to join a doomsday cult whose members believed that the world would come to an end on a specific upcoming day.24 The students were to see how members of the cult would react when the world (presumably) did not come to an end. After the day came and went, most of the cult members constructed elaborate rationalizations for why the anticipated event had not taken place, and many assumed that a new date was now set. They could not reconcile their belief in the cult with the reality they observed, namely, that it was wrong in its core belief, and were driven to construct a new, more acceptable reality. Festinger attributed such a resolution to the cognitive dissonance that people may encounter in experiencing circumstances contradictory to their established views, as did the members of the doomsday cult when the fateful day came and went uneventfully. The clash between these conflicting circumstances and the cognitive dissonance it produces lead to a state of arousal that is inherently unpleasant, one that people

26

What Is Spirituality?

are implicitly driven to avert. They do this unwittingly by changing or distorting their understanding of the circumstances, even to the point of compromising their common-sense views. In the realm of illness, consider the onset of a severe and prolonged episode of pain due to an unanticipated illness. People generally have a sense of security about their physical well-being, but an experience of unremitting pain and even threatened loss of life runs counter to that sense. This results in a conflict between their usual perspective on themselves and the newly perceived physical state and creates a potentially troubling sense of arousal. Given the pressure generated by this cognitive dissonance, the distressed sick person will be open to seeking out or responding positively to an explanatory model for the illness available in their environment. If they become engaged in conventional care, the model offered will be based on available biomedical mechanisms. My friend Charles Gerson, an internist, tells me about patients referred to him who are plagued by seemingly unresponsive gastrointestinal symptoms. Often their symptoms remit when he clearly explains to them their underlying physiology. On the other hand, some people may encounter and accept a spiritually grounded, nonscientific perspective, even if it has limited credibility. As in the psychology of the Moonie induction process, the likelihood of acceptance increases if it is made further acceptable by some friends or true believers who support the perspective.

Placebos: The Potency of Belief

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ost medical treatments act directly by altering the body's physiology. Placebo treatments, on the other hand, derive their effectiveness because the patient believes that the treatment they mimic will relieve their symptoms. This phenomenon carries considerable implications for the impact of spiritual beliefs on a person's mental state. Clinical depression is not just an emotional condition, as there is longstanding evidence that it is biologically grounded as well. Genetic determinants certainly support this; identical twins are more than twice as likely to suffer depression as are fraternal ones.25 Metabolic studies

A Psychological Perspective

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bear this out as well; radiographic imaging of brain function of depressed patients shows it to be markedly different from normal.26 Additionally, a variety of neurochemical and hormonal markers have been found to differentiate people who are depressed from people who are not. On the other hand, it has long been known that patients given placebo antidepressants experience symptom relief greater than do patients put on waiting lists for treatment, even though neither group has received an active drug. The difference in outcome apparently derives from the fact that the placebo patients believe that they should be getting better from the pills they take. The psychologist Irving Kirsch points out that both serotonin reuptake inhibitor antidepressants such as fluoxitine (Prozac) and other types of antidepressants show about the same level of effectiveness as placebos, even though they have different mechanisms of action. In addition, some active drugs not considered to be antidepressants show much the same effect on depression as that produced by those formally designated antidepressants.27 So we can ask: Why should seemingly inactive pills change a syndrome embroiled in physiology? A careful analysis of head-to-head, controlled comparisons of antidepressants against placebos is quite revealing in this regard.28 The portion of patients who showed material improvement in their depression on both active drugs and placebos increased appreciably over the period from the early 19805 to the year 2000. When the 2o-year course of both was graphed out for this period, the response to active drugs was seen to rise from about 40% to 55%, and for placebos the rise was from 25% to 37%. Thus, by the year 2000, the number of placebos responders was close to the same as that of patients who took the active drugs in the early 1980$. Symptomatic response to placebos has been found quite effective for the long term as well. One study maintained patients on pills for 2 years. While 91% of the patients who responded to active drugs did not relapse over the treatment period, 72% of the placebo patients avoided relapse as well.29 The medications tested over the 20 years of review were not materially different, nor was the physiology associated with depression. There was, however, a change in the attitudes of people taking the drugs, which likely led to this altered effect over the years. People have increasingly come to believe that antidepressants work, as bolstered by studies re-

28

What Is Spirituality?

ported in the media and in popular books, such as Listening to Prozac,30 and more recently, advertisements. People have increasingly accepted the culture of science as a belief system rather than as a convenient tool for testing hypotheses. As with shamanic potions, the placebo response is effective when both the treater and treated believe in the effectiveness of what is being administered. This was illustrated in the case of a surgical procedure. Arthroscopic surgery of the knee to relieve arthritic disease had been reported by patients and physicians alike to relieve both pain and functional limitations. Until recently the procedure had been applied more than 650,000 times a year. At a cost of roughly $5,000 for each operation, this came to more than $3 billion annually. The credibility of this was called into question when Dr. Bruce Moseley, chief surgeon for the basketball team the Houston Rockets, was carrying out the procedure in his teaching hospital and had a question posed to him: How did he know the surgery's apparent success was not due to a placebo effect? This seemed to fly in the face of received knowledge, since it was assumed that the arthroscopic intervention worked by removing painful debris and flaps of torn cartilage as well as inflammatory enzymes. Moseley put a small number of patients through a "placebo" surgical procedure, one in which he prepared them for surgery as usual and made incisions in the skin that produced surgical-like scars. He found that these patients responded with relief in their symptoms. He then conducted a large-scale controlled study and found that the placebo procedures resulted in relief over the ensuing 2 years equal to that produced by the actual surgery.31 Clearly, both physicians and patients had come to believe in this widely used approach, another illustration of the impact of belief in contemporary medical culture. The expensive surgical ritual would have been maintained in practice for this placebo effect if not for Walsh's initiative. To put these reports into context, we can consider the role of ritualized belief embedded in the mythology of one spiritually oriented culture, the Navajo Indians of the Southwest United States In the 19508 the anthropologist Robin Fox32 described a typical healing carried out in a Cochiti pueblo near the Rio Grande River in New Mexico. Following her mother's death, a woman in the tribe experienced an onset of symp-

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toms like those we currently attribute to the psychiatric diagnosis of major depression: insomnia, fatigue, social withdrawal, and anorexia to the point of severe weight loss. Fox described how a ritualized readoption into the clan brought these symptoms to an end: The clan's sanctity was understood to derive from mothers, and a mythic mother figure, mother of the people, was embodied in corn-ear fetishes that represented her power. The ceremony he observed was announced by relaying a pinch of cornmeal to all of the woman's close relatives, and she was then given a new name, and her head was washed with an herbal solution, the traditional method of sanctifying adoptions. The sanctification of her readoption into the tribe was understood to yield curative ritual healing, and her symptoms abated after the ceremony. Fox reported that the symptoms did not return during the seven years following the healing until the time of his writing. In this case, a consensually supported belief in the effectiveness of renewal was followed by relief from the symptoms of depression. This parallels the contemporary response to antidepressant placebos that renews today's depressed people. Members of both the Navajo and scienceoriented cultures respond to the belief in the transcendent powers of their totemic entities, the mythic mother figure on the one hand and medically generated pills on the other. We are inclined to dismiss the healing practices in societies whose cures rely on trappings of belief that are different from our own. Often the healers are called witch doctors. But the very same psychological mechanisms operating there may allow psychiatrists and even surgeons to generate healing in their patients in many cases. The limits of spiritual renewal and associated rituals for the treatment of mentally mediated symptoms clearly need to be further explored. Our entry into the domain of psychology began with the work of scholars and clinicians who studied the nature of intense spiritual experience, and then moved on to the way these experiences can be generated in group settings. The placebo effect shows how the plasticity of these experiences rests on the culture in which they reside. If belief in a placebo can revive the spirit, we might now choose to look at how this relates to what happens in the brain.

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What Is Spirituality?

3 Spirituality and the Brain

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f there is a spiritual side to people's thinking, clearly it must operate within the physical context of the brain. One way to look at this relationship is to consider how people deal with uncertainty, since spirituality is one way that we can deal with the greater ambiguities in life. We will begin to explore this issue by looking at how the brain deals with observations whose import is unclear. Stanley Schachter and Jerome Singer1 carried out an experiment that showed how a person's mental state interacts with nonspecific neural stimuli. They gave subjects an injection of adrenalin, a drug that produces a state of central nervous system arousal, which can, in turn, serve as the basis for a subjectively felt emotional response. Some of their subjects were exposed to a giddy and engaging actor, a pleasant social stimulus that might make them feel happy during the arousal state. Others were exposed to an actor who feigned anger, an unpleasant context that could produce malaise. They found that adrenalin could produce either a euphoric or an uneasy response, depending on the input that the actor created. The subject's environment interacted with the nonspecific physiologic stimulus and thereby determined the nature of the person's experience. The two researchers concluded that the physiology underlying a person's arousal does not necessarily determine the ensuing subjective experience, but that it is interpreted based on his or her mental context. 3i

Broadly stated, this suggests how our understanding of what we experience can be driven in rather different ways, each generated out of a need to bridge the inner workings of our brain and the experiences we encounter. One might draw an analogy. The agitation of a person aroused in a crowd can be directed toward a spiritual interpretation of their place in life, or alternatively, toward scapegoating an innocent minority group: transcendence or anger, depending on the social input. Another very different study illustrated the relationship between biologic function and the mental connotations attached to an ambiguous experience. Michael Gazzaniga2 studied people whose corpus callosum, which connects the right and left cerebral hemispheres, had been surgically severed to treat their severe epilepsy. He introduced a variety of stimuli to the motor areas of their right hemispheres that produced body movements, and then asked the person, who was awake at the time, to explain these movements. The left hemisphere is responsible for speech, but it was no longer connected to the hemisphere on the right. So it now had to come up with an explanation on its own of what it saw the right hemisphere produce, but with no communication from that right side. He stimulated one subject's right cerebral hemisphere electrically to make him wave his hand. When asked to explain the hand movement, he—that is, his left hemisphere—gave a fabricated explanation of seeing someone he knew at whom he had waved. When stimulated in the right hemisphere to laugh, he said he was responding to the joking approaches of the experimenters. Neither of these fabricated experiences had actually taken place, but the left brain had needed to make sense as best it could of what the body had done. As with the adrenalin experiment, an explanation of reality and its meaning was created by a person to cope with a physiologic nonspecific stimulus.

Emotion Driving Perception

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hese two studies begin to suggest the complexity of what takes place in the brain to make sense of an external world whose nature is not understood. We can move as well from the response to external stimuli to look at how the brain deals with its innate emotional energy.

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What Is Spirituality?

Here are some questions to start with: Where does this emotional energy originate in the absence of environmental input? How does it get infused into our abstract thinking to cause us to make up an explanatory reality? A model of brain function introduced by Paul MacLean3 gets us closer to the biology of this process. He conceived of an integration of certain lower brain centers that lie deep below the cerebral hemispheres and called this set of centers the limbic system. He described this system as a motor for emotionality, to which meaning is then ascribed by the cerebral cortex. MacLean wrote of the coordination among limbic structures, namely the hippocampus, the hypothalamus, the cingulate gyrus, and other related structures, yielding this integrated, functional network that generates primitive emotional drives. He even suggested that this system was responsible for the functions that Freud referred to as "id" drives in his metapsychology. Freud described the infantlike, primitive id, which can produce unfettered anger or dependency, but he did not localize it in a specific brain site. In his "structural" model of mental function, he posited that the id drove people to be instinctively motivated. In a manner of speaking, these feelings might now be seen to be driven by the limbic system. Freud's model can be reinterpreted to posit that the ego and superego operate within the cerebral cortex to modulate these id drives and to bring them into conformity with external reality and acquired standards for behavior. The neocortex, the brain's highest center for complex thought, became larger late in mammalian evolution and can ascribe complex interpretations to intense emotional needs. This search for meaning can be conceived as drawing on a person's own mentation and the environmental input that he or she encounters. There are neuronal projections among components of the limbic system and many cortical areas, and these allow for communication between the brain's emotional driver and its component part that conducts conceptual thinking. Further interconnections with the limbic hippocampus, which is associated with long-term memory, can play a role in the relationship between emotional drives and past experience. One illustration of these interconnections is evident in studies on the biology of dreaming. In relation to our topic at hand, dream symbolism is often associated with people's spiritual side. Interaction beSpirituality and the Brain

33

tween the cerebral cortex and the limbic system during sleep can generate dream experiences that emerge from intrinsic brain activity. Allan Hobson4 has developed a model that describes how the experience of dreaming results from suppression of certain brain circuits that are active during waking, while accentuating others. During dreaming stimulation from the limbic and immediately related subcortical areas creates an emotional activation that in turn stimulates dream experiences. For example, neuronal connections from the limbic system activate parts of the visual cortex to create the imagery we encounter in dreams. This is accompanied by the belief that one is awake at this time, and this experience of seeming wakefulness is likely caused by a selective inactivation of certain prefrontal cortical areas that control cognition. Hobson backed this model up by integrating a large body of brain research based on neurochemical and brain imaging studies. This model helps us understand how the seemingly nonrational imagery that governs much of the thinking associated with spiritual experiences can be framed by processes similar to the ones that operate during sleep or other subjective states such as meditation and trances. It represents an area that is under active exploration. Research on the brain's functional anatomy can shed light on the nature of transcendent experience in unanticipated ways. As we just noted, split brain studies have shown the way one hemisphere's need to fabricate a reality shows itself when confronted by puzzling behaviors that may be generated by the other hemisphere. Responses to electrical stimulation of a specific brain site can suggest the basis of some of the paranormal spiritual phenomena that are often assumed to be fictitious or simply the product of self-deception. One study5 was undertaken to find the seizure locus of a patient suffering from temporal lobe epilepsy. Her magnetic resonance imaging studies (MRIs) showed no apparent anatomic abnormality, so her neurosurgeons tried to localize the epileptic focus by activating electrodes placed on exposed brain sites. When her angular gyrus was stimulated, she reported a feeling of "sinking into a bed" or "falling from a height." When the electrical amplitude was increased, she had an out-of-body experience and said, "I see myself lying in a bed, from above," then experienced herself "floating" above the bed, close to the ceiling. In another context these experiences would have been called somatic and visual hallucinations. 34

What Is Spirituality?

This suggests an interesting issue. Transcendental Meditation, popularized by Maharishi Mahesh Yogi in the 19705, became quite popular among many educated members of the lay public. At one point, some of them, deeply involved in that movement, were giving apparently bizarre reports of their experiences during meditation. They said they were able to float above a bed on which they were lying while meditating. Reports such as these were seemingly laughable. Were these meditators deluding themselves? On the other hand, they might have acquired a capacity to prolong and intensify spontaneous activity in the angular gyrus, activity that we now know can be accomplished by direct stimulation to the brain. Clearly, more needs to be learned about the nexus between experiences associated with spirituality and verifiable brain-based events.

Institutionalizing Our Memories A nother important component of this biological model is the way -/"^.specific ideas become associated with emotional needs and then become permanently ingrained in our thinking. Thus, spiritually tinged experiences, such as compelling church services and meetings with revered people, become ingrained in memory and may then be recalled at a future time. To understand how this takes place, we can turn to cognitive science, which examines the processes of thinking and recollection. We can find the origins of this discipline in the work of Ivan Pavlov, the Russian physiologist and experimental psychologist whose studies at the end of the nineteenth century were influential in shaping contemporary thinking about memory and behavior. The dogs he studied in his laboratory would salivate upon being shown a bowl of food; this was a naturally occurring response. Pavlov would then repeatedly ring a bell each time he put food in front of a dog. Over time the bell itself could produce the conditioned response of salivation. This famous study demonstrated that there were innate brain-based mechanisms that governed the relationship between external experience and automatically triggered behavioral responses. This model can be applied to the manner in which more complex, subjectively grounded responses are laid down in human beings. The reSpirituality and the Brain

y>

peated presentation of a pleasant experience in association with a stimulus, such as a gift-bearing relative repeatedly encountered by a young child, will engender a pleasurable response to that relative, even without the child being aware that the process is taking place. An unpleasant stimulus, such as the barking of a dog repeatedly paired with the actual frightening creature, can be similarly conditioned and produce fear when barking is heard, even if a dog is not seen. In a more complex manner, a house of worship, regularly associated with a person's reflective response to religious services, can itself become a stimulus for spiritual reflection when that person later enters such a setting. Because of this prior conditioning it can automatically summon up a spiritual state of mind. This is one reason why the churches we build are so important to sustaining people's faith and spirituality. Pavlov's model of laying down habitual responses is termed classical conditioning. Operant conditioning, on the other hand, is a process elaborated in the research of the psychologist B. E Skinner. It, too, can shape human thinking and behavior outside a person's conscious intent. It takes place when an animal or person acts in a spontaneous way. A naturally occurring behavior can be rewarded when it takes place. For example, a piece of cheese can be automatically produced by an experimental device each time a mouse happens to step on a bar in its cage. Eventually the mouse will press that bar more frequently because it has been conditioned by the operant reward of the cheese. Because it has been conditioned, it will later continue to press the bar frequently even if the cheese is no longer produced when the bar is pressed. Once a behavior has been operantly conditioned, it will show itself more frequently. This can be applied to people as well. lerome Frank6 gave an interesting example of operant conditioning in the psychoanalytic situation. An analyst may nod repeatedly, showing interest whenever a patient spontaneously brings up a certain topic, such as experiences encountered in dreams, and this operant stimulation is not necessarily consciously perceived by the patient being analyzed. When repeatedly presented, however, this reinforcement can lead the analysand to bring up the issue that was of interest to the analyst more frequently, in this example, by discussing her dreams. The analysand then grows to impart importance and meaning to dream imagery. Similarly, if a person regularly encounters positive emotional experiences in relation to spiritual 36

What Is Spirituality?

activities early in life, say by people who acknowledge and support its discussion, he or she may continue to be interested in spiritual issues and perhaps seek related enlightenment, even long after the original rewarding situations. The physiologic psychologist Joseph LeDoux7 has described the way certain conditional responses can become fixed in a person's brain. He wanted to explain how memories of a given event, particularly ones associated with intense emotional experience, become embedded in the brain on a neuronal level. He drew on the concept of "cell assemblies,"8 in which irreversible connections between neurons can be established through experience. These cell assemblies effectively hold memories in place long after a person has encountered the external triggers that precipitated them. This neuronal process of learning can then engage subcortical limbic pathways that operate in the absence of conscious recognition of the origin of the associated memory. LeDoux suggested that this may help explain the development of syndromes such as posttraumatic stress disorder, lingering reactions ensuing from highly traumatic experiences. Intense spiritual encounters might also become consolidated in one's memory this way. This would happen when an emotionally charged spiritual experience becomes fixed in a person's mental apparatus, later reverberating in her thinking to trigger a complex set of spiritually oriented ideas and feelings. A religious experience at a church service may be automatically recalled when certain emotional stimuli are introduced. An encounter with the Dalai Lama may come up in one's memory at times when one experiences spiritual renewal.

A Note on the Placebo Effect

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lacebos work because we believe in what they represent. Because of this they offer the opportunity to examine the impact that belief— spiritual or otherwise—can have on the mind and brain. One particular study employing computerized electroencephalographic (EEC) analysis sheds light on the biological basis of placebo effects. From it we can draw some inferences about the biology that supports culturally grounded beliefs. Spirituality and the Brain

37

Depressed people who received either active or placebo antidepressants were studied 9 weeks after they started taking the pills, and both groups showed improvement (52% vs. 38%).9 No changes in the EEGs were found in the people who did not respond to treatment, but the active drug and the placebo were found to affect the brains of those who did. Members who improved in both groups had changes in activity in the prefrontal cortex, but the active drug yielded a decrease in activity, and the placebos produced an increase. Although the patterns of behavioral and emotional responses to placebo and active drug were the same, each agent apparently operated somewhat differently on the brain. At least in the case of antidepressant placebos, belief, embedded in social influence, can apparently change physiologic function and make people feel better at the same time. The physiology underlying this phenomenon is further evidenced in recent studies showing that changes in brain function activity following both antidepressant and psychotherapy treatment in depressed people are sometimes "remarkably similar."10 Why should not repeated episodes of spiritual renewal achieve similar well-being?

Meditation

T

he practice of meditation is an area of particular interest these days in the domain of spirituality. Its popularity in the United States was clearly enhanced in the 19708 by the wave of interest in Transcendental Meditation (TM) introduced by the Indian guru Maharishi Mahesh Yogi. TM apparently offered an antidote to the harried and busy lives of many in the professional middle class, providing them with the option of tuning out from the rush of their daily lives. They could do this by exploring their innate capability to operate at the mind-brain interface without having to turn to the psychotomimetics that Timothy Leary and others prescribed for the counterculture generation. These Westerners found TM a relatively easy technique to master. They would sit quietly with their eyes closed for 20 minutes twice a day and repeat a mantra in their minds in order to achieve relaxation. Their autonomic nervous systems and EEGs were found to be relatively deactivated at such times,11 and practitioners avowed that the practice relieved ten-

38

What Is Spirituality?

sion and even improved their perspectives on what was meaningful to them in life. Around this time the growing interest in Eastern religions led many seekers of existential meaning to explore a variety of more exotic meditative techniques. Many of them revered Hindu and Buddhist holy men who could draw on intense and mysterious—but apparently credible— capacities for achieving transcendence. Exotic practices studied in laboratories ranged from Tibetan Buddhist meditation,12 to Indian Tantric,13 and Kundalini14 techniques, to Qigong15 from China. These techniques were hard to master, and physiologic distinctions were found between the few practitioners with years of experience and relative novices. Tantric yoga, for example, involves intense concentration of attention and total absorption, with an end-point being Samadhi. Indian yogis who achieved this state through Raj yoga maintained that they were oblivious to external stimulation. They were found to produce high intensity alpha activity on EEGs that could not be blocked by various sensory stimuli but nonetheless appeared quite relaxed to the observer. Observers were, in fact, impressed: the Raj yogis in Samadhi were able to keep a hand in near-freezing water for almost an hour without experiencing discomfort.16 A Tantric yoga practitioner stopped breathing for nearly 2 minutes during a state of "near Samadhi" after experiencing a marked acceleration in heart and breathing rates.17 Andrew Newberg and his collaborators took advantage of the brain imaging technique SPECT and studied Tibetan Buddhist meditators. They found an increase in blood flow in the frontal cortex relative to the parietal lobes during meditation and inferred that this was likely associated with intense attention to visual images by these meditators and with their loss of a sense of space and time. The nature of these physiologic relationships, however, is far from clear. Thus, Newberg found that attempts to define the subjective states associated with these techniques left them "impossible to quantitate or analyze in a useful manner."18 Nonetheless, it is clear that the mind can direct the brain to alter its usual function and generate experiences in the spiritual domain. Are some people more physiologically disposed to such transcendent phenomena? One group of investigators19 used positron emission tomography to ascertain the density of serotonin receptors in various brain sites of their subjects. They then gave them a personality survey Spirituality and the Brain

39

that measured different character traits. It turned out that there was a strong (inverse) correlation between serotonin binding potential in certain brain sites and scores for the personality traits of religiosity and feelings of transcendence. This, along with genetic findings associated with studies of identical twins, suggests that there is a physiologic basis for the relative difference in people's inclination to have spiritually related experiences.

The Role of Social Support

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eople most often acquire a spiritual orientation in a supportive group context, so it is important to examine how social support relates to brain physiology. Numerous studies have illustrated the biological grounding of this process. One important body of research drew on the observations by Rene Spitz and John Bowlby, researchers of child development. They studied the responses of infants who lost supportive social ties after prolonged hospitalization and separation from their mothers.20 The infants first became highly agitated and distressed, and then after several days they became dejected and withdrawn. Continued separation resulted in a severe withdrawal, termed anaclitic depression. Recovery from this state did not take place, if it did at all, until after they had been reunited with their mothers. These observations are compatible with a basic need for social attachment, and these researchers posited that for infants the mothers provided a base of security to which infants could return after exploring their environments. When the attachment object was gone, the infants lost their sense of security and could no longer find refuge from frightening stimuli. Harry Harlow, a professor of psychology at the University of Wisconsin, was impressed by this work, and his studies on its counterpart in experimental animals shed light on biological aspects of social support. He and his students21 conducted a series of studies in which they replicated the phenomenon of anaclitic depression in 6-monthold rhesus monkeys. Each monkey was placed in an apparatus that prevented it from coming into physical contact with its mother for a

40

What Is Spirituality?

3-week period. The infant monkeys experienced responses much like those of the human infants: initial agitation followed by lethargy and withdrawal. From a physiologic standpoint, marked changes took place in their sympathetic nervous systems, with abnormalities evident in the hypothalamic-pituitary-adrenal axis and ovarian systems. The social and biological equivalence of these phenomena was highlighted by Stephen Suomi, who undertook studies that extended the work of Harlow to see whether it was possible to "treat" the infant monkeys' depression. He first tried to do this by introducing socially normal age-mates into cages with the depressed infant monkeys but found that the hostility directed by the healthy ones toward the frightened, depressed monkeys did not help at all to revive them. He then struck on the idea of putting the depressed infant monkeys in cages with ones that could offer more supportive social input. These were only 3 months old, too young to exhibit aggressive responses or adult social interactions, but instead they clung to their unhappy cagemates and began some simple play. These 3-month-old creatures, he found, became effective "monkey psychiatrists." They revived their depressed cagemates from their isolated stance and, over time, moved them to recovery.22 Suomi found that this social repair could be achieved by a pharmacologic intervention as well,23 by administering an antidepressant. The two sets of "therapy" studies, the social and the pharmacologic, were an early indication of physiologic and social equivalency in the remediation of depression. The monkey findings parallel my own observations on the impact of social support on depressed people who become engaged in the closeknit social environment of religious cults. In these adult humans, cohesiveness in the group augmented by a spiritual orientation served as a basis for their experiencing remission from their distressed states. The physiology underlying such social phenomena was also revealed in the genetic studies of the psychiatrist Kenneth Kendler.24 He contacted identical and fraternal twins who had been recorded in the Virginia Twin Registry when they were infants. He was then able to distinguish between genetic and environmental factors associated with the degree of social support these twins felt using questionnaires that tapped into their social attitudes and the nature of their social environments. By

Spirituality and the Brain

41

means of a statistical analysis, he was then able to distinguish between genetic loading—the same for identical twins but only half as great between fraternal twins—and environmental influences. He found that 40% and 80% of the variance in reported social support measures was due to genetically grounded (i.e., physiologic) differences in the individuals, rather than environmental ones. This makes clear that the social cohesiveness that we associate with an inclination toward spiritual affiliation appears to be grounded in innate physiology as well as experience. Our contemporary understanding of posttraumatic stress disorder (PTSD) also sheds light on the biological correlates of social support. PTSD results from encounters with extremely distressing experiences that profoundly disrupt a person's sense of security, such as physical assault, threatened death, or sudden loss of a loved one. In order to meet diagnostic criteria for this disorder, a person's response to the trauma must have involved intense fear or horror25 at the time of the traumatic event or shortly thereafter. People with PTSD have symptoms including flashbacks, nightmares, and inability to concentrate. The acute stress that engenders PTSD stimulates the release of hypothalamic corticotropin-releasing factor, and this in turn stimulates the secretion of cortisol, which in turn activates the autonomic nervous system. Magnetic resonance imaging studies of people with PTSD show that the hippocampus, associated with memory, is reduced in size relative to normal subjects, either due to damage produced by high levels of cortisol at the time of the trauma or perhaps the predisposition of a person to PTSD. In any case, there is a clear difference between the brains of people with PTSD and those of normal subjects.26 A review of studies27 on PTSD reveals that a lack of social support for the victim of trauma ranks highest among the risk factors associated with its onset. That is to say, social support clearly limits the degree of physiologic compromise produced by severe stress. To sum up: In examining the psychology of spiritually oriented groups, we learned that the social support inherent in such groups is likely to relieve depression and stress. It thereby serves to reinforce acceptance of the group's spiritually oriented philosophy. We can now better understand the basis of this relationship between biology and social interaction. We will next consider how this biologically grounded trait was adaptive over the course of human evolution. 42

What Is Spirituality?

Evolutionary Adaptation

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ertain patterns of behavior that are found in all members of a species may be grounded in their genetic makeup. These patterns, rooted in biology, can be understood to persist over the course of evolution because they have increased the ability of the species to adapt successfully to its environment. In their Nobel Prize-winning work, Nikko Tinbergen28 and Konrad Lorenz29 pointed out that such behaviors can become established in a species with as much consistency as can physical organs. That is to say, the basis for a particular behavior can initially emerge through mutation, and its genetic underpinnings can then persist over generations if it helps the species adapt and survive, just as the eye, the hand, and components of the brain have similarly evolved over the course of evolution. One example of this phenomenon is the trait of altruism. Sociobiologists who study the evolutionary basis of behavior examine this phenomenon in both lower species and in humans. They describe a trait called reciprocal altruism,30 which occurs across many species. It can be illustrated in geese when an individual member of a flock issues a call while in flight to warn other members of its flock of a nearby predator bird. In actuality, that particular goose puts itself at greater risk by attracting the predator's attention, and this behavior can effectively end its life and hence its reproductive career. On the face of it, this would seem to assure eventual extinction of this altruistic trait. Similarly, people also consistently make sacrifices for others, even though such sacrifices put them at risk for the kind of compromise that would leave them less likely to reproduce and transmit the genetic basis of the selfsacrifice manifested in such acts. Why do members of many species carry such a seemingly maladaptive trait? The answer to this question lies in the benefit incurred by others members of its own species who are helped by an individual's act of self-sacrifice. Although this is indeed maladaptive for the individual, in actuality it enhances the advantage of other genetically related parties who are likely to carry the same trait. Other members of the species, benefiting from the altruist's help, are therefore more likely to reproduce because of the benefit conferred on them by the presence of this altruistic trait in a close relative. Because of this, the "altruism" genes Spirituality and the Brain

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will persist to the next generation in the parties who were helped. Sociobiologists point out that such behaviors assure survival of other members of a flock of birds or a human family who carry the genetic basis for this behavioral trait. Can the sociobiologic perspective be applied to the human patterns of thought and behavior that underlie spirituality or religiosity? If so, the brain-based devices previously described as underlying a spiritual orientation, such as people's responses to ambiguous emotional stimuli and dream imagery, might be grounded in innate patterns of human behavior that have been adaptive in terms of helping our species to survive. These very patterns would predispose people to accept the symbolic nature of a spiritual orientation and help bind them to a group that is mutually supportive under a common set of spiritual values and rituals. In my study of youth cults such as the "Moonies," it became clear to me that people, by nature, are open to intense affiliation with a group promoted by spiritual experience. While the tendency to engage in a cult is hardly a hard-wired, brain-based tendency, it does reflect the innate inclination of people to establish themselves in kin-based subgroups like nuclear families or larger groups of interrelated individuals who share common beliefs. This tendency toward affiliation, with its elaboration in given subcultures (the youth cults, for example) may reflect a biologically grounded trait that draws people into groups whose members are bound together by a shared spiritual mission. It may then reflect an inclination that has evolved over time into a behavior pattern more often seen in smaller groups, such as families, but it operates as well in larger groups held together by religious ties. Edward O. Wilson examined the adaptive aspects of humans' religious orientation from an evolutionary standpoint.31 He pointed out that a religious orientation of one sort or another serves to bind adherents together in an unquestioning allegiance that can promote altruistic behavior. It can also engender willing subordination to a group, which then provides benefit to its members with a minimum of energy expenditure and risk incurred by any given member. This innate impulse could be elaborated in the culture of different human societies by the objectification of certain concepts (such as heaven and hell) and the

44

What Is Spirituality?

creation of a mutually acceptable mythology. Interestingly, in considering the psychology of spirituality, this perspective is similar in some ways to the innate religious archetypes we considered previously in relation to the psychology of spirituality. Carl Jung elaborated on an allied concept in his psychoanalytic model of spiritually oriented behavior, and it was picked up by Daniel Batson32 more recently, who associated it with the quest for religious fulfillment. It is not that the particulars of religious practice are innate in human biology, but rather that the impulse toward a spiritual or religious orientation may exist across all cultures, and that it has persisted because of its adaptive nature. The same is certainly said about innate inclinations toward sexual behavior and aggressiveness, which, in different settings, acquire ritual trappings particular to a given culture. The sexual inclination, for example, biologically grounded, may be ritualized in one culture by monogamous marriage and in another by polygamy. The impulse toward adaptive behavior that is understood by a person as spiritual in nature may be seen in one culture in the worship of ancestors and in another as commitment to the Twelve-Step process of addiction recovery. By this reckoning, we would say that a spiritual orientation, like human sexuality and aggressiveness, may be rooted in people's innate biological complement.

Our Forebears

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eligious groups can be understood to function as large organisms that evolved successfully because their various parts, that is, their members, operate together effectively.33 Coordinated action is necessary to tap many natural resources, so people must therefore bond together in adaptive units in order to make use of options such as the hunt for large game and shared use of tools. Coordination is also enhanced if resources are known to be equitably distributed. These adaptive advantages are increased when groups of people have moral systems expressed through imagery and symbolism that regulate their behavior. Some religious items, such as catechisms, may be viewed as "cultural genomes" and likened to the neatly packaged fossils that provide records

Spirituality and the Brain

45

of evolutionary change. From this perspective even the Ten Commandments can be seen as an evolutionary adaptation that assures proper moral character and avoidance of intragroup competition and conflict. In studying evolutionary aspects of group behavior, I was particularly impressed by descriptions of hominids, the early human precursors, such as Australopithecus. After emerging from the prehistoric rain forest about 5 million years ago, these primates became hunter-gatherers and predators of large game. Social affiliation was essential to such efforts, and it could be mediated through an enhanced capacity to deal with complex interpersonal relationship. The handling of such complex relationships was in turn made possible by a major increase in brain size that took place over the course of human evolution. For example, the cranial capacity of early man doubled over the 2 million years from the advent of Australopithecus (i.e., 400 to 500 cc) to the appearance of Homo erectus (1000 cc). This could provide the biological basis for the development of more complex aspects of social behavior and symbolic thought. Ironically, the wheel of scientists' thinking has come full circle to include some diverse perspectives on social behavior. Anthropology has posited that religion assured a linkage between members of a community by generating anxiety if rituals were not observed.34 This is not far removed from what Freud described as the "herd instinct," a force that led members of a group to coalesce around common goals and behavioral conformity.35 We are therefore left with an interesting duality: the mind drives the brain, and the brain plays on the mind, something for the spiritualist and something for the physiologist. Which of these two parties can claim the right to say they have the upper hand in explaining what goes on in the seemingly abstract world of belief? It is a question that may have no definitive answer.

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What Is Spirituality?

PART II

The Impact of Culture

I

t would be nice if there were a pill for every mental ill that plagues people. Some in the biomedical world anticipate this eventuality. Although this may seem something of a caricature, it was clearly implied by a prominent neuroscientist who asked me how I anticipated that my addiction programs would evolve toward the time ten years hence when neuroscience provided an answer to the problems of addiction. I said that many important advances had been made in that field and some indeed were being translated into useful medications, but it was important to understand that even after fifty years of antipsychotic medications, the wards of our psychiatric services had hardly been emptied out. His was one culture. Another culture is that of the increasing popularity of alternative medicine, with well-trained physicians writing books, running workshops, and appearing on television touting herbal medicines and meditative techniques to address emotional problems that may or may not respond to them. The lines and even the enmities between the two cultures are often highlighted by believers on both sides, sometimes with unfortunate consequences. Psychiatrists encounter their own problems in this domain. They have increasingly fallen prey to curtailing the relationship between the healer and the healed in the midst of this culture clash. Psychopharmacology replaces relationship, and managed care undermines

the opportunity for an empathic exchange. Many people continue to experience a nagging despair over the uncertainty of what to do with their lives, even after psychiatric care has done all it can for them. Other people may turn to cultic beliefs to salve their unhappiness, acquiring bizarre lifestyles that for all intents look like the trappings of mental illness. These next chapters examine the nature of the cultural divide between bioscience and spirituality and illustrate the problems that must be overcome when either psychiatric reductionism or spiritual excess causes people to get less-than-effective treatment or lose out on it entirely.

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4

The Apparent Conflict

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spiritual outlook implies a particular perspective on people's internal mental world. Biomedically based psychiatry implies a different one. We can understand the potential conflict between the two by looking at the cultures in which they are expressed. Spirituality is allied with the culture of the subjective and the introspective, in which people report how they feel and what they perceive as meaningful to them. This approach was framed by the psychologist and philosopher William James a century ago. His Varieties of Religious Experience1 brought the spiritual and experiential into the realm of psychology. The biomedical orientation, on the other hand, is framed by observers of measurable behaviors and analysis of what is externally validated. This latter approach has recently come to predominate in academic psychiatry, but it was also ongoing at the time of James when manifest behavior was examined by psychiatrists such as Emil Kraepelin, who classified schizophrenics by what he could observe and categorize. Almost half a century ago C. P. Snow2 argued that a breakdown in communication between the sciences and the humanities took its toll on how a nation promoted the welfare of its citizens. For him those divergent communities had not learned to speak with each other, let alone collaborate to frame a constructive approach to public policy and people's needs. I would contend that there is a similar level of conflict today in the mental health field. Because of this mental health professionals un49

derstandably have problems integrating what spiritual leaders describe as existentially meaningful into what the research community views as scientifically based. Psychiatrists are increasingly captive to biology and observable behavior, and their patients are left uncertain over their need to experience effective help. Psychiatrists (and other mental health workers) who fail to integrate the subjective and observational approaches will fall short in addressing the suffering they hope to resolve.

Two Protagonists

I

saw one example of this conflict play out in the opposing orientations of the two principal medical organizations that deal with addiction. One was the American Society of Addiction Medicine (ASAM) and the other, the American Academy of Addiction Psychiatry (AAAP). ASAM was established in 1954, when there were few approaches to the treatment of addiction available to the physician other than Alcoholics Anonymous (AA). At its inception many of its physician members were recovering from alcoholism through AA spirituality and had decided to dedicate their careers to others who suffered as they had. The other members had come to treat alcoholic patients based on the nature of their clinical practices, but they also relied on AA's spiritual commitment to move their patients toward recovery. In those days ASAM's meetings were imbued with the twelfth of the AA Steps, a commitment "to carry this message to alcoholics and practice these principles [the Twelve Steps] in all our affairs." Members sustained a remarkable degree of fidelity to the society because of the mutuality inherent in this approach. The intense influence of AA's spiritual grounding often played out in paradoxical ways. In conducting a survey of the ASAM membership31 hesitated to ask whether a given member had joined in the context of his or her own recovery, as the question might be seen to violate AA's unbreachable tradition of anonymity. On the other hand, I was later able to collaborate with the society's president in studying recovering physicians, most of them ASAM members, who had returned to a retreat sponsored by his treatment program to bolster their own AA commitments and get together with their compatriots. Responses to this survey indicated that most were working at least part-time treating other 50

The Impact of Culture

alcoholics. Of note, they rated AA as more influential in their recovery than had been the medical care and counseling they had received.4 The American Academy of Addiction Psychiatry, the second of the addiction organizations, was quite different in its orientation. It was organized by mainstream members of the American Psychiatric Association thirty-one years after the inception of ASAM, at a time when there was a broad array of treatment options available in addition to AA. These psychiatrists typically viewed addiction from a biomedical perspective and were more oriented toward clinical research. They looked on AA with a degree of reserve, not having had experiences themselves with Twelve-Step recovery. Most had little identification with its adherents, and some considered it to be something of a cult. Suspicions soon emerged on both sides of the organizational boundary. Many ASAM members had a jaundiced view of psychiatrists, who for many years had done poorly in helping people achieve recovery. It was quite common for a speaker at an AA meeting to describe years of treatment by a psychiatrist who never helped him or her with a compulsive drinking habit. Many AAAP members considered some of their ASAM counterparts as practicing something akin to witchcraft. I was elected president of both groups at different times but was always viewed with a degree of suspicion by many in the leadership in each one due to my affiliation with the other. There was always a conflict in being sympathetic to AA and being biomedically oriented as well. The gulf between the two organizations was evident in the experiences of two physicians, Barry, a leader in ASAM, and Jack, with a respected role in AAAP. Barry had been a victim of severe alcoholism, ultimately falling into penury and putting great stress on his wife and children. A dedicated physician, who himself was active in ASAM, salvaged him, virtually lifting him up from the gutter and introducing him to AA. As the years went by, Barry, like many ASAM members, went on to become a leader in the addiction treatment field but operated largely outside academic medicine. He made no effort to hide his alcoholic past or his profound commitment to the Twelve-Step movement. Jack, an AAAP member, provided a telling contrast as an accomplished clinical researcher with an important academic post. After years of acquaintance I happened to speak with him about the role of AA in alcoholism treatment, and we discussed my interest in carrying out reThe Apparent Conflict

51

search on Twelve-Step movements. In confidence he told me about his own experience, of which few if any people in the field had known. His secret was that he himself had recovered from alcoholism through affiliation with AA, but in operating within the context of AAAP and the academic subculture, he would not want to have his credibility compromised by being seen as involved in Twelve-Step recovery. Jack's secretiveness reminded me of a young resident in psychiatry whom I had encountered some years before, who told no one at work about his having joined a cultic group, the Divine Light Mission, for fear that he would be regarded as less than mentally competent. There was also an ironic parallel here between Jack and many religious converts over the ages who had hidden their spiritual commitments from those around them for fear of suffering fates much worse than those facing either him or that young resident. I wondered how the gulf between the two addiction organizations, both clearly dedicated to the betterment of their members' patients, would ever be fully bridged, and whether Jack would ever be able to reveal his secret tie to AA. I hope that a better understanding of the potential role of spirituality in psychiatric treatment can contribute to this.

Over-Reliance on the Laboratory

I

t is important to point out that the products of research into the underlying biology of psychiatry have themselves always been moving targets. Investigators in the laboratory have come upon their findings, pursued them with enthusiasm, and, if they were based on a methodology credible at the time, they might be taken up enthusiastically by their colleagues. But that does not mean that the inferences from these findings are definitive in themselves. Psychiatry is not an exact science by any means. The "catecholamine hypothesis" for depression was based on research in the early 19605. The field was excited by this straightforward formulation of the biology of this illness, based on the assumption of a paucity of certain neurotransmitters at receptor sites, and many studies ensued from this model. The conception clearly had some utility, but it has been found that this model of depression was more simplistic than was originally assumed. 52

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Around the same time, increased levels of dopamine were found to be available at the neural cleft in studies of schizophrenics, and the disease was labeled a hyperdopaminergic state—physiologically grounded in too much dopamine. It then became attractive to think that this represented a clear-cut physiologic basis for the disease, particularly since the medications used to treat it typically led to decreased dopamine activity. Years went by, other findings abounded, and recent careful assessments of etiology in schizophrenia have shown the basis for this illness to be much more complex and multidetermined.5 In the 19805 a series of studies employing computerized EEC techniques found that a specific pattern of response (at P30o) could be found in both alcoholics and their young progeny.6 Once again, excitement arose over a seemingly important biological marker for a psychiatric illness. In time, however, it turned out that this perturbation is found in many people suffering from a variety of behaviorally related problems. The dexamethasone suppression test7 was thought for a time to provide a reliable marker for what most people would call depression. This lab-based test generated enthusiasm and a string of related research studies but later turned out to have little actual utility in the diagnosis of depressive illness. These examples do not leave the integrity of the underlying research in doubt, but instead point out how legitimate laboratory-based findings cannot be—and, fortunately, generally are not—regarded as gospel truth. But they do tend to create an atmosphere of intense belief in the biomedical model because of the enthusiasm they engender, often far beyond the scientific community. Eager clinicians cling to them in the hope of helping their patients, and the press marvels at the latest evidences of how science is moving forward because of its objective outlook on the workings of the mind. Furthermore, in medical research good methodology can erroneously be associated with an assumption of clinically valid results. One example of a bizarre "methodology fallacy" was in a report recently published in the British Medical Journal, a scientific publication of great credibility. In this case apparently good statistical methodology generated acceptance of untenable results even though given a pass by the scientific peer review system. In this study8 a doctor had people pray for patients who had previously been treated for a blood-borne infection; The Apparent Conflict

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the prayer took place after the patients had left the hospital. He then analyzed the duration of fever and length of hospital stay of the patients prayed for and compared it to that of patients who had not received this benefit after their hospitalizations. He found that the former group had a modest but significantly shorter duration of fever and hospital stay. In his published report he did not invoke a divine intervention but assured readers that further investigation was warranted. This study was followed by a flurry of letters to the journal's editor saying that anything as outlandish as this study should not have been published. Most writers made clear that the thought of prayer going back in time and changing the course of medical illness made no sense. Nonetheless, the episode illustrates how the semblance of good methodology on paper does not necessarily produce credible results. Jaswang Neki, a psychiatry professor in New Delhi who had served for years as a consultant to the World Health Organization, gave me his own pointed critique of contemporary psychiatric research. He said that by giving up its appreciation of values, psychiatry has become paralyzed, not liberated, and that furthermore it embodies the fallacy that it is an objective science. He looked at me in a challenging manner and illustrated his point. "If I smile at a psychiatrist, how can he say objectively if it is a smile of happiness, embarrassment, or ridicule? Objectivity will not resolve that."

Alternative Medicine Emerges

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here is clearly a chasm between people's spiritual needs and biomedicine's preoccupation with the mechanics of the body. This becomes evident when people turn away from established medical practice and seek healing with unproven but comforting techniques. Alternative medicine is a term that applies to a variety of nontraditional medical techniques lacking legitimation in biomedical research. Many of them rely on an overlay of belief in spirituality for their validation. They range from herbal treatments, to aromatherapy and energy therapy, to encounters with acupuncturists and yoga teachers. The popularity of alternative medicine was first spelled out for the established medical community in an article by David Eisenberg in 1993 in the New

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England Journal of Medicine,9 in which he reported results of a detailed national survey showing that 34% of U.S. adults had received at least one of these treatments within the previous year, this much to the surprise of the journal's readers. The term complementary and alternative medicine (CAM) has now come into use, implying the legitimacy of combining these alternative techniques with established medical care. There is now a growing acceptance of CAM approaches. The National Institutes of Health turned its small but controversial Office of Alternative Medicine into a fullfledged federal agency, the National Center for Complementary and Alternative Medicine, as the agency's budget came to more than $100 million a year. CAM techniques are apparently achieving greater acceptance among younger people. They are most commonly used by the majority of young adults between the ages of 18 and 33 (fully seven out of ten), less by baby boomers, of whom half had used them, and least by the pre-baby boomers.10 These treatments are widely employed by the medically ill. One study of HIV-infected patients showed that two-thirds had used herbs, vitamins, or dietary supplements, and almost half had visited a CAM provider to deal with their illness.11 More than half of people polled who reported suffering from anxiety attacks or severe depression had used CAM therapies in the past year, and a fifth of them visited CAM healers during that time. These anxious or depressed people reported that they derived help from them similar to what their conventional therapies offered.12 The effectiveness of these treatments has (by definition) yet to be demonstrated in controlled studies, and their impact seems to lie mainly in belief in their validity from a quasi-spiritual standpoint. Not that belief in a treatment is irrelevant to its effectiveness: In fact, its role is reflected in studies of placebo treatments, in which only moderate differences between active antidepressant medications and placebos have been found.13 In psychiatric disorders, at least, belief in a treatment can be almost as important as the drug effect when emotional distress is at play. The split between alternative and mainstream medicine is hardly new. In the nineteenth century healing techniques with varying degrees of legitimation were applied by a broad range of practitioners. Lay healers abounded, and established medical professionals were viewed mainly The Apparent Conflict

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as a bulwark of privilege; their elite educations did not necessarily reflect credibility. Medical practice took place in something of a war zone, with alternative approaches ranging from botanical healing to hydropathy and mesmerism. Christian Science disavowed all medical care. In time established physicians moved to purify their ranks. The American Medical Association was founded in 1847 to protect properly educated physicians, and by the early twentieth century it disavowed the legitimacy of medical schools that were not in conformity with its research-based standards of care. The federal government set up the Food and Drug Administration (FDA) in 1906 to delegitimate bogus medicaments and exclude them from the medical pharmacopoeia, but the battle over what is acceptable to the public and what is not continues, with blurring of the line between medications legitimated by research and approved by the FDA and nutrients and naturally occurring products accepted on faith. So long as these latter health-related products make no explicit medical claims, they can be sold widely as "foods," even in supermarkets. In a way, we have created two tracks in the health care system that run largely independent of each other. One is based on research science and the other on spirituality-tinged folk medicine. This situation is not restricted to Western countries. As we shall see, traditional Ayurvedic medicine and research-based medical schools coexist in India, often side by side.

The Metaphor of Biomedicine

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esearch into the human genome has sparked enthusiasm for basic biomedical research while undercutting the glamour of clinical, and certainly spiritual, issues, but an overextension of this zeal is becoming evident in the common culture, with the use of the gene as a metaphor for a variety of issues that have nothing to do with biology. A profile in the New York Times on a young man, the son of a filmmaker and grandson of the Hollywood screenwriter Herman Mankiewicz, refers to him as entering the screen-writing field because he has "the genes for his genre"; what about the culture of his upbringing? The Range Rover SUV is described as "an Anglo aristocrat with German

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DNA" because BMW once owned the company that produces this "choice of the Rolex set"; can a gene transplant be done on a motor vehicle? Overextension of the biomedical concept into unrelated areas can be likened to the excessive reliance on religious and spiritual thinking in the centuries before the emergence of empirical science, or the inclination to explain all human nature by means of psychoanalytic concepts when Freud was most popular. However, beyond metaphors, the economics of pharmaceutical sales has crowded out the spiritual and psychological from contemporary psychiatry by virtue of the influence of drug manufacturers' advertising revenues: The American Journal of Psychiatry relies heavily on drug company ads for its support. A typical issue included sixty-three pages of such advertisements, whereas the widely circulated Journal of Addictive Diseases carried none. The addiction field's AA orientation and social treatments have no corporate dollars to underwrite marketing. In fact, the American Psychiatric Association, once a bulwark for psychologically oriented interventions, has become dependent on the pharmaceutical companies that provide much more of its revenue ($13 million in a recent year) than do the dues of its members ($8 million). Psychiatrists (including me) should lend some thought to this relative balance. Recent articles in the medical literature point out that pharmaceutical companies have, without overt indication, assumed considerable influence on the preparation of practice guidelines, the formal procedures prescribed for treating diseases. These are prepared by leading medical organizations. Although the physicians who write these guidelines receive extensive research and consulting funding from pharmaceutical companies that sponsor the very medications they recommend, no indication is given in the published material of these relationships or the potential bias they may engender.14 Furthermore, direct-to-consumer advertising of prescription drugs in electronic media has increased dramatically, with expenditures in this area recently reported at the level of $2.5 billion.15 Nowadays, one can turn on the television and see a variety of medications touted for depression and social anxiety, problems for which psychotherapy and group support approaches, even spirituality in the youth cults, can mitigate without drug treatments. Concomitantly, the number of psychi-

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atric patients receiving a complement of nondrug outpatient psychotherapy visits had gone down by 50% over the last decade, while the use of psychotropic medicines increased dramatically.16

A Historical Perspective

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he spiritual aspect of physicians' role dates back to Shamanic healers, whose legitimacy lay in their transcendent and theistic identification. These protophysicians conferred little actual benefit in treating physical illness, and their efforts were directed more at offering hope for relief, creatively applied to their patients. However, the evolution of contemporary medical care has resulted in a loss of this spiritual grounding, and, given the way the mind works, empathy and technical thinking are hard to maintain at the same time. Rather than healers, physicians have become technicians and front-line employees of corporate medical care. Looking at it positively, this transition has taken place as empirical research has generated effective treatments for somatic illness, but at the same time, this change in the doctor's mode of practice can run counter to the emotional needs of patients. From an economic perspective the cost of medical care has become too great to be left in the hands of medical "line workers" who apply treatment at the front end of the vast array of new technologies, as the cost of laboratory and diagnostic equipment can hardly be left for doctors to expend just to give solace to their patients. In addition, the pharmaceutical industry can invest sufficient funds in promotion of new drugs to effectively use the physician as a channel for marketing their products. All this has been facilitated by the integration of the medical profession into an organized cohort of workers for whom modes of practice are largely dictated by insurers, hospitals, and medical associations. A little history will fill in some details. In the mid-eighteenth century John Wesley, the English evangelical preacher and founder of Methodism, could justifiably write in his widely read book Primitive Physic17 that ordinary people were fully able to treat medical illnesses on their own. Physicians had little more effective treatments than did the lay public, and they were defined as much by their social affiliations as by

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their ability to resolve somatic illness. In England acceptance into the Royal College of Physicians was restricted to doctors who had studied the classics at Oxford or Cambridge. In the United States the social status of the medical elite was evident in the fact that four physicians were signatories to the Declaration of Independence. On the other hand, treatment of illness for the common folk typically fell into the hands of practitioners who applied folk remedies and gained modest economic support from their efforts. Professional development followed no fixed pattern for these healers, and most gained their experience through apprenticeships or from a diverse group of poorly organized medical colleges. For most of these healers success in practice often depended on courting whatever patients they could engage. Since medical licensure had yet to fall under the control of governmental agencies, physicians defined themselves as they chose to. Even by the mid-nineteenth century the few licensure laws that had been passed were being rescinded for lack of support from the public and from physicians themselves. Scientifically grounded medicine was slow to take hold, and different healing techniques were associated with a variety of diverse subcultures. In his study of the social history of medical practice, Paul Starr18 described how religious sects in the nineteenth century often maintained preferences for their own brands of medical practice. Second Advent Christians, who had regrouped after the first Adventists predicted the end of the world, favored hydropathy, the internal and external use of water for treatment. Adherents to the Church of the New Jerusalem, who viewed their founder's writings as the word of the Lord, were inclined toward homeopathic medicine. Thomsonians, who practiced herbally oriented medicine, treated illness through the application of the heat generated by emetics drawn from plants. Homeopaths saw disease as a matter of spirit and prescribed medicaments in small quantities that could mimic the very symptoms they were designed to treat. The establishment of the American Medical Association (AMA) in 1845 can be viewed as the beginning of consolidation of a national interlocking directorate that would define the nature of the country's medical practice. One major initiative of the nascent AMA was to do what it could to drum homeopaths and Thomsonians out of the profession.

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Starr pointed out that this initiative was largely defensive, rather than scientifically grounded, as the association was responding to slanders heaped on its members' allopathetic techniques, ones designed to directly counter the symptoms of illness. Medicine based on scientific research began to take hold by the end of the nineteenth century, bolstered by developments in the treatment of infectious disease: a vaccine against rabies, an antitoxin for diphtheria, and salvarsan for treating syphilis. The application of sterile techniques to prevent infection during surgery helped make operations life-saving, rather than life-terminating, procedures. By the end of the nineteenth century, Johns Hopkins University had established a formal four-year medical curriculum for physician training and required college degrees of incoming students. Its medical curriculum was based on the models of empirical research that were increasingly becoming the norm for the profession. Medical colleges that did not meet these emerging standards came under attack in a report released by Abraham Flexner in i9io,19 which had been underwritten with funding from the Carnegie Foundation. Those that did not meet the newly evolving standards of medical science soon closed down. Before the twentieth century hospitals were seen more as settings for convalescence than for curing disease. With advances in antiseptic surgery and the centralization of acute medical care, teaching hospitals were becoming centers for leadership in the medical profession. Progress in anesthesia and the opening of large diagnostic laboratories contributed to this development. No longer was an overlay of religious affiliation and spirituality needed to legitimate their existence. The concept of the physician as purveyor of a unitary spiritual message was clearly put to rest as medical practice came to be organized under (what is now called) the American Board of Medical Specialties, initiated in 1933. Scientifically based standards of practice for each of the diverse specialties of medical care, ranging from surgery and internal medicine through psychiatry, were soon each systemized under one umbrella collaboration for demonstrating competency and avoiding jurisdictional disputes as well. The family doctor, practicing with the compassion of long-standing relationship, now hardly exists, as almost all physicians are being trained under standards established for advanced specialization. 60

The Impact of Culture

As the twentieth century wore on, control over the economics of medical practice began to slip out of the hands of the doctors and into entities modeled on the organization of corporate America. Increases in the application of medical technology were abetted by the growth of large hospital complexes affiliated with universities and by the remarkable technology available to them. Attempts were now made to assure systematic provision of increasingly expensive medical care. These included the establishment of Blue Cross and Blue Shield in 1929. By the 19405 physicians were coming to be employed in large corporate entities. In California, for example, Henry J. Kaiser organized care for his employees, ultimately developing the Kaiser-Permanente network that built its own hospitals. Technology became infused into hospital care in the final days of life, a period that had in years past been the domain of spiritual accommodation. Hospitals became settings for endof- life rituals, in which medical technology, rather than the patients making peace with their maker, framed the role of the healer. After Medicare was instituted by the federal government in 1965, the Joint Commission on Accreditation of Health Organizations (JCAHO) was established to guarantee minimal standards of treatment. It now frames particulars of care across the nation for the way hospitals operate, applying its procedural expectations down to the techniques employed for improving performance on each of its wards. JCAHO reviewers can grill individual doctors, nurses, and aides to assure that its standards are applied consistently across the nation. The latitude of physicians to frame their relationships with patients, let alone infuse spirituality into those relationships, is rapidly coming to an end. Corporate management of physicians' prescribing practices has also emerged, as worldwide cartels have come to control the marketing of Pharmaceuticals. In light of the economic gain derived from applying medical science in the development of new drugs, pharmaceutical companies with capitalization in the scores of billions of dollars now propagandize and finance practitioners and researchers alike. For example, capitalization of Pfizer Inc., a giant in the industry, has reached the level of $250 billion in a recent year;20 its corporate board is unlikely to be preoccupied by its customers' spiritual needs. How does this affect the discretionary power of a given lone practitioner? Expenditures on marketing of drugs to American physicians The Apparent Conflict

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now stand at the level of $2.5 billion, with the emerging avenue for promoting sales to the lay public now a growing industry.21 Physicians are operantly reinforced to serve as the purveyors of the pharmaceutical companies' products through rewards that are modest relative to the overall profits these drugs generate. Some examples are free travel to marketing meetings, free meals at dinner symposia where hired experts tout a given drug, advertisements for the pharmaceutical products that support scientific journals, and reimbursement to physicians for studying a drug company's products in clinical trials. All this effectively serves to move the management of medical care and clinical choices out of the hands of physicians and into the large corporate entities that use doctors as vehicles for introducing new and costly medications. Often these new compounds are no more effective than the less expensive or generic ones they replace. Clearly, there are no similar corporate vehicles for promoting spiritually grounded relief of suffering from illness. Again, it is important to note that many of these developments are of great value in improving the effectiveness of medical care and moving scientifically grounded techniques into practice. We would be living shorter lives and suffering more pain without them. Nonetheless, as an unintended consequence, they have served to expunge the role of the physician as channeler of spiritual support, replacing it with that of the assembly-line technician. The tail has grown dramatically, so that it now wags the dog.

Psychiatry in Devolution

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he discipline of psychiatry has generally not been associated with the comforts of spiritual renewal. Benjamin Rush is considered to be its first American practitioner and wrote its first textbook, Diseases of the Mind. He signed the Declaration of Independence at 31, but his precocity did not set him apart from medical practices of the day. Bloodletting, often with leeches, was an established medical treatment at the time, and Rush, like many of his compatriots, prescribed it to address the symptoms of madness as well. Other approaches he supported to relieve the congested brains of the mentally ill were dropping them

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into cold water and binding them in leather straps to a gyrating chair,22 not the best beginning for scientific psychiatry, or for care of the spirit, for that matter. Until recently, psychiatrists were typically removed from communitybased practice. Psychiatric hospitals and retreats were located in remote sites to isolate the mentally ill from their families and communities of origin because of the patients' confused and threatening nature. This stood in contrast to the general medical care provided in hospitals closer to patients' homes. As late as 1930 nearly three-quarters of the members of the American Psychiatric Association worked in state mental hospitals.23 In their diagnostic system these psychiatrists categorized illness by observable behavior, with their inclination to think in terms of somatic causes, thereby slighting the value of subjective experience. The profession was transformed around the time of World War II, however, with the growing legitimation of the psychoanalytic model. Although orthodox psychoanalysts viewed religion as a neurotic remnant of childhood development, it did legitimate the importance of patients' subjectivity and inner life, inevitably allied with their spiritual needs. The Group for Advancement of Psychiatry (GAP), established in 1946, spearheaded the rebellion of psychoanalytically oriented members of the American Psychiatric Association (APA) against the mental hospital-based organic psychiatrists. GAP members effected major changes in the APA's orientation and spawned many of the APA presidents in the years following the group's inception. At the same time, however, biology and physiology were reigning supreme at the National Institutes of Health (NIH), and the wheel turned again with the emergence of biological psychiatry, funded by massive support from the National Institute of Mental Health (NIMH), a component of the NIH. Empirical science based on the model of biomedicine took hold in medical school departments of psychiatry, replacing the mind with the brain as the object of study. This was strongly abetted by NIMH funding for research psychiatrists across the country, who would now carry out studies largely within the ethos of the NIH model for medical science. Departments of psychiatry came to be managed by biologically oriented researchers and administrators driven by the economics of these federal grants. Medical schools and their psychiatry depart-

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ments came to rely heavily on this funding because of "indirect costs," that is to say, costs given for the administration of the medical institution, which were pegged at a level of 60% or more over and above the actual cost of carrying out a given research project. Hiring of full-time psychiatric faculty and designation of tenure came to be measured by ther winning of these grants. At New York University Medical School, for example, the seventy-three people who were given tenure appointments between 1995 and 2002 each had brought in an average of $2 million in grants. At the school's overhead rate of 67%, this represented a total of $95 million in revenue for indirect costs, nearly as much as tuition from all of the school's students during that time. This grant funding clearly represented an important part of the school's income, particularly since it could be directed at a large variety of administrative and developmental activities. With the publication of the "Feighner"24 criteria for psychiatric diagnosis in 1972, leaders of this new orientation promulgated a psychiatric lexicon based once again on observable behavior. Psychiatry moved away from looking at the subjective experiences of all people, not just the mentally ill. This was contrary to the psychoanalysts' orientation, who were searching for the verities of the human condition. Indeed, George Winokur, a psychiatric mentor at Washington University, now somewhat cynically distinguished between "problems of daily living" and biopsychiatry, the actual fodder of valid "science." He was implying that mere problems of daily life pondered by the psychoanalysts were best excluded from academic medicine. Phenomenology was now categorized by scientist reporters, rather than by people reflecting on the painful, or simply meaningful, experiences in their patients' lives. The biological approach has been promoted by other developments. Antidepressant sales are now running more than $10 billion annually. Clearly, medicines rather than "talking cure" have become a lucrative vehicle for treatment. Neuroscience advances and radiographic imaging techniques have become the lingua franca of advanced psychiatric research. Attendance at the annual meeting of the Society for Neuroscience dwarfs that of the APA. No longer can medical students interested in a career in mental illness hope to achieve advancement of tenure based on attending to the subjective or spiritual needs of their patients. Even at the APA's annual meeting, the press editorialized that several 64

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dozen drug companies paid about $50,000 per session at some symposia to "control" which scientists and papers were presented and to shape their presentations.25 The Washington Post referred to large-scale symposia sponsored by the pharmaceutical industry. The movement of psychiatry away from the subjective and spiritual and toward the technological has also been driven by the way treatment services are now reimbursed through health insurance. Managed care, an umbrella term for the variety of regulations established to curb the cost of medical care, has taken a toll on the time doctors spend with their patients. Psychiatric illness is by far the area of practice most compromised. This was coming to a head for physicians treating addictive disorders when I was president of the American Society of Addiction Medicine (ASAM). We undertook a study to obtain a concrete measure of the impact of this form of cost containment.26 In collaboration with independent evaluators of health insurance coverage, we obtained data on the decline in support for mental health and addiction treatment over the previous decade by analyzing the benefits covered by 1,017 U.S. corporate employers. Over the course of the 19908, the dollar limit on coverage for general medical care had decreased by 12%. In contrast, mental health coverage had been cut by 52%, and substance abuse coverage by fully 75% What was the impact of these cutbacks on attention to patients' need for more intensive therapy, beyond brief interventions, toward a meaningful emotional recovery? Certainly, they left little opportunity for providing exploration of a patient's spiritual needs. In the area of addiction treatment, the generation prior to the emergence of managed care had seen a remarkable rise in spiritually oriented rehabilitation. This was illustrated in the pioneering role of the "Minnesota model" for treatment, originated in the work of Dan Anderson, a psychologist who had initially encountered chronic alcoholic patients in a state hospital in Minnesota. In 1949 he opened a retreat for alcoholics that came to focus on AA-based recovery, thereby allowing its residents to recoup their compromised spiritual lives and become engaged in Twelve-Step programs. The Minnesota model spawned many "rehabs," typically organized around a 28-day-period of residence. Hazelden in Minnesota and the Betty Ford Center in California were well-known examples. If one were looking for an analogy to this development, these rehabs The Apparent Conflict

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might be likened to quasi-religious retreats, and the community-based AA meetings that addicted people later attended to local parishes, where spirituality could be sustained after a period of residential renewal. The administrators of managed care programs, however, applying their models for reimbursing only acute medical treatment, saw these protracted periods of residence as too costly. By the time our ASAM study was released, inpatient care for addiction was rarely reimbursed for more than 3 or 4 days of detoxification, followed by a limited number of outpatient visits. Needed convalescence or rehabilitation was also expunged from general psychiatric inpatient care, with hospital stays for the mentally ill cut back from a period of weeks to time measured in days. Outpatient psychiatric treatment was reimbursed only partially relative to other medical care. A struggle for assuring parity between coverage for psychiatric illnesses and general medical treatment was spearheaded by psychiatrists, psychologists, and other mental health professionals, but the real-life impact of this effort yielded little meaningful change in these constraints. As part of our report, we surveyed the physician membership of ASAM, and the large majority reported that their opportunities to promote addiction treatment were severely curtailed. Fully 79% said that managed care had had a negative impact on their ethical practice of addiction medicine. Although managed care was supposed to provide them with relief from administrative demands, thereby allowing more time for a better relationship with their patients, most (63%) reported that it had actually cut back on time available for their clinical work.27 Even in the domain of an illness labeled as spiritual by AA, doctors, at least, could hardly attend to this aspect of a patient's needs. One example that we cited of truncated care was that of a 28-yearold man with a history of multiple addictions and manic depressive illness. After a hospital stay limited to 3 days, he was referred to an outpatient program for which his managed care company approved only six visits a year. The managed care case reviewer responded to the clinician's phone call by denying further care, while explaining his denial on the man's evidently poor motivation because of his vulnerability to relapse. In the face of this perceived rejection, the man dropped out of treatment after his first visit, saying, "I don't know what I will do with

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myself. I'm just totally lost." Clearly, little attention had been paid to this combination of emotional, spiritual, and addictive problems. Such patients are now being left on their own. Not only were their acute and severe psychiatric needs untended, but spiritual renewal following these acute problems will not even be considered.

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5

Problems with Spirituality

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pirituality can be associated with both constructive, and also compromising, values; it is not without potential problems. When spiritual beliefs are introduced in the context of intense group influence, they can profoundly affect and even distort mental function. They can transform the mind, the brain, and the body. They can be manipulated, and not always for the better, but for the worse. A balanced appraisal on the treatise of this book cannot be made without acknowledging this issue.

An Attack on the Body

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he phenomenon of "voodoo death" stands out as a striking example of the potential effect of spiritual ritual on bodily function. Early in the twentieth century the physiologist Walter Cannon described how death could ensue from sorcery or taboo violation in aboriginal settings as far-flung as Polynesia, Africa, and the Caribbean. He pointed out that in these cases, poisons or violent assault could be ruled out as causes of death. To illustrate this he described what happened when an Australian aboriginal was subjected to the ritual of bone pointing: The man who discovers that he is being bone-pointed by any enemy is, indeed, a pitiable sight. He stands aghast, with his eyes 68

staring at the treacherous pointer, and with his hands lifted as though to ward off the lethal medium, which he imagines is pouring into his body.1 After trembling, gyrations, and a fall to the ground, the victim crawls into his hut, refuses to eat or drink, and withdraws from the daily affairs of the tribe, making a pariah of himself. Only a medicine man can reverse this process by producing a small stick or pebble and saying that it was taken from the bonepointed man; otherwise, the ritual results in the victim's death. He is not physically coerced by those around him, and it is the tribe's spiritual beliefs and his response to the sorcery that produce this outcome. Cannon drew on a variety of studies on the sympathetic nervous system to define a cascade of events that could lead to this dramatic outcome. He pointed out that an excitatory response could be generated in experimental animals that were stimulated physiologically to a high level of agitation comparable to the response of a terrorized human. A vascular constriction takes place that shunts blood away from the musculature and abdominal viscera toward the heart and the brain. By preserving these most vital organs, this shift ensures the animal's—and, by inference, a human's—capacity to survive in the face of continuing threat. The heightened stimulation that results from terror, however, cannot be sustained and is followed by an adaptive response as the body reinstates its homeostasis. If the threat continues, the oxygen-starved vessels of the viscera eventually become permeable to plasma and, as in surgical shock, this leads to a fall in blood pressure and a reduction in the volume of circulating blood. In time this results in dehydration and ultimately cardiovascular collapse. In humans this series of events can be promoted by a social response. In a bonepointed person, for example, dehydration is augmented by withdrawal from food and drink as the ritual wreaks its social impact. In such cases it is clear that the intense sympathetic activation within the bonepointed person could not take place without the spiritual overlay of the culture. Cannon pointed out that a similar process can take place in people as a consequence of other experiences of terror. It had been reported in sudden death after apparently trivial wounds experienced during war. It had also been known in some patients who were profoundly anxious Problems with Spirituality

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about undergoing a minor surgical procedure. In these cases as well, sudden death could follow a similar cardiovascular collapse, even though the wounds or procedures themselves were limited in their impact. Cannon's observations suggest that certain societies have come upon this physiologic reaction in the course of their cultural evolution, and it effectively became a tool for their ritualized management of behavior. This raises some interesting questions: To what extent has our Western society effectively adapted different biologically grounded rituals associated with emotional activation to aid in the management of its members? In the domain of spirituality, social pressures can generate anxiety over commission of a sin or depression over loss of one's place in a religious congregation. From a sociobiologic perspective, to what extent have certain physiologic underpinnings of emotion and cognition emerged in the course of evolution because they assure the adaptive capacity of primate groups? These questions are worthy of consideration, even though their import can only be inferred, since experiments on such issues are clearly not possible.

Thought Control

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n the heels of World War II, many social psychologists were greatly concerned by the way apparently civilized people had relinquished their autonomy and humane values under the impact of group influence. Social psychology had evolved into an experimental science by that time, and two classical studies in that discipline were designed to ascertain how deviant behaviors could be generated under social influence. Although they were both carried out in laboratory settings removed from the actualities of everyday life, they had a material effect on how psychologists, and the public as well, came to see people as vulnerable to social influence. For our purposes we shall consider how those studies help to explain the way intense group influence augmented by the claim to spirituality can transform people's values.2 In the first of the studies, Solomon Asch illustrated how people are vulnerable to accept distorted perceptions under group influence. He had experimental subjects report which of three lines on a large white card

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was the same length as a standard line presented nearby. When asked to do this on their own, almost all picked the correct line, ignoring the two incorrect options, which were obviously shorter than the correct one. The test was then presented to other subjects who were placed in a group with six other people, all of whom were confederates in the experiment. In these cases the confederates all picked the incorrect line, the one that was clearly shorter than the others. When the confederates chose the wrong line as a match for the standard one, the actual experimental subjects had to deal with an incorrect consensus. More than three-quarters of them actually went along with the wrong answer at least once. Some of the subjects later explained that they had been uneasy about giving the wrong answer but rationalized their actions by saying that other "subjects" might be suffering from some sort of optical illusion, and they felt obliged to go along with the group. Other subjects acknowledged no error, accepting the wrong answer without ambivalence. How can conformity like this play out in spiritually oriented group settings? The religious cults that attracted so many young adults in the 19608 and 19705 illustrate how the strongly-held views of unsuspecting people can be turned around in a spiritually oriented setting. I found this to be the case when the Unification Church, the "Moonies," recruited college-age youths who had previously used alcohol and drugs heavily and had maintained liberated sexual attitudes. In the course of a few weeks, many were turned into sexually and chemically chaste followers of the Reverend Moon, compliant with his demands that they become street mendicants. Most of these youths were "seekers," looking for a philosophy or perspective that would address uncertainties they were facing. Parallels between this Unification Church induction format that I studied3 and Asch's experimental groups are clearly instructive. The church functionaries organized their retreats around small group discussions in which a majority of participants were active followers of Reverend Moon. The context of communication was managed and essentially controlled by each group leader, an established church member, and the consenting church members played a role that paralleled that of the confederates in Asch's study. Potential inductees, out of

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courtesy for the prevailing perspective, effectively found it awkward to express dissenting views. In this case an entire weekend experience was infused with explicit or implicit references to the absolute validity of the movement's spiritual philosophy. Self-exposure regarding group members' intimate feelings and spiritual orientations was encouraged, while the church's theology was presented as an explanatory model to address the malaise that had motivated inductees to come. Given the certitude with which members stated their views and the reluctance of potential inductees to offend their hosts, a consensus inevitably emerged around the philosophy the Moonies espoused. The church leaders had come upon a vehicle for engaging the thinking and attitudes of many of the participants, clearly taking advantage of the vulnerability to the same group pressure that Asch had highlighted in his studies. These experiments of nature made clear that the laboratory-based research reflected aspects of psychology evident in the "real" world as well. Asch made clear how a group's prevailing culture can change and distort a person's view of reality. Can a belief system introduced in a social setting a person has just walked into distort his or her innate values? Can it make him or her do things to other people that he or she would not have done before? If so, we should be concerned over the risk associated with putting a spiritually oriented subculture into the hands of a leader who might use it to inflict harm. In order to better understand this element of risk, we can turn to a second study that illustrates how a prevailing culture can surprisingly easily lead people astray. Although our contemporary society ascribes objectivity to the scientific method, most people accept the validity of scientific research almost the way people in earlier centuries adhered to their respective religions. Medical research now carries a transcendent connotation, posited on the assumption that it will unlock the mysteries of nature and defeat the maladies that shorten our lives, perhaps even relieve us of our dayto-day unhappiness. This legitimates endless investment in education and laborious hours in the laboratory, often with little material recompense. It justifies intrusions into the body, from the dissection of experimental animals to the introduction of experimental drugs into sick and suffering people. Given this quasi-religious commitment to experimental science, a second study, conducted by Stanley Milgram, made use of the implicit 72

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sanction of a simulated psychology laboratory. It illustrates the vulnerability of people to distort their customary values under the influence of a transcendent philosophy. Subjects in the experiment were recruited on the campus of Yale University, far removed from the culture of the Third Reich that had inspired Milgram's concern. They were told that they were taking part in an investigation on how punishment affected people's learning. A second "subject," who was actually a confederate in Milgram's study, served as a "learner." He was supposed to perform a task involving memory by recalling the second word in a previously memorized pair of words. He was seated behind a glass screen and had been trained to act out what looked like a research protocol, but he had actually been scripted beforehand. The actual subject, ignorant of the staging in this supposed experiment, was designated to play the role of a "teacher," was instructed to read the first words of each word pair, and was told to punish any errors the "learner" made with an electric shock in order to improve the training. This presumed shock was delivered by an apparatus that looked like a credible laboratory instrument but was actually a sham device. It appeared to produce shocks that began at 15 and went up to 450 volts. The actual experimental subject, the "teacher," was told to increase the intensity of the shock with each successive error. In accordance with the protocol, the learner acted as if he were increasingly uncomfortable, thereby putting the teacher in the awkward position of having to comply with the presumed importance of scientific research or refuse to continue. If the "teacher" hesitated at what appeared to be higher levels of voltage, the "experimenter," also a confederate, would prod him on with statements like, "The experiment requires that you continue." Milgram's unsettling findings showed how people's values could be distorted by a prevailing subculture. The teacher-subjects' presumed standards to avoid inflicting pain on innocent people did not predominate over their obedience to the supposed values of scientific inquiry. Fully 60% of the teachers gave the entire series of shocks to what appeared to be innocent, suffering people. Although some teachers protested and asked that the session be ended, most continued to comply, even when the victim pounded on the wall, appearing to protest the painful shocks. Does this finding, when coupled with the vulnerability demonstrated in Asch's subjects, shed light on how long-lasting distortions can be Problems with Spirituality

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effected in people's beliefs and behaviors? How vulnerable are people to relinquishing their values when under the influence of a circumscribed group experience? To answer these questions, we will consider a dramatic example of how such influence acted on people in the world outside the laboratory. In 1978 914 American adults and their children, followers of the preacher Jim Jones, swallowed poisoned fruit juice and died in the Guyanese jungle. This event shocked the sensibilities of people around the world. It seemed all but impossible that a religious cult, however isolated and led by a maniacal leader, could inflict such a disaster on its members. Furthermore, its members were citizens of the United States, a society where independent thinking was presumably cherished and upheld. This event was reported in the press right before one of my visits to the "Moonie" headquarters, while I was planning my study on their induction workshops. Because of the intensity of ongoing publicity surrounding their cultic reputation, I was surprised to find that the members I spoke with did not express concern that a similar threat might be associated with their movement, as it certainly was by the press. The distortion of thinking that had been inculcated into these members was so well entrenched that they could see no parallel between the influence their group had over them and the control that Jones's movement had exercised in Guyana. More compelling, of course, was the cataclysm at Jonestown itself. Over the months preceding the Jonestown poisonings, the value of a person's physical and psychological integrity had been expunged from the group's culture. One of the few people who escaped death in the mass poisoning reported later that "Beatings were all over . . . people would be humiliated in front of the crowd . . . and Jones would just sit there and smile."4 The supposedly "spiritual" distortion in values that had become the norm for Jones's lieutenants paralleled, but dwarfed, the distortions of humane compassion seen in Milgram's experiment. The physician who served as medical officer at Jonestown, in violation of his Hippocratic oath, let alone any human scruples, prepared the fruit punch laced with cyanide that Jones ordered his people to drink. Before the final event, Jones's deputies, armed with rifles, had carried out suicide rehearsals and in the end had moved

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from cabin to cabin to make certain that all members were responding to the call for the mass meeting where the actual suicides took place. All this, however, could not have happened without the spiritual and religious unanimity that was engendered by Jones and his lieutenants. Before the cult had moved its members to the Guyanese encampment, Jones had been a charismatic preacher ordained by the Methodist Church. He had combined his religious philosophy with an espousal of social justice, in particular relation to the black residents in San Francisco to whom he preached. By the time his followers had migrated to their isolated site in South America, Jones was claiming to be the reincarnation of Jesus and other historical religious leaders. This transcendent spiritual role legitimated his grandiose claim to omniscience and his demands for compliance among his tragically misguided followers. A troubling conclusion is unavoidable: while spirituality can be a vehicle for effecting a positive transformation, it can also serve as an underlying philosophy for authoritarian control and, under the most unfortunate of circumstances, lead to inhumanity and self-immolation.

Emotional Conflict

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was invited to consult at a case presentation at the chaplaincy training program of New York University Medical Center. Bennett, a trainee in the program, followed the exercise's standard format and presented a "verbatim," the transcript of an encounter he had had with a patient at the hospital. This was followed by his personal observations on the experience and a formulation based on his religious perspective. Bennett was a compassionate and thoughtful man who had been teaching Bible classes in his local church for some years. He had undertaken chaplaincy training in order to broaden his understanding of the problems confronting the medically ill, and he planned to become a hospital-based chaplain. The 73-year-old woman he presented in his verbatim had been admitted to the hospital for evaluation following an unexplained episode of fainting. Although she had expressed some concern over her condition, she soon moved on to obsess at length over a conflict that had arisen between her two sons, one of whom demanded

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a change in her will because he had assumed primary responsibility for her care. After noting the woman's sad demeanor, Bennett said he had felt sympathetic toward her because her situation reminded him of problems he had experienced with his own children. He heard her out and then ended the exchange a bit abruptly by offering to pray for her, as he was unsure about what more he could offer. She thanked him for his announced intention and said it would help her get through her hospital stay. The Rev. Paul Steinke, the director of the program, observed that Bennett may have been reluctant to hear more about the woman's distress over her sons because of his own personal issues and had turned instead to a pat religious option to escape from dealing with them. Bennett's difficulty illustrated how a prayer—a spiritually oriented intervention—certainly well-intended, might have been summoned up as a means of avoiding a conflict between his chaplaincy role as a supportive figure and his personal conflicts. The cloak of spiritual leader was employed to protect its bearer. Leo, one of the other trainees, volunteered that he had encountered the woman when she appeared in the hospital's admitting office and that she had pressed him repeatedly about her sons as well. He said he was annoyed over her demands on his time "when other people were much more seriously ill." He did not hesitate to describe the anger he felt, which he acknowledged may have shown itself when they spoke. I was puzzled over the bitterness Leo expressed but later learned that he had decided to join the program for a limited time after the overdose death of his addicted daughter. He had approached the woman as a chaplain, presumably to support her in her distressed state, but his tone of voice, apparently related to his own problems, had conveyed a message quite different from what would have seemed compassionate. A perspective drawn from professional therapy could have been useful here to distance these trainees from the emotional pressures that can arise in well-intentioned people who are acting with spiritual sanction. Over years of training, psychiatrists are expected to deal with personal feelings and conflicts of their own that may compromise their response to a given patient. The emotional distance they maintain, although sometimes seen as an impersonal stance, allows them to avoid being com76

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promised by their own feelings, whether excessively positive or negative. This would have been useful in obviating the conflicts this elderly woman had aroused. It was also clear to me from both trainees' descriptions that she was moderately depressed, that this had accentuated her obsessive concerns over her sons, and that this was reflected in the sad demeanor that Bennett had described. Clinical training would have allowed a psychiatrist to understand her behavior better and avoid a personal reaction. The reactions of these chaplains-in-training illustrate how a spiritual orientation can provide solace but may not prevent its protagonist from experiencing emotional conflict and potentially compromising his or her relationship with a patient. The role of the chaplain carries with it the right to offer solace to people in distress, and the demand characteristics of the chaplaincy situation—the ones this role inevitably generates—weighed heavily on the trainees. Bennett and Leo had to maintain a spiritual role while dealing with their personal issues, but devoutly religious psychiatrists may be vulnerable to similar issues, as I found to be the case among members of the Christian Medical and Dental Society. In order to join the society, a physician must accept a literal interpretation of the Bible and the doctrine of the Second Coming. Although the members of the society often apply a Fundamentalist orientation in a beneficial way to the patients they treat, usually ones of similar religious orientation, their intense spiritual and religious commitment could introduce undue conflict at times. It could blind them to certain issues they should be aware of, especially if those issues run contrary to what a Fundamentalist and devout person feels comfortable addressing. One psychiatrist member told me about an experience he had had with a depressed, alcoholic woman. They had discussed the sexual problems she had experienced during a troubled marriage at some length. She came from a family of devout Christians who had shunned her when they found out that she had picked up men in bars during her episodes of drinking. Both her alcoholism and infidelities had led to shouting matches with her husband and ultimately to his walking out on her. Left alone, she fell deep into depression and drinking and had to be hospitalized. The psychiatrist told me how they had discussed this history and her guilt over her behavior in order to help her achieve reProblems with Spirituality

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ligious redemption. In some of their sessions she would ask him to pray with her, and he obliged her as they sat side by side. After leaving the hospital she went to AA and stopped drinking, and the psychiatrist continued to see her on a weekly basis. He was relieved that her religious feelings were now emerging all the more strongly. After a few months, however, she began drinking again and prayed for the strength to stop, as he continued to see her. At one point he was called out of town on family business, and in his absence she made a suicide attempt and was rehospitalized. Upon his return he found that the woman had left him a message saying she "cared for him greatly" but no longer needed to continue in treatment. I was concerned when he said that he viewed the outcome as positive insofar as the woman's religiosity had emerged in the course of their contact. He did not seem to appreciate the magnitude of the problem associated with this unstable woman's sudden departure. As he described the duration and intensity of their relationship, it had become clear that she was highly dependent on him and may have developed a sexualized transference that he, given his intense religious orientation, did not acknowledge to himself and therefore did not deal with in the therapy. In this case two contradictory processes, an unmentioned, unspoken, intense personal relationship and an overt, religiously oriented communication coexisted in material conflict with each other. Religious intensity can blind psychiatrists or counselors to issues that greatly impinge on the nature of their work. The impact of conflicting messages born out of a subculture of belief can be illustrated among psychiatric staff as well, such as when they adhere excessively to psychodynamic theory as if it were spiritually grounded dogma. Harold Searles,5 a psychoanalyst who worked in a residential treatment setting, lived with the ongoing emotional conflict inherent in day-to-day life with the mentally ill. He was impressed by how both staff and patients could succeed at "driving each other crazy" by generating conflicts that were apparent to neither the perpetrators nor their victims. Staff members would often impose conflict on their patients by playing into one side of their ambivalent feelings and suppressing the other. They might decide that a patient's grossly disturbed behavior reflected an unconscious need to stay secure in the hospital, even though the patient strongly insisted on leaving. Instead of taking 78

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her pleas at face value, a staff member would reply in a reassuring tone, "I realize that you really want to stay in the hospital and are afraid of moving out." The patient, bewildered by a reference to a presumed ambivalence, one that she may not have felt at all, would only become more agitated. Staff here were inappropriately applying their psychoanalytically based beliefs in a way that could only cause distress. Searles discussed a number of motivations for driving other people "crazy" and pointed out that the inherent cruelty involved often reflected angry, even murderous, feelings. Intense anger can also be aroused among family members of a mentally ill person, as in a parent's response to a child's inability to surmount mental illness. In such a case the family can become an emotional cauldron just as can an intensely spiritually oriented group. This is reflected in a body of research on how stabilized schizophrenic patients can be driven to a relapse in a family setting where the atmosphere is one of intense "expressed emotion."6

Groups Oriented to Professional Growth

T

here are many settings in which the intensity of group experience can illustrate problems that can arise in a spiritually oriented group. I first became aware of this issue of conflicting motives within a group during my own psychiatric training, where we residents participated in a "T group" to learn what it would be like when we operated therapy groups for our patients. The experience was a positive one, but it was always ambiguous whether the T stood for "therapy" or "training." In any case, it was clear that the relative potency of the group's influence could cut different ways, particularly for certain members who might be scapegoated when tensions arose. Like some of my fellow residents, I was careful to maintain a certain distance from the intense atmosphere, if only to avoid getting caught off guard in the emotional cross-currents of exchanges and potentially be embarrassed. At the time "marathon" groups had achieved some popularity as well. They were designed to run 12 or even 24 hours, with increasing intensity of members' involvement, thereby summoning up a more potent group experience in part to achieve a quasi-spiritual goal of personal growth. This idea was attractive in the years soon after my trainProblems with Spirituality

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ing because of my interest in group process and how group influence could be employed, and I conducted a few marathon sessions for the patients in my own practice. One issue that left a strong impression on me was the vulnerability of the leader—in this case, myself—to become a subject of the group atmosphere. In the context of intense exchanges, I sometimes found it hard to make a lucid judgment about the moment-to-moment impact of the group on individual members. Individual therapy allows for maintaining an objectivity that involvement in such a group makes harder to achieve. Spiritually oriented groups that generate intense involvement may seriously distort the thinking of their own leaders, as was likely the case with Jim Jones, whose grandiosity and paranoia emerged in the most bizarre way only after years of adulation by his followers. For now, however, we can consider how spiritually or ideologically oriented groups can cause damage to a participant, particularly one who is already emotionally vulnerable. This was illustrated by the psychological impact of certain encounter groups. The encounter format was developed by Kurt Lewin, a social psychologist who trained professionals and executives in interpersonal relations in the 19408. His followers moved in a variety of directions, some more intensively oriented toward personal change and a more meaningful life and others toward simply learning about group process. The personal change encounters ranged in orientation from Gestalt therapy to psychodrama and from psychoanalytic exploration to sensory awareness, often directed at the goal of minimizing the sense of alienation experienced by the participants. The groups were driven in large part by the ideology of their leader's background. Irvin Yalom and his colleagues7 carried out a study in the late 1960$ that illustrated the kind of encounter group atmosphere that could generate noxious emotional conflict. (It was not their intention to compromise any of the participants.) They solicited Stanford University undergraduates to enroll in a total of eighteen such groups. The students were told that this experience, although not labeled as therapy, would help them achieve a measure of personal growth, a goal regarded as admirable, if not spiritually ennobled at that time. The research team made observations on encounter group "casualties," participants who experienced a significant negative psychological 80

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impact for a period of months. The type of group leadership that was most influential in generating these casualties had created an atmosphere similar to the one associated with the victims of Searles's "driving the other person crazy" and in the families that precipitate relapse to severe mental illness. These leaders were characterized by high charisma and high confrontation. They encouraged attacks or rejection within the group and pressed members toward achieving unrealistic goals. Emotional "input overload" and group pressure heightened the impact of these characteristics. In effect, attention was not paid to the inherent conflict between an overt agenda of helping and a covert process, however unintended, of hostility. In this respect this experience served as a minirevival meeting gone awry. The case of one student illustrated how the experience generated psychological damage. She had joined the group because of "vague feelings of needing something," a motive like those that drew many youths at that time into religious cults such as the Moonies. As one of her fellow encounter group members described her, she thought that deep down she was not worth anything and decided it was better not to know. The group leader was described as flamboyant and confrontational, and pressed members of the group to "get in touch with their anger," and believed that his ministrations would enhance the lives of participants This resulted in an attack on her by both the members and the leader alike. After the leader said that she "was on the verge of schizophrenia" but would elaborate no further, she could not help ruminating over the remark. She gradually withdrew from her family and friends and became depressed and sleepless. It was only months later that she gradually returned to the state she had been in before she entered the group. Clearly, her need for support, had been met with contrary, intrusive input. We can look further on the issue of group leadership. The inclination to bond together cohesively and establish a dependency on a leader, which is characteristic of spiritual movements, was illustrated in a compelling way in the work of the British psychiatrist W. R. Bion, a seminal thinker in the study of group dynamics. Bion's studies first appeared in the British medical journal Lancet, reflecting a period in the early 19405 when studies of subjectivity in emotional experience still had a legitimate role in the medical world. He later wrote of his clinical work at the Problems with Spirituality

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Tavistock Clinic in London, where he took on leadership of small groups of neurotic patients in order to study the forces operative in group settings. In order to explore what might naturally emerge in these groups, he abstained from obvious leadership and only commented on the needs of the group as they occurred to him. By eschewing the role of active leadership this way, he found that a marked degree of anxiety emerged among the members, reflecting, as I might put it, an absence of spiritual certitude. As he put it, groups manifested an underlying need, or "basic assumption," for finding support and direction from a godlike leader. He wrote: I am certain that the group is quite unable to face the emotional tensions within it without believing that it has some sort of God who is fully responsible for all that takes place. . . .What is there in our present situation that would make us think that a leader of this kind is required? It cannot be the external situation, for our material needs, and our relationships with external groups are stable, and would not seem to indicate that any decisions will be required in the near future. Either the desire for a leader is some emotional survival operating uselessly in the group as archaism or else there is some awareness of a situation, which we have not defined, which demands the presence of such a person.8 This dependency need and "archaism" appear to be basic to the psychology of our evolved race. Individuals move toward a conjoint endeavor under a leader, perhaps of a godlike nature, as Bion suggests, and that in turn binds them together to avoid the emergence of unmanageable anxiety. This can lead us to a consideration of religious cults.

In the World of Cults

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ion made his observations on peoples' need to seek out an omniscient leader in the context of professionally managed therapy groups. He certainly had no intention of manipulating the members for his own personal advantage. When people are manipulated in larger cultic groups, however, the inclination to seek out an omniscient spiritual leader can portend serious problems. Certainly, there are many ex82

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amples of spiritually oriented groups that have been led astray by leaders whose motivations or misguided intentions have caused trouble. Some have even wrought havoc. Based on some years of research on youth cults such as the Divine Light Mission and the Unification Church (the "Moonies"), I wanted to affix a generic term to groups that hold sway over all aspects of their members' lives. This phenomenon encompasses political entities such as some revolutionary movements that justify absolute commitment on the basis of a transcendent goal (including all men created equal in a positive light, or purification of the race when gone awry), but it should not necessarily imply a negative value judgment. After all, some of our lauded religious denominations started out with leaders who were thought to be divine. The term charismatic group therefore seemed appropriate. The term charisma is apt because it derives from the Greek word kharisma, or divine gift, and is defined as "great personal magnetism" or "divinely inspired gift or power." A charismatic group can be defined as follows: It consists of a dozen or more members, even hundreds or thousands. Its members (i) have a shared belief system, (2) sustain a high level of social cohesiveness, (3) are strongly influenced by the group's behavioral norms, and (4) impute charismatic (or sometimes divine) power to the group or its leadership. Given this, we can consider how the impulse to comply with an allknowing leader's expectations is sustained. This was evidenced in my studies on the Moonies, introduced earlier in relation to the psychology of spirituality. Reverend Moon was seen as something of a godhead by his followers, and he certainly subjected them to considerable privation. They regularly begged in the streets, lived together without personal privacy, and usually married the person Moon designated for them. As a presumed expert on cults, I had been called by parents who had become profoundly aggrieved at the apparent loss of their children, who were complying with their leader's every edict and had severed ties with their families of origin. The marital engagement ceremonies that Moon established are a striking example of the way he subjected his followers to rituals that were incomprehensible to their families and to the general public. In one such ceremony, he assembled 1,410 members of his church at the Problems with Spirituality

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New Yorker Hotel in Midtown Manhattan in order to pair them off for future marriage. He did this without apparent prior information on most all of them. He went up to one member at a time and then pointed to another in the large auditorium. This indicated to the pair that they should go off for 15 minutes to converse. They then had the right to ask him to select different mates for them if they felt it necessary; otherwise, they were engaged in marriage. Some pairings were even made by "Kodak matches" between a member in New York and another who was overseas and only pictured in a photograph. I secured agreement from the Unification Church hierarchy i year after the ceremony to bring together members who were living in three areas of the northeastern United States to study the nature of the engagement process, 321 of whom filled out an extensive questionnaire, and the results were quite striking.9 The large majority (87%) reported that they had no preference for a specific person before the matching ceremony. Of those who did have a preference, very few (4%) said that they had been matched to the person they had hoped for, and the others (9%) said they had not received their choice. Less than one in ten (7%) indicated that they had asked for a second, different match at the time of the ceremony. Contact between fiances was quite limited at the time of the study. Only a small minority (15%) lived within a mile of their future mates, and many (42%) lived more than 500 miles away. More than a third (38%) had not seen their partners at all during the previous 2 months. To say the least, this was at variance with what they or their families would have expected for them before they joined this group. Responses to three scales on the questionnaire were revealing in terms of the way Reverend Moon's group sustained control over the members' behavior. One scale reflected the degree to which members believed in the religious orientation of the group, and a second the degree to which they felt cohesively toward other group members. A third was a standardized schedule for psychological general well-being. The scores for both religiousness and cohesiveness were highly correlated with those for general well-being. That is to say, the more closely a member felt affiliated with the group, the more likely they were to experience a sense of well-being.

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This fit in with the relief effect I described before regarding earlier studies on induction into the group: becoming affiliated with a charismatic group typically brings relief of distress, and continued affiliation sustains it. This relationship can be said to reinforce continuing membership in the group, since if a member were to acknowledge a sense of alienation to themselves, they would likely experience a recurrence of distress in the form of anxiety or depression. But membership in the group entailed a considerable degree of ongoing distress and privation. Why did this not drive people away? In order to understand this better, another scale of disruptive life events was completed by the members. It consisted of two types of items. The first items were standard events that had been found to be associated with subsequent psychological distress among the general population.10 These included experiences such as a change of residence, addition of a new family member, and loss of a job. The second half of the scale consisted of a separate set of events specifically tailored to the church. I constructed them by surveying a sample of members who rated disruptive life events that were relevant to the ongoing experience of church members. These were items such as moving into a home church (which denoted leaving a large church residence and settling into an affiliated community residence) and having a profound emotional experience. Altogether, the combined set of life events was associated with a lower sense of general well-being, as expected. The next step was to examine the statistical relationship between items reflecting the members' intensity of affiliation to the group (belief and cohesion) and the negative impact of disruptive life events. The score on affiliative feelings operated counter to the relationship between the life events and general well-being. That is to say, it muted the distressful consequences of disruptive life events. The group imposed disruptive events on members that generated distress in them. It was only by maintaining continued affiliation, however, that the members could counter this distress. They were effectively captive in a pincer, whereby the group forced them into situations that created distress, but this distress was relieved by their continuing to cleave to the group. This ongoing psychological pincer apparently served to sustain commitment to the group and to its unusual behavioral expectations.

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The members' life of privation was further underlined 3 years after the engagement study. I was able to follow-up, reaching 209 of the original respondents directly and getting information on all but sixteen of the rest through inquiries of other members and access to church records.11 Almost all (95%) of these respondents were still active in the church at this follow up 3 years later. The large majority (81%) of active members were married to the person to whom they had been matched 4 years before, and the remainder had either been granted a new mate, had separated, or had considered breaking up. This degree of retention was certainly remarkable given the unusual circumstances to which members were subjected. There was no significant difference in well-being between members matched to a party who had been living overseas (the Kodak matches) and those who had a preference for a specific mate before matching but had not received their choice. Significantly, though, the nine people who were at the time of the follow-up considering terminating their engagement scored much lower in well-being than did the others (53.9% vs. 70.6%) and were indeed within the range of people described by the National Center for Health Statistics as experiencing "clinically significant distress."

Living with Persecution

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nother difficulty arises for members of charismatic groups. These groups typically run into conflict with the surrounding culture, which then leads the members to become even more tenacious in their beliefs. In fact, persecution of a cult's members, if anything, increases their willingness to suffer privation. This was illustrated by followers of Li Hong Chi, a former clerk who left China for the United States in 1998 after he had established the spiritual movement Falun Gong. His arcane philosophy, which he posted on his Web site while in the United States, took root among a growing number of followers back home who were apparently lacking in a commitment to the prevailing ideology of the Chinese state. Within a year after his departure from China, many of Li's countrymen were said to have joined. Some Chinese scholars estimated that he had between 20 and 60 million followers. Even the Chi-

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nese Communist Party, which certainly would have liked to minimize the movement's success, put its membership at 2 million.12 Falun Gong was sufficiently threatening to the government for it to ban membership in it. This suppression generated a contrary response among the very people the government had hoped to discourage. Within months after the ban, 10,000 members staged a sit-in around the leadership compound in Beijing, seeking official recognition for their group. Soon members who congregated in Tiananmen Square in central Beijing every day were carted off in buses, often not seen again. Some were held in psychiatric hospitals, where a spokesman for the police explained that they were retained for reeducation. Ultimately, five members, including one child, committed suicide in Tiananmen Square by setting themselves on fire, causing government officials to redouble efforts to weed out members. What, in fact, was Li Hong Chi's philosophy, that it seeded the potential for protest and self-immolation? It was drawn from Buddhism and Taoism and was represented by the Falun, or Dharma wheel. Its practice included Chinese breathing and meditation exercises. Li described the Dharma wheel as a miniature cosmos and said that he could install it telekinetically in the abdomens of all his followers, where it would rotate in alternating directions, throwing off bad karma and gathering qi. Many of his adherents said that they could feel the wheel turning in their bellies. Overall, this charismatic group, although rooted in aspects of Chinese culture, illustrated the degree to which an apparently bizarre spiritual ideology could generate intense conflict with the surrounding populace and move its adherents to privation, suffering, and even self-immolation.

Narcissism

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f a person becomes engaged in a spiritually oriented group, the wisdom of their joining may be judged by the culture of the group overall. Does its philosophy make sense within any conventional cultural context? Is it altruistically oriented, or does it embody the selfishness of its leader? Does it work toward a positive goal, or is it destructive? To Problems with Spirituality

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the extent that affiliation leads members to lose objectivity, even lose a sense of reality, such a group can ensnare them in a dubious, even disastrous, set of behaviors. A quite different problem may arise when a person's egotism and self-centeredness predominate in his or her turning toward a spiritual goal. Christopher Lasch described the way this phenomenon has emerged in his book The Culture of Narcissism.15 He wrote about "the narcissist, who sees the world as a mirror of himself and has no interest in external events except as they throw back a reflection of his own image." Lasch related this phenomenon to a particular kind of adaptation that has arisen in a climate that promotes self-absorption. He related it as well to the prominence of psychotherapy in our contemporary culture: The new narcissist is haunted not by guilt but by anxiety. He seeks not to inflict his own certainties on others but to find meaning in life. . . . The contemporary climate is therapeutic, not religious. People today hunger not for personal salvation, let alone the restoration of an earlier golden age, but for the feeling, the momentary illusion, of personal well-being. This can be seen among people suffering from the malaise and loss of spiritual roots that primed young people to join cults and left the student at Stanford vulnerable to the psychological pressures in her encounter group. People can seek relief and an illusion of transcendence in a transient commitment to a conveniently available ad hoc tradition without relation to an abiding spiritual affiliation. This can allow for filling a void caused by anxiety or a sense of inadequacy but may address only the uneasiness of the moment. In this situation the self may predominate over the other, whether the other is one's fellow man or woman or the embodiment of one's historically valid religious ties. This issue can be considered in relation to the conception put forward by Gordon Allport's14 distinction between an extrinsic and intrinsic religious orientation. From his perspective the extrinsic orientation is characteristic of people who are disposed to use religion for their own ends. . . .Persons with this orientation may find religion useful in a variety of ways—to 88

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provide security and solace, sociability and distraction, status and self-justification. The embrace of creed is lightly held, or else selectively shaped to fit more primary needs. The intrinsic orientation is seen in people who find personal meaning and direction in their beliefs: Other needs, strong as they may be, are regarded as of less ultimate significance. . . . Having embraced a creed the individual endeavors to internalize it and follow it fully. It is in this sense that he lives his religion. While the American mainstream is characterized by strong and active religious affiliations, it is equally subject to the pursuit of transient gratification. In part this is because the individual, apart from others, has been accepted as a cultural icon. This iconic role then serves as a justification for a preoccupation with one's own personal needs. As Americans have been provided with leisure time and substantial economic resources, their investment in entertaining themselves, in filling the void of uncommitted days and hours, has become a major pursuit. They can leave home for prepackaged diversion: In a recent year, $9 billion was spent in American amusement parks,15 and $7.7 billion was directed at film industry box offices.16 Or they can sit trancelike at home in front of their TV sets. Material goals rather than personal meaning have increasingly come to predominate in our estimation of the country's well-being, as illustrated by the Index of Leading Economic Indicators, the Consumer Confidence Survey, and the Dow Jones Index, all watched closely as measures of national health and of where the country is headed. These are easier to measure than the strength of the nation's moral fiber or abiding spiritual values. Our legal system is based on the primacy of individuals' rights and personal needs. This emphasis on the promise of autonomy, however, can lead to the triumph of the person as an independent economic entity rather than a member of a society with commonly held spiritual ideals. Free agency in sports rather than team commitment is a natural outcome of this cultural norm. For the sports star, commercial products have become associated with rewarding individual accomplishProblems with Spirituality

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ment rather than fidelity to a team: Nike sneakers signed an 18-year-old to a $90 million promotional contract on the eve of his entering the NBA. Reebok signed a 3-year-old with exceptional basketball skills to appear in a television commercial, merging his own identity with that of their product and declaring, "I am Reebok."17 With such preoccupations characterizing the American culture, it is not surprising that a contrasting worldview, one that emphasizes collective belief over material self-centeredness, has emerged among people who have rejected our Western culture and who have chosen to oppose it. And this, indeed, is the fidelity seen in radical Islam, to the point of self-immolation. Its madrassas inculcate hundreds of thousands of children to acquire commitment to the transcendent, to selflessness rather than to pleasures of the moment. In Pakistan alone there are an estimated 30,000 of these schools,18 where children sleep on thin mats on stone floors and get up at 4:30 in the morning for their first prayers of the day. There is no TV or radio there, much in contrast to 12,000 schools in the United States where Channel One pipes in advertisements for the accoutrements of America's materially oriented society and where the for-profit Field Trip Factory sends children on school hours to visit sports stores and supermarkets, urging them to clip coupons out of advertising circulars for homework.19 A myriad of New Age philosophies have emerged within the American culture of narcissism, wherein people attend to their egos and bodies, grasping onto popularized, commercialized adaptations of Eastern spirituality. They do this in the hope of resolving the despair of anomie caused by a loss of their historically valid religious roots. One brochure20 touts courses ranging from "Sound, Chakras, and Healing" to "Fundamentals of Aromatherapy" and "Ayurvedic Nutrition." "Polarity Therapy," also available, works with "life energy in all its forms, using a comprehensive system of body work, exercise, nutritional guidance, and verbal counseling, to bring body, mind, emotions, and spirit into a state of balance, harmony, and vibrant health." Each of these options is captured in a series of several sessions into which registrants hoping for salvation can invest themselves in the hope of curing their bodies, troubled minds, and spirits. Is this a retreat into an ill-defined attempt to salve the wounds of a lost soul? Does it have more permanence than

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the experience provided by the 170 million visits to America's most popular theme parks each year?21 On the other hand, some people's experiences illustrate the way narcissistic needs are met by alighting on one spiritual reserve for a temporary uplift and then moving on to another. This was true for Rebecca, scion of an affluent family and very articulate. She had traveled widely in her youth and had completed a graduate degree in history a continent away from where she grew up, but she could not bring herself to settle down and make use of her education. She explained her restlessness: It's human nature to be dissatisfied and inquisitive. This is a source of creativity and destructiveness. But good can come from it too. She illustrated this "good" (however transient) with an experience of hers not long after she had finished graduate school. Buddhism can tap that source of good. But I'm not a Buddhist. I did stay at a Buddhist retreat though for some time where there was an emphasis on Tibetan yoga and Kundalini. We just chanted vowels, but sometimes I would cry when I heard them. I was surprised because I didn't know where that came from in me. Rebecca later moved on from the retreat, traveled more, and entered into some relationships with men with whom she soon broke off. She went through training in Japanese Reiki healing, and more recently she studied the Kabbalah, but gave them up as her interest waned. More recently, she settled on tutoring wealthy high school students by combining her background in academic history with her experiences with the variety of cultures to which she had been exposed. I wanted to know what she thought about spirituality after this long series of experiences. What was your religious background when you were young? Religion was something the maids had. So it was not relevant to you? No. Then how would you define spirituality? It's not a word I would use, either. I would call it epistemology rather than spirituality. Basic human nature is to turn to thought

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and creativity, and in this way I work with kids' experiences. I would call this epistemiology rather than spirituality. In retrospect I am not quite sure what she meant by this latter statement. At least it seems clear that she had met some personal need with all her spiritually related experiences. She was in no way depressed or emotionally needy but had apparently fulfilled herself by touching down at each of these subcultures as way stations that addressed some narcissistically grounded need of the moment. Many of these new pursuits, representing people's grasping at spiritual fulfillment, are promoted on the basis of their celebrity followers. The cult of the individual as model for narcissism promotes this. The Scientologists have their "Celebrity Centers," where the names of Hollywood figures such as John Travolta, Tom Cruise, and Lisa Marie Presley implicitly justify adherence to this dubious cultic movement. Madonna touts her commitment to Kabbalah, and this seems to confer a degree of legitimacy on this derivative of medieval Jewish mysticism. The recent popularity of Kabbalah illustrated the intersection of the need for spiritual fulfillment and the need to meet unrequited narcissistic needs. Admittedly, Kabbalah represents a long-standing tradition of arcane Jewish mysticism dating back to the Zohar, a dense and lengthy treatise written in the thirteenth century by a Castilian rabbi. In recent years, however, it has been promoted as a commercial product. One advocate of this is Michael Berg, who opened Kabbalah Centres in Los Angeles, New York, and London, and attracted a following (for whatever reason, mostly women) including the likes of Elizabeth Taylor, Courtney Love, Diane Keaton, Roseanne Barr, and Madonna. As described in the brochure of New York's Kabbalah Centre, evening programs offered a measure of redemption in a series of several sessions, wedding the Hebrew calendar to the astrological signs and pointing out that "when a new month begins, we have an opportunity to tap into all the positive aspects of the astral powers that govern the upcoming month, and to protect ourselves against the negative aspects." Thus, the first day of each Hebrew calendar month was wedded to one of these signs: "rosh chodesh nissan—Aries," "lyar—Taurus," and so on. Benefits of this movement could be derived from purchases of Kabbalah mineral water and by wearing a red string around one's wrist (as Winona Ryder, in a 92

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hiatus from her movie career, did during her shoplifting trial). In one of his little books, The Secret: Unlocking the Source of Joy and Fulfillment,22 Berg explains his movement by presenting the same questions that could appear in the mission statement of most contemporary New Age philosophies: Why are we in the world? What is the purpose of our lives? How can we find fulfillment in a world afflicted with pain and suffering? Do such movements offer a sustaining fulfillment? Or are they the product of their adherents' needs to fill a vacuum in values that has been generated by our contemporary culture, one that meets people's material needs but has failed to offer substantial spiritual fulfillment?

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6

When Something Is Missing

Life's Transitions

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ven the most resilient of people may need help with their emotional distress when they come upon difficulties they cannot surmount. In psychiatry's diagnostic manual, such troubles are encompassed in a neatly framed chapter on Phase of Life Problems (¥62.89), which can be diagnosed when the focus of clinical attention is a problem associated with a particular developmental phase or some other life circumstance that is not due to a mental disorder. . . . Examples include problems associated with entering school, leaving parental control, starting a new career, and changes involved in marriage, divorce, and retirement. Not all people, however, conclude that the "clinical attention" cited in this APA nomenclature will give them the relief they want, as they have a wide range of options to choose from. Jim, for example, had spent a year abroad as a college sophomore, living the last three months in a fishing village on an island off the African coast. He had learned to converse in Swahili and found a congenial existence among the people there, unfettered by pressures back home, but when he returned to college he found the trappings of materialism in the United States disillu-

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sioning. The impersonal nature and sameness of the shopping malls, with their GAP stores and supermarkets, stood in striking contrast to the comfortable familiarity he experienced on the island back in Kenya. He became depressed and was looking for something to make up for "the happiest I'd ever been" only a short time before. Jim went into therapy for a while but found that it offered him little in the way of comfort, so he decided to try to achieve some clarity on the meaning of his life and began by taking up a major in comparative religion. He remembered some visits with a friend to Quaker services while he was still in high school and recalled that the silent reflection in their meeting houses had given him a sense of comfort and certitude. So given what he was now learning about Eastern religions, he decided to go on a week-long retreat at a Zen Buddhist monastery, where he was expected to remain silent except for a brief encounter with the abbott each day. Much time was spent in meditation, which brought him into the state that he was seeking: After a few days of looking at a parquet floor while on a meditation mat, and not saying anything, I began to have a sense of this deep, black void which was just stillness. It was like skipping along the top of the blackness like the ball that dances on top of the words, when you sing along with the music at the movies. That was my voice kind of skipping along the top there, almost in a vacuum. It gave me a feeling of comfort again, of being at peace with myself. The voice was my identity. It wasn't the Jim Patterson who has a cell phone in his pocket and a telephone number, and all the mundane things in his life, like worrying about an exam, or worrying about what I was going to do after college. It was just a very calm feeling. "How do you look back on this?" I think it was helpful. It let me go on with my junior year with equanimity. "And how does it fit in with who you are now?" Well, that was 10 years ago. Now I'm married and have a yearold kid. I've got a family to support and I'm dealing with a startup business. It was really helpful then. That was my past. I've moved on. When Something Is Missing

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Some years before, Jim's distress might have left him open to an encounter with a cultic religious movement. When I studied people who attended Moonie workshops, it was the "guests" who felt most unhappy and alienated who stayed on the longest, and it was those with the highest scores on a scale that measured distress who finally joined. Mike's encounter with Eastern meditation, however, had apparently met his needs of the moment better than his brush with therapy, and he moved on from there. It allowed him to set himself right by changing his perspective on where he fit in the world around him. It did this by embodying a regressive experience in a spiritual setting that was validated by centuries of tradition. Mara, a psychologist, reached a point in her life when she needed a sense of renewal, as she was coping with a major loss, the break-up of a 2o-year-long marriage. She was distraught and felt she had no place to turn. She knew enough about psychotherapy to tailor that option to her needs, but she saw her own profession as lacking the capacity to deal with her abiding feeling of unhappiness in a positive way. Like some of her patients who were reluctant to label themselves as patients, she did not choose to see herself as suffering from any of the pathologies that psychologists claimed to resolve. Therapy, she said, "could undo the negatives," rather than give her a positive outlook. Additionally, she thought that antidepressants, about which she knew a good deal, could "cheer me up" but not add the meaning to her life that she felt she needed. In addition, she saw herself as resilient; in the right context she could "find" herself and move on. At one point a friend suggested trying out a group experience directed by the psychologist-philosopher (of sorts) and spiritual enthusiast Jean Houston. Houston's Mystery School is an example of New Age offerings that promise enlightenment and personal meaning in a series of group encounters. Such programs are sometimes run by a charismatic Americanborn person along the lines of his or her personal philosophy. As such, it is a cousin to the experiences provided by gurus who divide their time between India and the West and, for that matter, to the big-tent Christian revivalists who not long ago moved from one town to the next in the American heartland, plying their personal brand of spiritual redemption. Mara committed herself to weekend workshops at Houston's Mystery School that did not cost her much more than stays at an off-season 96

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hotel. In the end, she attended a weekend workshop in each of 9 months for 2 years, along with about a hundred other people whose motivations were similar to her own, which she characterized like this: You go to Mystery School because you are looking for something in your life that you feel is lacking. People may have a personal agenda. I think a lot of them go because they're in personal pain. It's not that they necessarily want to fix a particular problem but they may want to add a spiritual component to their lives. They may be looking for more meaning and purpose. Very few people wander into therapy because they are looking for meaning, although after a while they may begin to search for it. Houston's Web site (www.jeanhouston.org) announces her to be "a scholar and researcher in human capacities" and points out that her "mind has been called'a national treasure'"—without citing the source of this honorific, but she has indeed served as president of the American Association for Humanistic Psychology and has given the William lames Lecture at Harvard Divinity School. She was even brought to public attention when she helped Hillary Clinton converse with Eleanor Roosevelt, albeit not literally, after a poor showing by the Democrats in the 1998 congressional elections. On her Web site Houston conveys what she thinks attendees at her events may draw on to renew themselves: I think bliss and union are built into the very nature of everything. Our cells align in incredible ways. We have 1,500 processes aligned before our heart beats once. We are the ultimate epiphany of alignment, and we merely have to take it to the next stage and say, "it is there all the time." If this seems a bit vague, another of her Web sites (www.mysteryschool .info/what.html) explains that the Mystery School is her way of honoring ancient schools across the world and across history where women and men gather to explore and decipher the great mysteries and their resonance and application in order to live more freely and fully. The weekends are designed to provide rich experiences embracing sacred psychology: a synthesis of When Something Is Missing

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history, music, theater, the world's cultures, societies and peoples; philosophy, theology, comedy and laughter, science (fact, fiction and fantasy); metaphysics and general joy. As in youth cults and, for that matter, in many church parishes, social engagement combined with a quasi-spiritual revival is influential in the school's attraction. Liz illustrated this point: One of the great things that happened for me is that I found a community of people that I kind of bonded with years ago, and I still have friends from there. So the community experience was great for me, and on a personal level I got some answers on how I could lead my life. I got rejuvenated. "What actually goes on there?" Jean has a lot of exercises that you do to get in touch with who you are and what you want to do. There are a lot of visualization exercises, other ones where you move and you dance. It's almost as if she puts you in an altered state of consciousness and all sorts of things come out. . . . You get group feedback much like in group therapy. People hold their hands over your body, not touching you, but trying to feel the areas where you are closed off. In my case it was the heart. It was like my heart was all closed up. So we talked about ways to open it. Such groups are enhanced in their impact by a transcendent mission. Mara reported on Houston's mission, even if it did not generate much enthusiasm in her: She also has a global agenda, where everybody has to reach out and join hands or we're all going to annihilate each other. I guess she feels that if we are all on a level of higher consciousness it wouldn't be such a big problem for us all to live together. But as with many such leaders, a personal encounter carries with it a special meaning that may be seen to crystallize the transcendent nature of involvement. On this, Mara explained "the Gifting": On one of the weekends, everyone spends the night in the gym, and everyone gets a number and in sequence they get a private audience with Jean. Everybody has to come up with something to 98

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make a wish, like three wishes from a genie. Then you have a private audience with Jean and you present what it is that you most want in your life. She gave the example of her friend who had told Jean that she wanted a stable relationship with a man. Two years later she found a "soul-mate." Mara explained that "by making the request I think it opens up new options in a person. I don't think there's anything genielike or anything mystical." Nonetheless, as she described her friend's finding the soul-mate, she implied that without Houston it might have never happened. (It seemed to me that Houston's benediction might have worn out after 2 years, and other circumstances would have brought about this outcome. It is an open question.) Parallels between the Gifting and other personal encounters with spiritual figures underline the importance of such meetings. Examples abound: a young woman who was "deeply consoled" by a female Hindu guru who hugs each of the hundreds of people who attend her services, the chaplain who told me of an experience of illumination upon greeting Mother Theresa, the psychiatric resident who described the bright halo that appeared around a woman who was giving a religious sermon. Such encounters seem to embody an air of transcendence, implicitly conveying the spiritual message of the emotional healer. We see with Jim and Mara that there are alternatives to therapy, as currently practiced, when life's circumstances leave a person in need of something more than the relief of "target symptoms." Our culture has achieved a degree of ecumenism that offers alternatives to what traditional religion, psychoanalysis, or a comfortable family life once provided. Perhaps these options reflect the secular spirituality of our time. These alternatives provide a grounding, at least for a time, that people living in this era of ongoing social transition may turn to when the need arises.

Responding to a Spiritual Void

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he absence of a spiritual foundation can lead to uncertainty and then a quest for a meaningful and credible alternative. It can also lead to commitment to unusual, even bizarre, beliefs. We shall now conWhen Something Is Missing

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sider what can happen when traditional religious commitment has been lost in a subculture and how each of these options can be illustrated. The psychologist Valerie DeMarinis has tried to address this issue in her role at the Karolinska Institute in Stockholm, a leading center for research in biological psychiatry. As part of her undertaking, she came to visit me at New York University because of our research on spirituality in my division. She described how, much to her surprise, the institute had commissioned her to study the importance of "making meaning" in the lives of their alcoholic patients. Faculty of the institute had studied what the patients on their alcoholism unit felt was most needed in their recovery program. Unexpectedly, the pursuit of meaning in life came out as most important in this setting where studies of brain physiology are the focus of psychiatric effort. The Swedes have little commitment to formal religion, as illustrated in recent polling data.1 Only 10% of the population believe that religion is important, and less than 5% go to church each week. This stands in stark contrast to the United States, where the corresponding figures are a great deal higher, at 87% and 41%, respectively.2 Religion had once been important in Swedish culture, but families now bring their children to play on church grounds rather than to pray in their houses of worship, which are now often abandoned. DeMarinis3 had earlier written about an "existential-cultural perspective," by which she meant that in the absence of formal religion, secular rationality can offer a worldview that emphasizes individual identity and integrity. She was now studying the way making-meaning, an existential term compatible within this perspective, might have a place in these patients' lives. The issue had to be tailored this way because the term spirituality evoked displeasure in contemporary Sweden, where its religious connotations left academic psychologists and psychiatrists quite uncomfortable. She had to confront a paradox: how to buoy the spirit while denying the legitimacy of spirituality. The task was a daunting one and paralleled the gulf between the culture of contemporary psychiatry and people's need's for spiritual redemption. Shortly after her visit I spoke in the Netherlands with Peter Geerlings, a thoughtful clinician-researcher on the faculty of the Institute for Addiction Research of Amsterdam. Religion had been relinquished by many residents of his city, where coffeehouses serve marijuana to 100

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their patrons and where prostitutes beckon to pedestrians through display windows in its historic downtown area. For most of Geerlings's colleagues, an understanding of the mind's work emerged only from tightly controlled research. He, however, appreciated the value of looking at the social history of the Netherlands' culture wars in describing the rather striking collapse of religious tradition for many people there. This was helpful in explaining how the severance of traditional spiritually grounded ties could leave a generation of bright, well-educated people vulnerable to rebelliousness and deviancy in their struggle to "make meaning" in the society in which they lived. Geerlings described the emergence of the Provo movement in the 19605, analogous to the more alienated of the hippies, or more so, the Yippies, who surfaced around the same time in the United States. In the words of one of its leaders, "Provo's choice is between desperate resistance or apathetic perishing. . . . Provo realizes eventually it'll be the loser but won't let the last chance slip away to annoy and provoke this society to its depths." Political rebellion, rock music, and the drug culture created the context in which this movement had its brief but highly visible life, culminating in members' sneaking smoke bombs past police and army guards at the wedding of Princess Beatrix of Holland. This act was their attempt to underline their split with capitalism, communism, and socialism, all of which they had come to think of as oppressive and stifling. It clearly left little to believe in, as they had already dismissed Holland's Catholic and Protestant austere religious background as irrelevant to their lives. The drug culture of the time filled some of this vacuum and had initially been seen to offer a "cosmic experience," as articulated by the poet and performer Simon Vinkenoog, who published The Book of Grass,4 but as Geerlings pointed out, many members of the movement soon devolved into lives compromised by alcohol and drugs. It created as well the subculture that had led to the current widespread open use of drugs and pornographic display. This collapse of traditional values left many young people without spiritual moorings. A typical response was that of Bets, who had come from a conservative Catholic town in the south of the country, and was now working on a psychology thesis in graduate school, and was encountering people quite different from the proper folks with whom she When Something Is Missing

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had grown up. The experience of one teenage girl whom she had evaluated during her internship had impressed her with the country's loss of its spiritual moorings. The girl had been involved in petty crime that was suborned by her drug-using parents, who seemed to take pleasure in her antisocial behavior. Maartje had turned to her clinical supervisor in the hope of getting some help on what could be done for the young woman but was told that her patient was headed for an uncertain and quite unfortunate future and would likely end up in jail. It seemed that the country's traditional values offered little hope for such troubled people and perhaps for herself as well. After finishing the classwork and internship in her doctoral program, Bets decided to spend a year studying theology in the hope of defining a valid spiritual course for herself. As she said, "I couldn't understand some of the things in the religion I was raised in, and felt that I had missed something that I wanted to know more about," but the experience in theology left her with no more clarity, as her distance from her religious roots had already grown too great. She was doubtful as well about whether she could benefit from the nontraditional orientations that young people were picking up, "like Buddhism, yoga, and New Age philosophies." When asked what spirituality would therefore mean for her, she could only say that she might help others, not even necessarily through her work, but among people she knew. I asked her whether that was at all an issue of concern for her. She replied, "I'm working on completing my thesis, so luckily I don't have to worry about that for now." Suppression is a defense against dealing with unpleasant realities. It does not entail having to deny them but rather to consciously lay them aside to avoid malaise. In this case Bets's commitment to her work allowed her to do just this with regard to her uncertainty over the compromise in traditions she had witnessed. Maartje, a lawyer, on the other hand, had encountered an absence of spirituality in the Netherlands, and responded by adopting a demanding personal mission. She wanted to validate the role of spirituality in the Jellinek Clinic, a treatment center allied to the Addiction Research Institute and itself oriented to hard-core research as well. She had been introduced to the culture of the Twelve Step programs while trying to help a friend who had fallen prey to years of addiction. He had gone through a number of treatments, and none of them had set him on a 102

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positive course that he could sustain. Finally, while searching the Internet, he came across the Hazelden Foundation in Minnesota, a mecca for spiritually oriented rehabilitation through the acceptance of AA. Unlike the treatment programs he had attended in the Netherlands, the Hazelden people he phoned were welcoming, so he decided to give it a try. Maartje insisted on accompanying him to Minnesota to make sure he actually arrived there and enrolled, and while he was beginning his treatment she attended a number of Twelve-Step-oriented family education groups. Given her own existential uncertainties, she identified with her friend's disastrous plight but began to find a sense of purpose for herself in the program's spiritual orientation. Her friend did well both while at Hazelden and thereafter. She then translated her newfound enthusiasm into a quest to get the kind of spirituality embodied in AA adopted in the nonreligious cultural setting of the Jellinek Clinic. She was committed and well-spoken, but when she finally got an appointment with the director of the clinic, he seemed at a loss to understand her point. He was courteous to this articulate woman, but with a good dose of skepticism he asked her, "What is spirituality, and how does it relate to our research charge?" The director's question moved her to promote the concept further to show him that spiritual purpose could contribute to the recovery of the compromised people he was charged to help. Given support from her family, she gave up her legal practice and set out to study physiologic aspects of addiction. Perhaps this would give her the words she needed to make her point. As with the young people whom I had studied in the youth cults three decades before, this response of the heart was able to meet a number of uncertainties in her life and gave her the clarity of purpose she had been seeking. Both she and Geerlings were clear in their views of the culture at an institute where "hard science" reigned supreme, and they understood the value of wedding it to a spiritual orientation. For Bets, the graduate student, a course of action was less clear, but writing her thesis allowed her to put the issue aside. All three were able to consider this apparent spiritual void without losing sight of a rational approach to their pursuits. A person with a more deviant state of mind might have greater difficulty in the face of this quandary. This was evident in Corrie, a physician who presented a puzzling and complicated response to her need to When Something Is Missing

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find meaning in her life. Her adaptation was understandable from the psychology of the youth cults I had studied but underlined the degree to which contemporary psychiatry had little to offer in explaining how people may struggle to achieve a resolution of their spiritual needs. Corrie was a competent physician in her mid-5os, respected and appreciated by her colleagues. None of them were aware of a second life that she was living while working in a local hospital. Like Bets, she had come to Amsterdam from the south of the country. She had a traditional Christian Reformed background, one that was quite stern and forbidding in its view of human nature. She said her excelling in high school and college had given her the confidence to "be herself" in becoming a physician, and she was pleased with the career she had chosen. She was willing to describe for me the experiences she had kept secret from her colleagues in order help in my studies on spirituality. The import of her self-revelation, however, left her speaking in a halting voice. On her arrival in Amsterdam, her religious background left her uncomfortable with the prevalent "somewhat dissolute marijuana culture," as she called it. She said that after time, "There came a huge crisis in my life, in which a number of things came together," one of them being an upsurge in the abuse she was experiencing at the hands of an alcoholic man with whom she was living. She continued: I really wanted to kill myself, and felt there was nothing worthwhile anymore in my life. And then when something like that happens, things can get organized around you to give you the right signs. But even though I wanted to make an end to my life, I began reading about Eastern religion, and found that there was some core in me which didn't want to stop, which was not affected by my psychological problems. And it wanted to go on despite my not liking life at that moment. As I read more of those books, mostly Eastern philosophy, I thought, oh, this is interesting. There is a core of silence within all people that is not affected by their problems. That's the core of Hinduism, that's the core of Buddhism, and it's the core of Christianity, all the religions of the world. And this understanding was like coming home. I somehow knew it all my life and I just came home to this understanding again. 104

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Corrie seemed transfixed, with a beatific half-smile, as she said this. She was looking in my direction but it was clear she was reexperiencing the state of mind she had just described and was not fully in the room where we were sitting. After a moment she began to describe her reentry into the everyday world that had followed her realization. It was clear to me that the condition she had been in at the time of her epiphany had been unstable, given its intensity and its incompatibility with her role as a hard-working physician. So she apparently found her way to living two parallel lives, which over the course of ensuing years allowed her to experience a newfound spiritual intensity. In her second, parallel life she could relate to other people who were likewise living with intense spiritual experiences. As she described this: I found my way to a spiritual community after a while, the School of Philosophy. Their outlook was based on the Gita [Hindu writings] . It's a beautiful basis for life. So I learned to translate this concept into my daily life, and work without needing to reach a goal, but just to do things because they could be done in the moment. I learned the concept of living in the now, and not being busy with concerns of what should happen tomorrow. The moment she would live in, that community she joined, clearly had a cultlike quality, and she described how members' assets were handed over to the group's leaders and used to purchase real estate. Members were then expected to spend long hours renovating the buildings and tending to the surrounding gardens. Soon they were required to get up at 5:00 in the morning to meditate for 30 minutes. And as if these demands on her were not enough, Corrie began a course in homeopathic, nontraditional medicine, which took up even more of her time. After 5 years at the school, she realized that she could no longer sustain herself on this spiritual treadmill: Now I had three jobs: my medical work, the School of Philosophy, and studies in homeopathy. Suddenly I found that I couldn't breathe any longer, and I needed to get out. So I told them that I was leaving, which caused them great distress, and they tried to persuade me to stay. They said, "Oh, but Corrie, you're such a good pupil." But I left anyway. When Something Is Missing

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She still wanted—or needed—a validation of her spiritual needs: You know what I did after coming out of the school? I said to the cosmos, if I ever get a teacher again I want one on a different level than I've met until now. And I don't know why, but at that moment I asked for a teacher in the spirit world, not someone walking on this earth, because I didn't really believe that there was an inspiring source for me on this earth. So that's what I got within a year. A woman I really trusted started channeling a guide in the spirit world and she taught me a lot for another 6 years. "Was your guide an imaginary or fantasized one, or was it someone who had actually lived?" I asked. No, he had never lived on this earth. You know, it's amazing that I got there to be in contact with him. If someone had asked me five years before, I would have said, "Bullshit." But I came to a channeling when this woman, a professional woman, gave one of her first channelings of this guide, and felt an energy coming into the room, and it was pure love and pure light. So I could do nothing else but believe that there was truth in there. The funny thing was that what he taught me was that I was worthy as a human being, whatever my personality might be. I didn't expect that this could come from a spirit from the other side. Corrie clearly needed external support to validate her as an intact person, at least since her experience of abuse at the hands of her alcoholic boyfriend. She said that she was soon able to channel the wise man herself but stayed under the wing of the woman who began the channeling for the next 6 years, then moved on. A year later she went into therapy with someone whose orientation was also "compatible" with her own, who practiced "regression and energy therapy." She said that this encounter helped her understand why she felt troubled writing prescriptions for some medications and had needed to turn to learning about homeopathy. I asked her what regression therapy was, and she explained that it allowed her to look back on former lives to gain a better understanding of her current attitudes.

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"What sort of former lives?" "That is kind of private," she said, having apparently reached the limit of her willingness to reveal her secrets.

A Psychological Perspective

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lthough quite different in character and intensity, Corrie's experience is suggestive of the profound emotional storm that sometimes takes place at the onset of an episode of psychosis. Such disruption can be intolerable to the affected person, leaving them pressured to relieve it in any way possible. Feeling overwhelmed, they implicitly need to find some explanation for what has overcome them and are primed to grasp on to a fantasized tale as a rationale for what is causing them such distress. As this takes place, in what has been called an "experience of significance," they pick up on something in their environment, perhaps as minor as a glance from a stranger passing by in the street, or a longstanding tension with a neighbor next door, or even something they have read about. This can lead to the delusion, typically either paranoid or grandiose in nature, out of which an elaborate tale is then woven. It may devolve into: "They are trying to get me"; "I have powers that are transcendent in nature"; or perhaps, like Corrie's realization, "I had perceived a universal truth." If the delusional system is circumscribed and is not associated with disorganized or incoherent thought, the psychotic person may have enough insight to appreciate that it is not an idea they can hazard revealing. Corrie was a competent professional, not considered deranged by her colleagues. So she said, "If I told people about this, the psychiatrists I work with would think I was psychotic." People who harbor delusions may find it hard to avoid some effect on their behavior, though, and Corrie had said that she had taken up homeopathy because she had "problems writing for some medications, which was strange." The current psychiatric nomenclature does little to explicate Corrie's experience. It would be simplistic to say that her initial transformation had brought her close to psychosis. Did the "core of all religions" that she came upon reflect delusional grandiosity? To say so would be

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to condemn her, St. Paul, and countless other religious converts to the domain of deluded thinkers, hardly doing justice to their experiences of conversion. Relegating Corrie's experience to some pathological domain would miss consideration of her as a person. After all, she was able to associate herself with people of like thinking and deal with colleagues in the medical domain as well. In joining the School of Philosophy and in teaming up with mentors, she was able to translate her epiphany into a personal philosophy to "not be busy with what should happen tomorrow, but live in the moment instead." This does reflect the Hindu ethos of relinquishing active striving and accepting one's karma. It is a philosophy that can be imbued with spiritual import and, in fact, reflects the attraction of Eastern thinking for many people today. Ten personality disorders are listed in the American Psychiatric Association's diagnostic manual,5 each "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture." These disorders, from schizoid to antisocial, hardly capture the nature of Corrie's deviant but competent persona and also do little to contribute to an understanding of the broad range of spiritual experiences that people report, however they may deviate from "the expectations of the individual's culture." All this fits in as well with other persons I have interviewed, such as the young doctor who saw a bright light emanating from a woman giving a satsang in the Divine Light Mission and decided that it had to be a turning point in his life. People attending a Moonie induction workshop had intense emotional experiences that led them to join a movement most people consider quite bizarre. These experiences might be disparaged as cultic by outsiders but acceptable to other members of their new reference group. Both the young man and the Moonie members were operating effectively in their everyday lives: he as a doctor in his clinic, and the Moonies, albeit in a deviant group, participating and collaborating in joint efforts. Cultic phenomena can, of course, lead to unfortunate, even disastrous, ends. Witness the experience of a group of celibate men in Heaven's Gate, a cultic group. They were followers of Marshall "Bo" Applewhite, a college teacher who came to believe in UFOs. They and he ultimately

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committed suicide as a group in 1997 in Southern California in order to leave their "earthly vessels" and ascend to heaven. As a psychiatrist known to be an expert in cults, I have been asked to consult with distraught parents whose children have become involved in such groups. It soon becomes clear how psychiatry finds its limits in such situations, as the rational approach of the profession can neither pry the parents' progeny out of such a group nor placate the parents in their distress. An understanding of their children's plight does little to relieve them of their profound concerns. Attempts to remove people from a cultic group also are hardly productive unless they themselves seek out help when they are considering leaving. The people whose motives were discussed in this chapter had reached a point at which they felt a need to experience renewal and redirect themselves. Each responded in a way that resonated with his or her own background, whether it was earlier religious experience or an issue drawn from the contemporary culture. For them a spiritually oriented experience came to address what therapy might have been called on to do. A certain set of circumstances brought each of them to the point of discomfort. Disruptive life events—whether experienced as negative orpositive— have been found to precipitate psychological problems,6 and the "phase of life" problems (as the APA would have it) these people encountered illustrate this point. Jim experienced disruption after losing his sense of tranquility in Kenya, and Mara, the psychologist, after her divorce. In both cases they were left open to seeking an alternative source of fulfillment, not feeling that professional help offered what they wanted. A sense of community was important in the renewal that all these people experienced. Maartje, the lawyer, was drawn to the spirituality of AA in the Hazelden rehab center, and Jim, Mara, and Corrie (the physician) turned to support networks in their respective spiritual settings. Even the most stressful of events, such as the attack on the World Trade Center in 2001, can create a sense of community—and it was actually reported to have yielded a decline in the incidence of suicide, the most pathologic of responses to distress.7 In our own clinic, that event engendered cohesiveness among our addicted patients, who bonded together under the stress and were better able to stay sober. The value

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of community should never be overlooked as a support for people in distress. In the extreme such disruptions, in the absence of mutual support, can result in serious psychological trauma, as with uncontrollable events that threaten a person's sense of integrity.8 In such cases he or she may turn to a spiritual option that may or may not compromise ongoing adaptation, so that the ability to move on with life from that point will vary from one person to another. To a certain degree the ability to move on is a function of one's inherent resiliency, a product of both early environment and innate capacities. (The biological underpinnings of such readaptation are evidenced when a twin experiences posttraumatic stress disorder; the second twin, if identical, even if they were separated in infancy, is more likely to be vulnerable to posttraumatic stress disorder than a fraternal twin.)9 Corrie, the doctor who so intensely needed external support, however bizarre its source, was not able to achieve stability without being under the wing of a mentor. She stands in contrast to lim and Mara, who made use of their brushes with a spiritual option and then moved on with their lives. Corrie did not see professional therapy as an acceptable choice, although it might have helped her. We shall later consider how therapy can be conceived to meet such needs and at the same time embody both the science and art of professional work.

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PART III

Varieties of Spiritual Experience

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he attempt to put the encounter between psychiatry and spirituality in perspective is quite daunting. We have looked at psychological, biological, cultural, and even some economic aspects of it, but as any anthropologist can tell you, our examination, restricted as it is to the Western secular setting, can be narrow, simply by inadvertence. So it is useful to look at the issues in some different cultures to lend depth to our understanding. This is amateur anthropology at best, but hopefully it conveys a sense of how the issue of spirituality is more universal than that which we have discussed in secular Western culture. In India psychiatrists practice a sophisticated brand of psychotherapy and pharmacotherapy while still making use of the relief a patient finds in having his or her family protected by the goddess Durga. In Egypt, where the Al-Azhar is the seat of centuries-long study of the Koran, it is acceptable for Muslims troubled by emotional problems to seek counsel from a Coptic Christian cleric without violating their own religious traditions. In America people trained for hospital-based chaplaincy, because of the mantle of spiritual legitimation they bear, can address the fears and anxieties of those who are morally ill. And within the culture of Fundamentalists Christian psychiatrists, attitudes range from sensitivity to what is meaningful in

people's lives, religiously related or not, to healing that involves channeling the Spirit of Christ. Each of these traditions can anoint a healer to address certain issues of emotional import, ones that contemporary psychotherapy sometimes addresses at length and with less success. In each of these settings, what is spiritual can therefore illuminate our own sense of how psychiatry and spirituality intersect and shed light on some of the biases that each culture holds.

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7

Christian Psychiatry

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he annual meeting of the American Psychiatric Association (APA) attracts some 15,000 registrants. In addition to the usual scientific presentations, pharmaceutical companies typically sponsor their own symposia in the early mornings as part of the program. Each of these sessions attracts several hundred psychiatrists, in part because of the nicely appointed free breakfasts the companies provide. Instead of attending one of these breakfast meetings in the glistening Marriott Hotel down the block from the San Francisco Convention Center, I walked toward the city's downscale Tenderloin District, navigating around a few homeless men sleeping on the sidewalk. At one very modest, unrenovated hotel I found a small meeting room where the Psychiatry Section of the Christian Medical Association (CMA) was hosting a workshop unaffiliated with the APA. Unlike the pharmaceutical companies, this group has no marketing budget and had to charge a small fee for the modest breakfast it provided. Some thirty-five people were awaiting the start of the meeting. A Study on the Movement

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hen I first encountered the Christian Medical Association, I had been serving as chair of the APA's Committee on Psychiatry and Religion. We were asked to respond to a number of the association mem113

bers' complaints over problems with some small inpatient psychiatric services that had become "Christian-oriented." It turned out that Christian Fundamentalist psychiatrists had taken over management of some hospital facilities and were favoring practitioners of their own religious orientation to the exclusion of others. After we responded to these concerns, I became curious as to how the religious orientation of the devout Christian practitioners related to their clinical work. The Christian Medical Association had a membership of 7,500, 5% of whom were psychiatrists. Their membership application gave a sense of who might join the CMA, and it was quite explicit. Applicants had to sign a statement acknowledging "the final authority of the Bible as the word of God . . . the presence and power of the Holy Spirit and the work of regeneration . . . the everlasting blessedness of the saved and the everlasting punishment of the lost." The work done by these "Christian psychiatrists" was of interest to me as theirs was the only organization in which psychiatrists were making an explicit attempt to integrate a spiritual orientation into clinical practice. Dr. David Larson, who was active in the group, had helped establish a liaison with them, and I was able to obtain survey responses from 74% of their members to study the nature of their beliefs and work.1 Mainstream psychiatrists typically divest their clinical practices of any religious orientation or spiritual content, but when I compared the available Gallup polling data2 to the results to the survey, it turned out that most Americans espouse a religious orientation similar to that of these Fundamentalist practitioners. A majority of both the Christian psychiatrists and the public at large indicated that they believed in a personal God who "rewards and punishes" them for their actions (78% and 69%, respectively). Almost all the psychiatrists surveyed stated that they believed in the devil, as does the large majority of the general population (98% and 78%). Almost all the psychiatrists said they had been "born again" and had "encouraged someone to accept Jesus as Savior," and about half the overall population had done so as well (96%, 40%, and, respectively 45%). In many respects these psychiatrists were not out of keeping with the American mainstream. The survey illustrated the considerable degree to which these Christian psychiatrists felt that the Bible and prayer should play a role in

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emotional healing. They rated these options as slightly more effective than psychotherapy for patients with suicidal intent (an average of 3.5 vs. 3.2 on a 5-point scale) and considerably more effective for alcoholism (3.6 vs. 2.7). Indeed, 60% of the respondents indicated that they would use prayer in treating alcoholism among patients committed to Christian beliefs. In fact, 20% responded that they would also prescribe prayer for a nonbelieving alcoholic patient. Born-again experiences had played an important role in strengthening the Christian psychiatrists' commitment to their religion. The relief in symptoms of emotional distress they experienced in this process apparently paralleled that experienced by members I had studied of the Moonies on induction into their own group. The psychiatrists rated their levels of emotional distress as considerably lower for the period following their born-again experiences and gave responses that reflected very strong feelings of cohesiveness toward their fellow Christian psychiatrists. This suggested how relief of emotional distress and a strong identification with their Christian colleagues served as a nidus for a redoubled commitment to Christian doctrine and their acceptance of its importance in their work.

"Stealth Christians" Meet Together

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he group's meeting in San Francisco began with a worship service led by Dr. David Biebel, editor of the CMA magazine and author of Why Do I Hurt So Bad?3 The book articulates the Christian psychiatric philosophy well: Without faith I'm left alone with fate . . . when I finally invite Jesus into the now of my pain, emptiness, and loneliness (or, more realistically, every time I "finally" do that), I hear Him gently inviting me into the now of His presence and joy. Christians can relieve themselves of this suffering: So, you are ready now to let Jesus into your pain? If you are ready you may want to pray something like this:

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Dear Jesus I can see now that I've been carrying this heavy burden by myself. . . and, Lord, if You can help me see beyond this pain to the purposes and meaning of it all I will rejoice. Amen. The group's meeting, an annual integration seminar, helped to characterize the way its members were trying to include his or her approach to spiritual experience into professional treatment. It was moderated by Dr. Mark Servis, the director of psychiatry residency training at the University of California at Davis. Each intern then gave his or her name and background. The majority of them came from midwestern or southwestern states, but a few had come to the meeting from as far away as Great Britain, France, and a mission in Kenya. The tone was set by one member who added to his introduction, "God bless our time together. Thank you in Jesus' name." The issues brought up were instructive in terms of the problems that confront psychiatrists who try to integrate spirituality based on a formal religious orientation into their practices. One issue was the degree to which they could anticipate acceptance from the general psychiatric community. Those who spoke seemed to realize that most psychiatrists would view them as deviant and that they had to curb their enthusiasm for revealing their religious commitment to avoid alienating their colleagues. One participant asked, "Are we stealth Christians?" Another said he had annoyed people by serving as a "faithful witness" when he started out and later decided that "I would keep my mouth shut until You [God] prompted me." One Army psychiatrist expressed difficulty in distinguishing between "hypersexuality" and the usual sexual practices of recruits he treated. I was later told that many members of the group had resigned from the APA because of its apparent approval of homosexual practices and third trimester abortions. In recent decades psychiatry has become very attentive to issues of "boundary violations," specifically focusing on sexual relations with patients. For this group, however, this term was used more in relation to limits on the introduction of religious issues such as prayer, Bible reading, and belief in Jesus as healer into their sessions with patients. One person said that he preferred the term boundary crossings, implying less delineation between a therapist's religious views and the sepa116

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rateness of a patient's religious beliefs than most secular psychiatrists would expect. The participants were clear that the sanction of religious orientation could be helpful in bringing people to a resolution of the conflicts underlying their emotional distress. The consensus was that Christian forgiveness and understanding were themes that could lighten the burden of guilt that many of their patients had to confront. This emerged in a case illustration that the moderator presented for discussion: A "Christian" woman comes for consultation for chronic depressive symptoms. In her third session she tearfully tells the psychiatrist of her deepest secret, an affair that she had shortly after she was married. How should this be handled? The choices on the form distributed around the room were meant to trigger discussion: to deal with it as an issue of Christian sin and forgiveness, to look at the sexual indiscretion as a long-past event, or, for contrast, to prescribe an antidepressant and tell her to come back in a month. Most of the people at my table adopted a reasonable stance on the case. They made clear that it was important to understand the context in which the patient had presented the episode: One woman, a psychiatrist trained in Scotland and living in Canada, pointed out the value of exploring the issue of Christian forgiveness if it was appropriate, after the psychological issues were evaluated. Another said he would want to know whether the patient was raising the issue out of her long-standing concern or as a reflection of the guilt typically seen in depressed people? They agreed that an assessment also had to be made regarding the severity of the woman's illness relative to the need for antidepressant medication, although one participant from France said he avoided using antidepressants. Nevertheless, the intensity of people's belief was clear. One person said that he would want to know a lot more about the patient's relationship with Christ, although he would be a good listener first. He was aware that some of his fellow Christian psychiatrists would address a religious perspective very early on and said he would not broach religious issues as soon as some would. Another said with conviction that therapy in this case, as in others, need not be viewed as dyadic, between therapist and patient, but rather triadic. He was making it clear that Jesus was a participant in healing. Christian Psychiatry

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Opinions varied in terms of the degree to which religion should play a role in treatment. Interestingly, though, there seemed to be more reflection on the psychological issues underlying a patient's conflicts than would have been discussed in the symposia at the main APA meeting and certainly more than at the drug company-sponsored breakfasts scheduled at that same time in some of the convention hotels. A case discussion on the use of religion and spirituality to open psychological issues would hardly have found its way into the meetings. These devout physicians might have also prompted the expression of feelings that were otherwise suppressed through the use of a Biblical citation. One Christian psychiatrist whom I interviewed had treated a devout woman suffering from a major depression precipitated by the suicide of her teenage daughter. He treated her with antidepressant medication, and her depression abated. (Here is where a "psychopharmacologist" could revert to writing prescriptions.) This psychiatrist, however, described how the woman had been unable to express her sadness and anger, so after the acute depression resolved he read specific citations from the New Testament to her that showed how God allows justifiable anger and that a dejected person like her could rightly go through a period of grief. He used the citations to help her justify the expression of the feelings she had found hard to acknowledge and thereby, he told me, had allowed her to experience relief from her guilt over the daughter's death. Three of the Christian psychiatrists who attended the meeting illustrated the degree to which their strongly held beliefs influenced their treatment, from a flexible stance on to an intense commitment to doctrine. They shed light more broadly on the role that spiritual issues can play in treatment when they are introduced in the form of strongly held religious beliefs.

Robert: The Ability to Adapt

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amily practice had appealed to Robert because he thought it would allow him to establish a flexible and understanding relationship with his patients, more so than did the brand of psychiatry he had en118

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countered in medical school. After 15 years in family practice, though, he found himself pressed to spend only brief minutes with patients, and he decided to start training in psychiatry. Although he had grown up in the solidly Protestant Bible Belt, Robert's mother raised him to be a Catholic like herself. In his teens, however, he became a seeker of diverse religious orientations and traveled widely. He meditated, practiced yoga, and learned about Islam while traveling in Turkey. From there he went to Israel, "with James Michener's The Source in one hand and a Bible in the other," seeking out Biblical sites. In medical school he was still oriented toward "the unity of all religions." Robert spoke of his religious awakening while serving as a Navy physician. After a chaplain had asked him, "Who is the authority for the religion you practice?" he began to think more seriously about his Christian background. By the time we spoke he was deeply committed; his religious beliefs led him to go on a mission to Mexico's Copper Canyon, where the Tarahumara Indians combine Christianity with shamanic practices. When I asked him about his spiritual experiences, he spoke of feelings "more powerful than my usual reality" that took place in a group run by Jesuits called Spiritual Exercises in Everyday Life. The participants imagine themselves to be in Biblical settings, even to the point of experiencing what it would have been like to encounter Jesus in Biblical times. Robert readily distinguished between his approach to Christian believers, nonreligious people, and the psychiatry residents whom he trains, reflecting a flexibility in his orientation that no doubt derived from the breadth of spiritual options he had encountered earlier in life. For him a spiritual approach entailed lightening the burdens of guilt and selfpunishment that detract from a patient's ability to find meaning and a sense of purpose in life. He conveyed this in a compelling way as we spoke. In relation to nonreligious patients he said: Very often people with depression come in one way or other expressing "What's the point?" My response is "Wonderful question. What is the point? Let's find out. Let's talk about it. Let's understand what endows your life with some meaning." So spirituality to me may be God talk but it can also be about meaning and purpose and finding a reason for whatever is one's next action. Christian Psychiatry

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For those who experience some religious feeling, he finds that he can draw on that feeling to be of help: Even if they have some kind of religion that's not strictly Christian, they will very often believe in some kind of a God, and the question about whether He is good or evil or capricious is not hard for me to ask at some point—and just kind of gently nudge them forward and inquire. If someone keeps coming up with a punitive, angry, capricious, tormenting kind of God, I will try to get them to understand: Is that necessarily the reality? Robert was now working in a Veteran's Hospital in Tennessee and teaching the psychiatry residents there. As he said, it was his hope to "help them better appreciate man's spiritual plight and the importance of finding meaning for their patients, to aid in the recovery from mental illness," but he said that he was careful to avoid presenting an expressly Christian orientation there. I frankly was impressed by the way he described this approach. He said he would draw on the residents' understanding of the need for meaning in life, whatever its origin: I tell them to ask their patients what's spiritual and meaningful to them in their lives. My goal for them is to ask that question in a way that whether the patient has an answer for it or not, he'll know it's important and that it's open to be discussed later, and that it's a permissible topic, and one that I endow with value. For some patients this may lie in the woods, so I point out they can say, "Man, it sounds like it's really important for you, a place where you can feel connected, and we'll talk more about that later because I think that'll be part of your treatment and your healing." He described how he had interviewed an African-American man originally from the Deep South at a case conference for the residents. The patient was now a cocaine addict, a chronic abuser of alcohol, homeless, and seropositive for HIV, with a record of time spent in jail. He had many reasons to feel dejected and alienated from the hospital staff. (I thought of the patients in my own services at Bellevue Hospital who were in much the same situation.) Robert encouraged the man to talk about time he had spent as a youth singing in a church choir and en120

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couraged him to think about the possibility of getting a foothold back in a community that would be meaningful for him. He told the residents that at a time like this they can ask the patient "Why did this happen to you? Why has your life been like this? And what is valuable to you, important to you that you would want to get clean and sober now? What do you think can allow that to happen?" And those sort of connections to a patient's own story allow for making meaning, to gain a sense of purpose, their own sense of causation, their own sense of why they're on the planet. These are questions that I'm going to look for, to just kind of nudge and inquire about, and to endow with some importance and value. He spoke of how he had treated a Vietnam veteran at the hospital who was struggling with posttraumatic stress disorder that had emerged after participating in an atrocity with some members of his platoon, which had left him plagued by guilt. While on a leave from the hospital, the patient spent time alone in the nearby mountains trying to reconcile his religious background with the experiences he found so hard to overcome. He would soon be discharged, but he feared returning to Florida to rejoin his family, as he was still uncertain of his reconciliation with himself, his God, and his guilt. On his return from leave, Robert let the vet express his feelings about God without introducing his own views and helped him achieve a degree of forgiveness. His patient was now better able to go back to reunite with his family. In his own private practice many of Robert's patients had an orientation similar to his own. He said this allowed him to draw on his religious beliefs without compromising their sensibilities: For those who are Christians, there's a much deeper opportunity for me to connect with their particular culture, their particular assumptions, their belief systems, their own sense about right and wrong, what is sinful and where forgiveness comes from. Probably a key and repetitive theme that is so powerful for these people is that they project onto God a punitive parental judgment and overemphasize a legalistic approach to Him and their own feelings of worthlessness. Christian Psychiatry

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He gave an example of this approach in his treatment of a self-effacing 5O-year-old devout Christian woman who suffered from depression and compulsive eating. He encouraged her to question her belief that no one, not even God, could like her. He pointed out that Jesus loved everybody. In the Bible he even turned to prostitutes and sinners with affection. She had no reason to feel excluded from God's caring. He described how she made slow but steady progress on the issue and was able in time to dispense with the sleeping pills she had been taking and to go to a church group, Moms in Touch, to promote the educational needs of Christian high school students. At one point he felt comfortable praying with her and speaking about "God, as the Holy Spirit who can receive her." In listening to Robert speak enthusiastically and with a clear sense of commitment, I could see how he might ignite a glimmer of hope, even spiritual revival, in the most troubled of patients, whether or not they were believers in the faith that motivated him in his own mission.

Dwight: Firmly Embedded in Christian Psychiatry

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nlike Robert, Dwight had a lifelong commitment to his Fundamentalist orientation as a member of the Evangelical Covenant Church. He, too, experienced a spiritual pursuit as a teenager but recounted how the harshness he imputed to the church's beliefs had led him to become so highly demanding of himself that he had become depressed. He now saw himself as more at peace with himself and felt that his image of God was one of a more approving, loving one. Dwight had not considered going into psychiatry while in medical school because his fellow Christians saw the specialty as highly compromised by a Freudian, "godless" influence. While practicing internal medicine, however, he began to appreciate how many of his patients suffered from emotional problems and began reading psychological literature. After ten years in practice, he came to see psychiatry as broader in its scope than it had first appeared. He said by then he saw himself as a mature man and felt secure about his own views on life and his commitments. Having been a long-standing member of the Christian Medi-

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cal Association as well, he felt he could then embark on psychiatric training without compromising his beliefs. Dwight would often relate to Christian patients regarding their religious beliefs during his residency but dealt carefully with them and with his supervisors to avoid coming into conflict with his program's nonreligious format. When he entered private practice, however, he became known for his Fundamentalist orientation, and almost all the patients referred to him were religious Christians. By way of illustrating his mode of practice, he said that if a homosexual patient saw him for consultation, he would say, "I respect your homosexuality but that's not my orientation. You might want to see someone who is oriented that way." The connotation was implicitly clear: he was less than enthusiastic about the patient's choice in life. People in Dwight's church often approached him with questions about their own problems or those of people close to them, and he would take time to listen; if a problem could not be addressed briefly he would either refer them to another Christian psychiatrist or sometimes see them gratis for a few visits. He would gladly see Christian missionaries referred by his pastor, who were suffering from burnout. Dwight had written seven books and said that his most popular title, Why Do Christians Shoot Their Wounded?4 had sold 400,000 copies over the course of two decades. It was available through Christian booksellers, but he often saw it placed in drugstores, airports, and groceries. He commented wryly that this was not the kind of book that one usually found in Borders or Barnes & Noble. Dwight's model of mental illness, however, did not exclude issues other than Christian belief. He had just finished writing a book in which he described four quadrants that related to the origins of a major depression: the biological, the developmental, the existential, and the spiritual. Each one of these, he said, could be the major contributor to the problem, and it was necessary for the psychiatrist to discern clearly among them. I asked him for an example of a spiritual etiology, and he described a patient of his who was furious with God over the accidental death of his daughter after she had been hit by a drunk driver. The father had wanted to see a Christian psychiatrist but did not want Christian counseling as such. Dwight said, however, that he was able to

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introduce him to the concept of Christian forgiveness in an attempt to allay his anger and consequent suffering. Another patient of his, a devout Christian, suffered from alcoholism. Dwight insisted that he go to AA, and after a few months the man did stop drinking but, according to his wife, was still "inconsiderate" of her, paying no attention to maintaining a clean household. He recounted his stance with the patient: So I asked him, how would Christ want you to relate to your wife and to your children? So using that overall standard as a point of reference, the patient was able to come up with an appropriate answer. But he qualified this approach: The one thing that I try virtually never to do is to use the Bible or spiritual principles as a club. I think that's bad psychiatry. It's just not the way to influence people. So I'd be very, very careful about saying anything along those lines. It would be much more along the line of a question, you know, what do you think would be helpful to your wife? What do you think would be appropriate? Do you think God would have any input on how you might relate to her? In this way, it would be much more open-ended. . . . So at times we would refer to specific portions of the Scriptures, whether it's Beatitudes or some verses in Philippians that talk about behavior. "What particular aspects of Beatitudes were appropriate to that?" I think loving your neighbor is one aspect, and certainly your family is your neighbor. It speaks about loving your wife as Christ loved the Church. These are aspects that the Scriptures speak about that an individual certainly can relate to. The Scriptures can certainly carry weight but also a potentially heavy sanction. I wondered, does their evocation add credence and deft application of benign influence, or do they elicit undue guilt? When one of the participants in the Christian psychiatry meeting at the APA had distinguished between "boundary crossings" and "boundary violations,"

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I assumed he was considering what can invite patients to think and what can impose a demand on them. Biblical belief is a weighty issue for a devout Christian, and its use in treatment can be an imposition if the therapist is unduly motivated to apply it, or it can also serve as a lifeline in other situations. The distinction may not be an easy one to draw.

Enoch: The Literal Role of Jesus

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hile at the Psychiatry Section's Integration Seminar, I was quite interested to hear what was listed as "a brief overview of a type of spiritual healing called 'Theophostic Ministry,' an example of integrating Christianity and clinical practice." In introducing this approach, Enoch made his position very clear in saying, "I am sitting at the feet of Jesus and He is doing the healing." There seemed to be no ambiguity as he elaborated that it was Jesus Christ who was the healer, and, as a psychiatrist, he was merely channeling His healing power. Enoch held the rostrum for ten minutes and repeated this point in one way or another many times: Jesus the Savior and His role were the only means by which Theophostic Healing took place. I became restless as Enoch droned on, thinking that the people around me might be feeling the same, but as I looked around they were clearly nodding their heads in agreement. It became clear that there was a gap between members of this group and the less devout general population, even though many of them seemed to have a tempered view of the role of religion in their practices when they spoke explicitly about their communication to their patients. Enoch's wife, who was also involved in his prayer ministry, then gave testimony. She spoke about how she had felt guilty over the death of her father, who had suffered from cancer and had died shortly after she had given him a dose of Oxycontin, a long-acting narcotic analgesic, to relieve his pain. Thereafter she irrationally felt that she had killed him, but Theophostic Healing made it clear to her that "Jesus had worked through me and He revealed to me that I was comforting my father, and my depression lifted. Let the spirit of Christ heal." I later went to the Web site of the Theophostic Ministries (www .theophostic.com) and found that Ed Smith, who had a doctorate in

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education and family counseling from Southwestern Baptist Theological Seminary, had developed the technique. The "About Us" link made clear that "he leads training seminars in Theophostic Ministry across the nation for counselors, pastors and other helping professionals. Literally thousands of people are now successfully using the principles of Theophostic Ministry as a result of attending his training." Smith points out that "When I use the word sin, I am referring to any behavior (thought, word or deed) that we engage in as a result of choices we make which are less than God's ideal desire for our lives." He warns the reader that One approach is to become more tolerant with sin and less judgmental. . .What used to be called adultery is now only having an affair. What used to be called fornication became pre-marital sex (which says nothing about the morality of the act, just the point in time at which it occurred). . . . God's laws are consistent. If the "wages of sin is death" (Romans 6:23), it does not matter that you do not feel guilty or if your therapist tells you otherwise; death (or separation from God) is still the consequence. His prescription for the conundrum experienced by his patients is for them to acknowledge I must deal with the sinful choices and behaviors through confession and restitution as needed. . . . If I only addressed the sin and never deal with the lies behind my sinful choices I am doomed to a perpetual cycle of sin, confession, repentance, performancebased-spirituality and eventual defeat . . . I may still walk in defeat until my experiential lies are displaced with experiential Divinely provided truth. . . . Theophostic Ministry releases the experiential shackles and chains that hold me. At this end of the spectrum, the psychiatrist Enoch and his mentor on the Internet make no compromise with the "everlasting punishment of the lost" (as stated in the membership application of the Christian Medical Association). And so, as with many religious denominations, there is a range of views articulated, from the tolerant to the severe; from the literal interpretation of the sacred document to a flexible expression of its spirit; 126

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and from open acceptance to the austere and potentially compulsively demanding. The introduction of spirituality into the therapeutic process needs to be couched in the culture of the patient, but care must be taken to avoid introducing a doctrinal burden that can become traumatic in itself.

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Spirituality in India

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any people on the Indian subcontinent seek out the benefits of science and technology nowadays, but their traditional culture has been highly influential in teaching that meaning derived from within can be more important than the trappings of material success. This outlook stands in stark contrast to our contemporary culture, an amalgam of Christian and capitalist values, which has led people to associate worldly possessions with personal salvation. The Hindu worldview also offers the West an alternative to the way the mental health profession metes out discrete units of psychological treatment. Hindu spirituality is legitimated by an impressive and long history, as it has served as a culture on the subcontinent through the emergence of Buddhism in its midst 2,500 years ago, through Muslim conquests that began 1,500 years later, and on through the introduction of British culture and commerce 800 years after that. Western travelers in contemporary India see evidence of each of these episodes in the highly varied styles of the country's holy sites. The Indian south, never penetrated by the Muslim Moguls, boasts the elaborate temples of Madurai covered with multicolored sculptured figures of gods, goddesses, and mythic creatures. The massive stupa in Sarnath near Varanasi (once Benares) is said to mark the spot where the Buddha preached his first sermon. The Jama Masjid in Delhi, the country's largest mosque, attracts thousands of worshippers to its Friday services. St. Paul's Cathe128

dial in Mumbai (Bombay), with its steeple modeled after the one at Canterbury, was completed in the mid-nineteenth century, only a moment ago relative to the long history of India. These enduring artifacts validate the abiding nature of India's spiritual heritage and suggest that we should not ignore it as we consider the way psychotherapy can be practiced. The Hindu religion, with its hundreds of gods and demigods, predates Christianity by a millennium and retains elaborate myths and customs that must be respected, if not fully understood, in order to appreciate the spiritual ethos of contemporary India. Nirad Chaudhury,1 a scholar of the culture, pointed out that because of its complexity, India's cultural iconography can be an obstacle to understanding Hinduism, as it is typically equated with the religion itself. This iconography is elaborated in the Mahabharata, an epic poem of more than 220,000 lines that tells the story of Rama, who along with Krishna is one of the nine avatars, or incarnations, of the Hindu god Vishnu. This poem, in turn, contains within it the Hindu epic the Ramayana, which is introduced with this: "He who reads and repeats this holy life-giving Ramayana is liberated from all his sins and exalted with all his posterity to the highest heaven." India evidenced an ability to absorb contemporary trends as well. As elsewhere in the world, the information age has had a profound impact on its educated classes and even on its rural population. Movies from "Bollywood," the country's cinema production center in Mumbai, have been widely watched in its cities for half a century, but the widespread availability of television has brought them to an ever-growing portion of the country's rural population. Cars have replaced motorcycles, motorcycles are replacing bicycles, and bicycles, in turn, take countless Indians to their colleges and workplaces. Western slacks and shirts are now generally seen instead of the dhoti, the traditional garb for men, and, of course, India's competency in adopting electronic technology is unarguable. Nonetheless, the grand architectural monuments remain, the temples are well populated, and, of some irony, Western interest in traditional Indian values and practices has aroused a reciprocal interest in the Indian middle class. Networks of well-educated philosopher-teachers such as those touted in the glossy brochures of the Chinmaya Mission proclaim that they can "provide to individuals from any background Spirituality in India

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the wisdom of Vedanta, the practical means for spiritual growth and happiness." It has scores of centers around the country, where lectures and even management courses are given. In India today the soul can be reborn in a contemporary manner. I grew to understand the compelling nature of the Indian worldview over the course of a number of months during several trips traveling over much of the country. In the course of such travels anyone living with electronic appliances that are replaced each year can begin to appreciate a sense of permanence in traditional India, that life need not be characterized by an unending quest for "more," for worldly benefits and for improved status. Such experiences have a tranquilizing effect on the visitor and can point to how India's spiritual traditions carry lessons for our own understanding of what the mental health profession can teach people.

The Spiritual Center

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s the spiritual center of India, Varanasi is the definitive embodiment of India's spiritual heritage. It is a lifetime's destination for every Hindu, as is Mecca for all Muslims. In one sense it represents more than Vatican City for Christians and Jerusalem for lews because those religions have accepted the legitimacy of their religious diaspora in a way that Hindus have yet to consider. The origins of this city on the banks of the Ganges are lost to history, but when Siddhartha Gautama, the historic Buddha, first taught here in 550 BC it was already a developed settlement. Two and a half millennia later, Mark Twain, an inveterate traveler, visited it and wrote, "Benares is older than history, older than tradition, older than even legend."2 Ritual immersion in the Ganges, undertaken after stepping down one of the many ghats, or staircases leading to the river, washes away sins. Cremations at the Manika, or burning ghat, can be seen as the traveler or pilgrim travels by rowboat down the river. Bodies of the dead, forty or fifty a day, wrapped in white silk, are carried on bamboo stretchers to the ghat's platform overlooking the Ganges. They are allowed to burn while the family waits for any of the remaining bones to be thrown into the river. The souls of the deceased,

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whose worldly remains have departed here, will then go directly to heaven. Benares Hindu University was founded by a Hindu nationalist during the British Raj as a center for culture and learning, and its large campus on the outskirts of Varanasi embodies the duality in India's way of addressing people's psychology, as two very different medical schools are located on its campus. One teaches Ayurvedic traditional medicine and predated the arrival of the second, its biomedically grounded sibling. The two schools coexist without apparent conflict but have little to do with each other. Upon visiting both schools, the contrast between their clinical approaches illustrates not only a dramatic difference in the way they understand physical and mental illness, but also the gulf that can exist between protagonists of traditional Indian culture and the scientifically grounded, Westernized "modern" Indians. Dr. Indira Sharma, a professor and head of the department of psychiatry at the modern school, showed me a facility that was modest and certainly economically compromised relative to its American and European counterparts. Nonetheless, it housed a faculty and cadre of resident physicians as sophisticated as any in the West. They are empiricists who use the same medications and techniques as their counterparts in North America. They treat schizophrenia and mood disorders in a most progressive manner but also encounter patients who come suffering from unremitting possession states, whose demons the ojhas, or traditional healers, have not succeeded in exorcising. I gave a lecture at the institute on contemporary trends in alcohol and drug abuse that was followed by questions from the house staff that reflected their interest in American psychiatry as well as their considerable knowledge of contemporary psychiatry. After this Sharma told me how she has augmented their contemporary treatment approaches with yoga practice for those patients for whom it is appropriate. She understood full well its benefits and limitations and was quite familiar with related Western medical literature, including publications on Transcendental Meditation that had appeared in mainstream medical journals. However, what was typically Indian in her approach was her knowledge of the spiritual tradition from which yoga derived. It was quite

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clear from her description that its practice in India carries with it a good deal more redemptive rituals than does the yoga Americans typically practice, for whom it is often a pleasant way of limbering up, less exhausting than going to the gym. (A divorcing male patient of mine also pointed out that the majority of participants in the American yoga classes he attended were women, many of whom made attractive dates; this was not Sharma's view of meditation in her native India.) The Yoga Sutras of Patanjali date back to an era before the birth of Jesus and describe eight stages in its practice. As Sharma explained, they are arranged in sequence, conveying an expectation of intense reflection and the relinquishing of deviant traits such as venality, gambling, and excessive sexuality. The first four stages are restraint, virtue, body posturing (asanas), and control of breathing (pranayama). I remembered pranayama from my first trip to India. A native-born Indian, the director of a pharmaceutical company's branch office was enamored of yoga, likely because it was legitimated by its successful entry into the American mainstream. He wanted me to see what the practice was like in India and sent me to his guru, a gentle old man who lived in Delhi. The guru gave me a lesson in pranayama, the benefits of which were lost on me, in part because my restless temperament made the relaxation he expected hard to achieve. In any case it was clear that millennia of tradition could not be conveyed in one lesson. Four more steps of Astanaga yoga ensue after the first four stages: withdrawal of the senses, fixed attention, meditation, and finally complete tranquility (samadhi). Sharma's patients were not expected to achieve the intense state of samadhi but were able, according to her, to relieve themselves of some of the tension that had brought about their psychiatric problems. These patients were still treated with the medications that their diagnoses required but also benefitted from the culture of transcendence and removal from worldly pursuits that the daily practice of yoga provided. Sharma gave me an article of hers that reviewed some of the studies that had been published in Indian, American, and British journals that attested to the utility of this approach.3 A visit to the second, Ayurvedic medical school, on the other hand, left me puzzled and quite troubled, particularly because it seemed that many of the sick patients who encountered Ayurvedic healers might be seriously compromised because of a lack of contemporary medical 132

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care. Its director explained that the etiology of all diseases could be explained by derangements in the five elements found in the human body: air, space, fire, water, and earth. The resulting maladies were influenced by sensation (like the excess of light experienced if one looks directly at the sun), the season of the year, and good or bad deeds. Their treatments fell into three categories: prayer, using one's intellect (which involves choice of proper foods and a proper lifestyle), and controlling the mind (which could be done through yoga or the particular type of psychotherapy they practice). They prescribed a variety of herbal preparations and nutraceutics, preparations from nutritional agricultural products. I saw a paperweight on the director's desk provided by the manufacturer of the antibiotic ciprofloxacin and asked him if his practice of Ayurvedic medicine included prescribing antibiotics. He said that if a patient came to him with an antibiotic prescribed he could continue it but would not initiate such treatment himself. Furthermore, in response to further questioning, he said he would treat pneumonia with mineral drugs and herbal antibiotics and was not about to do blood tests for a patient whose fever suggested the possibility of a blood-borne infection. He and his deputy then showed me some of their treatment rooms. One contained a wooden box about 4 feet on a side with a hole on top that allowed a patient's head to remain outside while the body was treated with "dry" heat from the light bulbs that lined the box's interior. A second box of similar construction provided sauna-like "wet" heat. Another room contained sinks used for the emesis the doctors induced in their treatments. In a third room a woman's body lay under a blanket with her exposed head covered with oil, a treatment for her malady. On that day they did not use leeches, which they did at times apply to draw off excessive blood. And what of their treatment of psychiatric disorders? The school's dean spoke of articles they had published but did not have them on hand when I asked if I might see some, and it seemed impolite to press him to come up with them. He did, however, say he would apply psychotherapy as needed. He also spoke of infusing medications for mental disorders through the nasal cavities because of their proximity to the brain. Sharma was respectful of her university colleague throughout this exposition, displaying a congeniality that was her nature. I asked her later Spirituality in India

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whether she would go to an Ayurvedic healer for any illness she might suffer, and she did not hesitate to say she would not. However, when asked what she thought of the overall presentation on Ayurvedic medicine, she said that she did not want "to get into areas of controversy," a tactful statement given her need to coexist with the Ayurvedic school within the university structure.

A Healing Shrine: Religion and Trance

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raditional approaches to mental illness in India are most evident in its healing temples, and on one of my visits I was introduced to this culture in the town of Balaji. Its modest rural setting lies some six hours from Delhi by car along a road system that declines in quality as one approaches the destination. The healing temple accommodates hundreds of visitors each day who come to pray and ask for good health, fertility, and economic well-being. Its reputation, however, rests mostly on its mental healing, not by some twenty priests involved in the temple ceremonies but by the healers who live in the nearby guesthouses. Patients come to Balaji for a variety of symptoms, most often psychosomatic in nature, such as headaches, dizziness, and decreased appetite. The temple's mythology has it that Balaji, the infant form of Hanuman, the monkey god, consoled the goddess Sita after helping her husband Rama rescue her from a kidnapper. Because of this, Hanuman can serve as a helper for those tormented by the illnesses that bring them to the temple. The patients in Balaji are predominantly relatively well-educated and from the higher castes and middle social class. They come accompanied by family members who attend services in the main temple at dawn and at dusk, where priestly rituals are observed. They usually suspect a spirit affliction before arriving at the town and its temple, and the trip has typically been suggested by their local healer or priest. The afflicted typically undergo pesi, a ritual trance, during the evening service while hundreds of people sit on the floor singing hymns. While in trance the patients cry out in loud screams or verbal abuse. These are understood to be the protests of the evil spirits that inhabit them and who are being driven to surrender and be exorcised. The trances then come to an end

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as the leading priest appears on the veranda of the temple and sprinkles holy water on the assembled crowd. Family members are important in this ritual, as they provide support throughout and continuing care after leaving Balaji, by assuring that the recovering person will stay away from alcohol, meat, and garlic and spend time at home participating in regular worship. The Finnish psychiatrist Antii Pakaslahthi,4 in his treatise on these rituals, pointed out that the dissociative, or trance, states are culturally approved procedures to convey therapeutic effect and should not be denned as pathologic states such as hysteria and conversion; they almost always remit while the afflicted are still at Balaji. Balaji illustrates the power of Hindu spirituality to intervene in mental illness but shows as well the difficulty in studying the mode of action of traditional healing. Clearly, an experiment employing a "placebo Balaji" would not be possible, and, equally important, practitioners of such treatments have little incentive to subject themselves to formal study, as they are not wanting for clientele. What is more, the Heisenberg principle would apply to any interventional study, which is to say that the process of intervening, by its very nature, would change the phenomenon so as to vitiate the utility of such research. By the way, this latter conundrum applies to studies on treatments in the West as well. One study that has been often cited was conducted by Griffith Edwards, a British leader in research on alcoholism and hardly an enthusiast for psychotherapy. He found no difference between patients who were, as he put it, "given the usual smorgasbord" of treatments at the Institute of Psychiatry in London and those who received no such elaborate care.5 It always troubled me that both groups were carefully monitored by social workers who followed the progress of these subjects. They may well have served to promote an orientation to abstinence more strongly than was appreciated. Similarly, the very elaborate Project Match, conducted by the U.S. National Institute on Alcohol Abuse and Alcoholism, was replete with extensive monitoring and videotaping of the entire therapeutic process and follow-up. That this initiative yielded no significant difference between the three different treatments applied may well have been influenced by the consistency of the intensive research protocol across the three techniques as much as their equivalence in therapeutic effect.

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In any case, Balaji illustrated how the potent demand characteristics of a spiritual venue in traditional India quite dramatically elicited an intense response in the afflicted, given the culture in which they grew up and how the plasticity of people's mental states can be employed to promote recovery. It also leaves open the question: What parallels might exist between Balaji and our own Western "scientifically grounded" treatments. Clearly the psychotherapist's office provides its own set of demand characteristics: Speak to me, tell me how you feel, and you will be comforted. Intense religious and spiritual commitment maybe evident in Balaji, but spiritual pursuits can be profoundly influential even among scientifically minded practitioners in India. Satish Malik, a professor of psychiatry, gave an example of this. He described an occasion when he was holding oral exams in Bangalore for his graduate students and had scheduled the director of a major psychiatric research facility to serve as an outside examiner. The faculty members participating in this academic ritual were assembled when he was informed that the outside examiner would not be able to participate. Malik was concerned that an illness had intervened, given the time commitments that had been made by the busy senior faculty and the gravity associated with the academic event. The entire set of formalities had to be rescheduled to a later date. When the examiner did show up at the next appointed date, he explained that his guru, Sai Baba, had given him a task to perform on the previous occasion—to Malik, a seemingly inconsequential one. He gave Malik the explanation with little apology, as if following a guru's word was unquestioned, no matter what disruption it might cause his colleagues. There was no violating such expectations, even by a professor of high scientific standing.

Transcendence of the Family

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he family as a spiritual focus may be in decline in the West, but in India it plays a vital role as purveyor of the culture's traditional values. In New Delhi I spoke with Taj Bahadur Singh, who established one of the finest clinical psychology internships in India. He had begun his

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studies in the physical sciences 40 years before and later turned to psychology, hoping to apply his scientific experience to his new discipline, but in time he learned that cultural sensitivity and intuition were unavoidable concomitants of his clinical practice. When I asked him how spirituality played a role for his patients, he pointed out the transcendent role of family ties in India, which he said served as "shock absorbers" for people as they confront the pressures of everyday life. He described one man in his 2os who had recently moved to New Delhi from a small town a good distance away to earn money for his family. After a few months working as a clerk, he became despondent, lost interest in his job, and began to miss work. In order to treat him, Singh summoned his family; the wife, brother, and mother arrived as a group. In India it is not uncommon for an entire family to settle down near the hospital when a relative is admitted. Singh explained to the family the despair that can arise from disrupted close-knit family ties and told them that they should come to New Delhi after the patient returned to work to spend more time with him. Having been united with his family and now given this promise of more secure contact with them, the patient's depression soon lifted. Singh explained that this relief upon being reintegrated into the family was typical of the way such ties could buffer people in India from the pressures they confront. This stands in contrast to the United States, Singh emphasized, where separation from family is much better tolerated and even expected. A reunion with one's family in the States would be much less likely to relieve a depressive episode. Even the most scientifically minded psychiatrists I spoke with respected the paramount role of family ties in India. Nimesh Desai had gone to a boarding school of the English style, followed by university medical training and then a degree in public health at Johns Hopkins University. He now directed the clinical research institute, but he spoke with reverence of the spiritually grounded rituals that bind family members together. One of them is barsi, which brings relatives to the home of the bereaved on the twelfth or thirteenth day following a death in the family. The ceremony is sanctified by the presence of Brahmans from the community. He also described how his father assembled the extended family, children, and grandchildren on the anniversary of his

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own parents' death. In recent years Desai had come to realize how this had kept the family together, based on their parental lineage, even after many members had moved to areas remote from their birthplace. In Varanasi Indira Sharma also clarified the role of parents in governing childrens' lives, even into adulthood. Future spouses are typically selected by mutual agreement among the parents of the future partners. This approach results in stable relationships, even if the initial encounters between the betrothed are devoid of romantic choice. Sharma said further that parents will actively disabuse their son of a romantically selected mate if the choice he made is not to their liking, and would not hesitate to go to the girlfriend or her parents to squelch the relationship. I asked how they would justify this to their son before they spoke to the girl's parents. Pointedly, she said that they would intervene on their own without asking his approval and that such interventions seem to work much better than a Westerner might think. The young man would typically acquiesce to their demands. On the other hand, the intensity of Indian family ties can easily produce the most intense of psychiatric reactions. The very close-knit nature of the family structure can be oppressive, particularly when anger is repressed because of social convention. A resident in psychiatry presented a case to me that illustrated this and the effect it could have in generating conversion symptoms, seemingly physical problems with no somatic basis. He described a peasant woman from a small town who was admitted to his hospital with frequent fainting spells. Her story unfolded in this manner. Her father-in-law had recently died, and one of his sons, who had three children, had received almost all of the father's property. The patient and her husband had only one son, a retarded boy, and were given only a small allotment. Because of her son's limitations, she felt that the inheritance arrangement was unfair. She protested to her widowed mother-in-law to no avail, but the mother-in-law then subjected her to the abuse women regularly encounter in traditional India when they live under the in-laws' roof. She then turned to the townsfolk for support. This infuriated the mother-in-law, who saw it as a violation of the family's reputation, and accused the woman of having affairs with the townfolk, a sin of the gravest nature. The fainting spells began when the woman's retarded son accepted the mother-in-law's invitation to become part of her household and 138

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help with chores. The spells were frightening to the whole family but did elicit their concern, something the woman had been denied since the conflict over the inheritance had arisen. This secondary gain she was experiencing from her fainting bolstered the primary one—the conversion phenomenon. This phenomenon is well known to reinforce conversion hysteria, much as it did among sexually repressed women in Victorian society. A doctor in the town could not treat the problem, and the woman was then brought to an ojha, a spiritual healer, to exorcise the evil spirits that had apparently inhabited her. He tied a string around her neck with a locket containing a paper with a spiritual inscription and swept around her with a broom to chase evil spirits away, but these efforts came to no avail as well. The woman was finally brought to the hospital, where she also had some spells. The psychiatrist's role among his patients was that of a parental authority, and he was able to tease her story apart, initially under sedation with sodium amytal and later as he and she continued to speak. With removal from the family and the unfolding of her tale, the fainting soon abated. The psychiatrist then brought the family members in to frame a reconciliation and told them that it was important to provide the woman with the positive attention she needed when her behavior was appropriate, but to ignore her fainting spells. He then negotiated a practically oriented agreement with the mother-in-law to return the retarded boy to the patient's household. Family intervention coupled with a contemporary psychiatric approach successfully addressed the problem, whereas a traditional healing, perhaps bizarre but sometimes effective, had failed.

Integrating Tradition into Therapy

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ingh, the psychologist, described the utility of temple ceremonies when used to advantage: he pointed to the role of Durga, consort of Shiva and protector of rulers and warriors, who was often shown driving her spear into the chest of the demon Mahisha. One man treated for depression in the hospital was beginning to remit but wanted support from Durga before he went home and asked Spirituality in India

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to attend the semiannual festival that is dedicated to her, as it was about to begin. Singh felt that the goddess was an apt source of support for the patient, who might provide the reassurance he needed to assume his role as protector and provider for his family, so he arranged for the patient to get leave to attend the event at a nearby temple. The patient returned to the hospital from the festival relieved and ready to be discharged. Singh pointed out that a request for respite from distress presented at a temple generally brings reassurance and comfort, more reliably than a visit to a church would do in the West. He also described the nature of the self-analysis that Gandhi said should be practiced daily. It differs from the contemporary Western approach of psychoanalysis, which is typically value-free and oriented primarily toward understanding the self. For Gandhi, committed to traditional Hindu values, self-analysis entailed an examination of what a person had done right and wrong over the course of the previous day, allowing him or her to approach the following day with equanimity and bear its emotional burdens with renewed strength. Singh said that the self-analysis acted like a "shock absorber" against the vicissitudes of everyday life, much as does support from one's family. Integrating Indian values into the context of psychotherapy brings together two traditions, the traditional and the contemporary, that may seem at variance with each other, and few clinicians had attempted it. Avdesh Sharma was recommended to me as one psychiatrist who had tried to do this. His office had framed inscriptions from both Eastern and Western philosophers on its walls, and his waiting room had New Age music piped in. Even so, he was clearly not removed from the country's professional mainstream, as he had served as president of the Delhi Psychiatric Society and had made a series of television shows explaining contemporary psychiatry to Indian viewers. Sharma gave some examples from his practice to explain how the two cultures could be related to each other. He said that he had come to realize that acute schizophrenics need not anticipate a downhill course, and he felt it important to allow them to seek out a cultural context for their deranged thinking. He told me how he would attend to the symbolic meanings inherent in such patients' delusions and help them integrate them into a personal spiritual journey, rather than dismissing

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them out of hand. He could also accept that puja, offering of prayers, could facilitate a schizophrenic's recovery if he or she wanted to participate in such rituals. The psychotic episode could thereby represent a journey forward rather than a regression. In relation to depression, he described the experience of one woman whom he treated with medication, but he also accepted and supported her desire to become involved in the Chinmaya Mission, in which ancient texts are used to give meaning to contemporary life. When she felt the mission was giving her enlightenment, he helped her resolve a growing distance she felt from her husband, who was not associated with the group. Sharma might himself refer a patient to a New Age teacher who would then provide instruction in meditation, and these teachers would send him students whom they felt needed psychiatric intervention. Some of the issues he dealt with were handled much the same as they would be by therapists in the West who are sensitive to their patients' quests for renewal of a meaningful life. One patient had achieved considerable wealth as a corporate executive but suffered from chronic depression that had necessitated pharmacologic treatment. He was aided in his recovery as Sharma encouraged him to use his new-found wealth to develop a personal mission to help others and thereby relieve some of the guilt that had accompanied his depression. For Sharma, as for others who may undertake a transformed view of therapy, it was an episode of transcendence that led him to his own stance. He described an out-of-body experience he had had during a 5-day "deep spiritual retreat" during which he began to feel elated, with thoughts of renewal rapidly racing through his mind. Drawing on his psychiatric training, he concluded that the episode was not pathologic but rather a subjective response to the intensity of the retreat and its implications for his life. The practice of therapy in the West may evolve as experiences like his become more common among mental health professionals. Transformations of therapists' practices based on intense personal encounters have not been uncommon. In the early twentieth century analysands' regressions on the couch did much to frame the nature of psychotherapy, and this has happened with the response to drug therapy as well. Kay Jamison, an academic psychologist who was treated with lithium for manic

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depressive illness, did much to promote the benefits of pharmacologic treatment for this illness in public appearances and with her book An Unquiet Mind.6 We may hear more of such spiritual transformations as an emerging breed of therapists in both the East and West report experiences with Hindu and Buddhist traditions and develop ways to use these traditions with their patients. The trend is also reflected in growing interest among some scientists who decide to pursue research on the nature of spirituality. In time, their work, producing a body of credible scientific findings, can have a material effect on what is perceived as valid clinical practice.

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9 Liberal Islam

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he World Health Organization's (WHO) Eastern Mediterranean region stretches across the broad swath of its Islamic countries, from North Africa to Central Asia. Ahmed Mohit, who directs the WHO mental health and addiction programs for this region, is a published poet as well as a psychiatrist and has lent much thought to its complex religious and political issues. He described the diversity of its cultures: from Morocco with its Spanish heritage, to Egypt, where contemporary agrarian practices reflect pharaonic traditions, across to Iran, whose Persian influence predated Islam, and on to Afghanistan, recently dominated by the reactionary Taliban. Mohit pointed out that many of the mullahs in his native Iran have a more liberal orientation than is appreciated by foreigners, who are more acquainted with the austere face of the religious autocracy in that country. He told me of the acceptance there of his recommendations on how to address a potential AIDS epidemic, given widespread use of heroin and the liberated sexual activities among many Iranian youths. The mullahs to whom he consults were accepting of the need to provide needle exchange programs for heroin addicts and condoms for those young people whose sexual activities were far from traditional Islamic expectations. Mohit drew on the literature of Iran to describe some of the spiritual themes in the country's culture. He described how Persian poets of the 143

tenth and eleventh centuries, including Omar Khayyam and Jalal adDin Rumi, played a role in the emergence of Sufism, a semimonastic Islamic sect. Sufism carries on its own independent tradition that is Islamic but apart from the religion's mainstream. It incorporates Buddhist and Christian ideas and introduced a mystical element into the country's culture, emphasizing an immediate and personal relationship of one's soul with God. Another tradition that bears on spiritual values in contemporary Iran derives from the Shahnameh, a poetic work embodied in pre-Islamic traditional Persian mythology. It describes the heroic and physically powerful Rostam. As Mohit said, "like Hercules, he fights giants and wild lions, but at the same time embodies the concept of great wisdom" and can guide people through their personal conflicts. Both of these traditions come into play in the role of the Pir, understood in contemporary Iran as a wise person with great insight who can be relied on for spiritual guidance. Such a figure reflects an Iranian archetype, much like a Hindu guru, who can be at a person's side as a guide, "wanting good for him. He could be a teacher, a family member, a Sufi or a religious leader—a cultural model typical of Eastern rather than Occidental traditions." Mohit further pointed out how the spoken word of such a person carries great weight, "much more than that of a cognitive behavioral therapist," as he put it. People will turn to the Pirfor advice infused with spiritual import. This does not carry a religious connotation per se, but can be highly influential in addressing issues in the psychiatric domain. Cairo is the intellectual capital of Islam, in large part because of the role of its Al-Azhar mosque, which dates back more than a millennium. It now embodies both the office of the mufti, its religious leader, and its university, to which youths come from all across the Islamic world to study. The mufti at Al-Azhar interprets the Koran and provides Islamic rulings on all aspects of life, from marriage and divorce to the final decision on execution of criminals. I met with Shaikh Gamal Kotb, who is on the mufti's council, head of publication at Al-Azhar University, and a member of parliament as well. He has taken a particular interest in the problems of the addicted and the mentally ill. He appeared in his clerical robe, striking the dignified pose of his position. Souad Moussa translated his Arabic into English. She had spent 3 years practicing psychiatry at a teaching hospital in London and is now 144

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on the Cairo University faculty. She was wearing a business suit and was sitting next to the shaikh. Her perspective served as an interesting complement to his; she wondered if she should have worn a head shawl to make the shaikh more comfortable. He did not seem uneasy at all. The shaikh illustrated how Islamic traditions imbue the mainstream of Egyptian culture while accommodating contemporary values as well. He pointed out that The tradition of spirituality in Egypt relates both the psyche and body to the spirit of the Creator. The more that one is able to follow the word of God the more that person becomes spiritual. Given his interest in psychiatric issues, I asked him how this perspective related to mental illness. Through Moussa, he replied God is pervasive, like electricity running through a building, through all its lamps, so everything is regulated, and what we have is light. If anything goes wrong we might have a fire, whether in the wires, in the voltage, or whatever regulates it, and that's very similar to mental illness. He went on to acknowledge the importance of psychiatrists, psychologists, and social workers, who can be helpful in treating mental illness. He distinguished between the role of the cleric, who could actually read relevant verses of the Koran to disturbed persons, and the therapist, who could discuss Islamic values with them, but not literally read them the Koran. He also made clear that a therapist should not tell troubled patients what they must do in accordance with the Koran, but only remind them of their rights and responsibilities as human beings. These points seemed to provide a reasonable distinction between the roles of the clergy and the professional. The shaikh also pointed out that prayer five times a day is a central tenet of Islam. The pervasive nature of Islamic spirituality is indeed apparent in the calls to prayer one hears at those times all over Cairo. However commercial and secularized this city of some 10 million people may be, however crammed with automobiles are its streets, the ambience of spirituality inherent in these calls is unavoidable. It was far from the nonreligious atmosphere in the streets of large American cities and Liberal Islam

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inevitably conveyed a calming effect for all who heard it. Moussa spoke with me later about the nature of this pervasive atmosphere. She said that prayer is seldom directed at asking God for favors, but rather at expressing adoration and thanksgiving. She said it offers sakina, a feeling of comfort and stability after one has prayed. She described how the month of Ramadan carries with it a set of rituals that provide a heightened sense of spirituality and related this to her own experience. Families are brought together at sunset each day after fasting, and because that time is fixed, people lay aside their daily routines to adhere to this spiritual injunction. This fortified her own family ties, because during the other months of the year she would miss family meals while working late into the evening. She searched for an analogy in the United States and likened Ramadan to a month-long gathering for the Thanksgiving holiday. Even alcoholics and drug addicts, she said, admit themselves into the hospital to be detoxified a few days before Ramadan so they can put aside their compulsions during that month. Ramadan also carries with it the expectation of good deeds in general, of being kind to the poor, and of distributing money or food to the needy. She spoke fondly of her experiences of Ramadan as a child, of being brought by her parents to give clothes and toys to poor children in her neighborhood and of lighting candles in little lamps, a tradition of that month. Moussa elaborated on the flexibility with which religious advice is applied in her country. She had turned to a shaikh once when she was confronted by the quandary of how to give zakad, a portion of income that she had not expended that is supposed to be given to a needy person. She wanted to know whether it was acceptable to give it to the family of a middle-class student who needed the money for college, rather than to an indigent family. The shaikh sanctioned her plan, but she said that had she wanted, she could have scrutinized the Koran herself and decided to go ahead with the plan even if he had recommended otherwise. Koranic interpretation stems from a knowledge of the depths of its text and is not denied to a learned lay person. She also noted a flexible relationship that Cairenes have with the clergy, pointing out that when people turn to a Muslim religious person at a time of emotional difficulty and receive no respite, they may go to a Coptic Christian priest to resolve the problem. Indeed, Coptic Christians, who constitute about 146

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6% of the population, have coexisted peaceably with Egyptian Muslims for centuries. I later spoke with Nasar Loza, who directs an addiction program in Cairo. Some 35 years before he had translated the Twelve Steps of AA into Arabic, using "Allah" instead of "God as we understand Him." He spoke of AA's easy acceptability in a culture oriented toward religion. Indeed, a psychiatric case study was presented to me at the University of Cairo, and I was surprised to see that a long-standing intravenous heroin addict had recovered through the Twelve-Step approach. Such recovery in cases of heroin addiction is quite uncommon in the United States, but it was pointed out that addicts often pray to get better and therefore can better employ Twelve-Step thinking on that basis. Magdy Arafa, a professor of psychiatry in Cairo, spoke with me at some length after explaining, almost apologetically, "I am an Egyptian. I am supposed to be a Muslim, and I am in my own way"; he added, "and I've been around the world and practice psychiatry in a Western manner." He is head of the "integrative psychiatry" training program at the Cairo medical school, an approach that combines medications with psychotherapy. He told how he would handle a patient considering suicide, illustrating the way traditional Islamic beliefs could be employed in treatment: There are very strong emotions against suicide in Islam. People come up with these beliefs, and in treating a person who has attempted suicide you just have to remind him of these issues in a therapeutic context, and you'll find him ready to accept the idea. You may start to get through to the patient by exploring the issue and asking him if he believes in God, then asking what that would mean if he took his life, and he would reflect on this. But at this point I would leave it at that and move on to something else, rather than dwelling on the issue. I have only awakened an Islamic attitude in him, and then I would try to point out aspects of his life that should not leave him feeling so desperate. I would let him reflect on his own on the religious import of the issue. Arafa also described the importance of Sufism in the Islamic tradition, amplifying what Mohit had discussed and further clarifying how a spiritual tradition can lend weight to the psychological impact of a Liberal Islam

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guru-like figure when a person is distressed. He said that in the Egyptian context a Sufi can communicate even by his presence or by a brief statement and have considerable psychological effect. Such counseling need not entail an imposition and may not even include any verbal expression: "They might do what a good psychiatrist does, but do it much better than a psychiatrist would do." He felt strongly about the value of Sufism and took me over to a clerk to make sure I would receive a treatise on that sect that he had copied for me. These encounters left quite a different impression from those of my readings before coming to Cairo on the Muslim Brotherhood, a movement responsible for radical Islamic terrorism that had carried out the assassination of Egypt's president Anwar Sadat in 1981 and more recently did much to fuel radical Islam worldwide. There was clearly a benign culture in Islam, described here in relation to both Iran and Egypt. The role of this culture in people's emotional lives shows how a tradition can create a basis for renewal, how it can bring comfort through prayer, and how it can be called on to accomplish therapeutic ends.

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10

Hospital Chaplaincy: Confronting Illness and Death

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he HealthCare Chaplaincy Program at our medical center trains people of diverse religious backgrounds in "pastoral care for those facing the crisis of illness and loss," "medical ethics," and "the theology of suffering." This is a weighty burden, even for the mature adults who enroll because of firm religious convictions. Trainees are taught to approach patients and their family members with a nondenominational outlook, to listen to their concerns with patience, and then to offer support. I first heard of the program over lunch one day in our faculty dining room. At the time I had just begun to study the relationship between psychiatry and the spiritual perspective, and was struck by the fact that the chaplaincy training had no formal relationship with our department of psychiatry and was in fact, virtually unknown to the psychiatry faculty, apparently reflecting the gulf between these two ways of dealing with people's suffering. It seemed that an understanding of the program's approach might shed light on the problems of mental health professionals in dealing with people's needs for spiritual support. I made an appointment with Paul Steinke, a Lutheran pastor who directs the program, and he invited me to sit in on one of his trainees' conferences. It ran something like this: Jared, a man in his 6os, described the background of a patient he had encountered, then gave a verbatim account of what had been said, and then closed with an analysis of the

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exchange from a theological perspective. A discussion ensued that dealt with some of the psychological and spiritual conflicts raised by the encounter but skirted any focus on formal psychiatric diagnosis or evaluation. I was impressed by Jared's decency and concern for the patient's wellbeing and asked if I could speak with him later to help with our studies on spirituality. In the comfort of my office it became clear that a desire to draw on his own religious background had led him to dedicate himself to the chaplaincy. As a young man he had considered the priesthood but before ordination concluded that he could not accept a life of celibacy. He turned instead to social work and later became a deacon in the church. After we had spoken for an hour, he described one particular event that made clear how psychiatrists could distance themselves from the emotional needs of their patients. Jared had encountered a good deal of suffering in his own family. His wife had died of a brain tumor after a long illness, after which his daughter, a college student, became increasingly depressed. She was treated by a psychiatrist, but her depression continued unabated; she was found dead of an overdose in her dormitory room with her mother's picture on her chest and a tape of her mother's favorite song lying at her side. Jared was first told of the death by her psychiatrist. He was overwhelmed with grief and did not know how to respond. Looking hopeless and distraught even now, he told me he said, "This must be God's will." He could not forget the response of the psychiatrist, who said coldly that "It's magical thinking like that that led to your daughter's suicide." I wondered how far removed the psychiatrist could have been from compassion that he could make such a statement. Or was this a reflection of the level of training my profession offered in religious tolerance? The opportunity to speak with other chaplaincy trainees in the program allowed for exploring the ecumenical and spiritual orientation of their approach. Although their goal was to allow the hospital's many patients to confront illness, even mortality, with a measure of equanimity, the trainees had to struggle with issues that would carry an emotional burden for themselves. Harry served as a pastor in the Church of the Nazarene while enrolled in the chaplaincy program, and he described how his views had

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evolved since attending Bible college in Idaho in his youth. When I asked him what people there would have said if asked what was meant by spirituality, he said, "You might get a blank look or you might get a list of do's and don'ts. That's about it." His background was Fundamentalist, and he had been expected to avoid "drinking, smoking, or watching sex and violence in the movies or on TV." Indeed, his denomination had been established in 1905 in Texas by Methodists who thought that their coreligionists were no longer responding to the devout message that John Wesley had preached. Harry had held the pulpit of a congregation of predominantly poor, Central American immigrants in a New York suburb for some years, serving a group of people quite different from the church members he had known in his youth. He said that he had become good friends with a rabbi in his neighborhood and that they had exchanged pulpits at times: "When he came to my church he preached on holiness. All he would have had to do was to insert Christ into what he said and he would have made a good preacher at that." At our hospital's postpartum ward Harry had encountered a Catholic woman who had borne a stillborn child and was bitter and depressed. She was unable to understand how this could have happened to her. He told me, "Maybe some pastors would tell her that 'God is punishing you,' or they might say, 'God is taking care of your baby' and leave it at that. But that's an easy way out." "What did you say?" I said that, "You have a right to be angry at God. Why not tell him how you really feel, ask God why this has happened to you? I don't know why it happened to you." I think that I gave her a channel to be angry with God to express her feelings, that she had done nothing wrong. Somebody else in the church might have said it's going to be okay; trust God. But the reality was that she was very angry. In the chaplaincy program we learn to allow people to express their feelings and we listen to them. After all, in the Psalms David expressed his anger toward God, so why can't she do the same? "And how did she feel after that?"

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She was clearly relieved that she could express herself, and her husband thanked me for coming and listening. My whole point was to hear them out and then let them have some comfort. But Harry knew the limits of what he could offer people. While standing at the bedside of a man who had received a kidney transplant who was now dying 3 years later, he encountered the man's wife, who wanted her husband to be "healed." Harry said to me, "I could pray for them as in my tradition, but I could do no more. I had to put boundaries on my own belief." Like the other earnest, often devout, chaplains-in-training, Robert had learned to distinguish between spiritual support and formal religious practice. Sara, a Conservative rabbi, had worked at a cancer hospital and later at a hospice and was now studying to be a trainer herself, hoping some day to direct her own program. In describing her spiritual orientation, she emphasized the importance of belonging to a community of people who had lived and suffered through the ages and said that "this thread of spirituality provides meaning that may be intact at times, and at other times broken." She said it did not so much depend on a literal belief in God as on her Jewish lineage. Sara made clear how dealing with terminally ill patients could present problems that taxed her ingenuity at times, not only her compassion. She recounted speaking at the hospice with a man who was close to death. The encounter was complicated because the man asked her for "last rites" at one point even though he was Jewish and called himself an atheist. When she clarified that Jews do not typically participate in that Catholic ritual, it became clear that what he really wanted was some closure on his life, so they concluded that this might be achieved by their reviewing aspects of his life. He had been abused as a child and had had few relationships that might have brought him visitors at the hospice; he was alone in his final days. He asked if she could hold his hand and pray for him, and she recited a "spontaneous prayer," which she said she had learned to do from her Christian colleagues. He held her hand as he fell asleep. These chaplains could have used some of the tools of contemporary therapy, such as hearing out a patient's feelings, but their religious ordination, whatever the denomination, allowed them to make statements 152

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and offerings that a mental health professional could not. I was reminded of a comment made by the Islamic psychiatrist Ahmed Mohit on the importance of "the word" in spiritual discourse. He had meant that the spoken word of a spiritual ritual can carry with it weight and import beyond the meaning of an intervention based on practicality or even compassion. I could see better what it meant when the Nazarene minister had drawn on the words of the Bible's tale of David to sanction a grieving woman's expression of anger, and when Sara's spontaneous prayer, although not drawn from formal liturgy, could penetrate years of isolation that left a man to die alone. The nature of the sanctified word was made all the more clear by Peter, a native Pakistani who came from a small Catholic enclave in Pakistan where centuries before his forebears had been converted to Catholicism by Portuguese missionaries. He had been ordained a priest in Lahore and then, because of his talents, was encouraged to go to Rome to study for a doctorate in canon law. He had never heard of spirituality until an American professor in Rome had discussed the term and had evoked his interest in it. Now, at an American medical center, he could recount how he had a new perspective on his traditional priestly role and how he had adapted the chaplaincy approach of listening and reaching out to relating to the distress he confronted on medical wards. A patient he described who was suffering from stomach cancer had been alienated from his wife for many years and had all but abandoned their two daughters. The daughters had now come to see him before he died. Peter's English was not entirely fluent, but his thoughts about the patient were conveyed quite clearly. During his life I think he had many other women. And I think he never respected his wife, who was some years older than him, and who he married when he was 17. When he was small, his mother died, and I think he wanted to have a relationship with an older woman. I think she gave him motherly love when he got married, but he became bitter after a time. When I first went to him I said, "Hello, can you tell me something about yourself?" He said, "Father, I am all right. I do not have anything to say." But he was in the last stage before death, and it Hospital Chaplaincy: Confronting Illness and Death

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was so difficult, to say "I am dying." On the next day I saw him and he was so depressed. "What have I done with my life?" he said. I asked Peter, "Was he responding to you as a chaplain or as a priest?" Sometimes I wear a [clerical] collar and sometimes I go without a collar. That second day I came to the hospital without a collar, just to have a relationship with the people. With my collar, sometime people recognize, "He's a Catholic priest." So they don't talk about how they feel. They say "I am all right." And when I wear regular clothes, they talk about themselves. Without my collar, he said, "Oh, yes, now today you sit with me." So I sat with him and he told me about his daughters, who had been visiting. And then his daughters came in. I said to them, "I am a chaplain." One said, "We do not have any relationship with our father; he was a very angry man. I think, from the beginning he did not have a good understanding of our mother. And our father never, never kissed us. He never said, 'Oh, my daughter, come to me.' He allowed the other women, but not us. Maybe he has rejected our mother and he rejected her children, too." Then they said, "Okay, Father, what can you do? Can we pray for him?" So I said, "Okay." So then the youngest daughter said to her father, "The chaplain can let us have a prayer together," and he said, "Okay." And then the second daughter said, "Papa, would you like to have a prayer, because we'd like to have a prayer for you." Then he said, "Okay, we can pray together." And I said, "Let's hold hands." So I held his hand and he held one daughter's hand. And it was the first time that he had held his daughter's hand. So when he took the first daughter's hand, the second daughter started crying, before prayer. So I said, "What happened? Why are you crying?" She said, "I wish my father also took my hand." So we all held hands. So I connected the family together. And we prayed together. And his daughters were very, very happy after the prayer. And the third day and I sat with them again. His grandchildren were there. And the grandchildren, I think he had never, never kissed them. I said, "Jesus always kissed the children." He said, "Bring the children to me." So then I said, "Let us all pray together."

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So with the children and the family we prayed together. I tried my best to reconcile them. Now, the daughters felt that something very meaningful had happened to them. Clearly, to the daughters it was a connection with the father that they never had. "How did he feel, do you think?" I think he realized that he must have a relationship at the end. I think he was also feeling warmness in his heart by connecting with his family. . . . Three or four years ago I would have just acted like a sacramental priest. I would not have listened. I would have just paid my sacramental visit. But it would have not brought any change in their lives. But through this, as a chaplain, this has brought a change in their lives. Peter had apparently struck a balance between the sensitivity of a therapist and the role of a spiritual or religious mentor. In fact, his choosing between a clerical collar and informal attire illustrated in a concrete way the balance he was trying to achieve, so I wanted to get an understanding of what he had been taught in the chaplaincy program. Was there something here for psychiatry trainees to learn? I pursued this issue: "What have you learned in the program?" One of the basic things is the listening style. I had a tendency not to listen, but to talk, and by not listening I misunderstood. Sometimes I would think that I am better than the people I tend to. So the day I started listening I started to reflect. And if you reflect and then give a response it has some weight, it has some understanding, that I was not getting before. And the second thing is that I had the tendency to always look good. Nobody challenged my life, and here I was challenged. This challenge made me aware that priesthood is not an easy life. My vocation is not easy. It is a challenge and I have to improve a lot. My ministry was challenged. And the third thing I came to know about myself was that chaplaincy is a multinational religious education. It is not an evangelizing agenda. It is to heal the suffering of the patients in the face of their sicknesses, and to give value to their own religious re-

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sources. That I had never learned before. It has had a lot of impact in my life, how to give value to other religions. A psychiatrist involved in consultation on medical wards may have little opportunity to do more than evaluate disturbed patients' mental states and suggest ways of handling them to the staff, but with the dying man and his daughters, Peter was able to summon up the sanctity of prayer in combination with the empathy he felt for members of the family. He had promoted a resolution of emotional pain and disruption that had characterized their troubled family. Therapists may struggle over many sessions to help their patients achieve such ends, but the spiritual sanction inherent in Peter's thoughtful intervention achieved this end with much grace. Perhaps at moments like these even professionals need to invoke something more transcendent than their clinical training. Also, Peter had learned that he need not always wear his clerical collar, need not always "look good." To what degree could our psychiatry residents come out from behind a facade of formality as they relate to their patients? When should they reach out in a more empathic manner and figuratively touch their frightened, mentally ill charges, as Sara had done literally in holding the hand of her dying patient? Is there any appropriate clinical counterpart to her "spontaneous prayer?" Clearly, there are no easy answers to these questions. Over years of training, psychiatrists acquire a set of emotional boundaries that frame their need to maintain a certain remoteness from patients and a distance as well from any spiritual content in the clinical setting. What was the place for personal, much less spiritual, meaning in a profession increasingly rooted in the concepts of science and pathology? After the antianxiety agents, the antidepressants, and the antipsychotic pills do their job, when should "patients" become people?

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PART IV

Spiritual Recovery Movements

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n June 10,1935, two chronic alcoholics, Bill Wilson and Bob Smith, sat together in Akron, Ohio, in the hope of staving off their craving for alcohol. Over the ensuing days they were somehow able to avoid taking a drink. Heartened by that success, they decided that other people suffering from their seemingly incurable illness could work together to overcome their compulsion to drink. Bill W went on from there to frame an ideology and movement for which Aldous Huxley described him as "the greatest social architect of the twentieth century." The AA fellowship that emerged from this effort illustrates the remarkable capacity of people to join together under the banner of a movement for recovery from illnesses that have left them dejected and seemingly helpless. This psychological phenomenon takes place within a social structure whose members share a bond of affiliation enhanced by an earnestly held set of beliefs. Engagement can then lead to experiences that transform their members' thinking, feelings and behavior. This section of the book examines the ways such movements can relieve the symptoms of psychiatric disorders and infuse a culture with a redemptive ideology—as they have done in different ways for many compulsive behaviors and even for major mental illness. It is a phenomenon studied systematically, and it sheds light on a number of

issues implicit in this book. Among them is the popularity of alternative medicine—often the embodiment of techniques devoid of scientific validation—and its historical origins in shamanic healing. With a better understanding of such spiritually oriented movements, the mainstream mental health profession can consider ways of making use of their transformative powers.

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Alternative Medicine

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oday's culture of managed care and biomedicine leaves little time for caregivers to comfort sick people, nor does it necessarily create a relationship born out of compassion and caring. In addition, medications have side effects, leaving people uncertain about the harm they may be subjected to from treatment. They often live with the resentment of having no option to express the fear that accompanies their treatments. Spiritually oriented treatments, on the other hand, steeped in religious and cultural tradition, may carry with them the promise of transcendence beyond the physical and material at a time when a body or mind is wracked by suffering that has no apparent medical cure. Because of this, many people today adopt unconventional spiritually oriented treatments that are not based in contemporary biomedical research. These derive from a number of sources, such as New Age philosophies, the Twelve Steps, and long-standing Eastern healing traditions. Consider that 68% of the general population reported that they had employed some type of alternative medical approach in the previous year,1 and one study found that 35% of people turned to prayer for health problems.2 For sick people a spiritual orientation toward bodily function might seem to hold promise when they are confronted by serious illnesses for which there is no medical solution. For healthy people alternative medicine may offer a feeling of protection from ill health 159

and perhaps strengthen their minds and bodies. Both the sick and the healthy may oscillate between the options of spiritual healing and conventional medical approaches. Among the severely ill this was illustrated by a patient who was suffering from a neurodegenerative disease. After a series of metabolic studies, he was told that his malady had yet to leave anyone alive for more than 10 years. The physicians gave him and his wife little emotional support, and certainly no hope. Soon the couple found that his body and mind were in decline, with modest relief provided by analgesics that would mute his pain and disability while he continued to suffer from a depressing transition to helplessness. Neither he nor his wife, sophisticated New Yorkers on any count, had contemplated any medical treatment other than top-flight management at a university medical center, but racked by anxiety and looking for any help they might find, they went to a traditional healer in the city's Chinatown whom they hoped would help fight off the problem that conventional medicine could not resolve. In their case the exploration of this option offered little credible assistance, and they did not return. Others in their place might have responded differently and stayed on with an alternative healer. Among the healthy some people tailor their diets to conform to exotic and ill-founded theories that are remotely related to primitive cultures predating the emergence of modern medical science. They may begin to speak in terms drawn from ancient India and China and avoid conventional physicians, whom they distrust. When confronted with the flu or a minor health problem, they may turn to unconventional medical techniques recommended by a friend. With luck, they will get a treatment based in scientific medicine if they encounter serious illness.

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piritual recovery movements—as opposed to conventional medical care—can be considered to have three primary characteristics. They (i) claim to provide relief from disease; (2) operate outside the modalities of established empirical medicine; and (3) ascribe their effectiveness to higher metaphysical or spiritual powers. Christian tradition understandably serves as the basis for some of these movements, given that

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95% of American adults surveyed avow a belief in God or a universal spirit, and 43% attend church in a given week.3 This is reflected in a variety of inspirational books such as M. Scott Peck's The Road Less Traveled,4 which combines a religious and psychotherapeutic inspirational approach and was on the paperback nonfiction best-seller list for more than 500 weeks. This orientation is seen in the area of general medicine as well. Cancer patients often turn to religious healing, and many books, such as A Medical and Spiritual Guide to Living with Cancer,5 apply a Christian orientation to dealing with grave illness. The physician members of the Christian Medical and Dental Association avow that their religious faith is "absolutely critical to their personal and professional lives" and actively apply that faith in their clinical work. In my own study of psychiatrists in this association, 96% said that they had been born again, and a like number acknowledged having encouraged someone to accept Jesus as savior.6 Eastern spiritual approaches, generally related to the religious orientations in China and India, are reflected in a diverse group of practices. Acupuncture is associated with lesser-known exotic Chinese practices, including moxibustion and cupping, designed to remove noxious spirits by suction. Ayurvedic medicine from India has gained attention in the United States, with response in the media indicating its popular appeal. These spiritual traditions have also spawned considerable public interest in herbal preparations, leading to dissemination of related healing preparations among networks of people with AIDS and cancer. Holistic medicine is a term generally applied loosely by its advocates, but it is clearly influential for many psychiatrists and general physicians. It has been defined as "an approach to the whole person . . . appealing to lay people who feel their lives and health care are fragmented."7 It has been said that "its gift of spiritual wholeness is the crux of the health and vitality of creation."8 Advocates of the holistic approach generally focus on psychosocial and nutritional issues, and may encourage the use of unconventional treatments such as acupuncture, macrobiotic diet, meditative techniques, and body awareness.9 They generally promote active communication between physician and patient and may suggest that love or a religious conversion can help to resolve mortal illnesses. Self-liberating approaches derive their popularity from the assumption that mental and medical illness can be overcome by an ill-defined Alternative Medicine

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power of healing that lies within each person. This is thought to offer the means of releasing innate spiritual "energies" that can change the course of physical or emotional distress. Techniques range from healing through "creative visualization" of diseased organs to confronting memories of childhood abuse. The ways that relief is achieved are described by some advocates with vague expressions of enthusiasm and by others in terms drawn from neuroscience and immunology. Twelve-Step movements derive their spiritual message from the steps toward recovery developed by Alcoholics Anonymous, drawing on "the care of God as we understood Him." With more than a million members in the United States, AA has contributed greatly to recovery in the addicted population and has inspired other groups to adopt the Twelve Steps to address other problems associated with health risks, from narcotic addiction to overeating. However, some members of these groups have enlarged on this perspective by focusing on recovery from a wide variety of interpersonal problems, from "codependency" with troubled spouses to recovering from one's "dysfunctional" parents. Ubiquitous workshops and coverage in the mass media have yielded sales in the millions for individual books that have applied this format.

Psychological Impact on Health Status A religious or spiritual orientation has been found effective as a buffer ./Vagainst psychiatric symptoms in both the general population and the bereaved.10 Among members of cultic religious sects I was able to measure a decreased likelihood that stressful life events (such as physical illness) would produce depression, anxiety, or increased somatic pain.11 The personal meaning that people derive from social support can be beneficial. The support people get from marriage and community ties is correlated with lower rates of mortality in the general population and even among cancer patients.12 On a physiologic basis, psychosocial factors have been found to affect cardiovascular and immune responses. Factors that have been objectively assessed include psychotherapeutic support,13 self-expression of traumatic experiences,14 social deprivation,15 and loneliness.16 Relationships can be observed in the laboratory

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between psychological stress and hormonal responses from the hypothalamus and the sympathetic nervous system,17 but clearly much study needs to be done before the relationship between neuroendocrine factors and mental and general medical illness becomes clear. Certain psychological and social factors conceived as "spiritual" may promote healthful behaviors as well. This is highlighted by the fact that half of all U.S. mortalities can be attributed to a nongenetic etiology, and most of these reflect the direct impact of socially mediated causes such as smoking, alcohol and drug abuse, eating behavior, and violence.18 Clearly, any increase in society's ability to influence these health-related behaviors through a moral reconstruction of sorts could have a beneficial effect. On the other hand, people involved in alternative healing approaches may therefore miss out on conventional care when it is needed. Of those who sought out both alternative and mainstream care, 15% received alternative care first, and up to 72% did not even tell the doctor of that alternative care.19 Even among cancer patients who went for questionable alternative treatments, 17% did so before obtaining conventional medical therapy.20

Subcultures

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an an entire community be held together by belief in spiritually grounded recovery? A historical example of this emerged in the city of Geel, Belgium, where a movement dedicated to recovery from mental disease dates back several hundred years. As the legend goes,21 this tradition began with Dymphna, the daughter of the king of Ireland. After her mother died the king searched unsuccessfully for a new bride who resembled his late queen. When the search failed, he claimed Dymphna to be his bride because she had the appearance and beauty of her mother. Fearing a marriage based on incest, she fled to Geel with her confessor, St. Gerebernus. Her father found her there and put Gerebernus to death, after which Dymphna allowed herself to be decapitated rather than submit to her father's demands. The legend continues that the king's cruelties so frightened several "lunatics" who witnessed the

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slaughter that they were cured. Dymphna, whose suffering had led to this miraculous outcome, came to be known as the patron saint for recovery of the mentally ill. Residents of the town began taking in deranged and demented people on the basis of the town's mythic powers, and by the fifteenth century a church dedicated to St. Dymphna was founded in Geel, which by then had become a place of pilgrimage for those who sought to recover under St. Dymphna's protection. Residents of the town took these people into their homes and allowed them to mix with the townsfolk, so long as they helped with household chores and worked on the local farms. By the mid-nineteenth century an infirmary was built to take care of troubled souls who could not be contained within people's homes. A movement that had begun as a tradition of spiritually grounded charity was now being transformed into a social institution supported by the Belgian government, and the role of ecclesiastical input diminished. More recently, the Belgian government has come to provide stipends to families that house these people—now patients—in their homes.22 This tale is relevant because it shows how an entire community can come to aid in the recovery of the mentally ill when their efforts are based on a spiritual commitment, but it also shows that the contemporary culture tends to professionalize any such help, as it comes to be engaged in a medically grounded system of care. This can be the fate of other spiritually grounded movements when their merits are recognized as effective in the treatment of an illness, an example being how the spiritual recovery movement of Alcoholics Anonymous has become absorbed into our system of medical care. Like the community of Geel, AA emerged out of the need to help troubled people, and because of its merits, it has now been adopted within the professional medical system. The spiritual fellowship that Bill W. set up, based on the revivalist quasi-religious Oxford Movement, is now integrated into virtually all American professionally grounded addiction treatment programs. It has even been validated by the National Institute on Alcohol Abuse and Alcoholism in a large-scale medical research project.23 The acceptance of a spiritual recovery movement by sick people is enhanced if it is consonant with values common in a particular subculture. In preindustrial societies established healing practices and spirituality were generally compatible with each other, as they derived from 164

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the same value system. In many types of shamanism, for example, divinely inspired healers provide meaningful care and relief of somatic symptoms, if not actual cure. Tdng-ki healers in Taiwan address psychosomatic problems, transient illnesses, and pain associated with disease, while their credibility is reinforced by indigenous Confucian concepts of the healer and the healed.24 The impact of cultural values in traditional societies is apparent in healing rituals directed at mental disorders, too. Examples range from treatment of the mentally ill by Navajo shamans, originally described more than 50 years ago in the classic studies of Leighton and Leighton,25 to Zar healing ceremonies26 still common in Northeast Africa and Iran. When traditional healing and scientific medicine encounter each other the two can coexist or even support each other. Contemporary obstetric "faith clinics" in Nigeria embody Yoruba rituals that ward off demonic possession combined with the divine healing practices of the Christian Apostolic Church, but they also apply medically grounded midwifery techniques.27 Many Puerto Ricans in New York seek care for mental and general medical illnesses from local hospitals, while at the same time addressing their illnesses at the magical ceremonies of espiritismo healers.28 Religion and spirituality have their place among physicians as well, the large majority of whom report that they believe in God.29 In one study of primary care physicians, two-thirds said that praying with patients would be appropriate behavior,30 and a relatively small number apply Christian prayer directly in medical practice. More than half of the psychiatrists in the Christian Medical and Dental Association said they would prescribe prayer as a treatment for depressed and alcoholic patients.31

Do No Harm?

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ll effects of spiritually grounded approaches have also been found. For example, two studies carried out on alternative clinics prescribing a mystifying array of nostrums for cancer treatment32 showed that neither setting yielded any improvement in patients' survival, and they were sometimes associated with a decreased quality of medical care. Alternative Medicine

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Poorly conceived alternative therapeutic techniques were found to be harmful in settings ranging from intrusive encounter groups33 to the application of bizarre medicines such as toxic herbal preparations.34 The prohibition of sale of the stimulant ephedra because of its cardiotoxicity served as a warning for the general public about the potential danger of "natural" herbal products. On the other hand, there is also a history of antagonism between religious and secular healing systems in Western society, with deviant movements such as Christian Science regularly emerging. In 1875 Mary Baker Eddy, who initiated the movement, wrote that illness was to be addressed by recourse to her church to the exclusion of conventional medicine.35 Legal cases have been fought by Christian Scientists who have denied their children needed treatment for mortal illnesses. One study showed how intensity of belief in a spiritual recovery movement could generate an outright denial of reality. Mansell Pattison36 evaluated medically ill people in the Pacific Northwest in a denomination that practiced faith healing. He found that adherents to that healing process believed that their physical illnesses had improved in an objective way, although, in fact, there had been no measurable change in their status. At the same time, his psychological testing revealed a pattern of denial in these sick people. The healing ritual had apparently provided them with a basis for coping with illness that was in direct conflict with reality but that was comforting to them and supportive of their belief system. Belief in a movement can also affect a caregiver's judgment. In one study37 nurses' compliance with psychiatrists' orders was evaluated in the mid-1960s, when professional and gender roles allowed for more clearly delineated authority. Psychiatrists involved in carrying out the study telephoned the hospital with orders to administer seemingly toxic doses of a "new" drug. Almost all the nurses were willing to comply with the orders given, even though phone orders ran counter to hospital procedures. Such findings help us understand the harmful behavior perpetrated by members against recruits in some dubious movements such as Scientology. Once participants accept the authority of a supposed healing program, they may comply with its demands, even if they inflict harm. Such programs can manipulate new members' be-

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haviors, or they may induce them into a bizarre "treatment" program, one that is manifestly unreasonable or even hurtful.

Psychological Engagement in a Spiritual Recovery Movement

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onsider the onset of pain apparently due to illness. People generally have a sense of security about their physical well-being, but the experience of unremitting pain and threatened loss of life run counter to that sense. This results in a conflict between their usual perspective and the newly perceived physical state and creates a troubling sense of arousal. Given the pressure generated by such cognitive dissonance, the distressed sick person will be open to seeking out or responding to an explanatory model for illness available in her environment. If she becomes engaged in conventional care, the model offered will be based on available biomedical mechanisms. If she encounters an alternative healing movement, on the other hand, she may accept a spiritually grounded, nonscientific perspective, even if it has limited credibility. This likelihood increases when that movement draws on a spiritual theme that is credible to her. It can be made further acceptable by some friends or true believers who support the perspective. A group of true believers constituting a spiritual recovery movement often bolsters its internal stability by aggressively recruiting new adherents, since the acceptance of the movement's ideology by new recruits gives it (and its leaders) greater credibility in the eyes of the members. Adherents to these movements may therefore be eager to engage any sympathetic listener into a discussion of their healing philosophy. A similar group psychology may also emerge in relation to new, empirically validated treatments. The spiritually oriented recovery movements do, however, differ from those in that they are hardly ever amenable to research evaluation with control groups. Here is the case of one patient that illustrates this psychology: A doctor asked me to make sense of his encounter with a 32-year-old woman who had not complied with a regimen he had recommended for her. She told me that she had suffered a painful back injury 6 years before and was told by a radiologist that she had a "fracture at Ti2." Soon

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thereafter a friend introduced her to a practitioner of Chinese medicine, who she said provided her considerable relief of her pain with acupuncture treatments. She then became more interested in Eastern healing practices, attended meetings of a committed group of followers led by that practitioner, and began practicing meditation, "breathing deeply and focusing the energy on a series of organs, starting at the face, moving through the internal organs, and clearing the body." Two years later she developed a severe cough accompanied by chills and fever. Although told by the doctor that she might have pneumonia, she "took ginger baths, and was in bed with probably five quilts for a couple of days. I meditated and recovered." She saw no reason to accept her physician's treatment plan given her success with alternative healing techniques. How had this unfolded? While experiencing distress 6 years before, this woman was exposed to an explanation for her pain that was based on an unconventional alternative medical treatment. Feeling relief, she attributed the episode to a related spiritual philosophy. She later became more involved in the philosophy while participating in an enthusiastic group setting and felt a greater sense of personal control in applying it to another illness, potentially unwisely. A sense of self-efficacy,38 the conviction that one has the ability to actively master a challenge, can help a patient mobilize herself to face the need for addressing her illness. On the other hand, interventions made to improve self-efficacy can enhance compliance with conventional care, but they can also be wedded to an erroneous treatment choice. They can have a negative effect when associated with ineffective "alternative" care, or, as illustrated by this woman encountering Chinese medicine, lead to the avoidance of a potentially needed medical intervention. The experience of affiliation with a social or spiritual healing movement can offer relief to an unhappy or sick person. In studying religious cults, I called this the "relief effect," which can also serve as the basis for reinforcing membership in the movement. That is to say, there is an initial relief from malaise and uncertainty due to accepting a new attribution. This can then continue providing an ongoing reinforcement of the commitment to the group and its views. The sick person is thereby conditioned (operantly) to maintain affiliation. This is because of the posi-

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live reinforcement inherent in the continuing emotional relief offered by the spiritual recovery movement. Continued affiliation can also take place from the aversive distress that emerges whenever a member's commitment wavers. If more problems of illness later beset the patient, difficulties can be rationalized and their explanation attributed to some aspect of the movement's philosophy. The spiritual recovery movement thereby serves as a buffer against distress, much the way religion can help people deal with adversity by providing a supernatural rationale for their misfortunes. A variety of psychological therapies relieve distress by systematically replacing a perspective of disillusionment with a newer, more hopeful outlook. Professionally applied cognitive therapy39 is designed to do this by reconstructing the patient's understanding of the circumstances that make him depressed, but without introducing a value-laden ideological system. A self-help group such as Rational Recovery40 for alcoholics may disavow a religious orientation even though it espouses a tightly held ideology. It does this by bringing together members in intense mutual involvement and teaching them to suppress thoughts related to craving for a drink. The group treatment repeatedly takes steps to transform a person's initial perspective of hopelessness, just as a spiritual recovery movement can repeatedly negate the pessimism and helplessness people feel because of their previous response to their disease. The spiritual recovery movement, however, adds the unique dimension of quasi-religious faith to sustain the sick person in her cognitive restructuring. The transformation in a person's perspective takes place by instilling belief in transcendence. Bernie Siegel,41 a physician and popular author, conveyed to patients with cancer that with the appropriate change in attitude, they could become an "Exceptional Patients," and influence the course of their disease. Psychological issues even apply to medicines themselves when a subliminal issue is associated with how it is presented. A medication's apparent property—even its color—has been shown to enhance a patient's conviction that it is effective. Elixirs that I was shown by a manufacturer of alternative medicines in Varanasi (Benares), India, all had the same black color. They addressed indications ranging from liver problems to kidney disease and even brain disease. The latter medicine, called

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"Brainomed," included a puzzling array of herbs, with names such as shankhipushpi and mandukparni. It was touted to help with problems ranging from psychosis to dementia, but mainstream drug companies can also convey a message based on choice of name: X and Z seem to bespeak effectiveness and new technology in antidepressants; which include Prozac, Paxil, Effexor, Celexa, Lexapro, Luvox, Zoloft.

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12

Alcoholics Anonymous

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he redemptive potential of Alcoholics Anonymous can be underestimated, even by people acquainted with it in film and novels. At Bellevue Hospital I interviewed Michael, one of the many patients presented to me by our psychiatry residents and fellows. Michael had been living on disability payments for many years because of severe obsessivecompulsive symptoms and the depression that had emerged following the death of his mother several years before. Now only heavy drinking provided him with respite from his obsessive thoughts by drowning them out, but after the alcohol wore off he would succumb to hopelessness. The current admission took place when he had run out of alcohol and money, and his demons were plaguing him. He called emergency 911 and asked to be brought to the hospital when he realized he was preparing to throw himself in front of a car in onrushing traffic to end his life. Michael had been in detoxification programs on many occasions, and a few years back he had succeeded in remaining sober with the aid of AA long enough to return to his previous work as a nurse's aide. However, he now found himself living in the streets or in homeless shelters, in relative isolation. "What was it like out there?" "I really had nothing, and there was no running away from my thoughts. I didn't want to keep on drinking, but there was no way out." 171

Later I asked him about AA, which he had encountered in one of his many hospital detox admissions. He said he would try to go to a meeting whenever he could, which meant maybe once a week. "Has AA been helpful to you?" "The meetings are the only thing that have kept me alive. I had a place. Maybe some hope. Otherwise I would have killed myself long ago." The paradox of one hand grasping onto the lifeline of AA and the other seemingly forced to take a drink is not uncommon among our patients. They often find themselves with nothing else to hold on to but their belief in AA's higher power and its fellowship of people with similar troubles. They may sit in the back of an AA meeting room in the Times Square area. Often they are intoxicated and speak to no one there. They had no other source of respite and no other place where they were made to feel that their lives might have some legitimacy. Even so, AA, of course, is not only for helpless loners. Harry was a successful businessman whose drinking had brought a relationship with a woman whom he cared for to an end. His experience illustrates the profound impact of the kindness engendered by AA's Twelfth Step, "to carry this message to [other] alcoholics" and help them to overcome their helplessness in the face of addiction. He had been sober for several years when he told me about the last time he had taken a drink. He had befriended another alcoholic man while they were both in a rehab center, but neither of them found the idea of accepting AA particularly appealing. Knowing Harry, this was hardly a surprise, as he had suffered a good deal of abuse from his alcoholic father in his youth, trusted very few people, and had recounted his many difficulties with teachers and even police over the course of his high school and college years. He had, in fact, ousted his father from the family business after he had managed to assume a controlling interest in it some years before. It was unsettling to hear how Harry was always ready to vindictively compromise a competitor in business while at the same time placing his trust in me; on one level he clearly wanted to find respite from the suspicions he lived with. Harry told me that he had managed to avoid drinking the week after discharge from rehab and was curious to see how his friend from that program was doing. He called the man's house and was told by his distraught wife that the friend had died of an overdose of pills 2 days before. Harry was shocked and dismayed and could think of nothing else 172

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but getting to a nearby bar, and he soon got drunk to the point that he could hardly recognize his surroundings. He wandered out into the street and by coincidence encountered a man walking with some friends whom he vaguely recognized as having been at an AA meeting he had attended. He said that things became unclear after that, but he remembered them taking him back to his apartment before he fell dead asleep. He remembered as well fearing that they might be planning to leave his house with any valuables they could find. Harry woke up the next morning to find that his room, which had been left in disarray, had been put in order by them. Even some dishes that had long been lying in the sink had been washed and replaced in the kitchen cabinet. Nothing was removed, as he had apparently been left at peace to face the next day. All this ran counter to Harry's view of the world around him. As he told me, "I didn't quite know how to put it into perspective. This wasn't what I expected from people. It left me quite touched." He never took a drink again after going to a few AA meetings, later ran into the man from that night's encounter at a meeting, and thanked him for a show of support that he could not recompense. The spiritually grounded altruism inherent in AA has achieved a profound impact on many who have been touched by it. It certainly has left many of those who encounter it attributing their survival to some turning point that was remarkably compelling for them.

Origins in Spiritual Experience

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ou sometimes see a car labeled with "A friend of Bill W." bumper sticker. It is more than a catch phrase alluding to Bill Wilson, AA's founder. For many members identification with Bill W.'s spirituality defines a moral code that originated in an intense religious experience recounted in the movement's book Alcoholics Anonymous Comes of Age.1 In it the charismatic founder of AA recounted a dramatic conversion he experienced after many unsuccessful episodes of detoxification, as one night his despair was transformed into transcendence: All at once I found myself crying out, "If there is a God, let Him show himself! I am ready to do anything, anything!" Alcoholics Anonymous

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Suddenly the room lit up with a great white light. I was caught up on an ecstasy which there are no words to describe. It seemed to me in my mind's eye, that I was on a mountain and that a wind not of air but of spirit was blowing. And then it burst upon me that I was a free man. Slowly the ecstasy subsided. I lay there on the bed, but now for a time I was in another world, a new world of consciousness . . . and I thought to myself, "So this is the God of the preachers!" A great peace stole over me. Bill lent structure to his transformation in drawing on the model of the Oxford Movement, a zealous, quasi-religious group that had gained considerable popularity by 1935, the year of his redemptive episode. It was characterized by the open confessions of its recruits of their moral failings, coupled with guidance from established members. Bill modeled ten of AA's Twelve Steps after its creed and added two more explicitly associated with alcohol. After initial difficulties in securing a circle of adherents, Bill's fellowship was highlighted in the popular media at a time when alcoholic people had few, if any, options for help with their compulsion to drink. Some committed physicians were providing a brief period of detoxification, and some settings were offering a period of retreat. However, alcoholics had no handle to latch on to to redeem themselves once they had been kept sequestered from the object of their compulsion. Bill's initial revelation has now engendered a grand and remarkably successful movement. A recent AA publication points out that an alcoholic person can now turn to more than 100,000 of its local groups worldwide and join an estimated 2.2 million members. These days, 60% of its members have received some type of treatment or counseling before joining, and 75% report that their doctors know that they are in AA.2 AA illustrates the complicated differences between an organized spiritual recovery movement and religion as it is encountered in the public arena, and this issue has been played out in the courts. For example, AA's Third Step, in which members avow that they have "Made a decision to turn our will and our lives over to the care of God as we understood Him," has led some courts to prohibit treatment programs from requiring AA membership of their patients because of a person's right

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to the free exercise of religion. One judge even cited the separation of church and state in ordering the release of a man serving a murder sentence because the conviction had been based on an admission made in an AA meeting, likening it to confession in the Catholic Church.3 On the other hand, AA illustrates the difference between religion and spirituality, and this is important in understanding the distinction between most spiritual recovery movements and an established religion. John Chappel is a psychiatrist in the addiction field and one of the nonalcoholic members who was asked to serve on the AA board of trustees. He has emphasized that this distinction lies in the fact that "there is no dogma, theology, or creed to be learned" in AA.4 Additionally, membership in AA is characterized by a nondenominational journey toward relief from the pain of alcoholism, a journey characterized by the Serenity Prayer, in which members distinguish between things they can change and accept with equanimity things that they cannot (a dictum originally derived from the religious preaching of the minister and philosopher Reinhold Niebuhr).5 For our purposes, it is worth contemplating how this state of mind parallels what adherents to Eastern religions may achieve through the practice of meditation. Both approaches are premised on the importance of an escape from worldly pressures through achieving spiritual transcendence. For the psychiatric community this might be perceived as undercutting subclinical anxiety or depression. AA members see themselves as belonging to a "fellowship," thereby relieving them of the idea of having to join a formal religious denomination. In years preceding AA, religion was the only consistent medium available to support an alcoholic's abstinence, and much of its success derives from well-conceived aspects of its operating procedure. On a cognitive level members are explicitly led to avoid "persons, places and things" that would trigger a desire to drink—a dictum that has been clearly put into practice by cognitive-behavioral therapists in their development of an approach to recovery couched in a structured set of treatment encounters. Social support is carefully structured in AA, as illustrated by the expectations that members will find a sponsor with established sobriety to lead them through the adoption of the Twelve Steps as well as attend meetings with a variety of well-established procedures.

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These meetings are spiritual in nature but may be likened to religious services because of their ritualized structure. They range from those assembled listening to a speaker "qualify"—or recount the experiences of his or her personal struggle with addiction—to a "round robin," in which members speak of experiences that help to relate each person's travails to those of the others present. AA's success as a coherent organization, with more members than any corporate body's worldwide roster, is no coincidence. It reflects a remarkable example of one way in which a spiritual recovery movement can move from charismatic inspiration to a social entity of effective and coherent structure. Bill W. was an astute social engineer. In addition to conveying the concept of spiritual recovery, he worked hard with fellow members to set the movement on a sound organizational footing. He no doubt drew on his acquaintance with the corporate world, having worked as a consultant in the field of financial securities. AA operates under a board of trustees, of which fourteen are AA members and seven are nonalcoholic people who understand the movement and can provide a perspective from outside its ranks. Its General Service Board in the United States consists of delegates from areas throughout the country and the staff of its central office, headquartered in New York. Bill W.'s foresight in moving to include nonmembers of AA in the General Services Board is illustrated by his having invited onto it Vincent Dole, the physician who developed methadone as a physiologically grounded treatment for heroin addiction. Although Bill saw the fellowship's spiritual orientation as required to address the needs of the alcoholic, he hoped that medications might some day be developed to address the relief from craving that Dole had produced for heroin. Along with fellow members, Bill also established the Twelve Traditions, which have served the movement well in terms of maintaining its organizational integrity. Although the traditions allow for autonomy of the respective AA groups, they require a singular focus on recovery from alcohol addiction, to the exclusion of any political or social agendas. Of particular importance is the maintenance of anonymity in relation to membership, a tradition that has been highly valuable in avoiding members' use of the group for invidious gossip or personal aggrandizement.

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The Subjective Experience

What is it like to be in a spiritual recovery movement such as AA? I went to my first AA meeting when I was beginning to teach about addictions and chose a meeting at the Church of the Heavenly Rest on Manhattan's Fifth Avenue, in an upper-class neighborhood. It was an open meeting, that is, one that nonalcoholic people could attend along with those who may have been long-term AA members. As the meeting progressed, I began to feel a certain euphoria, a sense of envelopment in the supportive atmosphere that is typical of the movement and, for that matter, most spiritual recovery movements. It reminded me of the mood evoked in a day-long marathon therapy session I had held for patients of mine a few years before, an oceanic feeling in which there was less of the sense of individuality and separateness that we usually carry with us in everyday life. Whereas one experiences clear and reasonable boundaries between oneself and others at work or in casual conversation (or, for that matter, while conducting psychotherapy), some of that separateness can dissolve in a setting like this. It became clear that the very ambience of an AA meeting could be quite influential and transformative. I began to send groups of medical students to AA meetings, as it seemed important for them to gain a sense of what participation might be like and so they could refer alcoholic patients to the program to stop drinking. It became apparent that the students' responded in one of three ways. Some found that the visit elicited in them feelings much like my own, and others found the visit interesting but maintained a distance from personal engagement, and a third group found it off-putting, even offensive. Is there some inherent characteristic within people that leads to a distinction between one or another of these responses? That is a subject for research to disentangle, and it may be hard to undertake. Interestingly, however, Kenneth Kendler, a creative researcher who studies the interface between psychology and genetics, may have given us a clue. He found that identical twins raised apart were more likely than were fraternal ones to experience the same degree of social support in their environment and were more likely to maintain the same degree of religious commitment.6 Others have even found differences in brain metabolism

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between people who experience transcendence in their daily lives and those who do not.7 This may suggest a physiologic grounding of the spiritual response that merits further study. I find that if my patients become involved in AA, I can certainly take a less active stance from session to session in making sure that they are not drinking, but an initial experience of euphoria can be short-lived as well. One alcoholic patient came back from the AA meeting I sent him to saying: I can't tell you how remarkable it was. I sat quietly in back, almost hiding from anyone who would acknowledge my presence, but each speaker drew me in. There was a magnetism and passion in their tales, and I felt moved by them as people who had just then become important to me. It was personal in a way I never expected. However, his enthusiasm soon wore off, and he decided not to go to further meetings, saying that AA was not for him. He could not see it otherwise. Evaluating AA Participation

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ome time after my initial experience with AA I became involved in working with the American Society of Addiction Medicine and got to know Douglas Talbott, a physician dedicated to promoting recovery among impaired medical colleagues. Together we arranged for an evaluation of patients from his treatment program, one oriented toward the AA recovery format. I went to Atlanta, where he was running a workshop for physicians who had achieved sobriety in his program,8 and embarked on administering a structured self-report questionnaire that allowed for an examination of different aspects of the physicians' current status and past treatment. In the course of this, I went to one of the AA meetings that was conducted at the site. These doctors, drawn from all over heartland America, expressed religious feelings that were clearly more strongly felt than those typical of the AA members I had encountered in New York. The intensity of spiritual feeling apparent in this group was profound, and the recitation of the Lord's Prayer at the end of the meeting came across as deeply religious—however much AA may allow for a nonreligious orientation. One could easily see how such in-

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volvement could lead a participant to struggle against even the greatest temptations to return to a life of addiction. The large majority of the recovering physicians (83%) had used alcohol daily for at least i month continuously. Most (55%) had used narcotic analgesics with this frequency as well. They could prescribe narcotics in their patients' names but take them themselves. Their continued involvement in AA after leaving the program an average of 33 months before was measurably intense. They attended an average of 5.5 Twelve-Step meetings each week, dedicating about 2 hours to each, a remarkable commitment of time for these busy doctors. Although the majority (54%) were currently in some form of psychotherapy, they ranked AA as the most important factor leading to their recovery (4.4 on a scale of 5), with physician counseling, family therapy, and urinalyses for drugs of abuse rated significantly lower. Further evidence of their commitment to AA was evident in responses they gave on a scale that measured their level of belief in the Twelve Steps. The average score for the six items, each modeled after one of the steps, was 4.6 out of a possible 5; 99% responded 4 or 5 in agreeing that "The alcoholic is powerless over alcohol." Furthermore, to measure their cohesiveness toward other AA members, they were given another set of items that applied both to the ten Twelve-Step members they knew best and the ten nonmembers they knew best. They scored their commitment to the members they knew best significantly higher, even though the nonmember group no doubt included friends and close associates. Almost half (43%) had served as AA sponsors by now, and many (38%) were currently involved in clinical work in addiction programs. All in all, it was apparent that these recovering addicted people had become deeply committed to AA and felt it to be the most influential aspect in their recovery from addiction. So much for these doctors who went through intensive treatment. How about addicted people in the general population? One major methodological problem in studying AA is that this fellowship, deeply concerned with the welfare of its members, understandably does not allow them to be randomized to one experimental treatment or another. One group affiliated with Stanford University, however, did conduct an 8-year study on people with drinking problems who had no previous treatment. After i year those who attended AA showed significant improvement, Alcoholics Anonymous

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and the number of AA visits made by year three was positively associated with improved status at year eight.9 Still, it is hard to know if the better outcomes reported were causally related to exposure to AA or if the more motivated alcoholics would turn to it while the unmotivated would likely not. The most elaborate study on exposure to the AA model was the project MATCH, funded by the National Institute on Alcohol Abuse and Alcoholism, and it sheds some light on this matter. Three treatment techniques were evaluated: (i) a cognitive-behavioral approach, (2) a technique for enhancing patients' motivation for dealing with their alcoholism, and (3) a procedure for encouraging patients to attend AA. AA facilitation did as well as the other two approaches, both of which had been developed out of psychological theory and extensively refined.10 This was for the short term. It is important to note that for the long term, AA would clearly provide a free resource to the patients who had been inducted into it. The federal government spent a great deal of money on Project MATCH (and, ironically, its principal aim of finding the best match of patients to treatment never panned out), but its results have been mined extensively by the research community. Some of its findings shed light on parallels between the psychology of induction into AA and engagement into the zealous cultic movement I had studied, the Moonies. For example, I found that the participants in Moonie workshops who were the most likely to join were the most distressed and had the least cohesive ties to friends and family.11 People who join zealous movements that espouse a new set of beliefs or an ideology are escaping unhappiness as much as being attracted by the creed itself. This was highlighted by the fact that most of the Moonie workshop participants initially responded positively when asked to evaluate their reaction to the movement's philosophy, but it was only the distressed ones who were likely to join in the end. Indeed, this was found to be true of alcoholics who are likely to join AA as well.12 Entry into AA involves a considerable commitment and in many ways a leap of faith. This is unlikely to take place unless a person is experiencing considerable despair. Bottoming out is a term that AA members often affix to the state in which alcoholics, hopeless over their circumstances, will turn to a movement that entails an acknowledg180

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ment that they have been denying the consequences of their drinking. The subsequent emotional uplift, like that that Bill W. reported, has been recounted many times over by members worldwide and has assumed mythic proportions for AA members. Today it is coupled with acceptance and caring for anyone who is a prospect for AA's only criterion for membership, "the desire to stop drinking." (The Moonies also offered potential recruits something close to unconditional love.)

Encounters with Members

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ne woman described her state of mind after a drinking bout that had left her frightened and embarrassed over her previous night's drunken behavior. She asked a friend of hers if he thought that she was an alcoholic and recounted what she then said to herself: "I think I'm going to an AA meeting tonight because they're the right people to tell me. And you know what, if they're not, then I'm going off the roof when I get home tonight." My biggest fear was what if I'm not. What if I was totally crazy. What if I walked in there and they said no, you're not an alcoholic, you're just nuts. It was my last hope, because I knew I could not go on living the way I was. I was so full of self-hatred and fear. I didn't know what this monster was that was living inside me, and I really thought I was insane. At the AA meeting that night, I had a little Styrofoam cup and I remember tearing it to shreds, little itty bitty pieces and shaking, shaking, shaking, partly from withdrawal. I remember people saying, "Just come back, you're in the right place."

They gave her something to grasp on to in the hope of salvaging herself, and it was the acceptance by people at that meeting that allowed her to continue to come. Her identification with the group's spirituality came later. She was now sober 20 years later. Professional referral is increasingly common as the initial contact with AA, an example of how a spiritual recovery movement with a valid approach can become accepted in the mainstream medical community. The implicit sanction of AA meetings by hospitals legitimates acceptance for many patients who would otherwise be wary of a quasi-religious afAlcoholics Anonymous

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filiation. One man experienced such a hospital-based legitimation and a consequent spiritual awakening. Ron had originally come to see me because of his concern over his son's severe cocaine dependence. We both spoke with the son, who was reluctant to lend any credence to what we were offering. I was puzzled. The son's despair—he was in debt, increasingly isolated, and about to be fired from his job—was the basis for many patients' accepting help in such an encounter. I called Ron 2 years later to follow-up on the mystery. His son eventually did go to the rehab program that I had recommended. It was only when we spoke this second time, however, that Ron acknowledged his own heavy drinking to me, as much as a pint of vodka every night. This had clearly left our discussion with his son with an implicit lack of credibility. Ron then told me how he himself found his way to AA and how it opened a door to spiritual renewal: It was my son's first week at the rehab and I was at a family meeting, a very emotional meeting. They asked everyone to say something and all I could say was "I should be in AA, too," and a few days later I went to my first meeting. "And how did you get involved in AA's spirituality?" I wasn't a religious man, and when I first entered the program, for the first few months I couldn't make sense of a Higher Power, so for me the Higher Power was the group. I wasn't sure how to relate to the program and my concept of God was lost long ago from my Jewish background. But then I began reading a page or two of AA's daily reflections and then a page or two from the book a rabbi wrote about AA. It took me a year and a half until I began to understand the concept of a Higher Power. And then the God of my understanding became Hashem [Hebrew for the deity]. It now seemed clear that Ron's guilt over his impact on his son's prior refusal of treatment had driven him to confess his alcoholism at the hospital's family meeting. He knew implicitly that he had been living a lie, one that might have cost his son greatly. He had become the sinner, much like one who could not help but stand up at a religious revival meeting begging forgiveness of the Lord. 182

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Because AA has become the mainstay of rehabilitation programs nationwide, it has served as an effective medium and messenger for explicitly introducing the need for alcoholics to maintain full abstinence. A psychiatrist cannot convey this absolute concept as effectively as can a spiritual program with validation by peers. One patient who had been drinking heavily for more than a decade came to me after discharge from his hospital rehab program. The occasional alcohol withdrawal seizures that he experienced had never convinced him that a drink or two would not lead to more, and the amount of denial implicit in this was underlined by the fact that he knew full well that he could aspirate, choke, and die during one of his seizures. The AA meetings at his rehab, however, introduced with full credibility the importance of absolute abstinence. His subsequent treatment in my hands thereby benefited from this acceptance of the idea of abstinence, without my having to convince him of its value, as he undertook his long and hard journey. We were therefore able to deal from the outset with aspects of his life that needed to be reconsidered as part of his recovery.

Different Attitudes Among Members

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eople vary considerably in how they react to a spiritual recovery movement, as such groups have neither the structure dictated by hard science nor the dogma associated with orthodox religion. Thus, if a movement promotes a healthful set of behaviors, it can be adopted by an adherent on pragmatic grounds alone. One patient used AA to bolster his self-esteem on emerging from his addiction. He never "worked the Steps," that is to say, never labored over each of the Twelve Steps in a searching manner under the guidance of a sponsor. He did, however, maintain a congenial relationship with his sponsor and went on to chair a number of AA meetings in local hospitals; he apparently enjoyed the leadership role. When I had him come to sessions with his family, he would keep them updated on his recovery, as if chairing our meetings as well. The spiritual context of AA never came up. Other patients also approached the fellowship on pragmatic grounds. I asked another patient, Linda, how she related to the spiritual aspect of membership, and she said quite explicitly that it did not make much sense to her personAlcoholics Anonymous

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ally. She was quite content to use the meetings simply as a means of reminding her of the dangers of having a drink. Linda illustrated as well how personal inhibitions, or character pathology, tend to color a person's encounter with such a movement. She was initially ambivalent about attending the meetings, given her early experiences at the hands of her deranged mother, whose explosive temper was often directed at her. At AA meetings she tended to succumb to criticisms that some members would direct her way, even implying that she was not a "good enough" AA member. Her passivity, unfortunately, complemented some members' need for control, even their sadistic impulses. In response to them she would shy away from a given AA group rather than dealing with a potential confrontation. Another patient, Jason, construed the fellowship as an austere and demanding setting. This was apparent in his understanding of the Fourth Step, which points out that "We made a searching and moral inventory of ourselves." For most members this entails reflection on people whom they have wronged in the course of their drinking. For Jason, though, "This means that you write down the dirtiest, filthiest, nastiest thing you've ever done in your life. Or had done to you. That seems to open a floodgate," hardly a comforting or supportive stance. Jason also associated AA's spirituality with relinquishing one's autonomy, the kind of attitude that keeps many away from the movement. Here is what he tells his sponsees: So what you do is you turn your life and your will over to the care of this Higher Power, and whatever happens, from the moment you wake up in the morning until you go to the wrong exit, get off on the wrong floor, if a person is not on the other end of the telephone, that's God's plan for you. In turning your will over to God, that's really the concept of powerlessness.

In Relation to Professionals

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he term evidence-based medicine has gained currency among academic physicians and hence the psychiatrists among them. It reflects a desire to codify and apply only those medications and procedures that

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have been validated by carefully controlled research techniques. Presumably, the profession will consequently become more like a science (or maybe an engineering job). This also will presumably enhance the competencies of the practitioner, who will then be known to act on techniques with scientific validation. Many in the general population, however, may not be impressed by the words of an engineer. Spiritual recovery movements, on the other hand, are largely validated through personal ties with their leaders and fellow members. They are much more susceptible to the vagaries of these people's—AA sponsors, for example—natures. There is a downside to this relative to the evidence-based approach. On the other hand, it does allow the movement latitude to infuse its practice with charisma and potentially elicit greater compliance. Whatever one thinks of AA, it does provide indisputable benefit for many alcoholics who become involved. Economic pressures limit the amount and duration of contact that a person can maintain with a professional therapist, and circumstances will often lead to loss of contact over time. AA, on the other hand, can be a constant in an alcoholic's life in terms of availability and support. One can always turn to any of the hundreds of meetings available in any populated center across the country in time of need. One of my patients called me after a hiatus of several years from across the country, where she now lived. In our original therapy she had achieved long-standing abstinence over the course of 2 years of AA attendance. She described how she was able to return to a number of AA meetings during a period of distress and uncertainty following the breakup of a lengthy relationship with her boyfriend. Doing so had bolstered her abstinence; it represented an insurance policy that had been invaluable in a time of need, one that she called on 3,000 miles from her original AA home group. Psychiatric research is typically conducted on the basis of epidemiologic investigation, biological studies in the laboratory, or controlled clinical trials. A spiritual recovery movement such as AA, however, cannot be effectively evaluated by any such means. Because of this, biomedical models often suffer from incompatibility with a spiritually oriented approach such as AA. This was made dramatically clear to me in my work as program chairman for the medical-scientific conference of Alcoholics Anonymous

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the American Society of Addiction Medicine. The papers and workshops we screened and scored for presentation were evaluated on the basis of the scientific methodology they drew on (evidence-based medicine). At one point, directors of some of the most prominent rehab centers in the country threatened to quit the organization because workshops that they hoped to present never passed muster on scoring because their proposals drew primarily on subjective aspects of recovery. Although each of our meetings had a time apart from the scientific sessions for AA meetings, these directors, typically in recovery themselves, felt excluded because it appeared that their efforts were restricted to those settings alone. We had to set up separate meetings where their work could be presented. The program committee was not about to leave our research-oriented members irate over what they saw as detracting from the validity of the organization. However, physicians do underestimate the degree to which addicted patients may respond to a spiritual orientation, and this begins early in their education. Medical students nowadays devote a large part of their preclinical training to biomedical issues, with an emphasis on arcana such as the laboratory science of molecular biology. Despite noble attempts to introduce the importance of the doctor-patient relationship in training, "better living through chemistry" may predominate during the clinical years as well. Students labor to absorb the technology associated with the ever-expanding list of drugs they must contend with. Over the course of their clinical years, they may encounter any of the medications that appear in the small print of the 3,538-page Physicians' Desk Reference.13 This leaves little time to contemplate the spiritual.

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PART V

Therapy of a Different Kind

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any innovations have emerged within the practice of psychotherapy over the last half century, illustrating the flexibility of the therapeutic encounter in incorporating new approaches to treatment. In the 19405 and 19505 psychoanalysts displaced organically oriented, hospital-based psychiatry at the helm of the APA. In the 19608 psychiatrists demonstrated how a community's social resources can be organized to address mental illness among its residents. Cognitive approaches, interpersonal therapy, and group therapy had become widely accepted as the century came to an end. But what about a psychotherapy that draws on people's innate spiritual resources? Such an option now lingers outside the mainstream of the mental health field and is not yet actively considered. This section of the book is intended to introduce some ways that the human spirit can serve as an instrument for recovery from psychologically grounded disorders. The approaches discussed here, quite different in nature, illustrate that people have within them the ability to accomplish more in such ways than is usually realized. In the psychiatric hospital management of patients with major mental illness can be augmented by approaches analogous to those used in AA. In the therapist's office we can learn from a diverse set of examples. We can see how one doctor of rehabilitation medicine facilitates the relief of physical pain in his patients by giving them an ex-

planation for it that he himself believes. Mindful meditation has been shown to relieve the burdens of anxiety and depression by drawing on people's ability to take distance in their minds from distressing feelings and by employing innate resources long associated with spiritual experience. Many people who harbor capabilities compromised by emotional disorders can be helped to reap greater joy and comfort by drawing on values that are truly meaningful to them. This section of the book therefore gives some indication of how psychotherapy can gain effectiveness from the many resources available within people, ones that often go untapped.

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13 Rethinking Care of the Mentally 111

The Problem

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he nature-nurture dichotomy has long been played out in opposing views on the roots of mental illness and has also framed how psychiatric treatment is provided. It was reflected in the nineteenth century in the origins of our contemporary view of psychosis, as experimental medicine was emerging as a science at that time led in France by the physiologist Claude Bernard. A psychiatrist colleague of his, Benedict Augustan, was influenced by the findings of physiologic research and saw mental illnesses as rooted in innate biology.1 He introduced the term dementia praecox, a syndrome we now call schizophrenia, which he presumed to be a progressive organic illness. Indeed, we now do find that there are differences between the brain structure and function of schizophrenics and normal people. On the other hand, environment has also been seen to play a prominent role in the course of schizophrenia. Hebephrenia, for example, is a term introduced in the late nineteenth century for a form of schizophrenia characterized by incoherency, giddiness, and markedly inappropriate and disorganized behavior. This term carried through to the psychiatric nomenclature as late as 1968,2 but with the advent of more intensive rehabilitation of the mentally ill, this regressed form of schizophrenia is seen less often nowadays. In actuality, the severe regression that charac189

terized it typically resulted from the isolation from normal social contact that such people were subjected to, either in attics at home or back wards of state hospitals. Sociologists have raised the issue of labeling of the mentally ill, which is thought to be responsible for many of the behaviors observed in these patients. Kai Erikson emphasized how many of the institutions that society has constructed to inhibit deviance actually operate to perpetuate it. Marginal people segregated in such settings are labeled mentally ill and learn from one another how their deviancy is to appear by observing one another's behaviors.3 They thereby acquire a career of deviancy, reinforcing their sense of alienation from the rest of society. Erving Goffman brought this issue home quite clearly. He spent a year as a participant-observer among patients at St. Elizabeth's Hospital in Washington, DC, and described the dehumanizing effects of life in the mental hospital, which he described as having in common traits with other "total institutions" such as penitentiaries and the army, which fully take over the lives and identities of their members. Goffman made a convincing argument that the identity of mental patients could be formed as much by life in an institution as by the innate illnesses they suffer.4 Interesting evidence of this emerged from a study conducted by David Rosenhan, a professor of psychology and law, who dispatched people who were quite sane to a variety of mental hospitals around the country to feign mental illness in order to gain admission.5 These pseudopatients were instructed to arrive at the respective admission offices complaining of hearing voices but otherwise to present their life histories as they actually had lived them. All were admitted immediately, but upon entry they stopped simulating any symptoms of mental illness and asked to be discharged. Despite repeated requests to leave the hospital, they were unable to get out until an average of nineteen days had passed, and each was given a diagnosis of schizophrenia on departure. The pseudo-patients spent much of their time taking notes on the experiences of their hospital stay, and their writing was presumed by the staff to be an aspect of their pathology. Their personal histories, which were actually unremarkable except for the "recent onset" of hallucinations, were reinterpreted by staff to validate the origins of their mental illness. Notes such as this framed the staffs understanding: "While 190

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he says he has several good friends, one senses considerable ambivalence in these relationships." In the hospital the pseudo-patients were treated in a cursory manner by the staff, who took little time to speak with them in any meaningful way. Encounters with the doctors frequently took a form that would be considered bizarre in usual social conduct. The pseudo-patient would say, "Pardon me, Dr. X, could you tell me when I am eligible for grounds privileges?" To this the physician, walking briskly by, would say, "Good morning, Dave, how are you today?" and move on without looking directly at Dave. Rosenhan, in fact, tabulated the many times in which encounters with the staff were characterized by their heads being averted, their eyes making little or no contact, and their not responding directly to the "patients'" queries. As Erving Goffman pointed out, entering such an institution means that a (real) mental patient will be denied the legitimacy of a personal identity. He considered the "deeply discrediting nature" of stigma under such circumstances. When internalized as a "spoiled identity," it created a feeling of being inferior and shamefully different. "Persons who have a particular stigma tend to have similar learning experiences regarding their plight, and similar changes in conception of self—a similar 'moral career."'6 In other circumstances, the converse could be true. A spiritually oriented group can offer a sense of personal meaning and hope for the future in the face of despair. We can therefore ask: Can a secular adaptation of this redemptive psychology be introduced into the psychiatric hospital? Can it negate the labeling that so gravely compromises people if they are subject to hospitalization in these institutions? If this is to happen, one keystone of the labeling must be addressed: the hopelessness implicit in a "career" of mental illness. Hopelessness is a hallmark in the life of most people suffering from mental illness, and the problem of suicide is one measure of how serious this is. According to the World Health Organization, suicide is the leading cause of violent death worldwide, greater by half than homicide and more than twice as common as war-related deaths.7 Nearly a third of all schizophrenics attempt suicide, and almost half of those who attempt it will succeed at some point.8 A similar portion of people with severe depression take their lives.9 Also for these mentally ill patients, alcoholism provides an addiRethinking Care of the Mentally 111

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tional serious risk, as this disease ends in suicide at a rate at least sixty times that of people without psychiatric illness,10 yet alcohol and drugs often provide the mentally ill their only escape from despair. For many years the combined problem of mental illness and substance abuse was not addressed by the psychiatric community, and there are reasons for this. For one thing, the denial associated with addiction had been common among patients and psychiatrists as well and regularly ignored in treatment. Alcohol and drugs are also more readily available on the street than in psychiatric wards, so that although the agitation and delusions of schizophrenics or severely depressed people are apparent after admission, their substance abuse problems do not reemerge until after they have left the hospital. This issue of such "dual diagnosis," however, was becoming unavoidable as an epidemic of cocaine use began to sweep across the United States in the 19805.1 first encountered it after giving a lecture at Manhattan's state psychiatric hospital. The state hospitals are less aggressively policed than are the acute psychiatric services where I had worked, so I was surprised, even shocked, to hear that crack cocaine vials and liquor bottles could be found littering the floors of that hospital. Powdered cocaine had initially been prescribed by German army physicians to reduce soldiers' fatigue in the late nineteenth century and had even been lauded by Freud for its euphoriant qualities, but its ability to produce addiction, only later appreciated, had led to its being outlawed in the United States as early as 1914. The chemically transformed crack form is much more rapid-acting than the powdered form, as it can be smoked and absorbed through the pulmonary mucosa. As crack emerged from illicit laboratories in minority neighborhoods in the 19805, emergency rooms soon became crowded with patients for whom it had tipped the balance toward a need for acute psychiatric treatment. Users could be driven to a paranoid psychotic state during intoxication or to suicidal depression after stopping a cocaine run. The drug therefore had the dubious ability to fulfill both criteria for hospital commitment: "dangerous to themselves or others." At Manhattan's Bellevue Hospital we studied the consequences of the cocaine onslaught and found that the dually diagnosed perceived that alcohol and heroin relieved their distress, but that cocaine made them feel worse. It was only the first moments of the cocaine rush that 192

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reinforced their addictive pursuit of the drug, as it gave momentary relief from their unhappy lives, effectively conditioning them into an addiction.11 We reviewed the charts of patients admitted to the general psychiatric units and found that no less than 64% of them had a substance abuse problem, and more than half of these (38%) had abused cocaine.12 When we polled directors of general hospital psychiatry units statewide, most reported that substance abuse was a major problem in their own facilities,13 considerably more than the state's official database suggested.14 Most schizophrenic patients are deeply disillusioned and can hardly face the reality of their mental illness and their inability to deal with the realities they confront. One patient about to be discharged illustrated how this hopelessness led him into denial of the very illness that had brought him to us: Now that you're ready to leave the hospital, can you tell me what brought you here? I was having trouble sleeping because I had a headache. But why did they bring you to the emergency room? They were helping me out. I needed a good night's rest. He had, in fact, been brought to our emergency service by the police after ranting at commuters taking their trains home from Grand Central Station. He had struggled with them, pleading that devils were trying to take over his body, and he was also clearly drunk: for the public, quite a nuisance; for us, a man whose illness we could only partly address. He could not bear to face the shame and stigma he had acquired while in the hospital, so he had to create a false reality to justify the admission. Other patients would explain that their hospitalizations were caused by a bad backache, or by neighbors who had been jealous of them, or by a mother who had felt they were not eating enough. They were clearly unable to deal with what they feared most: despair over a brain and mind that had created overwhelming anxiety and that became their own demonic enemy. As if psychosis and addictive drugs were not enough, we found that AIDS was becoming increasingly prevalent among these patients: 23% were infected with the HIV virus,15 and transmission took place primarily through promiscuous sexual activity. At low doses of crack, two Rethinking Care of the Mentally 111

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or three vials, men were aroused and could maintain an erection. (At higher doses they could not.) Women turned to prostitution to maintain their habits, and, not surprisingly, they reported disliking sex and feeling degraded.16 Diseased minds were leading these people to despoil their bodies.

Deinstitutionalization

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hy were these frightened, deranged, often intoxicated people now loitering on street corners with paper cups in hand, hoping to be favored with a quarter by a passerby? Why did they bed down at night in the open or in cardboard boxes when the weather turned cold? Should they not all be kept in some mental hospital (far away from public view)? To a degree, this was the unintended consequence of a good intention: to close down oppressive state hospitals and liberate their seemingly imprisoned patients. The removal of chains from the incarcerated mentally ill by French psychiatrist Philippe Pinel has come to be understood as the beginning of the "moral treatment." This was reflected in the subsequent emergence of the York Retreat in England under William Tuke, and in the United States in the Bloomingdale Asylum in New York and the Hartford Retreat in Connecticut. The movement was premised on the assumption that interactions between benign authority figures involved in the management of an asylum and their patients treated as rational adults could result in the amelioration of mental illness. By the early twentieth century this approach had evolved into the concept of "mental hygiene," championed by Adolf Meyer, a psychiatrist at Johns Hopkins University. He emphasized the role of a humane medical system of care for the mentally ill, whereby acute treatment would be provided in hospitals followed by community-based aftercare. In this way a short-term inpatient stay would precede patients' reintegration into their respective neighborhoods. This concept evolved into a national community mental health movement in the United States, carrying with it the assumption that this model would minimize the problems of the mentally ill. It came to a head during the Johnson

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administration's "Great Society" and "War on Poverty." After all, didn't we expect good will to break down barriers between blacks and whites? Weren't we on the verge of bringing all the poor into the ranks of the middle class? It was an era when well-intentioned intervention was seen as a potential panacea for society's problems. Many mental health professionals got swept up into the wave of community psychiatry and assumed that the visionary and potent impact of good will could be infused into community-based clinics. Mary Ann Madden, in her critique of this euphoria,17 cites Daniel Blain, the medical director of the American Psychiatric Association, who in 1955 predicted its outcome: "The 750,000 patients now in this country's mental hospitals" will be returned to the community "cured." The movement to deinstitutionalize the mentally ill and move them into community-based outpatient care is often associated with the development of medications to treat their deluded states. In fact, it was already rooted in governmental and psychiatric thinking by the time these drugs were developed. The marketing of Thorazine, the first of these neuroleptic drugs, was initiated in the United States only in 1954, and its acceptance was not immediate. Its appeal was fueled by the expectation that spending would be minimized when the mentally ill were no longer housed at public expense. Deinstitutionalization was further promoted by certain civil libertarians who saw legally grounded commitment of the mentally ill as an abridgement of their legitimate rights. However, ensuing events did not quite bear out this optimism, as little of the money from the state hospitals was reinvested in outpatient care. From 1955 to 1975 admissions to state and county mental hospitals doubled (from 178,003 a year to 376,156), while the overall census in these facilities dropped to a third of its previous level (from 558,922 to 193,436).18 That is to say, hospital stays were cut back in length by a factor of six. Although antipsychotic and mood stabilizing medications helped a good deal, most patients did not leave as "happy campers." Nevertheless, many did leave as campers, as housing shortages for these poorly adapted, unemployable people left many living on the streets. Some were living—but many refused to live—in single-room occupancies or shelters that were infested with predatory alcoholic and drug-abusing people, often mentally ill themselves. More recently, some

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700,000 to 800,000 Americans are known to be homeless on a given night, with 150,000 of them single adults, hard-core, long-termers.19 So much for the problem.

A Sense of Community

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ne way to approach this sad circumstance is to create a treatment environment that shows that there is a meaningful path to recovery, for a secular spiritual renewal, as it were. A recent approach to the development of such environments was initiated by Maxwell Jones, a British psychiatrist.20 He developed the concept of a "therapeutic community" (TC) as a means of using the social milieu of a hospital unit to rehabilitate the mentally ill. The idea behind it was that all the unit's participants, staff and patients together, could serve as a well-coordinated medium for promoting a hopeful outlook and improved adaptation for the patients. Jones opened his innovative program to address the psychological disabilities experienced by British prisoners of war after World War II. His concept stood in contrast to the approach of most mental hospitals at the time; theirs effectively came down to eliminating the noxious presence of the mentally ill among the general public by warehousing them, with relatively little attention paid to their needs for ultimate reintegration into the general community. Jones's idea was to let these people see themselves as constructive members of society by teaching them about their condition, establishing open communication between them and staff, and allowing them to govern their own activities on the psychiatric ward. Traditional roles were rethought so that the distinction between the medical staff and patients was diminished; staff wore street clothes, and patients could address them on a first-name basis. All of the interactions on the ward were oriented to have a therapeutic impact, with consequent social pressure moving patients toward a more positive outlook on relief of their shell-shocked state. A wider use of this approach in other hospitals was hard to achieve, though, as there was a natural tension between the medicalized structure of the psychiatric hospital and Jones's concept of openness between patients and staff. The approach did emerge more prominently, how196

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ever, in the drug-free therapeutic communities such as Phoenix House and Daytop Village designed to rehabilitate addicted people who suffered primarily from drug habits rather than from mental illness. A distinct ideology was therefore developed to underlie treatment in the TC culture: addiction is believed to be unavoidably entwined with a maladaptive personality structure, and salvation is achieved only through its reconstruction. This justifies one of the better-known characteristics of these TCs: they can intrude on residents' (as their clients are called) behaviors in a sufficiently aggressive way when bad character shows its face. Thus, a resident is expected to "drop a dime"—or tell—on another who has been seen to violate expected behaviors, such as avoiding an assigned chore. Such misbehaviors are then confronted within the group. In the old days punishment might mean a literal "haircut" as a sign of the violator's malfeasance. Nowadays the term means only a verbal confrontation and potentially a job reassignment. The need for undertaking such corrections of the maladaptive behavior patterns of mentally ill addicted patients was supported by one study we did. We looked at the impact of personality disorders that complicated these patients' recovery in the hospital. Unlike psychotic symptoms and symptoms of major depression, which are ameliorated at least by targeted medications, the personality disorders, we systematically evaluated were significant factors in yielding a poorer outcome of treatment. According to the psychiatric nomenclature, such disorders are characterized by "behavior that deviates markedly from the expectations of the individual's culture," leading to "impairment in important areas of functioning."21 The dually diagnosed patients who had additionally diagnosed personality disorders (53% of all our admissions) had less years of history of employment and more previous psychiatric admissions. In the end, they were less likely to follow-up on the aftercare plans that were designed to avert relapse.22 On reflection, it became clear how the people, in interaction with the general society and with the institutions, both social and medical, they had lived in had acquired their maladaptive character structures. Our hospital stays, benign as their intentions might be, were not making material changes in this process. One question became relevant in considering an appropriate treatment format: Why did the residents in the original drug-free TC tolerate demands to conform to the behaviors required of them? After all, Rethinking Care of the Mentally 111

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they could have left the confines of the TC residence if they chose to. When these programs were first developed, most of their residents were under no legal injunction to remain within the program. The fact was that the TC environment was highly cohesive and implicitly very supportive. There was a strong sense of commonality, with an almost spiritual ideology of good versus evil (redemption from addiction versus the drug-addicted life). This Manichean divide paralleled that seen in religious cults: us inside, bonded together, against them, the outsiders, in sacred battle. Additionally, there is a path toward transcendence that TC residents could follow. They could identify with their peers who had adopted constructive behaviors and move up a structured hierarchy into responsible roles and leadership in the community's structure. By behaving appropriately they could acquire validation of a newly redeemed state. All this makes for a quite effective social entity, one that has transformed many street addicts into responsible citizens, and we chose to adopt its inherent ideological system for the dually diagnosed patients at Bellevue. It could not, however, allow for housing patients in typical TCs, as the agressivity of the TCs toward their residents, even if only verbal, could not be handled by the troubled mentally ill, as they might sink into paranoia, depression, or acute psychosis when put to the test of such a program. A case in point: A 21-year-old man was transferred to our Bellevue unit from a drug-free TC after trying to hang himself early in his stay there. Our evaluation revealed that in addition to his drug use since age fourteen, he had been hospitalized once for a suicide attempt made during an acute depressive episode, but upon admission to the TC he was not apparently depressed. That program's ideology was suited to an aggressive approach to addiction, but it effectively blinded the TC's staff to the man's psychiatric vulnerability when he became increasingly depressed under intrusive pressure to meet the program's demands. We had to treat him on our unit for the depression that had been aggravated by the traditional TC culture. In order to merge the TC and general psychiatric format, we collaborated with George De Leon to modify the TC format so that it would be suitable to our patients, fragile as they might be. De Leon, director of a national center for TC research and an inspirational clinician as well, 198

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had extensive experience in tailoring the TC model to specific patient populations.23 Treatment of the dually diagnosed would thereby be built around instilling hope in a TC based on an ideological orientation, but ultimately framed by professionals' understanding of general psychiatric disorders, such as like the vulnerability to major depression that the transferred patient just mentioned had experienced. The idea was to take advantage of the social psychology inherent in cultic movements, transformed into an acceptable model like AA, but adapted to the needs of disordered psychiatric patients, including the progressive use of psychotropic medications.

The Issue of Belief

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ow can a psychiatrist return delusional patients to a normal state of mind? The false beliefs of the deluded cannot be shaken through confrontation, any more than one can change the mind of a person who believes in the sanctity of his or her religion. This quandary was illustrated in the classic case of three state hospital patients, each of whom believed that he was the embodiment of Jesus Christ. Even when their psychiatrist placed them all together, he could not shake their respective delusions about their fantasized identities.24 On the other hand, there is a growing body of research showing that a slow and systematic introduction of rationality into the thinking of schizophrenic people can help them give up the delusions they had come to accept.25 This cognitive approach has long-standing parallels in the treatment of depressed people, who can be taught to reframe their self-defeating views and thereby be relieved of their bleak outlooks on their lives.26 Such transformations make clear that the self-defeating thinking of a mentally ill patient is amenable to change if properly addressed, just as the alcoholic's denial of her addiction can be undermined and then extinguished under the right therapeutic circumstances. Reshaping of thought can also be successfully achieved in a supportive group situation, and the impact of AA on alcoholic denial has made this clear many times over. Experiences that I witnessed in zealous religious sects, let alone the many religious conversions that have taken place at revival meetings over the years, show that new beliefs can be inRethinking Care of the Mentally 111

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troduced into people's worldviews in the right group setting. Given these observations, we can consider how a program to instill the concept of personal renewal can be introduced into the thinking of the addicted mentally ill. Some years back, Jerome Frank, a master clinician and researcher, wrote about the commonalities among a variety of redemptive experiences.27 He pointed out that one ingredient that group therapy, AA, and religious revivalism all have in common is the instillation of hope. It is, he pointed out, the basis of any effective therapy. Hope combats demoralization and engages people in a journey that can lead them toward a better life. With this perspective in mind, we considered whether an innovative approach to our patients at Bellevue, drawn on an unusual model for dealing with psychosis, might be relevant. It had been developed during the counterculture period of the 19605, at a time when drug-induced hallucinations and altered consciousness were seen by some psychiatrists in a positive light as life-transforming experiences. One of them, R. D. Laing, espoused a philosophy (a belief, in fact) that his schizophrenic patients, in withdrawing into their own deluded views, were responding in a reasonable, rather than pathologic, way to the disturbed families and—as he saw it—pernicious society in which they lived.28 He applied this belief in Kingsley Hall, a group home in London where staff imbued with his philosophy promoted his redemptive view of the experience of mental illness, one that put a positive cast on what was usually seen only as pathological. Laing instituted a sense of community and a commitment to his philosophical ideal in Kingsley Hall. The staff conveyed to the residents that the altered consciousness they experienced could be seen as a breakthrough, divesting them of the constraints of oppressive social structures, and thereby offering the opportunity for personal renewal. He did not dismiss the fact that the residents might have a genetic predisposition to their disorders but saw this as reflecting only a variant of a genetically grounded adaptation. His program was successful in engaging his patients to adapt to a milieu held together by his own charisma. Eventually, though, he declared himself "worn out and burned out" and moved out of the group's communal setting along with a number of the

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other doctors. Kingsley Hall then fell into decline and came to an end as its patients drifted away. Clearly, this was one of the many countercultural phenomena that carried with it a measure of validity but that was expressed in a manner that could not sustain itself. An important inference one might draw from it, however, is that when once a group of people are labeled deviant or impaired, they themselves and those around them may begin to expect less from them. Their ability to move forward in a positive direction becomes compromised unless a positive perspective is introduced. Laing's approach was adopted in the United States by Loren Mosher at the National Institute of Mental Health, who subjected it to a controlled study in Soteria House, a residence in San Jose, California. He instituted a number of changes in Laing's model, though, and important among them was a better-structured environment and admission of only first-break, acute psychotic patients. We now know that many of these patients can have a relatively good prognosis if given proper supportive treatment after their acute episodes, but they are nonetheless subject to persistent disillusionment and poor adaptation if not given appropriate help to take advantage of their innate skills after their acute psychosis remits. The Soteria program avoided the use of antipsychotic drugs except in the case of a few highly aggressive patients, and then only on a limited basis. The staff maintained a positive outlook that paralleled Laing's and conveyed it in an intensive, round-the-clock manner that Mosher explained in the following way: Few clinicians would disagree with a description of the evolution of psychosis as a process of fragmentation and disintegration. But at Soteria House, the disruptive psychotic experience is also believed [italics mine] to have potential for reintegration and reconstitution resulting in a more stable sense of self, if it is not prematurely aborted or forced into some psychologically straitjacketing • 9Q compromise. The staff was therefore intent not to invalidate the psychotic experience but to regard it instead as a transformative life event; they saw it as an opportunity to initiate personal growth.

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Mosher compared the outcome of his patients to some who were treated on a conventional ward and at follow-up clinic where antipsychotic drugs were given routinely. He found that after discharge the Soteria patients needed less outpatient care, achieved a better occupational level, and were more able to live independently than were those given conventional treatment. His study supported the idea that the institution of belief in a meaningful and positive identity could promote the ability of the mentally ill to achieve a more positive recovery from their disorders. So why has mainstream psychiatry not adopted an approach that embodies respect for the experience of the mentally ill, so that hope can be instilled over time? For one thing, many chronic schizophrenics do not remit from their downward decline and are not able to undertake such a course toward recovery. For others of the mentally ill, however, this option can be considered, but setting up such a milieu entails a degree of commitment and clinical talent that exceeds what is expected of staff in most psychiatric facilities. Additionally, accrediting bodies and unions do not readily allow for hospital-based programs that let patients take an active role in running their own services, and it is hard nowadays to provide residential care in a way that will cost less than that of typical hospital bed rates. If one wants to be accredited, one has to commit to what is the current model of treatment and its elaborate cost and control structure. This leaves the Soteria option beyond what insurers or the state will accept. In addition, there is relatively little interest in undertaking such a venture, given the reliance of psychiatrists almost exclusively on drugs that target psychosis and severe mood disorders and given the practice of labeling patients' identities that Goffman's and Rokeach's studies of mental hospitals described. Indeed, the hegemony of psychopharmacology goes back to the early 19508, when Thorazine (chlorpromazine), the first of the neuroleptics, was introduced. Smith Kline & French invested large sums of money in promoting the drug and developed a national sales force to assure its acceptance.30 It is no surprise that such marketing is sustained to the present in a most aggressive manner, given the fact that the current generation of antipsychotic drugs (such as Risperdal, risperidone; and Zyprexa, olanzapine) now chalk up sales of $6.5 billion a year.31 These drugs do work, but they address only half the problem, the acute symp202

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toms, not the disillusionment of the mentally ill. In addition, the field of medicine, from which psychiatrists fear exclusion, is, not surprisingly, oriented toward the use of medicine rather than incantation. This leaves psychiatry inclined to turn to a pharmacologic approach rather than one premised on hope and belief.

Are the Patients Interested in Redemption?

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t would be easy to see our Bellevue patients as interested in survival and little more, and the numbers certainly reinforced this. When admitted to the hospital, 91% had relapsed after previous treatment, and 94% were neither married nor cohabiting; virtually all were indigent, and 46% were, in fact, homeless.32 In order to see what role a redemptive culture might actually play in these patients' hopes for recovery, I worked with two of my fellows to study the patients' and staff members' attitudes on this. We asked medical students on the unit to rate which issues they considered important to the patients' recovery, and the students ranked housing needs and government benefits highest; belief in God and inner peace ranked far below. The long-standing nursing staff rated the patients' commitment to any spiritual renewal just as low, even though they themselves rated high on a measure of their own spirituality. But when we gave these patients the same items to rate, belief in God and inner peace ranked highest, more important to them than various material issues such as housing and government benefits.33 Clearly, the very students and staff who had been working with these patients had a limited sense of what the patients—as people—saw as a way out from their seemingly hopeless condition. The promise of spiritual redemption was clearly an untapped motivation for these patients to achieve recovery. These findings were compelling for us and have also repeatedly been regarded as most intriguing at the conferences where they have been cited. They suggested that we in the psychiatric community are missing out on levers that can be pressed to engage many of the highly compromised people we hope to help. Implicit in these observations are also intimations of how to negate the shame and inferiority associated with the labeling of the identities of the mentally ill. Rethinking Care of the Mentally 111

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We next polled residents at Daytop Village, a drug-free therapeutic community, on this same issue. Nowadays they are not only hard-core addicts but usually are remanded by the courts for their treatment, under more external constraints to stay in treatment than were residents when TCs were originally developed. We knew that the TCs operated on the premise that addicts' problems devolved from maladaptive personality traits, but we wondered whether there might be more interest in spiritual issues among these TC residents than expected. As a matter of fact, the majority of them acknowledged they knew that "there is a power greater than I" (78%), practiced meditation or prayer (59%), and felt that spirituality should be featured more in their TC (74%).34 All this said, it seemed reasonable to frame a program for our hospitalized, mentally ill, substance-abusing patients that would employ the spiritual orientation implicit in AA along with a commitment to transforming their attitudes and personal identities to help them stay drug free and look toward a more positive future.

The Program Evolves

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ellevue Hospital began serving the poor and alienated of New York in 1736, when it occupied a room on the upper floor of the city's "Publick Workhouse" and was staffed by one physician who supplied his own medications. Cells for the pauper insane were first noted in its reports in 1825, and an alcoholic pavilion was built in i892.35 More recently, its large psychiatry building, with some 900 beds, was featured in the film The Lost Weekend, which won the Academy Award for best picture in 1945. It tells the tale of a hapless alcoholic whose delirium tremens was treated at Bellevue but whose recovery would come through AA. On coming to NYU's School of Medicine to teach at Bellevue, I offered to take on patients admitted to the psychiatry service for general psychiatric disorders plus substance abuse. The plus made these patients a double headache, and the hospital's psychiatrists were pleased to see someone else relieve them of tailoring a program for this difficult population. Over the next several years my colleagues and I developed a program for the dually diagnosed in which acute patients were admitted from the 204

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emergency service to our inpatient psychiatric ward, then were moved on to our "halfway house" residential unit when stabilized, and finally were treated in a day program and clinic when they could live on their own in the general community. The idea of a staged format for rehabilitating the mentally ill was not uncommon in some communities (applied at least in theory), but we premised our format on promoting cohesiveness among patients combined with a redemptive view of their experiences. This was translated into a practical format by having the patients themselves play an increasingly instrumental role in running the program, as in AA and the drug-free TCs, and acquire the spiritual orientation implicit in the Twelve-Step movement. Unlike the programs at Laing's Kingsley Hall and Mosher's Soteria House, we drew on the best that psychopharmacology had to offer. It was amply clear that contemporary medications were essential to the treatment of mental illness in this severely and chronically disturbed population. The idea that the mentally ill could assume a role in hospital-based treatment of their own peers had not been implemented to any appreciable extent in the psychiatric mainstream, but we had some advantages in translating this format into practice. There was the mantle of legitimacy that had been conferred by my heading New York State's Task Force on the Dually Diagnosed. This was augmented by a respectful and comfortable working relationship with the psychiatry department chair and with the head of psychiatry at Bellevue, who had previously served as the state's mental health commissioner and who knew full well that substance abuse had undermined his agency's efforts to treat the mentally ill. Then there was municipal politics, as Bellevue was a city hospital. Each step in developing and then maintaining the program necessitated lengthy negotiations with a multibillion-dollar bureaucracy of the city's Health and Hospitals Corporation that oversaw Bellevue, along with a league of its other diverse municipal agencies. Good working relationships were essential here, some dating back with psychiatrists whom I had taught years before when they were medical students or residents, but throughout, professional credibility and the aura of common sense and cooperativeness were essential for gaining acceptance. In any case, it was reassuring that we received significant research grant support from the federal government and private foundations and were given the Gold Rethinking Care of the Mentally 111

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Award of the American Psychiatric Association for innovative treatment, rather than being dismissed as irritants in a lumbering bureaucracy.36 The alienated and displaced people who had migrated to Midtown Manhattan and then found their way to Bellevue were indeed uniquely compromised. Many told stories like that of Louise, a 43-year-old woman who had been brought to our emergency room drunk and disheveled. Her mental illness had been aggravated when she stopped taking her medication for manic depressive illness. Over the course of her decline into a disordered state, she had found her way from a Mormon background in Utah to homelessness on the Manhattan streets. The staff at a shelter for the homeless had called the police when they found her behaving uncontrollably and quite drunk. Her complaint on arrival at Bellevue was typical of the paradoxical statements we had come to expect: "I didn't say I wanted to kill myself. I said I never wanted to be alive." She explained her behavior at the shelter: "The people there wanted to make an example out of me." She was depressed and tearful when she quieted down, was admitted to inpatient psychiatry, and then was discharged 2 weeks later after her mood-stabilizing medications were reinstituted. A month later she was readmitted under similar circumstances and was presented to me by a resident with the question, "What do you do, and what are your responsibilities, when a patient has no interest in getting better?" Louise initially explained to me that she was "a happy drunk" like other members in her family and saw no reason to cut back on her heavy drinking. As a rule, the psychiatry residents treat patients' "target symptoms" on the ward to patch them up and move them on as soon as possible. Discharge plans consist mainly of assuring that there is a place for them to sleep the night after discharge (although in actuality not always available) and a referral to a clinic (which many patients do not attend). Louise's situation looked pretty bleak, as explained, but on looking for a more positive side of her situation certain things began to emerge. I pressed her to think about what she would like for herself for the future, and, after pausing, she said that maybe she did have something she wanted. It turned out that she had kept in touch with her sister, nieces, and nephews in Utah and cared for them a great deal. She and they had somehow managed to maintain regular phone contact, and she hoped some day to return home and live closer to them. She had also had a pe206

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riod of sobriety for 4 years when she was in AA and said that she had "liked the atmosphere there," as it had allowed her to find some moments of peace. She said "I was a hard nut to crack but they got me involved." These latter points could serve as a start in getting her to think more positively about recovery, but somehow in the thick of things they were not pursued, as her symptoms were addressed only for the short term. She and I spoke further about how, with a period of residence in a rehab facility and reinvolvement in AA, she might indeed look forward to seeing her sister and the kids in some reasonable period of time. The resident and I discussed this and framed a plan to be implemented on her discharge from the hospital to help her achieve this goal. Louise, like many dually diagnosed patients, had within her some things that she really wanted, things that were meaningful to her and that were usually not addressed when acute symptoms were the focus of the staff. The important question of "Why might you want to get better; what is really important to you?" needed to be asked of each of these seemingly recalcitrant patients. They needed a chance to search within themselves to begin to think about what was meaningful to them, what could be redemptive. Here are some of the things that we built into our inpatient unit in order to capitalize on options for patients like Louise. We added educational groups that dealt with alcohol and drug problems, as well as those for mental illness, and we instituted Twelve-Step meetings each day. These might obviously seem relevant, but, in fact, they are typically absent from psychiatric units, even though a good half of patients in public facilities, and almost as many in private ones, suffer from substance abuse problems as well as mental illness. These efforts were designed to introduce an understanding that could serve as a basis for acquiring a belief that recovery from addiction was worthwhile and within these people's reach. In terms of the ward's social structure, we instituted the rudiments of peer support and leadership, even for relatively regressed patients. We developed a system whereby stabilized patients could monitor the newer patients' dressing themselves properly, making their beds, and attending the ward's group activities. All of this was orchestrated so that the senior inpatient peers could assign credits for the newer patients' proper behaviors, which would in turn yield additional privileges for those Rethinking Care of the Mentally 111

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newer patients. One psychiatrist whom I had brought in to run this unit was expert in developing this format for the mentally ill (by adapting the concept of a "token economy"37), and together we modified it toward a peer-support orientation and combined it with a substance abuse rehabilitation format. The system of operant rewards helped keep the ward running smoothly by introducing into the patient culture the idea that each member of the ward community had a stake in a cooperative venture, with options for self-improvement. The formats of both cultic movements and the drug-free TCs carry with them the opportunity for advancement toward a higher status as one complies with behaviors that reflect the required attitudes. In the cults one gets closer to God. In the drug-free therapeutic community one moves up a work hierarchy and see oneself as heading toward a secular redemption. Movement upward in both settings is validated by seeing people who have succeeded in achieving these goals. Patients who have moved up such a ladder are, however, typically absent from view in our psychiatric hospitals, as they leave the environment that has stigmatized them as quickly as they can. On the other hand, we decided to offer our newly admitted patients examples of a successful adaptation to our program in two ways. Over time, we were able to institute opportunities for patients from our own clinic to work as hospital volunteers and then to move on and get paying jobs in the hospital. These patients were well known around the psychiatry service and were held up as examples of the opportunities that might ultimately be available to new admissions on the wards; they might embark on such a course themselves. In addition, patients from the halfway house would come to the ward each week and describe what the next stage available after discharge would be like. That next stage unit offered patients extensive rehabilitation during a 6-month residential stay. The program included an enhanced role for patient peers but was still tailored to deal with their relatively fragile state. We established this unit by means of an elaborate arrangement between us at Bellevue and the city's Departments of Mental Health and of Homeless Services by instituting a day program within one unit of the Bellevue shelter. This shelter for the homeless was located two blocks from the hospital proper and was, ironically, lo-

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cated in Bellevue's original psychiatric pavilion, which had been filmed in The Lost Weekend. We were able to gain the use of a thirty-bed unit from this massive goobed building and take over the unit's food preparation and housekeeping functions. Acquiring this latter set of responsibilities was important because it enabled us to run the unit with the kind of work hierarchy typical of the TCs. The program did not idealize patients' problems as did R. D. Laing's Kingsley Hall but did allow them to have a sense of ownership of their unit that lent meaning to their lives and provided the chance to learn that they had the competency to run their own affairs. We let the patients name the unit themselves, and it became the "Greenhouse." The unit ran with an intensive full-day program and, as in a TC, each resident could confront another who did not maintain expected standards of behavior. Each week they sent a delegation to our hospital-based dual diagnosis ward to explain their program and recruit new residents. When they came to visit the ward, the Greenhouse residents dressed smartly and carried themselves in a manner that would gain the trust and respect of people who were very much like they themselves had been when they were originally hospitalized. Speaking out for the Greenhouse gave all of its residents pride in the program. Here is how the presentation began one day, as one member of the delegation of three began to speak to a group of patients on the ward who were soon to be discharged: My name is Carl and I'm from the MICA [Mental Illness and Chemical Addiction] program at the Greenhouse. Francis and Luis and I are here to answer all your questions about what you might want to know about the program and what it has to offer you. We give you room and board, but with that we give you treatment. We're considered to be a family: we're all together. It's a safe environment. Mental illness is a big part of our addiction, and the stigmatism [sic] that goes behind it is important too. I don't know about you but I am an alcoholic and an addict, which is very easy for me to say, but when I say mental illness it gets tough for me because of the stigmatism out there.

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Then the emissaries went on to discuss the format of the full-day program, which begins at 6:45 in the morning and ends at 8:00 at night. One patient on the ward then asked, "What can you offer there to get back into society after the program has finished?" Francis answered that question: "They break you into society at a slow pace. Then when you go from our program you go to the day program which will be taking care of you. It's all at a gradual pace." Another patient: "What about the fact that it's like a TC? Do they sit you in a chair for 3,4, or 5 hours and tie a sign to your chest?" Francis: "No. It's not like that. That's the way they do it in some TCs, but here it's not that rough. You have to be responsible for your actions but there's nothing like dehumanizing kind of experiences." Luis adds: "It's all about change, something to make you feel your life is at a point to drop the humiliation, the feelings, the emotion; something to keep you activated enough that you'd be thinking about a new way of life." On arrival at the Greenhouse, new residents are introduced to the structure of shared responsibilities, which was explained to one of them this way by a recovering peer: Everybody has learning experiences like cleaning the dining room and the bathroom, and then you can work in our boutique, or in the laundry, or in the kitchen. So you work your way up the levels. . . . Nobody leaves the Greenhouse alone. We watch out for each other. So if you have some appointments like going to the Medicaid office or a doctor's appointment, one of us will escort you because you can't go alone. Patients were watched over by their peers to assure they stayed away from alcohol and drugs. Over the course of their 6 months of induction into the program's philosophy (the belief system, if you will), patients come to adopt a more constructive attitude and assume increasing responsibilities, after which they could move into community-based housing and attend our full-day Recovery Clinic. This clinic is also peer-led and is based on intensive group exchanges among the patients. As in the Greenhouse, most meetings in the clinic involve all the patients to strengthen the sense of community and create the atmosphere of a "movement," much as cultic groups increase validation of their beliefs by generating a sense of 210

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universality when members are brought together in large groups. Attendance at AA meetings in the community enhances this approach. On the other hand, group sessions of six or seven peers are also organized. These capture some of the redemptive qualities of the confessionals that take place at AA meetings, but in a secularized way, and embody the TCs philosophy of character restructuring. One such meeting illustrates this format, with Patient A serving as leader and introducing Juan, who was to describe his recent experience: PATIENT A, LEADER: Today we have Juan Perez. He's going to self-disclose about his life. JUAN: Hi. My name is Juan Perez and I've got to change my attitude. I have a real anger issue and I need to work on it because I disappeared from the [recovery] program for 2 weeks after I got angry in a group, and thank God I didn't pick up, but I came close to it. PATIENT B: Why did you go back to the drug-infested area? JUAN:

I had to go back. Anywhere you move is drug-infested.

PATIENT c: You've got to be careful. When you first came here you had this macho image and now it seems like you calmed down a lot. You came a long way, and if you keep this up you'll move ahead. And later: JUAN: I got a lot out of this group, the way to express myself. I'm getting to where I'm suppose to be, but I still have to make sure to not let my ego or my self-esteem get too built up, because it's how we fall down hard. I'm trying not to fall back down, I'm trying to keep myself clean. We carried out studies on each of the three units—the ward, the Greenhouse, and the Recovery Clinic—and our findings lent clarity to the impact of the programs. For example, we found that patients discharged from the ward were more likely to get to the treatment setting to which they were referred than were comparable patients discharged from Bellevue's traditional units, but this was true primarily for those patients who had been less frequently hospitalized for their illness.38 Rethinking Care of the Mentally 111

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The patients on our ward with multiple previous admissions were indeed more willing to accept referral than were those on traditional units but made it to their outpatient clinics no more frequently. These chronic patients needed additional support in making the connection with the next stage of treatment, even though their motivation was enhanced on our unit. Some of the characteristics we thought might predict a priori a poorer outcome did not. For example, in the Greenhouse the large majority of residents (81%) had been arrested, and most (57%) had been incarcerated. However, those with more arrests adapted to the Greenhouse structure as well as did those with fewer or no arrests and were retained as well in the program.39 The format we employed in the hospital apparently worked well for the severely mentally ill patients, as it did for TC residents who suffered from drug abuse without major mental illness. In fact, our patients diagnosed for schizophrenia or severe mood disorders were actually retained better in the Recovery Clinic and were more likely to stay abstinent from alcohol and drugs than were those who were singly diagnosed with addiction alone.40 Finally, we also applied this peer-led format to the heroin addicts in our methadone program and found it effective in dealing with a group of patients who also seemed to be less than promising. Methadone patients, effectively strait-jacketed by their dependence on the opioid drug dispensed in the clinic, are typically alienated from staff and often continue to use alcohol and nonopioid drugs. In addition, because they are on opioid maintenance they are, by AA tradition, not allowed to speak at Twelve-Step meetings, which exclude anyone from speaking who is taking an addictive agent. We therefore set up Twelve-Step-oriented meetings of our own in our Methadone Clinic. The patients introduced to this "Methadone Anonymous" program cut back on secondary drug use and conveyed a positive attitude to other patients in the clinic.41 Another unexpected outcome was the staying power of this highly organized intensive program, no doubt because of the culture of mutuality among patients and staff, the sustaining quality of the ideology introduced in each of these three settings, and the continuity assured by a well-organized hospital structure. Staff came and went over time and

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bureaucratic disruptions intervened, but even now, almost 20 years after we initiated the program, the culture is still sustained and serves as a model for our trainees as well as for trainees from other American and overseas programs who have come to see how such a program can be set up and sustained.

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14 A Shaman in the Halls of Medicine

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s a discipline, psychiatry is increasingly committed to methods that are evidence-based, that is, based on controlled research. Because of this its practitioners need to draw a broad, dark line between the clinical work they do and the shamanic traditions practiced in primitive societies, but in doing this they can lose perspective on powers considered spiritually grounded, ones that may, in fact, achieve the very healing that the mental health professional aspires to. Some 70 years ago Morris Opler1 described how Apache shamans maximized their reputations as effective practitioners. He wrote that they were astute in selecting clients who were receptive to their approach and rejected skeptics and people with seemingly incurable conditions. In a similar way, interestingly, psychoanalysts have generally rejected schizophrenics as victims of "incurable" narcissistic neuroses, and psychopharmacologists will typically avoid treating sociopathy because of sociopaths' refractory personality disorders. These presumed empiricists might be described as practicing some aspects of shamanism if one applies its definition as "a body of techniques and activities that supposedly enable its practitioners to access information that is not ordinarily available by members of the social group that gave them privileged status. These practitioners use this information in attempts to meet the needs of this group and its members."2

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We do well to remember that "nonspecific factors" of many different schools of psychotherapy are often more effective than the particulars employed in each of them. According to Jerome Frank,3 these include issues such as a confiding relationship, the expectation of help, and providing meaning to symptoms—issues not unlike those inherent in shamanic rituals. We should also not forget that in the domain of psychopharmacology, Walsh evaluated placebo-controlled studies on antidepressants. He found that for every hundred patients responding to an active medication in clinical trials, more than 60% of patients given the placebos for that drug achieved relief as well.4 He warned of the dangers of lending credence to antidepressant studies that evaluate active drugs alone. Not all drug effects are based on seeming "evidence" of biomedical effect. Given these observations, might there be ways in which a shamanic role of spiritual orientation could be applied within the medical mainstream? Or, put another way, could some of the more elaborate procedures undertaken by physicians be replaced by shamanlike rituals that are effective and perhaps more efficient? In addressing this question, we can consider one physician embedded in the medical establishment who has practiced an approach that looks as if it has some of the trappings of shamanism; in many ways, in fact, it is preferable to those of his colleagues. His story illustrates the difficulty that empirical medicine has in accommodating a technique that some would consider spiritualized hogwash because it does not conform to traditional, evidence-based practice. The reputation of John Sarno, a physician and professor of rehabilitation medicine at NYU, had preceded him long before we met. I first heard of him from Adam, a patient of mine and a pragmatic and successful owner of his own business. Adam was free of the symptoms for which he originally entered treatment but came by intermittently to put a perspective on ongoing problems he was having in his marriage. During periods of difficulty, he tended to suffer from headaches rather than from anxiety and depression. He had long experienced these headaches, for which he had gone to a number of physicians, was evaluated at some length at a clinic dedicated to the medical nature of such problems at a local teaching hospital, but had received no relief. I remember

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thinking how close the relationship is between the mind and body when Adam's headaches came to an end shortly after he decided to divorce his wife, with whom he had been locked in seemingly irresolvable conflict. After the divorce Adam and I worked on problems he had in achieving comfortable relationships with the women he dated, but he was suddenly laid up with painful backaches. During one protracted episode he told me that he was going to see a doctor who had helped a friend get rid of similar symptoms. He came back the next week much relieved. His backaches had come to an end after he had read the doctor's popular book, Mind Over Back Pain.5 He had done this at the doctor's suggestion over the phone, even before their scheduled appointment. The story was somewhat puzzling, but Adam continued in our psychotherapy for some time and saw me again several years later. He continued to be free of his backaches. Some time after Adam had experienced his abrupt cure, I heard other reports of people who had found similar benefit from their contact with this doctor, John Sarno. At one point I was treating Morrie, who had suffered from a major depressive disorder since childhood. He was actually brilliant, lucid, and well-read, but was profoundly compromised by anxiety and inhibitions. He had suffered from school phobia as a boy, had later dropped out of high school, and had been hospitalized for his problems more than once. Morrie and I had been meeting for some time in trying to get him to enter the work world, as he was having difficulty holding any steady job. After a variety of medication trials with antidepressants, I had finally come upon a regimen that largely relieved his searing unhappiness and anxiety but still left him afraid to engage socially with women or to move beyond the relatively menial job he struggled to maintain. At one point Morrie complained of backaches, so I suggested he see Sarno. The problem did not seem so severe that he could not benefit from the good doctor's benign intervention. An appointment was set for the following week, but in the interim Morrie was laid up in bed, all but immobilized by back spasms. As he reported this to me over the phone, I thought that perhaps he would have been best referred to an orthopedist, a neurologist, or some other physician who did not deal with backaches "lite," particularly because of his emotional vulnerability. None216

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theless, he somehow got himself to Sarno's office for his appointment and came back to mine at our regular time, relieved of his pain. At one point I concluded that I had to meet Sarno before he retired or passed on; he was not a young man. I wanted to get a sense of the remarkable personality that lay behind his seemingly magical clinical skills.

Questioning the Somatic Approach

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or the moment, let us consider how widespread is the problem that Sarno addresses and some of the ways that the conventional medical community approaches it. Studies in Western Europe6 have shown that an average of 34% of the population report a recent episode of back pain, and similar figures are cited for the United States. Radiographic studies are the most common approach to diagnosing the nature of this problem in a given person, and many of the people evaluated are found to have apparent spinal pathology. The only problem with drawing inferences from these studies is that most adults will show some such abnormalities whether or not they complain of backache. Even half a century ago, one noted orthopedist wrote that "any patient over 30 years of age, no matter what symptoms or signs he presents, is apt to have posterior cervical protrusion demonstrated, if he happens to have a myelogram."7 Indeed, in one study of myelograms, no significant correlation for cervical root deformities was found between symptomatic and asymptomatic people.8 An interesting and compelling illustration of the role of psychology at this intersection of mind and body was reported in relation to the prevalence of chronic pain due to whiplash injury, a common source of lawsuits brought by people who have had rear-end car collisions. When the prevalence of pain, both acute and chronic, was assessed in Lithuania, where there was no insurance coverage for such injury, no differences in neck pain were found between people involved in such accidents and those who were not.9 Apparently, a pecuniary incentive can produce a traumatic injury that some lawyers would send to a consulting orthopedist. Psychology certainly plays a role in how people respond to treatment for back pain. It has been reported10 that people who tend to catastroA Shaman in the Halls of Medicine

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phize (that is, respond to problems with fright and anxiety, as if they were of catastrophic dimension), people who have fearful thinking in response to pain, and those who have less belief in their ability to control pain all tend to have poor treatment outcomes for their back problems. In fact, a high-tech workup alone seems to provide reassurance in and of itself. This was found when some patients were given elaborate MRI-based work-ups and other received only conventional x-rays for their backaches. It was found that people were comforted by the more extensive MRI diagnostic procedures for back pain and tended to be happier with their care than the latter group who received an adequate but low-tech evaluation.11 What about surgery for back pain? An operation certainly makes an impression on a patient but may not solve the problem. Of people undergoing surgery for a herniated disc, 70% reported continued pain up to 17 years after surgery,12 and no more than 20% of patients who had left work because of their symptoms returned to work after surgery.13 What is more, these procedures come with great economic cost. In a recent year 317,000 such surgeries were performed at a cost of $4.8 billion.14

Encounter with the Shaman

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o I met with John Sarno. He was a reserved, neatly dressed, slight man, not more than five and a half feet tall and apparently well into his 705. He spoke in measured tones, hardly coming across as a firebrand, but did begin by saying, You know, 90% of orthopedists' back surgeries are malpractice. And they regard me as if I were swinging a rabbit around my head in some kind of strange ritual. . . . I came to Bellevue in 1951, and as late as the 19605 no one was interested in back pain because there was no money in it. Now it's an industry. He then described for me his model for why so many people suffer from problems, ascribing the pain to tension from the "unconscious anger" that people live with nowadays. He said this stemmed from three sources. The first was the burden of inferiority that people feel due to mental

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abuse they have experienced at their parents' hands. The second was the need to achieve perfection, and thereby to be perceived as "good." For the third he pointed to life circumstances that build up resentment in people's minds. All this, he said, devolved into tension that can emerge in the muscles of one's back or neck. The symptoms are caused by the impact of repressed rage on the autonomic nervous system, which in turn causes a restriction of blood flow and a consequent decrease in oxygenation of muscles and nerves. When I asked him for more details on the pathophysiology of this process—we were, after all, sitting in the faculty dining room of a major research university—he said that this was something that needed to be studied but was outside the domain of his expertise. His theory seemed somewhat speculative, although not unreasonable, but I could see that the way he presented it would not win him a following in the world of laboratory-based medicine. What did make clear sense, however, was his clinical experience. He described, for example, how many patients came to him with diagnoses of pressure on one spinal nerve root or another but with symptoms that were felt on the opposite side. In his estimation, orthopedists were often either careless in the way they explained diagnostic issues to their patients or were careless with the diagnoses they were inclined to make. He mentioned the study I just cited about the lack of correlation between radiologic findings and clinical symptoms. I hoped to get a better idea from him about how he carried out his clinical work, perhaps to infer what psychological mysteries underlay his contact with patients. He seemed to have captured some aspect of the spiritual powers of shamanism—clearly never "evidence-based"— ones that psychiatry seemed intent on expunging from its armamentarium. So I asked him how he managed his patients. In fact, there seemed to be little overt wizardry there. He described how he would speak with a potential patient on the phone for 5 minutes or so to see whether they might be amenable to his approach and would turn down most people who called. If he accepted a patient, though, he would have them come in to spend an hour with him for a physical exam and a discussion of how he understood the nature of their back pain, essentially telling them what he had just told me. He said that this would be fol-

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lowed by the patient's attending his lectures. He would refer some patients who he felt needed more intensive work to untangle their conflicts to a number of psychologists. Sarno's office was in the main medical school building, a more genteel setting than Bellevue Hospital. Nonetheless, he was eager to establish a liaison to the hospital, where most of the school's clinical teaching takes place, so I invited him to speak to my staff. At first he was concerned whether there might be an orthopedist in the audience, as he wanted to be frank in his talk, and I assured him that we had only psychiatric staff present. I asked him if we could videotape his talk, and he said he would rather we did not, because some of the things he said might be misconstrued. This I could understand because he did begin speaking to our group by repeating his contention about the inherent "malpractice" in some orthopedic procedures. Before he arrived I asked one of my research assistants to set up the conference room for him, and she said that she knew his work well. And how was that? She had heard him extolled by Howard Stern, whose bawdy morning radio talk show had been under assault for its presumed obscenity. Stern apparently regarded Sarno as something of a magician for having relieved him of his chronic backache and was, in fact, quoted on the dustcover of one of Sarno's books. The word of Sarno's shamanic powers had gotten around. We had discussed the option of having a patient with back pain come to the conference so that Sarno could speak with him. However, at the conference our patient, whose back problems had derived from a series of motorcycle accidents followed by multiple surgeries, was quite rambunctious, and Sarno decided not to interview him. As he had told me, he chooses those whom he thinks he can treat. The patient did, however, ply Sarno with some questions, asking him, for example, why, if he woke up at night in great pain, would Sarno say that such problems were just in his mind. The good doctor explained with no hesitation that all this was caused by a signal from his brain. Overall, the patient seemed to be subdued in the face of Sarno's conviction, but one could see why he may not have been suited for shamanic intervention. After all this I could only speculate for myself as to how Sarno's words could enter the minds of his patients and put their pain to an end. It just seemed that the calm conviction that he conveyed came through to his 220

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patients and somehow relieved them of tension that they were feeling, tension that he said was causing the pain for which they had sought him out. There did seem to be some parallel to the way faith healers could relieve conversion symptoms such as hysterical blindness and falling mute, aided by the anticipation in their subjects of a miraculous cure. The patient from our clinic might have been typical of those whom Sarno chose not to treat. Those from my psychiatric practice whom he had seen were drawn from a subculture in which reflection and psychologizing were more the style of dealing with tension. Even so, Sarno had never embarked on a controlled study to determine what portion of patients or which ones responded to his approach. Because of this the effectiveness of his approach has yet to be assessed in an objective manner. It was clear to me, however, that patients of mine who had encountered him would likely have been subjected to a more extensive intervention in the hands of another, more conventional, doctor. Sarno put his practice in the following perspective. He said that he saw himself operating somewhere between traditional and alternative medicine. He explained as well that he was committed to Alfred Adler's psychiatric model of the inferiority complex driving much of human emotion and that he felt psychotherapy was useful for his more refractory patients. I wondered whether approaches like his, in some ways bearing as much similarity to spiritual healing as to contemporary psychiatry, would find their place in the mainstream. If so, conventional medicine might be able to take advantage of the techniques of shamanic healers without questioning their merit because they have not emerged from randomized, controlled trials. The shamans, including those in Balaji—the town in India where spiritual healing takes place for the mentally ill—were wise to restrict themselves to those conversion symptoms they could address. They would be wise as well not to compromise their seemingly magical incantations by subjecting themselves to the Heisenberg effect, whereby scientific observation could change the very nature of their impact if it were subjected to scrutiny. Sarno seemed to fall into the same category as did some of the Indian psychiatrists whom I described earlier. Through the nature of their encounters with patients, they were able to relieve the fainting spells of the woman who was suppressed and abused by her A Shaman in the Halls of Medicine

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mother-in-law and the young man who had experienced a sudden onset of hysterical paralysis. The encounter with Sarno also reinforced the meaning of what Mohit, director of the World Health Organization's psychiatric activities in the Islamic Middle East, had meant when he spoke of the power of "the word" in discussing the spiritual issues associated with mental health.

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15

Meditation

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herapists can learn to address their patients with compassion in a variety of ways. Some draw on their training in listening for unconscious conflicts. Others are taught to use a behavioral approach after hearing out a patient's emotional distress. However, those who apply meditation in treatment usually draw on their own subjective experiences after exposure to some aspect of Eastern spirituality. My own encounter with meditation practice, however, was derived primarily from an interest in psychological research, which has hopefully provided me a measure of objectivity to complement my general clinical experience. This began in an acquaintance with the Divine Light Mission, a cultic group for whom meditation was central to their ritualized practices. When I first contacted this group some 30 years ago, I found that some of its recruits had embarked on mental health careers before they had joined. To see if this spiritually related meditation had found its way into some of those members' professional practices even now, I contacted Zach, a psychologist who had followed the group's leader, Guru Maharaj Ji, and who was now in clinical practice in Manhattan. He was now well into middle age and was willing to tell his story as long as I did not reveal his identity, as he feared compromising his professional status. He described how both he and the mission itself had evolved over the years.

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Zach had become interested in meditation while practicing psychology before he was aware of Maharaj Ji. On one occasion he had called a cleaning service for his office and was visited by members of the Divine Light Mission, who were supporting themselves by working in office maintenance. On hearing of his interest in meditation, they invited him to go to one of Maharaj Ji's festivals, and he went, "just to be involved with people who are on a spiritual path in that kind of consciousness." Soon thereafter, though, he became intrigued by the guru, who said of the Mission's meditative practices, as Zach recalled, Don't believe—experience. If you don't experience anything, forget about it. But be prepared to receive it. And if you do, practice it and see what you experience. Zach decided to "receive knowledge"—that is, undergo induction into the group: You had to have a knowledge session to be initiated, which in my day ran for hours. It was given in a large group either by Maharaj Ji or one of his mahatmas. Then you went home and meditated for 2 hours at a stretch every day. You did "service," too, which could be anything from sweeping the floor to child care. In those days there were a lot of festivals, but now there aren't too many any more. "What happens when you receive knowledge?" I can't explain what happens in a knowledge session because you're not supposed to tell. It's a promise you make at that time. But there's a connection between you and the teacher. The knowledge gives you a kind of consciousness that frees you up from the drama of everyday life. You're in life, but you're not as affected by everything that goes on around you. The purpose is to grow your own consciousness to a higher level, always having that awareness, that mindfulness [italics mine; we will get to this]. The idea is that your mind is yapping at you all day long for most of your life. In meditation you quiet the mind, and go back to the technique. You can even stay in meditation all the time.

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"What's the technique?" I'm not supposed to tell you, but I can say what the meditation is like. There are four experiences: light, music, holy name, and nectar. The nectar involves taste, for example. To see light within you, you have to have your eyes closed. It's encompassing. It feels really wonderful and it's within you. You feel like you're in a very peaceful place. His answers illustrated the role of mystification in the process of engaging people in a cultic meditation. Transcendental Meditation practitioners are given a mantra by Maharishi Mahesh Yogi or one of his trainers to repeat during meditation, but they are to reveal it to no one else. Certainly, many of the most compelling experiences people encounter do revolve around secrets they may keep to themselves: sex, primitive fears, spiritual epiphanies. Some of these retain their intensity because the person does not quite know how or with whom to share them, and this was true of many of the people I interviewed about their own spiritual feelings. As Zach and I were talking, it was as if we had entered an envelope that was intensely personal and whose contents would not easily be revealed. Meditation was clearly a deeply mystical experience for him, but since he had been prohibited from going beyond what he had already said about the meditative experience, I asked him instead what it had been like to encounter the guru. Years ago we used to do darshan, and I passed by him in a long line of premies. My wife had died 4 years before. She was the love of my life, and I had never gotten over it. I had since been with another woman and we had a child together, but I always had that sorrow. I don't know what happened, but within a half hour after my first experience with darshan, I had no more sorrow. It lifted my grief. I can't explain it. I had seen the darshan ceremony myself when I first undertook my study of the Maharaj Ji's movement and had been taken to the front of a very long line of supplicants by my friend Beth, the guru's doctor,

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hoping to show me what he was like. His devotees kissed his feet, but since this did not seem appealing, I moved by quickly, hoping to get on with the study I had planned. It was clearly different from what Zach had experienced. Zach further described how the guru's movement had become more secularized, how the guru now used videos to instruct on meditation, and how he had renamed the mission Elan Vitale. After all, he had moved to Pacific Palisades with his American wife, a former stewardess. The guru still gives talks that attract his followers, and Zach had gone as far as Australia to join in with others of the enlightened followers. I asked how all this affected his practice of psychotherapy, and his response illustrated the way a mental health professional, even one following a guru, may be reluctant to veer away from what is considered proper practice: I always felt that there would be something unethical about promoting a guru to patients. On a very practical level I don't want people in psychology to think I'm nuts, or a fringey, or a New Agey, because I'm not. I'm just a person who's practicing a profession, period. In fact it's funny, because one woman came to me and didn't come back because she wanted spiritual treatment, and I said that I didn't offer it. "Does your own spiritual experience play any role in your clinical practice?" I do teach abdominal breathing to some people and teach them to concentrate on their breathing. That's all. Because it really does help them relieve themselves of anxiety. Breathing from your diaphragm isn't compatible with being anxious the way breathing from your upper chest is. I treated one businessman who was traveling all the time. He was tough and didn't believe in therapy [here Zach gestured with his fist, mimicking the patient's assertiveness], and just came to me under pressure from his wife, who had given him an ultimatum. But I taught him to breathe, and then he said, "You know, I use it every day." It was a tool he could use when he was on a plane, if he was in Japan, or wherever he was. That alone can be beneficial to somebody's mental health. 226

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I wondered if the experience with Eastern spirituality had led Zach to be attentive to his patients' religious feelings, and apparently it had not. He said, I think very few people who go to church every week experience anything. I treated a woman whose family had objections to her getting married out of her religion and had to help her relieve herself of that burden. What he said illustrated how many mental health workers think of religion: as an imposition to be relieved, rather than a beneficial experience, or it is considered not quite relevant to a profession that is supposed to touch on what people care about. I pursued the issue: "If someone says they're religious and goes to church on Sunday, would you deal with it?" They would have to bring it up as something that's relevant. Maybe most people go to church, but that's a separate thing. People can compartmentalize spiritualities: their own—if they feel it—is revered, but that of others can be dismissed, even maligned. Of course, this is nothing new.

Mindfulness Meditation

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n considering the use of meditation in dealing with psychological problems, we encounter some perplexing issues. One is the paradox inherent in what therapists are prepared to hear. On the one hand, they will discuss their patients' most intimate thoughts, their sexual conflicts, and their shameful experiences; on the other, they typically avoid dealing with patients' spiritual or religious feelings and thereby miss the opportunity to enter a domain that can be important in the clinical encounter. Another is that entry into the mental health field does not necessarily make a person ecumenically liberal or even religiously tolerant. Ironically, it may be for the best that therapists are trained to steer clear of spiritual matters that may touch on their cultural biases. These issues are illustrated in the contrast between Transcendental Meditation (TM) and the "relaxation response," both of which emerged Meditation

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as popular options during the 19708. Maharishi Mahesh Yogi, who insisted that his TM meditators keep their mantra secret, wrote that, "With more and more practice, the ability of the mind [expands] to maintain its essential nature while experiencing objects through the senses increases. When this happens the mind and its essential nature, the state of transcendental Being, become one."1 TM gained wide popularity, with training centers across the country, but its most devoted adherents moved increasingly into a circumscribed subculture looking for "cosmic consciousness." Some established a residential community of their own in Fairfield, Iowa, with their own university, and raised their children as devotees to their philosophy. Given all this, TM may be too cultic in orientation to be acceptable to a medical-scientific community. On the other hand, Herbert Benson at Harvard was popularizing "the relaxation response" as a fully secular approach with no spiritual trappings around the same time that TM was flourishing.2 People who applied Benson's approach were encouraged to pick a word of their choosing, assume a comfortable posture in a quiet setting, and repeat that word in their mind while gaining a feeling of relaxation. There was no guru and no spiritual overlay. Researchers on this approach found that it provided relief from tension and that hypertensive patients who applied it achieved a lower blood pressure, even after their original training.3 The relaxation response, however, devoid as it is of an associated philosophy, did not engage converts the way a spiritually oriented movement can. Is there an intermediate option between the cultic and the coldly clinical? A format acceptable to health professionals would have to approximate the standards for treatment that empirical researchers espouse but would also touch on people's spiritual inclinations. To illustrate this we can consider the technique of "mindfulness meditation." It is reasonably well defined and is applicable in the context of a conventional clinical setting. Although it draws on both Hindu and Buddhist traditions, it reflects work in academic medicine as well, such as the work of Arthur Deikman, a professor of psychiatry at the University of California in San Francisco. During the height of the counterculture period, Deikman drew on an understanding of Eastern thought and a range of mystical and cultic phenomena to put issues related to meditation into a formal 228

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psychological perspective. He emphasized the distinction between one's observing self and the experience that one feels subjectively, and pointed out that, "Awareness is something apart from, and different from, all that of which we are aware. . . Awareness is usually confused with one type of [mental] content or another."4 In Thoughts Without A Thinker,5 another psychiatrist, Mark Epstein, recently described traveling in India and Southeast Asia during his medical studies and encountering teachers of meditation. He wrote about psychotherapy from the perspective of a Buddhist "psychology" and elaborated on the concept of mindfulness meditation, which could augment the practice of psychotherapy or even supplant it in some respects. He pointed out how this approach could allow for "being aware of exactly what is happening in the mind and the body as it is occurring . . . the catalyst for a profound change in the way self is experienced." Mindfulness meditation accomplishes this by lending moment-tomoment attention to breathing, thoughts, and feelings while standing apart from them. This is done in order to alter one's attitude toward the concerns that populate one's mind—not to change or disavow them, but to avoid getting lost in them. They are therefore accepted as the natural behavior of the mind, but they do not necessarily define one's "self." As one acquires an ability to take some distance from these concerns, one can learn to distinguish between the troubling thoughts one may encounter and how one perceives oneself as a person. At the University of Massachusetts the psychologist Jon Kabat-Zinn has applied this approach to patients with medical and psychological problems in an 8-week course in which participants attend weekly 2-hour classes followed by a full-day intensive meditation retreat. He and his colleagues offered the course to patients diagnosed with generalized anxiety and panic disorder and contrasted them with a group of patients similarly diagnosed but not treated with the meditation technique. They reported reductions in symptoms right after the meditation intervention6 and on follow-up 3 years later.7 Investigators at Cambridge University in Great Britain applied a similar approach to people who had been depressed and were receiving conventional care.8 They found that when they trained half the patients in the mindfulness approach, the more chronically relapsing patients' rate of relapse was cut in half. Meditation

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These findings suggest that mindfulness meditation might also help with physically grounded disorders that are influenced by stress, and some studies illustrate just that. Pain, for example, is materially affected by a person's psychological state. Kabat-Zinn's group9 has trained patients suffering from medically grounded chronic pain in mindfulness meditation to help them acknowledge their pain but detach themselves from it. By paying careful attention to the pain and distinguishing momentary sensations as separate events, the patients could stand apart from their experience of it and be less troubled, much as did those who were suffering from anxiety and depression. The investigators reported a high degree of compliance with the meditation practice and a material improvement in the patients' distress and pointed out the importance of uncoupling the sensory component from its cognitive and emotional dimensions. They also emphasized the value of patients' active participation in the meditative process, thereby promoting a sense of self-mastery. Another study dealt with fibromyalgia, a chronic illness characterized by widespread moderate pain, fatigue, and sleep disturbance. Although psychological factors are thought to play a role in the distress it causes, it can lead to limitations comparable to those of rheumatoid arthritis. The syndrome is being reported with increasing frequency, with as many as 10 million Americans meeting its formal diagnostic criteria.10 Treatment approaches based on somatic interventions, however, are generally unsuccessful and have ranged from cardiofitness training to hypnotherapy as well as various somatic interventions. One group of investigators11 found a material resolution in these symptoms when patients applied a mindfulness meditation regimen. Similar success has been achieved12 in treating patients with psoriasis, another physical syndrome known to be affected by psychological factors. When patients were given a standard regimen of phototherapy and chemotherapy, those who also received an audiotape-based mindfulness stress reduction regimen achieved considerably greater clearing of their skin rashes. This meditation technique may also be able to change physiologic responses to infection, since stress can affect susceptibility to infection. One compelling study on the relationship between stress and infection was completed at the Common Cold Unit Research Center in Great Britain. Subjects indicated the number of experiences they had en230

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countered that were negative and uncontrollable in the last year and the degree to which they felt nervous, unhappy, and the like. They were then given a dose of nose drops containing viruses that cause the common cold. The more stress that was reported, the more likely a subject was to catch a cold.13 Investigators have also found that the mindfulness technique apparently alters physiologic functions related to influenza, increasing antibody response to flu vaccine.14 While more studies need to be done to determine whether specific aspects of mindfulness meditation can predominate over a well-framed placebo treatment, it is clear that it is acceptable to patients in a medical setting and can be helpful as well. An approach such as this may come to be used more widely as health practitioners respond to patients' growing interest in alternative medical techniques.

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16

Psychotherapy for Personal Meaning

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here is often quite a difference between the way psychiatrists treat their patients and the way people want to be heard and cared for. In trying to legitimate their identity as medical scientists, to meet the demands of insurers, and to respond to the promotions of drug companies, many in the profession have lost track of what may make a patient feel worthwhile, what can validate them. This undermines their opportunity to motivate a person who has suffered a loss of purpose to make the best use of what psychiatry can offer. However, this point is not new. It was put forward with eloquence more than 50 years ago by the psychiatrist Viktor Frankl, who wrote: For too long a time—for half a century, in fact—psychiatry tried to interpret the human mind merely as a mechanism, and consequently, the therapy of mental disease merely in terms of a technique. I believe this dream has been dreamt out. . . . a doctor, however, who would still interpret his own role mainly as that of a technician, would confess that he sees his patient as nothing more than a machine, instead of seeing the human being behind the disease.1 Indeed, if there is one psychiatrist who best expressed the importance of personal meaning as central to recovery from anguish, it would certainly be Viktor Frankl. His wife, father, mother, and brother died in 232

the concentration camps of Nazi Germany, and he himself endured the brutality of Auschwitz and Dachau. He emerged somehow strengthened by the realization that it is personal meaning, even if derived from suffering, that can have redemptive value. Frankl pointed out that for the psychiatrist, emotional distress is a legitimate issue when it derives from existential needs, even if it does not conform to our models of "mental disease." He had a talent for refraining the very ideas that underlay patients' pain to offer them relief. As he said, "In some way, suffering ceases to be suffering at the moment it finds meaning, such as the meaning of sacrifice." His approach, logotherapy, was designed to help people find meaning in their lives and to release what he regarded as a natural will to achieve that end, rather than find mere gratification of emotional drives alone. He gave the example of a depressed woman who was admitted to the hospital after a suicide attempt she had made after one of her two sons died. The boy's death had left her alone with her second son, who was crippled and confined to a wheelchair. Frankl asked her to contrast her life with that of a woman who might have lived to eighty in great wealth and comfort with no child at all. She then spoke of her remaining son and burst into tears, realizing that at 80 she could say that her life had been meaningful: "'I have done my best—I have done the best for my son. My life was no failure!'" She had come to see the justification for her living despite the suffering she had gone through. One issue that detracts from psychiatrists' acting on Frankl's therapeutic philosophy is a narrow focus in their lexicon of symptoms, namely, a focus on those that are held in common by groups of people rather than meaningful to the individual. All too often psychiatrists are taught these days to look at diagnostic problems as if scanning x-rays and lab results, but not to search for a basis for emotional fulfillment. Such an approach can be quite limited in its value, sometimes even fruitless.

The Therapeutic Alliance: But to What End?

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esearch has shown that the success of a given episode of psychotherapy in providing symptom relief may be more the product of a sound alliance between therapist and patient than the particular theoPsychotherapy for Personal Meaning

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retical approach or the specific techniques applied.2 This alliance is based on mutual trust and an implicit agreement on why the therapist and patient are working together. For this reason, a patient must be given the opportunity to sort out what he or she would really like to achieve. Take one brief encounter with a hospitalized patient: Marilyn was brought to Bellevue Hospital after grabbing a policeman's gun and saying she was going to shoot herself. She was now being presented to me as one more patient typical of many brought to our emergency service who could not be "T and R'ed"—treated and released—without admission to the psychiatry service. The psychiatry resident explained that Marilyn needed to have her dose of antidepressant increased and to be held as an inpatient until it was seen to work. She was being presented as one of those patients who seemed to get increasingly agitated at being held in the hospital. The resident provided this background: The police officer had been called to a homeless shelter where Marilyn had been staying because she was shouting and crying uncontrollably. Staff at the shelter had explained that she was drinking heavily around the time of the incident. The resident described Marilyn as uncooperative and having little meaningful to say about her situation, except that she was in a rush to get out of the hospital. He pointed out that she was like many of our patients who decided they were OK long before they had reached the point when we thought they were "stabilized," not realizing the dimensions of their illness. In speaking with Marilyn, I asked her to talk a bit about why she was so concerned about leaving the hospital. What was really important to her emerged as she told the tale of her sorrows, what had led her to this point. We talked about what she wanted, so that we in the hospital might ally ourselves with her. As we spoke it became clear that Marilyn had not always been this compromised. She lost her job as a data entry clerk after the World Trade Center disaster 2 years before, and right before admission there had been a fire in her apartment building, and her floor was evacuated and her furniture put in storage. Because she was an only child, she had been given compassionate discharge from the army 12 years before to tend to her mother, who was dying of cancer, but she was plagued by the memory of not being able to bring herself 234

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to go to her mother's bedside as she lay in a coma in the final days before her death. Marilyn became depressed after her mother passed away and began to have drinking bouts to relieve herself of her grief. We spoke further, and Marilyn made clear why she felt pressed to get out of the hospital; it was not on impulse or to get back to drinking. She said: I need to get to welfare before the storage building adds on another $100 to my bill. What's in storage that you need to get? There's a rocking chair that I used to sit in all the time; it was the best thing I had. What was so special about it? It would be hard for you to understand, but my mother and I both used to use it. And that's it? That's not all. They'll throw it away if the storage isn't covered by next week. That's why I really need to get out. I can't afford to lose it. Marilyn became tearful over the thought of losing a relic she held in common with her deceased mother. It would not have seemed as important to the frightened shelter staff, or as relevant to the resident, as a policemen's gun and the raft of medications that we hoped would address her depressed state, but indeed that was what was worrying her most. It was easily lost under the pressure of the presumably larger issues that her hospital-based psychiatrists had come to see as part of an effective "work-up." Marilyn returned to the ward, and the staff and I discussed this issue. We would see how we could work out a way for the crisis in storage payment to be addressed with some help from the local welfare office. We could now address what Marilyn regarded as most meaningful to her. She had been allowed to express it, rather than our assuming that more medication and time for it to work was the immediate issue at hand, and we would avert having an angry and resistant patient. A psychiatrist can sometimes make the mistake of relying on more medicine to solve a problem, and this can be unproductive, if not compromising. Often an intervention in a family situation is essential to Psychotherapy for Personal Meaning

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address what is important to a patient. This was the case with Jeanne, a 24-year-old who was interning at a large corporation between her first and second years of business school. She called me to make an appointment, explaining that she was depressed and had on impulse taken "some tranquilizers" that she had found in a friend's medicine cabinet. She said she had passed out and was taken to an emergency room, and her father was called. She explained that she had latched on to the pills to relieve a panicky feeling that had come over her. As we continued on the phone, she said with some reluctance that she had been drinking, too, maybe too much. In my office Jeanne told quite a story for a student in business school from an upperclass background. Her mother had died when she was 10, and she had been anorexic at 13. By the age of 15 she was drinking heavily and taking Ecstasy at clubs. After having an abortion, her father put her into therapy, but she was soon using heroin and cocaine. Over the course of her first year in college, she was making regular visits to Harlem to buy the drugs she had come to need. Her drug problem was becoming increasingly clear to her father, and he insisted she go to a rehab. Two weeks after discharge she relapsed to heroin use. He sent her away again for treatment, this time to a long-term recovery program, after which she stayed in ambulatory care nearby and worked in an agency as an aide to a social worker. She remained sober, took antidepressants prescribed by a psychiatrist, and finished college, but she started drinking again after college and now maintained that she could drink socially, despite the recent ill consequences. Interestingly, she kept up with the antidepressant, which she said was quite helpful. We met a second time and spoke briefly with her father on the phone to set up her treatment, but this was followed by an appointment that she missed with an excuse related to demands at her internship. I was quite concerned for her well-being and spoke with her and her father on the phone. It now turned out that her father had been calling her daily, insisting that she come for therapy, but she was reluctant to do what was implicitly needed: to stop drinking. Jeanne and I spoke further. She was very angry at her father, depressed, and "miserable" over his demands that she continue in a business career, which she had embarked on only because of continuing pres-

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sure from him; he had threatened to withdraw his financial support at every turn if she veered off the path he had conceived for her. She had been too intimidated to do anything but comply with her father's demands, but Jeanne was concerned about the well-being of the disadvantaged, not about the needs of the business world. It was becoming amply clear that her anguish and self-destructiveness were entwined with the feeling that her father had stolen her very identity, and she was confronting a life in his lucrative business, a life she saw as meaningless. Why, she asked of herself, did she buckle when he insisted she have a career that would make her a "good living"? Why could she not become a social worker, to continue with the kind of work she had found meaningful and important after her rehab experience? On the one hand, her problem was framed by depression and drinking. A psychopharmacologist might have chosen to relieve her depression with an adjustment in medication, not having the time to become involved in the details of her family conflicts. He would have admonished her about her excessive drinking, perhaps sending her to AA (which she did not want to attend, as she wanted to be a social drinker), but it was amply clear that a resolution of her problems would not come about unless she could look forward to a more meaningful life than she was anticipating. I sat with her, her father, and a sympathetic aunt to discuss what options there were, given their fear for her very survival and her distress over her future. We agreed that despite Jeanne's initial avowals that she could handle her alcohol, we would make a deal that she would not drink over the course of the coming year if her father would agree to let her sort out for herself whatever career path she would chose. He agreed to this, and Jeanne's misery abated with the realization that she could be freed from the fate that frightened her, of being forced into a course in life that she did not want. The experiences with Marilyn and Jeanne clarify why it is important to hear out a patient's concerns. In neither case would psychiatry, acting under the gun for "efficient" use of time and medications, have achieved this. The two situations arose in very different settings, one in a hospital for indigent, homeless people, and the other in the comfortable office of a private psychiatrist. In both cases, though, some time

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and openness were needed, commodities that are often in short supply as psychiatry is defined these days, but this should not be the case. Some 70 years ago the psychologist Henry Murray emphasized the importance of studying people's personalities as a whole, an approach that was at odds with the mechanistic behaviorists among his academic colleagues. He used the term personology1 to define a scientific approach to studying a life in continuity and pointed out that the content of one's life should be viewed in its entirety rather than as an accumulation of behaviors, or symptoms, for that matter. Murray emphasized the importance of biography in such studies and even hoped to see personologists do research on scientifically framed biographies. Keeping Murray's perspective in mind, we can consider how a compromised engagement with life's challenges can be as disabling as discrete symptoms. To this end a patient, aided by a therapist, would do well to clarify what is worthwhile so that the treatment can move his or her life story along in a positive way. This issue is relevant from a biological standpoint as well, as we are gaining an increasing appreciation of the physiology that underlies many syndromes of maladaptation. Personality disorder, as defined by the psychiatric nomenclature, acknowledges the issue. The schizotypal personality is characterized by a reduced capacity for close relationships, perceptual distortions, and eccentric behavior. There is evidence from family studies of it being related genetically to schizophrenia spectrum disorders. Borderline personality disorder is characterized by instability in interpersonal relationships, self-image, and mood and may be marked by impulsiveness. It is often seen among people who make suicide attempts. Such people are frequently troubled by chronic feelings of emptiness, but their lives may be stabilized by treatment with antidepressants or low doses of antipsychotic medications, again suggestive of a relationship to a biological vulnerability. People with alcohol problems may differ physiologically among themselves. Those who experience an early onset and are more characterized by sociopathic behavior have been reported to differ in their response to pharmacologic intervention from those who are better adapted and only begin problem drinking at a later age,4 and, indeed, alcoholism, long known to run in families, occurs with greater frequency among children born to alcoholics, even when they are adopted and raised by 238

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nonalcoholic parents from the earliest age. Their genetic makeup apparently shows through. On the other hand, nurture, not only nature, plays its role. Psychodynamic psychology has long shown that a person's character structure can be established in childhood by interactions within the family and will then show itself in a particular style of adaptation over the course of a lifetime. On a most troubling level, we know that children who are beaten by their parents are more likely to beat their own children later in life. However, subtle patterns show themselves as well, and dependency, rebelliousness, and mistrust are examples of this. Both biological and social issues, therefore, illustrate the need for viewing patients in a holistic way in order for them to achieve well-adapted and meaningful lives, that is, to redirect their biographies, as Murray might say. Mental health professionals today would therefore do well to take some implied advice from Henry Murray and attend to individual people as a wholes over a lifetime, to investigate the nature of the trajectory of their lives over the decades, and to see if they can be helped to an adaptation that carries meaning and value for them. After all, this can be as important in generating sorrow as are their individual symptoms. In some ways this parallels an approach inherent in traditional psychoanalytic therapy but allows for emphasis on achieving what is meaningful, even redemptive, for a person to help them be actualized. Again, this idea is certainly not new in the domain of psychotherapy, but it is being lost these days. Allen Bergin5 has lent much thought to the issue of values in psychotherapy and has pointed out that the therapist's input is not a value-free activity. This implies that a therapist and patient do not only explicate scientifically framed problem areas. They can collaborate on effecting a better life for the patient, one based on values that are clarified in the treatment context in mutually accepted goals. Therapists are people with values of their own that they must recognize and then deal with in a meaningful way themselves in finding common ground with a patient. Kenneth Kendler, a leading investigator of the interaction between personality and biology, has shed light on the importance of how a person can experience a compelling life event in relation to the onset of major depression, a disorder usually considered to be biologically grounded.6 In addition to the well-established role of personal loss in Psychotherapy for Personal Meaning

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the onset of depression, he found that events experienced as humiliating, ones that devalued a person, were strongly linked to the onset of depressive episodes. Therapy should be directed at reconfiguring the impact of such events to transform their negative effect. Even the most difficult of circumstances have been reframed to be seen as meaningful. Viktor Frankl made this clear from his own experience in the Nazi death camps. The apparently tragic and seemingly disabling years he survived allowed him to lend meaning to his life. Given these observations, we can consider the merit of a therapeutic approach designed to help a person achieve a more meaningful perspective on life, and such meaning can serve as a secular counterpart to the kind of experience associated with spirituality. I emphasize this latter point because there is a natural extension from the attention needed to spiritual needs in the world of psychotherapy as a secular discipline. In the contemporary world the achievement of a life that is meaningful in itself may be what many or most people want, rather than experience that is spiritually oriented. In any case, therapy clearly should be directed at what patients see as meaningful for them. Such an approach can certainly benefit from all that is offered today in the way of psychiatric treatment: pharmacology, psychodynamic understanding, and an examination of a patient's most important relationships. Under the best of circumstances many patients do get such help nowadays, but many do not. Here is one example of how such help can be provided. Some might say it is just what a reasonable course of therapy should be. Others might find it a bit unusual in today's climate of managed care, but we shall get to feasibility later.

Beyond Treating the Symptom

D

an, an executive in the garment industry, was in his mid-4os. He explained in our first encounter, "I don't want to live the rest of my life in terror and panic." He suffered from anxiety, depression, and fear over the inevitability of death and was often humiliated by his boss, who was as crude as any in the "rag trade." All this gave Dan little opportunity to consider what his very real talents at marketing might

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allow him to achieve, let alone how he could value himself as a person. The pressure of his mood disorder was largely relieved by antidepressant medication, but even after some months his life was still compromised: he still worked under the thumb of his boss, often barked at his wife, and had mutually provocative exchanges with his teenage daughters. His life was still oriented toward meeting material needs and coping with his remaining fears rather than achieving any sense of fulfillment. As he said, "I feel better, but I'm not sure what it means." Could psychiatry intervene to move him toward a more meaningful and positive life? He could have been left in his less symptomatic state after the initial months of antidepressant treatment, but he would have been missing out on what life might offer him. As a child Dan had been subject to an iron-willed mother who was intrusive and demanding, but because she was caring as well, he had accepted a subservient role in relation to her and did not gain a sense of autonomy. The onset of moderate depression in his teen years aggravated his feelings of inadequacy and left him uncertain about his ability to capitalize on his high intelligence. Over those years he had also lost contact with friends in the Jewish community in which he had been brought up, even though many lived nearby and were involved in similar business activities. At work he operated with considerable skill, but two earlier employers, each callous in his own way, recreated the pattern of dominance established by his mother. His work, however successful, meant little to him other than providing an income to support his family and assure stability after retirement. As his acute distress abated, I asked Dan what goals he would set for himself for a more meaningful life several years hence. I ask this of all my patients and those interviewed in conferences for psychiatry residents as well. It is unfortunate that such a query is not a regular component in the early stages of every psychiatrist's encounter with patients. In Dan's case it was important for him to appreciate the validity of considering what he could have in life besides its rudiments. He said he wanted his boss to get off his back, to feel better at home with his family, and to have a little fun in life. In line with these goals, he could work with me to take advantage of the benefits that antidepressant medication had provided: He directed his talents to develop

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a better relationship with his own client base and was able to establish a more independent role at work. Dan also gave up the resentments that colored his exchanges with his wife and daughters. He had a religious background that had been meaningful to him in his youth, but in the midst of his troubled adolescence and adulthood it had been lost to him. In his new-found sense of security he was able to return to it, joined a synagogue, and became active in its charitable activities. In addition he took his family on a 2-week vacation for the first time, being able to tear himself away from work. He said more than once, "I owe you and the antidepressant a debt of gratitude for my new-found life." It was significant that he considered both as an integrated whole in his treatment. Such changes do not necessarily come about through the relief provided by antidepressant medication alone, as ongoing dysfunction and alienation become embedded in a person's adaptative style over decades. Careful attention to dispelling problems such as these through therapy is generally necessary in order to free a person from a chronically troubled past. One aspect of Dan's psychology reflected the point made in Kendler's findings on the impact of humiliating experiences in generating depression. He might well have evolved into a less dependent and insecure person, and even less depressed, if his earlier relationship with his mother had left him less accepting of humiliation at her hands. The antidepressant may have provided a basis for acute relief and minimized the worst of his anxiety and depression, but it was an ongoing collaboration in treatment that allowed him to respect his autonomy in a meaningful way. He overcame a habitual sense of inadequacy with his wife, daughters, and religious community and was able to rediscover areas that were meaningful to him. The need for a meaningful adaptation arises as well during the period of protracted adolescence that many young adults go through these days, as the rebellious behavior of this period can be as compromising as are some easily diagnosed symptoms. It can emerge from uncertainty about whether a young person sees his or her future as meaningful and promising. In such cases the issue of "Who am I?" is clearly as important as "What is the symptom?" One young man's experience in therapy illustrates this point.

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At 25, Dwight's life was sandwiched between layers of bureaucracy in a large corporation. He knew little of who he was at work beyond needing to be compliant with the company goals and getting drunk with his friends on weekends. The idea of developing a sense of his own worth had been compromised in his youth, as his self-esteem was premised largely on his identity at home as a mischievous son. His interaction with his parents was defined by their attitude, which was, in effect, "What have you done wrong lately?" and collaboration or negotiation was hard to achieve with these two worried and judgmental people. In the face of this, his response to authority had come to be either compliance or rebellion. This role within the family was fueled by his father's fear that Dwight would end up like his own father. Dwight's grandfather was an alcoholic who had been a ne'er-do-well; he had been neglectful of his son and was an irritant to the family throughout the years of his son's marriage. Both of Dwight's parents were alert for signs of the grandfather's behavior showing up in their son, and their fears had also been aggravated by the consequences of his mild attention-deficit/hyperactivity disorder. He had always been mischievous in class as a child, while his older sister, a star student, was seen as a "good" child, with her occasional peccadilloes overlooked. Dwight had played out the role his parents feared with rebelliousness that he never hesitated to act on, while at the same time reinforcing his own negative self-image, so while he was now punctual at work, he would consistently come late to family events. However, his principal area of malfeasance was now the drinking bouts with his friends, which often ended in an effective notification to mom and dad that he looked to be was headed toward a troubled life like his grandfather's. Thus, he was brought home by taxi one night, disoriented after a night of drinking, and left at their front door. Another time he phoned them while obviously drunk to ask about some minor issue that had arisen the day before. His parents, frightened and frustrated by such episodes, insisted that he see a psychiatrist for this problem. A potential life of alcoholism was the fate that they wanted me to prevent, and Dwight, when we all met, could not bring himself to speak up for anything positive about himself. The irony was that Dwight's life was, of course, more complex than this diagnosis of alcohol abuse. When he came to see me he was indeed Psychotherapy for Personal Meaning

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holding a responsible position in his corporate niche and was well regarded for his compliance and his diligent approach to his work. He was as cooperative in treatment as he was on the job, and congenial as well. For his parents, though, who I saw at intervals along with him, there was still the attitude of, "What have you done wrong?" even when his later progress in the drinking domain became apparent and while he began to prepare for applying to law school. Dwight's story is relevant here because the applications for law school presented him with a problem that was important beyond the immediate task. The essay questions dealt with why he wanted the education, how it fit in with his future plans, and, by implication, who he was as a person. Dwight was at a loss: How was he to present himself on his applications and in his interviews? How could he put forward a distinct identity and interests that would distinguish him from other candidates. He had spent years living up to his negative labeling and saw no asset of his own other than his ability to comply with the expectations of his superiors at work, or to go drinking with his friends to effectively assert his autonomy. It was clear that in order to address his drinking problem and, by extension, to address the law school applications, he needed to sort out a meaningful identity for himself and thereby validate himself as a decent person rather than a repentant sinner. As we spoke of his past, it emerged that he had had a collaborative and congenial relationship—not unlike our own—with a professor in college who was dissecting out historical issues related to the legal prerogatives of corporations, the subject of the professor's scholarship. Dwight had given little attention to his schoolwork in his first 2 years in college, but this experience had led to a valuable contribution in the form of a paper he wrote and a marked improvement in his academic performance. The relevance of the experience with the professor had been lost to him in the midst of the need to comply with the demands of his superiors at work and get drunk with his friends. It had, however, been highly influential in his decision to become a lawyer. I encouraged him to reflect on this part of his life, and he could see how the experience related to what he might see for himself as an attorney and an accomplished adult. He apparently had the ability, he realized, to act in a way that was both fulfilling for him and highly regarded. On an immediate

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level it became clear to him that this could provide a character to the person he was as a law school applicant. Experiences of suppression in early life can leave a person unable to articulate an identity that provides him or her with a sense of personal worth and direction. In Dwight's case the idea that he could perform in a way that was meaningful to him and a mentor clearly important to his evolution into an adult with a sense of direction. It was also important in allowing him to give up his symptom of heavy drinking, which he did over the several months that he was in treatment.

Spreading the Word

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s it feasible to employ an approach to treatment that requires considerable time to move a person toward a more meaningful life? Let us put aside the issue that countries such as Canada and Germany do support such an approach within their government-funded health care. What options do we have in the United States within our existing mental health system? Groups such as the Rand Corporation have carried out analyses on the cost of full mental health coverage under current insurance plans, revealing an overall increment in premiums that would be quite modest.7 This is due in part to reduced hospitalization rates, a relative decrease in demands for medical care for psychosomatic complaints, and the option of employing professionals for psycho therapeutic rehabilitation who are less costly than are psychiatrists. (The benefit of giving a troubled person a meaningful and productive life would not be unimportant as well.) Psychiatrists constitute only a small portion of practitioners in the mental health field, and the approach involved in psychotherapy for Dan and Dwight can be undertaken by nonmedical disciplines as well. The practice of psychiatrists prescribing medications while psychotherapy is carried out by nonphysicians such as psychologists and social workers is also well established. The actual number of practitioners available within the mental health field illustrates the option of broader access to such care. Clinically trained professionals among psychologists (77,456) and social workers (192,814) predominate over psychiatrists (40,731) by

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a factor of more than six.8 Federally funded programs have also demonstrated the feasibility of training suitable people who have no graduate professional degrees to provide ongoing psychotherapy, thereby adding further to the pool of potential therapists. Additionally, the field of certified alcoholism and addiction counselors has emerged on a large scale in recent years, adding more to this pool of professionals. As substance abuse programs have proliferated, it became necessary to train a large cadre of professionals to staff them. The certification process for these counselors, formalized only in the last two decades,9 illustrates the way psychosocial therapy training can be disseminated. It typically involves 2 years of supervised clinical work and the equivalent of a master's degree in instructional hours, followed by examination. The broadening base of psychoanalytic practitioners over a similar period illustrates the acceptance of professionals other than psychiatrists by psychiatrist-psychoanalysts themselves.10 Certification of training for psychoanalysis in the United States was restricted to medically trained practitioners until 1984, when the American Psychoanalytic Association agreed to accept psychologists and social workers into its ranks. While psychoanalysis per se is not necessarily a modality congruent with the approach described in this chapter, its history in the United States illustrates the feasibility of disseminating a mode of practice more widely. In sum, an approach compatible with the benefits of psychopharmacology that promotes the pursuit of a meaningful life could be made more widely available. Why should we not promote the achievement of a meaningful life in people troubled by years of unhappiness or unfulfilled potential? Is it really necessary to expunge this goal from the domain of mental healing?

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Epilogue

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he idea of introducing an approach based on spirituality into the practice of a scientifically grounded treatment is quite daunting, but I have tried to suggest how this might be done. We began with the observation that spirituality is important in the lives of many people but that its expressions vary widely. Because the concept itself seemed elusive, it was pursued here by triangulation, from psychological, biological, and cultural perspectives. Although the nature of spirituality maybe ambiguous, psychiatry itself is not easily defined. It is a profession, not a science, and one that seems to renew itself every few decades in different colors. The dictionary defines a profession in terms of its practitioners' "receiving pay" or "possessing great skill or experience in a field or activity," but these terms provide little help in capturing how the culture of any of the mental health professions is framed, psychiatry included. How is psychiatry defined by its practitioners? One esteemed member of the profession insisted that the members of his profession had no obligation to deal with "problems of daily living" and advocated defining psychiatry on the basis of diagnoses constituted by symptoms pieced together like choices on an a la carte menu. So trainees in psychiatry now learn to do "work ups" that break down patients' presenting problems into a series of symptoms and socially defined misbehaviors. They

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acquire knowledge of psychopharmacology from sources such as the American Psychiatric Association's weighty 1,248-page textbook on that subject.1 To be certified they interview patients to test their skills in handling the current lexicon of symptoms, interviews they must structure along relatively narrow lines, but their own patients will not "get better" solely by removing items from symptom lists; they also need to aspire to what they would like for themselves in a positive way. The quandary of introducing spirituality into clinical practice is not restricted to psychiatry. University-based departments of psychology, for example, are increasingly pressured to demonstrate their legitimacy as science-based by carrying out NIH-sanctioned research, which is usually physiologically or cognitively oriented. In fact, cognitive-behavioral therapy, based on paradigms drawn from academic psychology, is beginning to look like that profession's clinical hallmark, but like psychopharmacology, it is a structured approach that addresses specific problems, one that was initially directed at phobic anxiety, later at depressive thinking, and more recently at drinking problems, as well. At its heart the approach circumvents the need for considering what is meaningful in a person's life. Mental health professionals, who have such compelling entree into people's deepest concerns, are being painted into a corner and are in danger of losing their chance to help their patients in a very important way. Hence, they will either engage them on issues that lend meaning to life or be superseded in this domain by people who claim to heal and offer succor but answer only to idiosyncratic groups or to themselves alone. Here are some messages relative to this quandary for the people who deal with it: clinicians, researchers, and patients themselves.

For Clinicians

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t may not be easy to get at what can be meaningful in the lives of your patients. Many have had their ability to explore their inner worlds and their initiative to look forward compromised by their emotional difficulties, if not by a lifetime of problems. Others have even lost track of the rudiments of "self care"2—discerning the realities they confront,

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exercising good judgment, and avoiding harmful situations. All this is a problem even before you have had to contend with the pressures of economics and managed care. An amalgam of these problems can delimit what journey, hidden from expression, they may undertake to find validation, but each patient deserves the opportunity to—at least— consider that journey. Consequently, it will take a good deal of creativity and commitment to frame a meaningful course with your patients that they can pursue. However troubled they may be, the people you treat can still be asked what they consider most important in their lives: family, friends, some interest that has engaged them. You can ask them if they have had religious or spiritual experiences, even moments of epiphany, that inspired them.3 If they have trouble coming up with answers, they may be able to think of something that they found interesting or enjoyable, that broke through the unhappiness they may have experienced. As soon as they have become engaged in therapy, you can ask them for some goals they would like to attain in a few years. Then weave all these answers into the fabric of their treatment and bring up the goals they initially mentioned over the course of your work with them to help them set a course for themselves. The guidelines for clinical care published by the American Psychiatric Association have been detailed and revised in compendia4 totaling more than 2,000 pages. No mention is made in them of the importance of the hopes and aspirations of patients and of how they should be helped to lead more meaningful lives. Perhaps a modest addendum to this detailed body of work is in order.

For the Research Community

H

ow can we do research on the complex issue of spiritually oriented recovery? Neuroscience is becoming increasingly prominent in psychiatric research, but what is meaningful to a given person is largely an issue of the mind rather than the brain. Academic psychology is increasingly adhering to reductionist models of investigation drawn from the physical world and is moving away from the subjective experiences

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that can define the identity of a given unique person. In any case, it is not possible to conduct randomized, controlled clinical trials—the darlings of treatment research—on the issue of spiritual meaning. A more hopeful note derives from the trajectory of scientific investigation over the long haul. Thomas Kuhn5 pointed out that "normal science" embodies the established model of research at a given time. The practitioners who apply this model garner support for their work because it generates useful answers to the questions it poses. New paradigms of research do not necessarily arise because they prove established ones wrong, but often just because the established techniques employed in the normal science run out of useful questions to be answered. A newly emerging paradigm is then accepted because it can raise challenging issues and produce answers to a flurry of new questions. People's pursuit of alternative medicine and of spirituality suggests that with all our medical advances, many important questions are left unanswered, even unasked. Hence, we now have the option of applying a new research paradigm, one for understanding spiritually related issues such as the motivating role of personal values, the intensity of subjective experience, and revelatory influences in group settings. Approaches to research in this domain may be developed. They may constitute a paradigm for posing new and compelling questions to be answered. And what questions might be asked within that paradigm? One was posed at the outset of this treatise: what is the nature of spirituality, and how does it intersect with psychiatry? We have examined a variety of approaches to this question, including the integration of psychological and biological models, and how this phenomenon is expressed in different cultures. What is needed now is an approach that integrates a large variety of observations like these in a creative manner. No scientific discipline will lay claim to having the one valid perspective on this issue. Physiology can give us lessons about those aspects of brain function that support the spiritual experience. Social psychology can be used to examine the way related movements and the cultures they are embedded in can shape people's experiences, and so on for cultural anthropology, psychodynamic and cognitive psychology, and the like. We will need researchers who understand these disciplines well enough to integrate their respective findings. 250

Epilogue

For the Patient A fter reading this book, you can see that there can be a unique and ./^individual path for each person to take toward recovery from his or her emotional problems. Your own choice may be determined by the immediate concerns that brought you to treatment: depression, loneliness, anxiety, or trouble harnessing a compulsive habit. You may have even come largely at the behest of others. It is first important that you choose a clinician to help you whose practices and competency are recognized by a well-established professional organization to assure that you receive the benefits that medicine and psychology have drawn on from carefully constructed research, but your spiritual needs should be addressed as well, so that you can achieve a well-supported recovery and attain goals that are meaningful to you. Spirituality is an option for pursuing this, but you should know that it has a fairly narrow window of applicability in your treatment. It is delimited by the domain of formal religious practice, on the one hand, and by the constraints of scientifically validated treatments, on the other. It is also important that your therapist be sensitive to your spiritual orientation, even though it may be different from hers or his own. So what remains at the intersection of the spiritual and the scientific aspects of treatment? Here is one option: you can draw help from a therapy that is secular in nature, but one that also addresses what is meaningful in your own unique life. Your recovery can go beyond what is purely pragmatic, beyond issues of physical and economic comfort, and even beyond emotional comfort. It can transcend the dictates of other people and the surrounding society and help you seek out the opportunity to pursue the fruits of your own individuality. So while your acute symptoms are being addressed, even before you feel a full sense of recovery, consider these questions: • What have you missed experiencing or doing because of the problem that brought you to therapy? • What were some of the things that you enjoyed at any point earlier in life that excited your interest or enthusiasm? • What spiritual resources can you draw on to help you consider a more meaningful course in your life? Epilogue

251

After you have considered these questions, ask yourself: • What are some goals you would like to achieve in a few years once your current problem is addressed? • What could you see, read, or visit to pursue these goals? If you have a therapist who can understand the quest embodied in these questions, raise these issues in your treatment, although your therapist may have neither the time nor the inclination to address these questions. The fact is that many people in the mental health profession are not prepared to see such issues as relevant to their work, but that does not have to mean these issues are unimportant to you. Remember, recovery from pain, trauma, distress, and even the harshest of symptoms can carry with it a unique gift: the opportunity to look into the mirror and ask yourself if there are some aspects of your life that you can start anew. In answering this question, you can then look beyond that mirror and see what lies on the other side.

252

Epilogue

Notes

PROLOGUE

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

M. Galanter et al. 1972; M. Galanter et al. 1973; M. Galanter et al. 1974. M. Galanter 1976. M. Galanter 1980. M. Galanter, D. Talbott, K. Gallegos 1990. M. Galanter et al. 1994; Galanter et al. 1998. L. Goldfarb et al. 1996; D. McDowell et al. 1996. G.O. Gabbard 2000, p. 103-123. K. Hausman 2004, p. 2 ff. M. Galanter et al. 2000. D.M. Eisenberg et al. 1993.

CHAPTER 1. S P I R I T U A L I T Y E M E R G E S

i. G.H. Gallup 2002.

C H A P T E R 2. A P S Y C H O L O G I C A L P E R S P E C T I V E

1. 2. 3. 4.

R.T. Hales and S.C. Yudofsky 1999. American Psychiatric Association 1994. G.H. Gallup 2002. W. James 1929, p. 14

253

5. A.H. Maslow 1964. 6. S. Freud in Strachey J. (ed) 1955 7. O. Pfister 1948. 8. C.G. Jung 1936. 9. D.W. Winnicott 1971. 10. A-M. Rizzuto 1979. 11. W. James 1929, p. 32. 12. E. Fromm 1947. 13. G.W. Allport 1961; 1967. 14. A.E. Bergin 1980. 15. CD. Batson 1983. 16. M. Galanter and P. Buckley 1978. 17. M. Galanter 1980. 18. M. Galanter 1980. 19. M. Galanter 1978. 20. M. Galanter 1978,1980,19833. 21. M. Galanter 19831?. 22. H.H. Kelley 1967. 23. W. Proudfoot and P. Shaver 1975. 24. L. Festinger 1957. 25. M.T.Tsuang 1996, p. 79-109. 26. J.C. Scares and J.J. Mann 1997. 27. I. Kirsch 1999, pp. 303-320. 28. B.T. Walsh et al. 2002. 29. S.A. Montgomery, P.E. Reimitz, and M. Zivko 1998. 30. P. Kramer 1993. 31. J.B. Moseley et al. 2002. 32. J.R. Fox 1964.

CHAPTER 3. SPIRITUALITY AND THE BRAIN

1. S. Schachter and J.E. Singer 1962. 2. M.S. Gazzaniga 1970. 3. P.D. Maclean 1990. 4. J.A. Hobson et al. 2000. 5. O. Blanke et al. 2002. 6. J. Frank 1961. 7. J. LeDoux 1996. 8. D.O. Hebb 1949. 9. A.F. Leuchter et al. 2002. 10. H.A. Sackeim 2001. 11. J.C. Corby et al. 1978. 254

Notes

12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

A. Newberg et al. 2001. J.C. Corby et al. 1978. C-K. Peng et al. 1999. C-K. Peng et al. 1999. B.K. Anand, G-S. Chhina, and B. Singh 1961. J.C. Corby et al. 1978. A. Newberg et al. 2001. J. Borg et al. 2003. J. Bowlby 1973; R.A. Spitz 1946. B.M. Seay, E.W. Hansen, and H.R Harlow 1962. S.J. Suomi, H.R Harlow, and W.T. McKinney 1972. S.J. Suomi et al. 1978. K. Kendler 1997. American Psychiatric Association 1994. A.D. Solomon and D.M. Johnson 2002. C.R. Brewin, B.Andrews, and J.D. Valentine 2000. N. Tinbergen 1951. K. Lorenz 1966. R.L. Trivers 1971. E.O. Wilson 1975; 1978. C.D. Batson 1983. D.S. Wilson 2002. A.R. Radcliffe-Brown 1939. S. Freud 1961.

CHAPTER 4. THE APPARENT CONFLICT

1. W. James 1929. 2. C.P. Snow 1993. 3. M. Galanter, S. Blume, and L. Bissell 1983. 4. M. Galanter and D. Talbott 1990. 5. L.E. DeLisi et al. 2002. 6. H. Begleiter et al. 1984. 7. S. Brown, R.L. Steinberg, and H.M. van Praag 1994. 8. L. Leibovici 2001. 9. D.M. Eisenberg et al. 1993. 10. R.C. Kessler et al. 20013. 11. K.M. Fairneld et al. 1998. 12. R.C. Kessler et al. 20Oib. 13. B.T. Walsh et al. 2002. 14. N.K. Choudhry 2002. 15. M.B. Rosenthal et al. 2002. Notes

255

16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

M. Olfson et al. 2002. J. Wesley 1960. P. Starr 1982. A. Flexner 1910. Thomson Financial Datastream 2002. M.B. Rosenthal et al. 2002. KG. Alexander and and S.T. Selesnick 1966. P. Starr 1982. J.P. Feighner et al. 1972. Washington Post 2002. M. Galanter et al. 2000. M. Galanter 1999.

CHAPTER 5. PROBLEMS WITH SPIRITUALITY

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

W.B. Cannon 1929. S.E. Asch 1956; S. Milgram 1974. M. Galanter 1980. J.M. Weightman 1983, p. 116 H.F. Searles 1965. G.W. Brown, J.L. Birley, and J.K. Wing 1972. I.D. Yalom and M.A. Lieberman 1971. W.R. Bion 1959. M. Galanter 19833. T.H. Holmes and R. Rahe 1967. M. Galanter 1986. New York Times 1999-2002. C. Lasch 1979. G.W. Allport and J.M. Ross 1967. Saferparks Database 2003. New York Times Almanac 2002. Time Magazine: Inside Business 2003. Time Asia 2003. Quart 2003. New York Open Center 2003. Associated Press 2002. M. Berg 2002.

CHAPTER 6. WHEN SOMETHING IS MISSING

1. T. Pettersson 2000. 2. G.H. Gallup 2002. 256

Notes

3. 4. 5. 6. 7. 8. 9.

V. DeMarinis 2003. G. Andrews and S. Vinkenoog 1967. American Psychiatric Association 1994. T.H. Holmes and R. Rahe 1967. E. Salib 2003. M.J. Horowitz 1986. I. Skre et al. 1993.

C H A P T E R 7. C H R I S T I A N PSYCHIATRY

1. 2. 3. 4.

M. Galanter, D. Larson and E. Rubenstone 1991. G.H. Gallup 2002. D. Biebel 1998. D. Carlson 1984.

CHAPTER 8. SPIRITUALITY IN INDIA

1. 2. 3. 4. 5. 6.

N.C. Chaudhury 1979. B. Thomas 1997. I. Sharma 1989. A. Pakaslahthi 1998. G. Edwards and G. Kissin 1977. K.R. Jamison 1996.

C H A P T E R 11. A L T E R N A T I V E M E D I C I N E

1. R.C. Kessler et al. 20013; 2ooib. 2. D.M. Eisenberg et al. 1998. 3. G.H. Gallup 2002. 4. M.S. Peck 1985. 5. W.A. Fintel and G.R. McDermott, 1993. 6. M. Galanter et al. 1991. 7. J.S. Gordon 1990. 8. A. Robinson 1994. 9. D. Chopra 1989. 10. D.R. Williams et al. 1991; L.E Berkman 1978. 11. M. Galanter i983a. 12. D.W. Goodwin 1985. 13. S. Waldfogel and P. Root Wolpe 1993. 14. J.W. Pennebaker, J.K. Kiecolt-Glaser and R. Glaser 1988. Notes

257

15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41.

R. Glaser et al. 1985. D. Russell et al. 1980. J.T. Cacioppo 1994. J.M. McGinnis and W.H. Foege 1993. D.M. Eisenberg et al. 2001. A.A. Skolnick 1991. W. Parry-Jones 1981. E. Roosens 1979. Project MATCH Research Group 1997. A. Kleinman 1980. A. Leighton and D. Leighton 1941. J.G. Kennedy 1967. J.A. Adetunji 1992. M. Singer and M.G. Borrero 1984. T.A. Maugans and W.C. Wadland 1991. K.K. Trier and A. Shupe 1991. M. Galanter et al. 1991. B.R. Cassileth et al. 1984; F.S. Bagenal et al. 1990. I.D. Yalom and M.A. Lieberman 1971. I.J. Lerner and B.J. Kennedy 1992. M.B. Eddy 1989. E.M. Pattison et al. 1973. C.K. Hofling et al. 1996. A. Bandura 1986. A.T. Beck 1976. M. Galanter et al. 1993. B.S. Siegel 1990.

CHAPTER 12. ALCOHOLICS A N O N Y M O U S

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

258

Notes

Alcoholics Anonymous 1957. Alcoholics Anonymous 2002. New York Times, August 2001, page Bi. J.N. Chappel 1993. E. Sifton 2003. K. Kendler 1997. J. Borg et al. 2003. M. Galanter et al. I99ob. K. Humphreys et al. 1997. Project MATCH Research Group 1997. M. Galanter 19803.

12. C.D. Emrick and J.T. Tonigan 2004. 13. Physicians' Desk Reference 2004.

CHAPTER 13. R E T H I N K I N G CARE OF THE MENTALLY ILL

1. F.G. Alexander and S.T. Selesnick 1966. 2. American Psychiatric Association Committee on Nomenclature and Statistics 1968. 3. K.T. Erikson 1967, p. 300. 4. E. Goffman 1963. 5. D.L. Rosenhan 1973. 6. E. Goffman 1963, p. 32. 7. World Health Organization 2002. 8. M.T. Tsuang 1978. 9. S.B. Guze and E. Robbins 1970. 10. G.E. Murphy and R.D. Wetzel 1990. 11. R. CastaUneda et al. 1989. 12. M. Galanter et al. 1992. 13. G. Haugland et al. 1991. 14. M. Galanter 19893. 15. C. Silberstein et al. 1994. 16. A. Kim et al. 1992. 17. M.A. Madden 1990. 18. D. Rochester 1997. 19. Gimme a roof over my head. The Economist, August 23,2003, pp 23-24. 20. M. Jones 1953. 21. American Psychiatric Association 1994. 22. S. Ross et al. 2003. 23. G. De Leon 1997. 24. M. Rokeach 1964. 25. D. Turkington, DG. Kindon and T. Turner 2002. 26. A.T. Beck 1976. 27. J. Frank and J.B. Frank 1961, p. 33. 28. R.D. Laing 1967. 29. L.R. Mosher and A.Z. Menn 1978. 30. B.A. Johnson et al. 2000. 31. M. Peterson. The New York Times, February i, 2004. Section 3, page iff. 32. M. Galanter et al. 1994. 33. L. Goldfarb et al. 1996 and D. McDowell et al. 1996. 34. H. Dermatis et al. 2004. 35. Alumnae Association of Bellevue 1915.

Notes

259

36. 37. 38. 39. 40. 41.

Gold Award 1993. H. Franco 1995. H. Dermatis et al. 2004. D. Mierlak et al. 1998. M. Galanter et al. 1998. S. Gilman, M. Galanter and H. Dermatis 2001.

C H A P T E R 14. A S H A M A N IN THE HALLS OF M E D I C I N E

1. M.E. Opler 1936. 2. S.C. Krippner 2002. 3. J.D. Frank 1971. 4. B.T. Walsh et al. 2002. 5. J. Sarno 1982. 6. E. Volinn 1997. 7. D.L. McRae 1956. 8. A.J. Fox et al. 1975 9. H. Schrader et al. 1996. 10. M.E. Tota-Faucette et al. 1993. 11. J.G. Jarvik et al. 2003. 12. J.M.L. Dvorak, Gauchat and Valach 1988. 13. G.M. Franklin et al. 1995. 14. National Center for Health Statistics 1997.

C H A P T E R 15. M E D I T A T I O N

1. Maharishi Mahesh Yogi 1966. 2. H. Benson 1975. 3. C. Patel et al. 1985. 4. A.J. Deikman 1996. 5. M. Epstein 1995. 6. J. Kabat-Zinn et al. 1992. 7. J.}. Miller, K. Fletcher and J. Kabat-Zinn 1995. 8. S.H. Ma and J.D. Teasdale 2004. 9. J. Kabat-Zinn, L. Lipworth and R. Burney 1985. 10. D.L. Goldenberg 1987. 11. R.H. Kaplan, D.L. Goldenberg and M. Galvin-Nadeau 1993. 12. J. Kabat-Zinn et al. 1998. 13. S. Cohen, D.A.J. Tyrrell and A.P. Smith 1991. 14. R.J. Davidson et al. 2003.

260

Notes

CHAPTER 16. PSYCHOTHERAPY FOR P E R S O N A L M E A N I N G

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

V. Frankl 1984. L. Luborsky et al. 1985. H.A. Murray 1938. B. A. Johnson et al. 2000. A.E. Bergin 1980; 1991. K.S. Kendler et al. 2003 R. Sturm 1997. U.S. Substance Abuse and Mental Health Services Administration 2000. R.C. Page and J.B. Bailey 1991. M. Margolis 2001.

EPILOGUE

1. 2. 3. 4. 5.

A.F. Schatzberg and C.B. Nemeroff (eds) 2002. E.J. Khantzian, K.S. Halliday, and W. E. McAuliffe 1990. R.M. Miller (ed) 1999. American Psychiatric Association 2002,2004. T. Kuhn 1962.

Notes

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Index

AA. See Alcoholics Anonymous AAAP (American Academy of Addiction Psychiatry), 50-52 Academic psychology, 249-250 Addiction to alcohol. See Alcoholism Islamic treatment program, 147 mental illness and, 209 Minnesota model for treatment, 65-66 substance abuse, mental illness and, 192-193 Adolescents, developmental norms, 9 Adrenalin, 31,32 Advertising revenues, drug manufacturer, 57 Arafa, Magdy, 147 Affiliation, group, 25,168 AIDS/HIV, 193-194 Al-Azhar mosque, 144 Alcoholics Anonymous (AA) denial of addiction and, 199 different attitude of members and, 183-184 efficacy/success of, 176 encounters with members, 181-183 evaluating participation in, 178-181 medical community acceptance of, 164 meetings, 175-176

membership, 175 origins, in spiritual experience, 157, 173-176 professional relationships and, 184-186 Project MATCH and, 180 redemptive potential of, 171-173 spiritual recovery and, 6, 51,162 subjective experience and, 177-178 Alcoholism mental illness and, 192-193 sociopathic behavior and, 238-239 suppression in early life and, 243-245 treatment. See also Alcoholics Anonymous absolute abstinence and, 183 cults and, 22 making meaning in life and, 100 Minnesota model for, 65-66 Rational Recovery program for, 169 role of spirituality in, 102-103 therapeutic community for, 196-199 Allport, Gordon, 18,19 Alternative medicine do no harm concept and, 165-167 emergence of, 54-56 popularity of, 159-160 spiritual recovery movements. See Spiritual recovery movements 279

Altruism, 20, 43-45 AMA (American Medical Association), 59-60 American Academy of Addiction Psychiatry (AAAP), 50-52 American Board of Medical Specialties, 60 American Journal of Psychiatry, drug manufacturer advertising revenues and, 57 American Medical Association (AMA), 59-60 American Psychiatric Association (APA) annual meeting, 64-65,113 clinical care guidelines, 249 Group for Advancement of Psychiatry and, 63 pharmaceutical companies and, 57 psychopharmacology and, 248 American Society of Addiction Medicine (ASAM), 50-52,65,66,186 Anger against God, 151-152 intense, 79 toward father, 236-237 unconscious, 218-219 Anthropology, 46 Antibiotics, 133 Anti-Communism, 8 Antidepressants for depression, 117,118,197, 241-242 effectiveness of, 170 meaning to life and, 96 placebo-controlled studies, 28-29, 215 sales of, 64 vs. social support for depression, 41 Antipsychotic drugs, 195, 201-203 Anti-Semitism, 8,15 Anxiety disorders cultic religious sects and, 162 curbing, cults and, 22 meditation for, 229 spiritual explanation of, 26 APA. See American Psychiatric Association Apache shamans. See Shamans, Apache Applewhite, Marshall "Bo," 108-109 Archetypes, 15 Arthroscopic surgery, 29 ASAM (American Society of Addiction Medicine), 50-52,65,66,186

280

Index

Asanas, 132 Asch, Solomon, 70-72 Astanga yoga, 132 Attention-deficit/hyperactiivty disorder, 243 Attribution theory, 25-26 Aum Shinrikyu, 20 Australopithecus, 46 Authoritarian religious viewpoint, 19 Autonomy, 89 Awareness, 229 Ayurvedic medicine, 7,132-134 Back pain treatment, 217-218 Balaji, religious/spiritual commitment in, 134-136,221 Batson, Daniel, 20 Beatitudes, 124 Behavior, evolutionary basis of, 43-45 Behavioral traits, biological factors and, 20 Bellevue Hospital, New York, evolution of mental health program, 204-213 Benares Hindu University, 131 Bergin, Allen, 19,239 Bernard, Claude, 189 Bible, 114-115,153 Biomedicine metaphor of, 56-58 research, 63-64 Bion,W.R., 81-82 Biopsychiatry, vs. problems of daily living, 64 Blue Cross and Blue Shield, 61 "Bollywood," 129 Bone pointing, 68-70 Borderline personality disorder, 238 "Born again" Christians, 12-13,114,115 Bottoming out, 180-181 Boundary crossings, 116-117,124-125 Boundary violations, 116,124-125 Brain electroencephalography of placebo effect, 37-38 emotional energy and, 32-35 evolutionary adaptation of, 43-46 meditation and, 38-40 memories and, 35-37 metabolism, transcendence experience and, 177-178

nonspecific stimuli and, 31-32 social support and, 40-42 Brainomed, 169-170 Branch Davidians, 20 Buddha, 130 Buddhism, 128, 229 CAM (complementary and alternative medicine), 55 Cancer patients alternative treatments for, 163, 165-166 religious healing for, 161 Cannon, Walter, 68-70 Cardiovascular system, psychosocial factors and, 162-163 Caregiver, judgment of, 166 Catechisms, as "cultural genomes," 45 Catecholamine hypothesis, for depression, 52-53 Catholics, 8 Cell assemblies, 37 Cerebral cortex, 34 Chaplaincy clerical collar and, 154,155 dealing with anger against God, 151-152 demands of, 76-77 listening style and, 155-156 therapeutic tools for, 152-153 therapist-spiritual mentor relationship and, 155 trainees, 149-151 Charismatic groups definition of, 83 psychological well-being of members and, 84,86 Children, praying with, 154-155 Chlorpromazine (Thorazine), 195,202 Christian Medical and Dental Association, 77,161 Christian Medical Association (CMA), 113-118 Christian psychiatrists with Fundamentalist orientation, 122-125 literal role of Jesus and, 125-127 working with, example of, 118-122 Christians beliefs of, return to, 10 "born again," 12-13, n4> 115 Second Advent, 59

Christian Science, 166 Church attendance, 161 Cingulate gyrus, 33 Classical conditioning, 36 Clerical collar, 154,155 Clinical practice, introducing spirituality in, 247-248 Clinicians, spiritually oriented recovery and, 248-249 CMA (Christian Medical Association), 113-118 Cocaine, 192-193 Codependency, 162 Cognitive-behavioral therapy, 248 Cognitive dissonance theory, 26 Collective unconscious, 15-16 Community sense of, 109-110 support from, 162 Complementary and alternative medicine (CAM), 55 Compulsive eating, Christian psychiatry for, 122 Conditioned response, 35-37 Conflict, in mental health field, 49-52 Conformity, 71 Contraceptives, 9 Conversion symptoms, 138-139 Coordination, in religious groups, 45 Corpus callosum, severed, 32 Corticotropin-releasing factor, 42 Cortisol, 42 Crack cocaine, 192,193-194 Creative visualization, 162 Cremations, Manika, 130 Cults decreased stress in, 162 disasters, 108-109 group affiliation and, 44 leaders of, 74 mass poisoning incident, 74-75 problems associated with, 82-86 spiritually oriented perspective of, 20-23 Cultural reintegration, beginning of, 10-11 Culture distortion of reality and, 72 impact of, 47-48 sexual inclination and, 45 Cupping, 161

Index

281

"Daily affirmations," 7-8 Darshan ceremony, 225-226 Daytop Village, 204 Deikman, Arthur, 228-229 Deinstitutionalization, mental illness and, 194-196 Dementia praecox, 189 Demonic possession, 165 Denial, of mental illness, 193 Depression catecholamine hypothesis for, 52-53 Christian psychiatry for, 117-118,122 cognitive approach for, 199 cultic religious sects and, 162 dealing with, hospital chaplaincy training for, 150 drug therapy for. See Antidepressants etiological factors, 27-28 humiliating experiences and, 242 management, cults and, 22 placebo treatment for, 28-29 psychotherapy for, 241 social support and, 40-41 treatment, integrating tradition into, 139-142 Dexamethasone suppression test, 53 Diet therapy, 160,161 Distress, psychological cult members and, 96 improvement, social cohesiveness and, 22 relief effect, 24-27 Divine Light Mission meditation and, 223 "receiving knowledge" and, 224-225 relief effect and, 24, 25 Satsang, 13-14,108 spiritually oriented perspective of, 20-22 Do no harm concept, 165-167 Dream imagery, importance/meaning of, 36-37 Dreaming, biology of, 33-34 Drug culture, 101 Drug marketing, to physicians, 61-62 Drug use, illegal, 9,22,192-193 Dual diagnosis, 192-193,197,204-205 Dymphna, 163-164 Dysfunctional parents, recovering from, 162

282

Index

Eastern spirituality, 7,159,161,223,227 Economics, of medical practice, 61 Eddy, Mary Baker, 166 EEC (electroencephalography), 37-38,53 Egotism, 19 Egypt, spirituality in, 144-145 Electroencephalography (EEC), 37-38, 53 Emotion, perception and, 32-35 Emotional control, 75-79 Emotional distancing, 76-77 Emotional distress, dealing with, Muslim religious persons and, 146-147 Emotional support, 160 Encounter groups, 80-81 Engagement, in cults, 23,25 Enlightenment, 96-97 Environment, in schizophrenia, 189-190 Ephedra, 166 Epilepsy, 32,34 Epistemiology, 91-92 Epstein, Mark, 229 Ethnicity, religion and, 8 Evidence-based medicine, 184-185 Evolution, 45-46 "Experience of significance," 107 Faith clinics, 165 Falun Gong, 20,86-87 Family childhood interactions with, 239 transcendence of, 136-139 FDA (Food and Drug Administration), 56 "Feighner" criteria, for psychiatric diagnosis, 64 Festinger, Leon, 26-27 Fibromyalgia, mindfulness meditation for, 230 "Finding oneself," 10 Fluoxitine (Prozac), 28 Food and Drug Administration (FDA), 56 Forgiveness, Christian, 117,123-124 Frank!, Viktor, 232-233,240 Freud, Sigmund, 14-15,16 Fromm, Eric, 18 Fulfillment, spiritual, 92-93 Fundamentalist religion beliefs in, 10

Christian Medical and Dental Society and, 77 Christian psychiatrists and, 111-112, 122-125 conversion experiences and, 26 Gandhi, 140 Ganges, ritual immersion in, 130 GAP (Group for Advancement of Psychiatry), 63 Gautama, Siddhartha, 130 Gender roles, 9 Genetic studies, of social support, 41-42 Gifting, 98-99 God anger against, 151-152 belief in, 17,114,161,182 conception of, 17 Grief, hospital chaplaincy training for, 150 Group for Advancement of Psychiatry (GAP), 63 Groups, spiritually oriented, 20-24. See also specific groups affiliation intensity, 85 affiliation with, 25,168 charismatic, 83 disruptive life events and, 85 harm to participants and, 80 induction process, 85 intense experiences in, 79-82 intense influence from, 68 leadership of, 80-82 prayer in, 154-155 Halfway house, 205,208 Hare Krishnas, 20 Healing, spiritually oriented, 25-26 HealthCare Chaplaincy Program. See Chaplaincy Health-related products, medical claims for, 56 Health status, psychological impact on, 162-163 Heaven's Gate, 108-109 Hebephrenia, 189-190 Heisenberg effect, 221-222 Herbal remedies Brainomed, 169-170 for HIV, 55 toxic, 166

Herd instinct, 46 Heroin, 175 Higher power, belief in, 6,182 Hindu spirituality, 108,128-129,135 Hippocampus, 33 HIV/AIDS, 193-194 Holistic medicine, 7,161 Homeopathic medicine, 59-60 Homicide, 191 Homo erectus, 46 Hopelessness, mental illness and, 191,193 Hormones, stress and, 163 Hospitals. See also Mental hospitals historical overview of, 60-61 Humanity, respect for, 19 Hypersexuality, 116 Hypothalmus, 33

Id, 33 Immune system, psychosocial factors and, 162-163 Inadequacy, sense of, 242 India Ayurvedic medicine in, 132-134 contemporary trends in, 129-130 Hinduism in, 108,128-129 integrating tradition into therapy, 139-142 psychiatrists in, 111 spiritual center of, 130-134 trance states and, 134-136 transcendence of family in, 136-139 yoga in, 131-132 Individual identity, 100 Infantile drives, 16 In-laws, 138-139 Inspirational books, 161 Integrative psychiatry training program, 147 Integrity, 100 Intensity, of spiritual experiences, 13 Interpersonal relationships, in shaping human experience, 16 Irrational personal unconscious, 15 Islam addiction treatment program and, 147 clergy, 146 culture and, 143-144 importance of "the word" in spiritual discourse, 153,222 intellectual capital of, 144

Index

283

Islam (continued) prayer and, 145-146 radical terrorism and, 148 spiritual figures in, 144 Sufism and, 144,147-148 suicide and, 147 James, William, 14-15,17-18,49 Jellinek Clinic, 102-103 Jesus, literal role of, 125-127 Jews, 152 Joint Commission on Accreditation of Health Organizations (JCAHO), 61 Jones, Jim, 74-75 Jonestown poisonings, 74 Journal of Addictive Diseases, 57 Jung, Carl Gustav, 15-16 Kabat-Zinn, Jon, 229 Kabbalah, 92 Kaiser-Permanente network, 61 Kendler, Kenneth, 239-240 Koran, 145,146 Kotb, Shaikh Gamal, 144 Laboratory-based findings, over-reliance on, 53-54 Last rites, 152 Leaders of charismatic groups, 83 group, vulnerability of, 80 omniscient, 82-83 Lewin, Kurt, 80 Life events, disruptive, 109 Life transitions, 94-99 Limbic system, 33,34 Logic, definition of, 16 Lord's Prayer, 178 Macrobiotic diet, 161 Mahabharata, 129 Making-meaning, of life, 100-101 Maladaptation syndromes, 238 Maladaptive behavior, 25 Malpractice, orthopedic procedure, 218, 220 Managed care programs, 66-67, *59 "Marathon" groups, 79-80 Marijuana, 9,100-101,104 Marriage, support from, 162

284

Index

Maslow, Abraham, 14 Materialism, 89-90,94-95 Maturation, 16 Meaningful life, moving toward, 245-246 Meaning of life responding to spiritual void and, 99-107 search for, 95-99,100 A Medical and Spiritual Guide to Living with Cancer, 161 Medical illness, spiritual approaches to, 7 Medical materialism, 13 Medicine, scientifically grounded, 59-60 Meditation brain during, 38-40 mindfulness, 188,227-231 mystification process, 224-225 Transcendental Meditation, 35,38, 227-228 Memory long-term, 33 of spiritual experiences, 35 Mental health field, conflict in, 49-50 Mental hospitals deinstitutionalization and, 194-196 pseudo-patient experience in, 190-191 Mental hygiene concept, 194 Mental illness belief issue and, 199-203 deinstitutionalization and, 194-196 denial of, 193 historical treatment of, 62-63 hospital-based program evolution of, 204-213 interest in redemption and, 203-204 labeling of, 190,203 program evolution, 204-213 substance abuse and, 192 therapeutic community and, 196-199 Mental state, neural stimuli and, 31-32 Methadone, 175 Methodism, 58 Methodology fallacy, 53-54 Milgram, Stanley, 72-73 Mind-body connection, 215-216 Mindfulness meditation, 188,227-231

Minnesota model, for addiction treatment, 65-66 Mohit, Ahmed, 143-144 Moonies. See Unification Church Mother-in-law, 138-139 Moussa, Souad, 144-145 Moxibustion, 161 Music, popular, 9-10 Muslim Brotherhood, 148 Muslims, 111 Mystery School, Houston's, 96-9 Narcissism, 87-93 National Institute of Mental Health (NIMH), 63-64 National Institutes of Health (NIH), 63-64 Navajo Indians, ritualized beliefs of, 29-30 Needs, hierarchy of, 14 Neocortex, 33 Netherlands, absence of spirituality in, 101,102-103 Neurodegenerative disease, 160 Neuroleptic drugs, 195 New Age philosophies, 90-91,159 New Age programs, 96-97 NIH (National Institutes of Health), 63-64 NIMH (National Institute of Mental Health), 63-64 Obedience, 19 Ojha, 139 Operant conditioning, 36 Oppression, in close-knit family, 138 Out-of-body experience, 141 Oxford Movement, 174 Pain, somatic alternative healing techniques for, 167-170 backache, 216-218 cultic religious sects and, 162 illness and, 27 mindfulness meditation for, 230 Panic disorder, 229 Parents, mate selection for children, 138 Pastoral care, 149 Patient, spiritually oriented recovery and, 251-252 Pavlov, Ivan, 35-36

"Peak experiences," 14 Perception, emotion and, 32-35 Perfection, need for, 219 Persecution, living with, 86-87 Personal change encounters, 80 Personal conflicts, dealing with, maintaining spiritual role during, 76-77 Personality, biology and, 239-240 Personality disorders, 108,197,238 Personality traits measurement of, 19 of religiosity, 40 Personal meaning promise of, 96 psychotherapy for, 232-246 spirituality and, 11 Personology, 238 PET (positron emission tomography), 39-40 Pfister, Oskar, 15 Pharmaceutical companies drug advertisements, 57 drug marketing to physicians, 61-62 influence of, 57 promotion of new drugs, 58 Pharmaceutical sales, economics of, 57 Pharmacological treatment, 141-142 Physicians drug marketing to, 61-62 as purveyor of unitary spiritual message, 60 role, historical perspective of, 58-62 underestimation of spiritual orientation, 186 Pinel, Philippe, 194 Pir, 144 Placebo effect alternative medicine and, 55 description of, 27-30 electroencephalography of, 37-38 Hindu spiritualism and, 135 Positron emission tomography (PET), 39-40 Posttraumatic stress disorder (PTSD), 37,42,121 Practice guidelines, 57 Practitioners, definition of, 247-248 Pranayama, 132 Prayer in Alcoholics Anonymous, 175

Index

285

Prayer (continued) in avoiding conflict, 76 in emotional healing, 114-115 group, 154-155 Islamic, 145-146 power of, 53-54 spontaneous, 152,156 Premarital sexual intercourse, 9 Prescription drugs, direct-to-consumer advertising of, 57-58 Primitive societies, spirits and, 8 Problems of daily living, 247-248 Professional relationships, Alcoholics Anonymous and, 184-186 Project MATCH, 180 Prostitution, mental illness and, 194 Protestants, 8 Provo movement, 101 Prozac (fluoxitine), 28 Psychiatric disorders, with substance abuse, 204-205 Psychiatric hospitals, 63 Psychiatrists Christian, 114-115,116 community-based practice, 63 devoutly religious, 77 Fundamentalist Christian, 111-112 in India, in Psychiatry biology of, 52 spiritual perspective and, 149-150 Psychoanalysis, 14-17,16 Psychoanalytic practitioners, 245-246 Psychodynamic psychology, 239 Psychological damage, from group experience, 81 Psychological perspective, 20,107-110 Psychological well-being, measure of, 23-24 Psychopharmacology, 47,202 Psychosis, 107,193,200,201 Psychosocial factors cardiovascular system and, 162-163 immune system and, 162-163 Psychotherapy with medications, 147 nonspecific factors in, 214-215 for personal meaning, 232-246 spiritual experience and, 19-20,226 therapeutic alliance and, 233-240 Psychotomimetics, 9

286

Index

Racial segregation, 8 Ramadan, 146 Ramayana, 129 Rational Recovery, for alcoholics, 169 Reality denial of, belief in spiritual recovery and, 166 vs. subjectivity, 16 Reciprocal altruism, 43 Redemption, 203-204 Redemptive experience, belief in, 199-203 Redirection, need for, 109 Reframing, 233 Relaxation response, 227-228 Relief effect, 24-27,168-169 Religion ethnicity and, 8 secular viewpoint of, 17-19 spirituality and, 165 trance and, 134-136 vs. spirituality, 6-7,175 Religious, as "cultural genomes," 45-46 Religious awakening, 119 Religious experience disavowal in psychoanalytic movement, 15 meaningfulness of, 14-15 Religious faith, psychological validity of, 13 Religious groups, coordination in, 45 Religious intensity, 13,77-78 Religious orientations altruism and, 44-45 extrinsic vs. intrinsic, 88-89 impulse toward, 45 intrinsic, 19 sanction of, 117 types of, 19 Religious view, of spirituality, 17 Renewal, spiritual, 109 Research biomedical, 56-58 community, spiritually oriented recovery and, 249-250 Resiliency, no Rights, individual, 89 Ritualized beliefs, 29-30 Rizzuto, Ana-Maria, 16-17 The Road Less Traveled (Peck), 161

Rostam, 144 Rush, Benjamin, 62-63 Samadhi, 39,132 Sarno, John, 215-221 Satsang, 13-14,108 Schizophrenia environmental factors, 189-190 historical aspects, 189 offering of prayers for, 140-141 recovery from, 202 suicide attempts and, 191 symptoms of, 21 Schizotypal personality, 238 Scientific research, validity of, 72 Scientology, 10,166-167 Second Advent Christians, 59 Secular viewpoint, 17-19 Self-absorption, 88 Self-actualization, 14 Self-analysis, 140 Self-care, 248-249 Self-efficacy, 168 Self-justification, 19 Self-liberating approaches, 161-162 Self-realization, 19 Serenity Prayer, 175 Serotonin binding potential, 40 Serotonin reuptake inhibitor antidepressants, 28 Sexual inclination, culture and, 45 Sexual orientation, 9 Sexual practices, 9,116 Shahnameh, 144 Shaikh, 145,146 Shamans, Apache, 214-222 Sin, 126 Skinner, B.F., 36 Social cohesiveness, distress improvement and, 22 Social support brain and, 40-42 personal meaning from, 162 Sociobiological model, 20 Somatic approach, 217-218 Somatic hallucinations, 34 Soteria program, 201 SPECT, during meditation, 39 Spinal nerve root pressure, 219 Spirits, primitive societies and, 8 Spiritual Exercises in Everyday Life, 119

Spiritual experiences intense, 37 varieties of, 111-112 Spiritual healers, 139 Spiritual healing, placebo effect and, 29-30 Spirituality brain and. See Brain contemporary perspective, 8 definition of, 5-6 in India. See India as intense personal experience, 12-14 origin of, 7-10 personal nature of, 5-6 problems with, 68-93 cults. See Cults emotional control, 75-79 in groups oriented to professional growth, 79-82 narcissism, 87-93 persecution, 86-87 thought control, 70-75 "voodoo death," 68-70 religion and, 165 in Sweden, 100 vs. religion, 6-7,175 Spiritually oriented recovery clinicians and, 248-249 patient and, 251-252 research community and, 249-250 Spiritual needs, validation of, 105-107 Spiritual orientation evolution of brain and, 43-45 impulse toward, 45 Spiritual perspective, psychiatry and, 149-150 Spiritual recovery movements, 157-158. See also specific spiritual recovery movements acceptance of, 164-165 belief in, denial of reality and, 166 caregiver's judgment and, 166 characteristics of, 160-162 extreme, 20-21 psychological engagement in, 167-170 subjective experience and, 177-178 validation of, 185 Spiritual renewal, 37 Spiritual subcultures, 20-21 Spiritual void, responding to, 99-107 Spontaneous prayer, 152,156 Steinke, Paul, 149

Index

287

Stomach cancer, dealing with, 153-154 Stress, hormones and, 163 Subcultures, spiritually oriented, 163-165 conflicting messages in, 78-79 reality, distortion of, 72 value distortions and, 72-73 Subjectivity, vs. reality, 16 Substance abuse, 9,22,192-193 Sufism, 144,147-148 Suicide borderline personality disorder and, 238 hopelessness and, 191 Islam and, 147 schizophrenia and, 191 Suppression, as defense mechanism, 102 Surgery for back pain, 218 placebo, 29 Sweden, formal religion in, 100 Tâng-ki healers, 165 Target symptoms, 206 TC (therapeutic community), 196-199, 204, 208, 210, 212 Temporal lobe epilepsy, seizure locus, 34 Ten Commandments, 46 Terminal illness, 152 Terror experiences, 68-70 "T group," 79 Theophostic Ministry, 125-127 Therapeutic alliance, 233-240 Therapeutic community (TC), 196-199, 204, 208, 210, 212 Therapeutic relationship, effect of religious intensity on, 77-78 Thomsonians, 59-60 Thorazine (chlorpromazine), 195, 202 Thought control, 70-75 Thoughts Without a Thinker, 229 Tiananmen Square suicides, 87 TM (Transcendental Meditation), 35,38, 227-228 Token economy, 208 Traditional values, without spiritual ties, 101-102 Tranquilizers, overreliance on, 235-236 Transcendence, spiritual belief in, 169 escape from worldly pressure and, 175 feelings of, 40,141 illusion of, 88 need for, 8,10-11

288

Index

Transcendental Meditation (TM), 35,38, 227-228 Transcendent experience, functional anatomy and, 34 Transitional objects, 16 Treatment, spiritually oriented, 159 Twelve-Step process. See also Alcoholics Anonymous adaptive behavior and, 45 belief in, 179 at Hazelden Foundation, Minnesota, 102-103 liberal Islam and, 147 spirituality in, 7,50-52,159,162 Unification Church (Moonies) conformity and, 71 group affiliation and, 44 induction process, 27,71-72,74,108 marital engagement ceremonies, 83-84, 86 mental health professionals and, 23 relief effect and, 24,25 Reverand Moon and, 83 spiritual orientation of, 20 Universal spirit, belief in, 161 An Unquiet Mind (Jamison), 141-142 Validation, of spiritual needs, 105-107,185 Values distortion, by prevailing subculture, 72-73 Values orientation, 17-20 Varanasi, India, 130-131,169 Varieties of Religious Experience (James), 49 Visual hallucinations, 34 "Voodoo death," 68-70 Wesley, John, 58 Whitman, Walt, 17-18 WHO (World Health Organization), 143 Winnicott, D.W., 16 Witch doctors, 30 World Health Organization (WHO), 143 World Trade Center disaster, 109-110 Yoga, 131-132 Yoga Sutras, 132 Yogi, Maharishi Mahesh, 228 Yoruba rituals, 165 Zakad, 146