Marc Galanter M.D.-spirituality and The Healthy Mind - Science, Therapy, and The Need For Personal Meaning-Oxford University Press (2005)

Spirituality and the Healthy Mind
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Science, Therapy, and
the Need for Personal Meaning
MARC GALANTER, M . D .
OXPORD
UNIVERSITY PRESS
2005
OXFORD
UNIVERSITY PRESS
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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. PsychotherapyReligious aspects. 2. Spiritual healing.
3. Spirituality. [DNLM: i. Psychotherapymethods. 2. Spirituality.
3. Spiritual Therapiesmethods. 4. Spiritual Therapiespsychology.
WM 420 &47S 2005] I. Title.
RC489.S676G34 2005
6i6.89'i4dc22 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
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 every-
thing 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 gen-
erate a sense of purpose in his patients: "Very often people with de-
pression 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 mean-
ing.' 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 med-
ications 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 revolutionone
that might be considered spiritual in naturein 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 be-
tween what scientifically grounded treatments do to allay specific symp-
toms nowadays and what imagination, compassion, and belief can offer
in making people's lives worthwhile. This is why psychiatry, which ben-
efits 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, so-
cial, 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 pro-
gressed, it became clear that one could systematically research the en-
counter 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 teach-
ing about addiction treatment, I began to study the nature of conscious-
ness in relation to drug intoxication.2 But when more practical needs in-
tervened 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 tradi-
tional 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 re-
cruits 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 reha-
bilitate our indigent, addicted patients. We were able to frame a treat-
ment system in which the commitment seen in AA was infused into our
secular hospital-based services for mentally ill addicted patients.5
Prologue ix
We then evaluated these patients , the folks who you could see pan-
handling on the street or dealing drugs to buy whatever alcohol, cocaine,
or heroin they could garner. The results were quite striking.6 The pa-
tients 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 pa-
tients would answer that way as well. It was becoming clear that psychi-
atry 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 psychi-
atric residencies over recent decades. There was even an ongoing debate
over the merit of providing any training at all on how to help psychia-
trists 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 benefi-
cial 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 medicinetreatments based on a personal, often spiritual,
commitment to medically unproven techniquesthan on traditional
ambulatory medical care.10
Could some rethinking of this divergence of two important ways of
dealing with people's distresssymptom relief and the pursuit of
what is personally meaningfulbe achieved? Could psychiatry re-
claim 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 inter-

views 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 Univer-
sity Drs. Robert Cancro, Steven Katz, and Manuel Trujillo were likewise
responsible. My work was carried out because of their having con-
tributed to these academic settings. To these leaders in American psy-
chiatry I owe appreciation. Dr. Helen Dermatis and my fellows and ac-
ademic colleagues collaborated with me on the research conducted.
Kristin Frillmann played an invaluable role in preparing this manu-
script, and appreciation is due Fiona Stevens, my editor.
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
xiv Contents
PART I
What Is Spirituality?
P
eople in all cultures seek out meaning beyond the material,
usually within the context of religious practice, but when long-
standing religious traditions are found to be unfulfilling,
marked changes in belief and practice may come about. In the eigh-
teenth century the Great Awakening heralded the emergence of Bap-
tist 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 emer-
gence 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 psycho-
logical 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 ma-
jority (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 bio-
medical 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 pro-
found 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 under-
taking. But as we spoke further we agreed that our patients needed some-
thing 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 re-
lief 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 plu-
ralism that has emerged in recent decades, as tolerance for diverse be-
liefs 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 na-
ture 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 feel-
ing 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 spiri-
tual fellowship, and in AA's Second Step they say they have come "to be-
lieve 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 peoplethat'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 al-
lied to religion, but it is a thing apart, allied to other people but it is also
apart from everyday relationships. Although it was different for each of
them, each knew what it meant to him or her personally. Clearly, spiri-
tuality is not easily encompassed by a singular definition, nor is it eas-
ily parsed and subjected to research, but it is very real for those who ex-
perience 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 follow-
up 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 spiritual-
ity 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 medita-
tion 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 fellow-
ships has had a major impact on the way people have come to view ill-
nesses of compulsive behavior.
Where Did the Idea Come From?
T he term spirituality has now gained considerable currency in Ameri-

can 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 7
which they were born. The trappings of other religious groups were dis-
missed 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 as-
sociated with shamanistic practices that we see as being quite different
from our own.
The contemporary perspective on spirituality became evident fol-
lowing the radical cultural transitions that took place in the United States
over the latter part of the twentieth century. Traditional social moor-
ings 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 histori-
cally defined denomination, almost always segregated by race. The reli-
gious 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 re-
flect 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 presi-
dency was followed by antiwar riots at the ensuing Democratic National
Convention.
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 genera-
tions. 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 adoles-
cence 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 chil-
dren to liberal educational institutions where youths could devote them-
selves to contemplating their direction in life, even their life's very pur-
pose. 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 re-
flect 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 amplifica-
tion of the new rock music, itself derived from the collapse of tradi-
tional barriers between blacks and whites. His words would now con-
vey the consequences of these cultural transitions for many youths who
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, andfor their
eldersScientology 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 as-
sets, 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 tradi-
tional values. These new communities of belief, or ad hoc families, con-
stituted by severing ties with the members' families of origin, gave ex-
pression 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 congrega-
tions in megachurches with thousands in attendance, mainly in middle
America. Fundamentalist belief offered both social stability and a rela-
tionship 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
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.
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 Ameri-
can Psychiatric Association's 1,070-page Essentials of Clinical Psychia-
try1 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 impor-

tant, even central, to their psychological well-being. For some it may
be felt as members of a church, as part of their lifelong religious affilia-
tion. 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, embark-
ing on years of learning about the nascent Christian faith and preach-
ing to its converts. The psychological issues we will consider here can be
highlighted by such intense, sometimes spontaneous, personal encoun-
ters, and experiences like his, of course, abound throughout history.
They are regularly recounted by people "born again" into faith for whom
12
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 psy-
chology, 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. Fran-
cis of Assisi as a hereditary degenerate.4
James drew on these awakenings and those of his students as evi-

dence 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 op-
erates. In doing this, he legitimated these phenomena as a valid dimen-
sion 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 invita-
tion 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 lis-
tening to a woman convert extolling the guru's wisdom. As he was some-
what 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 dis-
missed and that it would somehow influence the course of his life. He
soon joined the movement and began to build his life around its spiri-
tual orientation. At first he tried to recruit new members in his medical
clinic. He got little response, as people thought his pleas reflected a mea-
sure of derangement more than a spiritual awareness. He then decided
to keep his experience to himself but still kept close ties to the sect, liv-
ing 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 mid-
twentieth 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 hier-
archy of needs that people have, and it is only after safety, belonging-
ness, and self-esteem are achieved that self-actualization, the highest of
these needs, is addressed. This follower of the guru was apparently seek-
ing 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 per-
sonal illumination, and also interviewed people who he felt had attained
an exceptional degree of self-actualization. He lent a more contempo-
rary 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
P 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 mean-
ingfulness of religious experience, Freud, himself experienced in physio-
logic 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: per-
haps because of his orientation toward biologic science, perhaps be-
cause 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 em-
pirical 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 empha-
sized 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 sci-
entific 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 un-
conscious but came to believe in a collective unconscious, positing the
existence of innate mental constructs, archetypesprimordial images
that existed in all individuals. These serve as the basis for elaborating
the diverse religious imagery and myths that arise across different cul-
tures.8 Jung did not ascribe validity to a particular creed or to member-
ship in any specific organized religion, but instead believed that his
perspective took into account the full range of spiritual experiences, in-
cluding people's acceptance of a godhead. He viewed the self as lying
midway between the unconscious and consciousness and pointed out
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 psy-
chological 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 beha-
vior. Psychoanalysis would liberate people from the neurotic views fueled
by these drives. Jung's model, on the other hand, posited a collective un-
conscious 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 eventu-
ally 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 in-
fant 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 ma-
terial needs, even judging other people's motives. For Winnicott, an-
other 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 artis-
tic imagea floating angel, the spirit of a voodoo maskthese have
reality in this domain, even if they are not seen in nature. This transi-
tional divide, Winnicott wrote, matures into the domain in which the
arts and creativityas well as religionemerge.
Winnicott's conception was later elaborated on in a way that is rele-
vant to our thinking about spirituality by Ana-Maria Rizzuto, a psycho-
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 psycho-
analysis 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 per-
formance. 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 de-
clare a belief in God, something that had been alien to her and her fam-
ily before, and started practicing rituals from her family's Jewish back-
ground. 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
S pirituality can be experienced from either a secular or religious stand-

point. The secular is manifest in an emphasis on the place of values
in a spiritual orientation, rather than theistic or formally religious be-
liefs. 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:
I could turn and live with animals, they are so placid and self-
contained,
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 ex-
pansive 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 onto-
logical emotion suffuses his words, and ends by persuading the
reader that men and women, life and death, and all things are di-
vinely 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 im-
moral. 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 denomina-
tional 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 Gor-
don 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 psycho-
analyst in the United States. These experiences and his understanding
of existentialism and social psychology led him to a secularized view of
religion as a way of life.12 He described two types of religious orienta-
tion. The first promotes a respect for humanity, allowing the individual
to achieve self-realization. It stands in contrast to an authoritarian reli-
gious 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 over-
come the limitations of egotism and thereby feel love and exercise hu-
mility. This clearly brought him close to a humanistic spiritual view.
Around the same time, Gordon Allport, respectful of the introspec-
tive 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. All-
port 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 ob-
served 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 main-
tained a lasting religious orientation that reflected their family back-
grounds. He measured the distinction between an intrinsic religious ori-
entation, 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 in-
trinsically felt sense of purpose, one that that lends meaning to life. All-
port 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 psycho-
therapy. He emphasizes the importance of recognizing that psycho-
therapy is not value-free and points out that acknowledgment of this
can free psychology from a historic bias against religious and spiritual
values. In this manner, he writes, an acknowledgment of the impor-
tance 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 support-
ing mutuality and altruism. He points out that this aspect of altruism is
adaptive for the survival of a social group and has therefore been sus-
tained 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' spiri-
tual 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
C 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 vari-
ous 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 immo-
lated in Waco, Texas); Aum Shinrikyu (who spread poison gas in the
Tokyo subways); and politically oppressed, spiritually oriented organi-
zations, 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, how-
ever, we can also shed light on the way induction takes place in less in-
tensive 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
remarkable opportunity to learn about the impact of a spiritual sub-
culture on people's thinking. In the mid-1970s and 19808 cults that at-
tracted 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. Further-
more, the tenacious commitment that the inductees sustained was in-
scrutable to their parents, who would usually grieve the loss of their
children to what appeared to be a bizarre and alien culture. For me, ac-
cess 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 em-
igrating 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 actu-
ally in a Manhattan apartment not far from my home. She was now
serving as the guru's physician, and because she had issued the invita-
tion, I was warmly received.
At the ashram the intensity of the members' involvement was strik-
ing. 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
interview a number of very troubled people who supported these ob-
servations. 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 move-
ment. 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 struc-
tured 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 mari-
juana 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 hav-
ing 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 de-
clined by half since they had joined (from 71% to 37%).
The degree of improvement in substance use and distress was signifi-
cantly correlated with the respondents' scores on a scale for social co-
hesiveness in the questionnaire. For example, their scores on this scale
accounted for 37% of the variance (statistical variability) in their de-
cline in distress symptoms, a high figure for a psychological study. Ap-
parently, 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 suc-
ceeded in engaging recruits into close ties to other members.
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 con-
tact 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 recruit-
ment workshops at a remote California site. These reflected a sophisti-
cated 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 invita-
tion 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 re-
main 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 re-
sponded with high scores on both cohesiveness to the attendees and be-
lief 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 pre-
dictive 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
sample from the general community.18 These latter scores were not based
on retrospective self-assessments, so they were not subject to the dis-
tortion 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 re-
cruitment process, as it gave them answers to uncertainties they were
confronting. Engagement in the church's beliefs and the emotional sup-
port 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 consider-
able 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 signifi-

cant decline in distress or, conversely, an improvement in gen-
eral 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 sta-
tus 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 signifi-
cantly below those of members who had already been in the
group for 2 years.21
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 cor-
related with the degree of their religious belief and their cohesive-
ness toward church members. Items that were most highly cor-
related 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 asso-
ciated 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 emo-
tional 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 pro-

mote 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 feel-
ing better. They may therefore be candidates for responding to spiritu-
ally oriented healing that would buoy their spirits and then for affiliat-
ing 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
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 condi-
tion may feel helpless and may despair of receiving help from her physi-
cians. Because of this distressed state, she may be open to considering
an alternative spiritual explanation for her illness and a related "treat-
ment" 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 "spiri-
tual" 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 gradu-
ate 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 (pre-
sumably) 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 contradic-
tory 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
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 them-
selves and the newly perceived physical state and creates a potentially
troubling sense of arousal. Given the pressure generated by this cogni-
tive dissonance, the distressed sick person will be open to seeking out
or responding positively to an explanatory model for the illness avail-
able 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 symp-
toms remit when he clearly explains to them their underlying physiol-
ogy. On the other hand, some people may encounter and accept a spiri-
tually 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
M ost medical treatments act directly by altering the body's physi-

ology. Placebo treatments, on the other hand, derive their effec-
tiveness because the patient believes that the treatment they mimic will
relieve their symptoms. This phenomenon carries considerable impli-
cations 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
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 mecha-
nisms of action. In addition, some active drugs not considered to be anti-
depressants 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 improve-
ment 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 place-
bos 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 place-
bos 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 materi-
ally 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-
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 func-
tional limitations. Until recently the procedure had been applied more
than 650,000 times a year. At a cost of roughly $5,000 for each opera-
tion, 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 as-
sumed 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" surgi-
cal 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 pro-
duced 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 sur-
gical 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 ritual-
ized belief embedded in the mythology of one spiritually oriented cul-
ture, 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-
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 cere-
mony 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 re-
newal was followed by relief from the symptoms of depression. This
parallels the contemporary response to antidepressant placebos that re-
news today's depressed people. Members of both the Navajo and science-
oriented 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 spiri-
tual renewal and associated rituals for the treatment of mentally medi-
ated 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 ex-
perience, and then moved on to the way these experiences can be gen-
erated 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.
3
Spirituality and the Brain
I 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 rela-
tionship is to consider how people deal with uncertainty, since spiritu-
ality 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 pro-
duces a state of central nervous system arousal, which can, in turn, serve
as the basis for a subjectively felt emotional response. Some of their sub-
jects were exposed to a giddy and engaging actor, a pleasant social stimu-
lus 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 per-
son's arousal does not necessarily determine the ensuing subjective ex-
perience, but that it is interpreted based on his or her mental context.
3i
Broadly stated, this suggests how our understanding of what we expe-
rience 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 bio-
logic 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 sur-
gically 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,
hethat is, his left hemispheregave a fabricated explanation of see-
ing someone he knew at whom he had waved. When stimulated in the
right hemisphere to laugh, he said he was responding to the joking ap-
proaches 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 experi-
ment, an explanation of reality and its meaning was created by a person
to cope with a physiologic nonspecific stimulus.
Emotion Driving Perception
T 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.
Here are some questions to start with: Where does this emotional en-
ergy originate in the absence of environmental input? How does it get
infused into our abstract thinking to cause us to make up an explana-
tory 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 sys-
tem 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 un-
fettered 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 speak-
ing, 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 stan-
dards for behavior. The neocortex, the brain's highest center for com-
plex thought, became larger late in mammalian evolution and can as-
cribe 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 be-
tween the brain's emotional driver and its component part that con-
ducts 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 sym-
bolism is often associated with people's spiritual side. Interaction be-
Spirituality and the Brain 33

tween the cerebral cortex and the limbic system during sleep can gen-
erate 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 ac-
tive during waking, while accentuating others. During dreaming stimu-
lation 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 expe-
rience 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 under-
stand how the seemingly nonrational imagery that governs much of the
thinking associated with spiritual experiences can be framed by pro-
cesses 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 na-
ture of transcendent experience in unanticipated ways. As we just noted,
split brain studies have shown the way one hemisphere's need to fabri-
cate a reality shows itself when confronted by puzzling behaviors that
may be generated by the other hemisphere. Responses to electrical stimu-
lation of a specific brain site can suggest the basis of some of the para-
normal 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 epilep-
tic 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 in-
creased, 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.
This suggests an interesting issue. Transcendental Meditation, popu-
larized 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 meditat-
ing. Reports such as these were seemingly laughable. Were these medi-
tators deluding themselves? On the other hand, they might have ac-
quired a capacity to prolong and intensify spontaneous activity in the
angular gyrus, activity that we now know can be accomplished by di-
rect stimulation to the brain. Clearly, more needs to be learned about
the nexus between experiences associated with spirituality and verifi-
able 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 cog-
nitive science, which examines the processes of thinking and recollec-
tion. 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 con-
temporary 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 exter-
nal 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 re-
Spirituality and the Brain y>

peated presentation of a pleasant experience in association with a stimu-
lus, such as a gift-bearing relative repeatedly encountered by a young
child, will engender a pleasurable response to that relative, even with-
out the child being aware that the process is taking place. An unpleas-
ant 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 reflec-
tive response to religious services, can itself become a stimulus for spiri-
tual 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 elabo-
rated 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 de-
vice 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 con-
ditioned by the operant reward of the cheese. Because it has been condi-
tioned, 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 inter-
esting 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 encoun-
tered in dreams, and this operant stimulation is not necessarily con-
sciously perceived by the patient being analyzed. When repeatedly pre-
sented, however, this reinforcement can lead the analysand to bring up
the issue that was of interest to the analyst more frequently, in this ex-
ample, by discussing her dreams. The analysand then grows to impart
importance and meaning to dream imagery. Similarly, if a person regu-
larly encounters positive emotional experiences in relation to spiritual
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 re-
warding 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 as-
sociated 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 post-
traumatic stress disorder, lingering reactions ensuing from highly trau-
matic 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 ori-
ented ideas and feelings. A religious experience at a church service may
be automatically recalled when certain emotional stimuli are intro-
duced. An encounter with the Dalai Lama may come up in one's mem-
ory at times when one experiences spiritual renewal.
A Note on the Placebo Effect
P lacebos work because we believe in what they represent. Because of

this they offer the opportunity to examine the impact that belief
spiritual or otherwisecan have on the mind and brain. One particular
study employing computerized electroencephalographic (EEC) analy-
sis sheds light on the biological basis of placebo effects. From it we can
draw some inferences about the biology that supports culturally grounded
beliefs.

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 phenome-
non 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 West-
erners 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-
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 medi-
tative techniques. Many of them revered Hindu and Buddhist holy men
who could draw on intense and mysteriousbut apparently credible
capacities for achieving transcendence. Exotic practices studied in labo-
ratories 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. Tan-
tric 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 oblivi-
ous 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 breath-
ing for nearly 2 minutes during a state of "near Samadhi" after experi-
encing 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 asso-
ciated with intense attention to visual images by these meditators and
with their loss of a sense of space and time. The nature of these physio-
logic relationships, however, is far from clear. Thus, Newberg found
that attempts to define the subjective states associated with these tech-
niques left them "impossible to quantitate or analyze in a useful man-
ner."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 transcen-
dent 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

that measured different character traits. It turned out that there was a
strong (inverse) correlation between serotonin binding potential in cer-
tain 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 re-
lated experiences.
The Role of Social Support
P eople most often acquire a spiritual orientation in a supportive

group context, so it is important to examine how social support re-
lates to brain physiology. Numerous studies have illustrated the biologi-
cal 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 support-
ive 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. Contin-
ued separation resulted in a severe withdrawal, termed anaclitic depres-
sion. 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 at-
tachment, and these researchers posited that for infants the mothers
provided a base of security to which infants could return after explor-
ing their environments. When the attachment object was gone, the in-
fants lost their sense of security and could no longer find refuge from
frightening stimuli.
Harry Harlow, a professor of psychology at the University of Wis-
consin, was impressed by this work, and his studies on its counter-
part 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-month-
old rhesus monkeys. Each monkey was placed in an apparatus that
prevented it from coming into physical contact with its mother for a
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 high-
lighted by Stephen Suomi, who undertook studies that extended the
work of Harlow to see whether it was possible to "treat" the infant mon-
keys' 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, de-
pressed 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 in-
tervention 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 close-
knit social environment of religious cults. In these adult humans, co-
hesiveness 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

means of a statistical analysis, he was then able to distinguish between ge-
netic loadingthe same for identical twins but only half as great be-
tween fraternal twinsand 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 indi-
viduals, rather than environmental ones. This makes clear that the social
cohesiveness that we associate with an inclination toward spiritual affilia-
tion 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 as-
sault, 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 includ-
ing flashbacks, nightmares, and inability to concentrate.
The acute stress that engenders PTSD stimulates the release of hy-
pothalamic 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 rela-
tive 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 ac-
ceptance of the group's spiritually oriented philosophy. We can now
better understand the basis of this relationship between biology and so-
cial interaction. We will next consider how this biologically grounded
trait was adaptive over the course of human evolution.
Evolutionary Adaptation
C ertain patterns of behavior that are found in all members of a spe-

cies may be grounded in their genetic makeup. These patterns,
rooted in biology, can be understood to persist over the course of evo-
lution 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 behav-
iors 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. Sociobiol-
ogists who study the evolutionary basis of behavior examine this phe-
nomenon 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 at-
tracting 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 self-
sacrifice manifested in such acts.
Why do members of many species carry such a seemingly maladap-
tive 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 indi-
vidual, in actuality it enhances the advantage of other genetically related
parties who are likely to carry the same trait. Other members of the spe-
cies, benefiting from the altruist's help, are therefore more likely to re-
produce because of the benefit conferred on them by the presence of
this altruistic trait in a close relative. Because of this, the "altruism" genes

will persist to the next generation in the parties who were helped. Socio-
biologists point out that such behaviors assure survival of other mem-
bers 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 stim-
uli and dream imagery, might be grounded in innate patterns of human
behavior that have been adaptive in terms of helping our species to sur-
vive. These very patterns would predispose people to accept the sym-
bolic 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 in-
nate inclination of people to establish themselves in kin-based sub-
groups 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 re-
flect 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' reli-
gious orientation from an evolutionary standpoint.31 He pointed out
that a religious orientation of one sort or another serves to bind adher-
ents together in an unquestioning allegiance that can promote altruis-
tic behavior. It can also engender willing subordination to a group, which
then provides benefit to its members with a minimum of energy ex-
penditure 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
creation of a mutually acceptable mythology. Interestingly, in consider-
ing the psychology of spirituality, this perspective is similar in some
ways to the innate religious archetypes we considered previously in re-
lation to the psychology of spirituality. Carl Jung elaborated on an
allied concept in his psychoanalytic model of spiritually oriented beha-
vior, and it was picked up by Daniel Batson32 more recently, who asso-
ciated 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 ori-
entation may exist across all cultures, and that it has persisted because
of its adaptive nature. The same is certainly said about innate inclina-
tions toward sexual behavior and aggressiveness, which, in different set-
tings, 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 an-
cestors and in another as commitment to the Twelve-Step process of
addiction recovery. By this reckoning, we would say that a spiritual ori-
entation, like human sexuality and aggressiveness, may be rooted in
people's innate biological complement.
Our Forebears
R 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 neces-
sary to tap many natural resources, so people must therefore bond to-
gether 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 en-
hanced if resources are known to be equitably distributed. These adap-
tive 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

of evolutionary change. From this perspective even the Ten Command-
ments 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 particu-
larly impressed by descriptions of hominids, the early human precursors,
such as Australopithecus. After emerging from the prehistoric rain for-
est 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 com-
plex relationships was in turn made possible by a major increase in
brain size that took place over the course of human evolution. For ex-
ample, 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 ap-
pearance 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 in-
clude some diverse perspectives on social behavior. Anthropology has
posited that religion assured a linkage between members of a commu-
nity 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 behav-
ioral 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.
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 antici-
pated 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 medica-
tions, 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 popu-
larity 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. Psycho-
pharmacology 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, ac-
quiring 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 spiri-
tual excess causes people to get less-than-effective treatment or lose
out on it entirely.
48 The Impact of Culture

4
The Apparent Conflict
A spiritual outlook implies a particular perspective on people's in-

ternal mental world. Biomedically based psychiatry implies a dif-
ferent 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 bio-
medical orientation, on the other hand, is framed by observers of mea-
surable 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 ex-
amined by psychiatrists such as Emil Kraepelin, who classified schizo-
phrenics 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 di-
vergent 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 un-
49
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 work-
ers) 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 treat-
ment of addiction available to the physician other than Alcoholics Anony-
mous (AA). At its inception many of its physician members were re-
covering from alcoholism through AA spirituality and had decided to
dedicate their careers to others who suffered as they had. The other mem-
bers 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 fi-
delity 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 re-
treat sponsored by his treatment program to bolster their own AA com-
mitments and get together with their compatriots. Responses to this sur-
vey indicated that most were working at least part-time treating other

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 or-
ganized by mainstream members of the American Psychiatric Associa-
tion 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 bound-
ary. 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 com-
pulsive 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 sym-
pathetic to AA and being biomedically oriented as well.
The gulf between the two organizations was evident in the experi-
ences of two physicians, Barry, a leader in ASAM, and Jack, with a re-
spected role in AAAP. Barry had been a victim of severe alcoholism, ul-
timately falling into penury and putting great stress on his wife and
children. A dedicated physician, who himself was active in ASAM, sal-
vaged 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 accom-
plished 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 re-
The 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 affilia-
tion with AA, but in operating within the context of AAAP and the ac-
ademic subculture, he would not want to have his credibility compro-
mised 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 con-
verts 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 mov-
ing targets. Investigators in the laboratory have come upon their find-
ings, pursued them with enthusiasm, and, if they were based on a meth-
odology 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 neuro-
transmitters 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.

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 statephysiologically grounded in
too much dopamine. It then became attractive to think that this repre-
sented a clear-cut physiologic basis for the disease, particularly since the
medications used to treat it typically led to decreased dopamine activ-
ity. Years went by, other findings abounded, and recent careful assess-
ments 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 spe-
cific 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 pro-
vide 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 beand, fortunately, generally are notregarded 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 evi-
dences of how science is moving forward because of its objective out-
look on the workings of the mind.
Furthermore, in medical research good methodology can erroneously
be associated with an assumption of clinically valid results. One ex-
ample of a bizarre "methodology fallacy" was in a report recently pub-
lished in the British Medical Journal, a scientific publication of great
credibility. In this case apparently good statistical methodology gener-
ated 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 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 fol-
lowed by a flurry of letters to the journal's editor saying that anything
as outlandish as this study should not have been published. Most writ-
ers made clear that the thought of prayer going back in time and chang-
ing the course of medical illness made no sense. Nonetheless, the epi-
sode 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 para-
lyzed, not liberated, and that furthermore it embodies the fallacy that it
is an objective science. He looked at me in a challenging manner and il-
lustrated his point. "If I smile at a psychiatrist, how can he say objec-
tively if it is a smile of happiness, embarrassment, or ridicule? Objec-
tivity will not resolve that."
Alternative Medicine Emerges
T here is clearly a chasm between people's spiritual needs and bio-

medicine'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 ther-
apy, to encounters with acupuncturists and yoga teachers. The popu-
larity of alternative medicine was first spelled out for the established
medical community in an article by David Eisenberg in 1993 in the New

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 sur-
prise 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 ac-
ceptance of CAM approaches. The National Institutes of Health turned
its small but controversial Office of Alternative Medicine into a full-
fledged 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 ac-
ceptance 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 be-
lief in a treatment is irrelevant to its effectiveness: In fact, its role is re-
flected in studies of placebo treatments, in which only moderate differ-
ences between active antidepressant medications and placebos have been
found.13 In psychiatric disorders, at least, belief in a treatment can be al-
most 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 heal-
ers abounded, and established medical professionals were viewed mainly

as a bulwark of privilege; their elite educations did not necessarily re-
flect credibility. Medical practice took place in something of a war zone,
with alternative approaches ranging from botanical healing to hydropa-
thy 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 contin-
ues, with blurring of the line between medications legitimated by re-
search and approved by the FDA and nutrients and naturally occurring
products accepted on faith. So long as these latter health-related prod-
ucts 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, tra-
ditional Ayurvedic medicine and research-based medical schools co-
exist in India, often side by side.
The Metaphor of Biomedicine
R 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 be-
coming 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

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 inclina-
tion 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 com-
pany 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 psychologi-
cally oriented interventions, has become dependent on the pharmaceu-
tical companies that provide much more of its revenue ($13 million in
a recent year) than do the dues of its members ($8 million). Psychia-
trists (including me) should lend some thought to this relative balance.
Recent articles in the medical literature point out that pharmaceuti-
cal companies have, without overt indication, assumed considerable in-
fluence 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 re-
ceive extensive research and consulting funding from pharmaceutical
companies that sponsor the very medications they recommend, no in-
dication 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 miti-
gate without drug treatments. Concomitantly, the number of psychi-

atric patients receiving a complement of nondrug outpatient psycho-
therapy visits had gone down by 50% over the last decade, while the use
of psychotropic medicines increased dramatically.16
A Historical Perspective
T he spiritual aspect of physicians' role dates back to Shamanic heal-

ers, whose legitimacy lay in their transcendent and theistic identi-
fication. 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 ground-
ing, and, given the way the mind works, empathy and technical think-
ing are hard to maintain at the same time. Rather than healers, physi-
cians 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 ill-
ness, 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 doc-
tors 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 prac-
tice 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 Method-
ism, 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

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 sta-
tus 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 typi-
cally fell into the hands of practitioners who applied folk remedies and
gained modest economic support from their efforts. Professional de-
velopment 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 en-
gage. Since medical licensure had yet to fall under the control of gov-
ernmental 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 differ-
ent healing techniques were associated with a variety of diverse sub-
cultures. 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 in-
clined 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 dis-
ease as a matter of spirit and prescribed medicaments in small quanti-
ties 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 inter-
locking directorate that would define the nature of the country's medi-
cal practice. One major initiative of the nascent AMA was to do what it
could to drum homeopaths and Thomsonians out of the profession.

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 di-
rectly 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 diphthe-
ria, and salvarsan for treating syphilis. The application of sterile tech-
niques 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 col-
lege 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 emerg-
ing standards came under attack in a report released by Abraham Flex-
ner in i9io,19 which had been underwritten with funding from the Car-
negie 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 sur-
gery 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 mes-
sage 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 inter-
nal 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.

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 remark-
able technology available to them. Attempts were now made to assure
systematic provision of increasingly expensive medical care. These in-
cluded the establishment of Blue Cross and Blue Shield in 1929.
By the 19405 physicians were coming to be employed in large corpo-
rate entities. In California, for example, Henry J. Kaiser organized care
for his employees, ultimately developing the Kaiser-Permanente net-
work that built its own hospitals. Technology became infused into hos-
pital care in the final days of life, a period that had in years past been the
domain of spiritual accommodation. Hospitals became settings for end-
of- 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 oper-
ate, applying its procedural expectations down to the techniques em-
ployed for improving performance on each of its wards. JCAHO re-
viewers 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 com-
panies with capitalization in the scores of billions of dollars now propa-
gandize 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 practi-
tioner? Expenditures on marketing of drugs to American physicians

now stand at the level of $2.5 billion, with the emerging avenue for pro-
moting 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 study-
ing 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 doc-
tors 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 pro-
moting 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 mov-
ing 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
T 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 ad-
dress the symptoms of madness as well. Other approaches he supported
to relieve the congested brains of the mentally ill were dropping them

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 community-
based 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 men-
tal 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 rem-
nant 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 mem-
bers of the American Psychiatric Association (APA) against the men-
tal hospital-based organic psychiatrists. GAP members effected major
changes in the APA's orientation and spawned many of the APA presi-
dents in the years following the group's inception.
At the same time, however, biology and physiology were reigning su-
preme 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 compo-
nent 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 bio-
logically oriented researchers and administrators driven by the econom-
ics of these federal grants. Medical schools and their psychiatry depart-

ments came to rely heavily on this funding because of "indirect costs,"
that is to say, costs given for the administration of the medical institu-
tion, 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 appoint-
ments between 1995 and 2002 each had brought in an average of $2 mil-
lion 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 tui-
tion from all of the school's students during that time. This grant fund-
ing clearly represented an important part of the school's income, par-
ticularly since it could be directed at a large variety of administrative
and developmental activities.
With the publication of the "Feighner"24 criteria for psychiatric di-
agnosis in 1972, leaders of this new orientation promulgated a psychi-
atric 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 cate-
gorized 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 imag-
ing techniques have become the lingua franca of advanced psychiatric
research. Attendance at the annual meeting of the Society for Neuro-
science dwarfs that of the APA. No longer can medical students inter-
ested 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

dozen drug companies paid about $50,000 per session at some sym-
posia 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 com-
promised. 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 cov-
erage by fully 75%
What was the impact of these cutbacks on attention to patients' need
for more intensive therapy, beyond brief interventions, toward a mean-
ingful emotional recovery? Certainly, they left little opportunity for
providing exploration of a patient's spiritual needs. In the area of ad-
diction 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 or-
ganized 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

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 num-
ber 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 mean-
ingful 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 pro-
mote addiction treatment were severely curtailed. Fully 79% said that
managed care had had a negative impact on their ethical practice of ad-
diction 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-year-
old man with a history of multiple addictions and manic depressive ill-
ness. After a hospital stay limited to 3 days, he was referred to an out-
patient program for which his managed care company approved only
six visits a year. The managed care case reviewer responded to the clini-
cian's phone call by denying further care, while explaining his denial on
the man's evidently poor motivation because of his vulnerability to re-
lapse. 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

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

5
Problems with Spirituality
S pirituality can be associated with both constructive, and also com-

promising, values; it is not without potential problems. When spiri-
tual 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
T he phenomenon of "voodoo death" stands out as a striking ex-

ample 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 pour-
ing 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 re-
verse 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 sys-
tem to define a cascade of events that could lead to this dramatic out-
come. 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 mus-
culature and abdominal viscera toward the heart and the brain. By pre-
serving these most vital organs, this shift ensures the animal'sand, by
inference, a human'scapacity 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 ex-
ample, dehydration is augmented by withdrawal from food and drink
as the ritual wreaks its social impact. In such cases it is clear that the in-
tense 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 69

about undergoing a minor surgical procedure. In these cases as well, sud-
den 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 asso-
ciated with emotional activation to aid in the management of its mem-
bers? In the domain of spirituality, social pressures can generate anxi-
ety over commission of a sin or depression over loss of one's place in a
religious congregation. From a sociobiologic perspective, to what ex-
tent have certain physiologic underpinnings of emotion and cognition
emerged in the course of evolution because they assure the adaptive ca-
pacity 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
O 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 influ-
ence. 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 influ-
ence. Although they were both carried out in laboratory settings re-
moved from the actualities of everyday life, they had a material effect
on how psychologists, and the public as well, came to see people as vul-
nerable 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

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 ex-
periment. 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 experi-
mental 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 un-
easy about giving the wrong answer but rationalized their actions by
saying that other "subjects" might be suffering from some sort of opti-
cal 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," re-
cruited 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 fol-
lowers 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 dis-
cussions in which a majority of participants were active followers of
Reverend Moon. The context of communication was managed and es-
sentially controlled by each group leader, an established church mem-
ber, and the consenting church members played a role that paralleled
that of the confederates in Asch's study. Potential inductees, out of

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 ex-
periments of nature made clear that the laboratory-based research re-
flected 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 so-
cial setting a person has just walked into distort his or her innate val-
ues? 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 under-
stand 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 sci-
entific method, most people accept the validity of scientific research
almost the way people in earlier centuries adhered to their respective re-
ligions. 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 day-
to-day unhappiness. This legitimates endless investment in education
and laborious hours in the laboratory, often with little material recom-
pense. It justifies intrusions into the body, from the dissection of ex-
perimental 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

sanction of a simulated psychology laboratory. It illustrates the vulner-
ability 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 experi-
ment, 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 train-
ing. 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 com-
ply 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 stan-
dards 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

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 dra-
matic example of how such influence acted on people in the world out-
side 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 in-
duction workshops. Because of the intensity of ongoing publicity sur-
rounding their cultic reputation, I was surprised to find that the mem-
bers 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" dis-
tortion in values that had become the norm for Jones's lieutenants paral-
leled, but dwarfed, the distortions of humane compassion seen in Mil-
gram'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 or-
dered 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

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 Fran-
cisco to whom he preached. By the time his followers had migrated to
their isolated site in South America, Jones was claiming to be the rein-
carnation of Jesus and other historical religious leaders. This transcen-
dent 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 under-
lying philosophy for authoritarian control and, under the most unfor-
tunate of circumstances, lead to inhumanity and self-immolation.
Emotional Conflict
I was invited to consult at a case presentation at the chaplaincy train-

ing 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 under-
taken 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 con-
cern 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

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 prob-
lems 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 hospi-
tal stay.
The Rev. Paul Steinke, the director of the program, observed that
Bennett may have been reluctant to hear more about the woman's dis-
tress 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 prayera spiritually oriented
interventioncertainly well-intended, might have been summoned up
as a means of avoiding a conflict between his chaplaincy role as a sup-
portive 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 mes-
sage quite different from what would have seemed compassionate.
A perspective drawn from professional therapy could have been use-
ful 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 some-
times seen as an impersonal stance, allows them to avoid being com-

promised by their own feelings, whether excessively positive or nega-
tive. This would have been useful in obviating the conflicts this elderly
woman had aroused. It was also clear to me from both trainees' de-
scriptions 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 spiri-
tual 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 situationthe ones this role inevitably
generatesweighed 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 vul-
nerable 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 doc-
trine 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, es-
pecially if those issues run contrary to what a Fundamentalist and de-
vout 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 prob-
lems 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 re-

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 reli-
gious 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 posi-
tive insofar as the woman's religiosity had emerged in the course of
their contact. He did not seem to appreciate the magnitude of the prob-
lem associated with this unstable woman's sudden departure. As he de-
scribed 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, un-
spoken, intense personal relationship and an overt, religiously oriented
communication coexisted in material conflict with each other. Reli-
gious 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 be-
lief 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 sup-
pressing 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

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 am-
bivalence, one that she may not have felt at all, would only become
more agitated. Staff here were inappropriately applying their psycho-
analytically 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 re-
flected angry, even murderous, feelings. Intense anger can also be aroused
among family members of a mentally ill person, as in a parent's re-
sponse 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 po-
tent group experience in part to achieve a quasi-spiritual goal of per-
sonal growth. This idea was attractive in the years soon after my train-

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 leaderin this case, myselfto 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 mo-
ment-to-moment impact of the group on individual members. Indi-
vidual 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 grandios-
ity 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 psy-
chological impact of certain encounter groups. The encounter format
was developed by Kurt Lewin, a social psychologist who trained profes-
sionals and executives in interpersonal relations in the 19408. His fol-
lowers 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 partici-
pants. 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 com-
promise any of the participants.) They solicited Stanford University
undergraduates to enroll in a total of eighteen such groups. The stu-
dents 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 "casual-
ties," participants who experienced a significant negative psychological

impact for a period of months. The type of group leadership that was
most influential in generating these casualties had created an atmo-
sphere similar to the one associated with the victims of Searles's "driv-
ing 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 pro-
cess, 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 feel-
ings 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 fel-
low 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 confronta-
tional, 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 schizo-
phrenia" but would elaborate no further, she could not help ruminat-
ing 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, in-
trusive input.
We can look further on the issue of group leadership. The inclina-
tion to bond together cohesively and establish a dependency on a leader,
which is characteristic of spiritual movements, was illustrated in a com-
pelling 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 legiti-
mate role in the medical world. He later wrote of his clinical work at the

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 spiri-
tual 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 psy-
chology of our evolved race. Individuals move toward a conjoint en-
deavor under a leader, perhaps of a godlike nature, as Bion suggests, and
that in turn binds them together to avoid the emergence of unmanage-
able anxiety. This can lead us to a consideration of religious cults.
In the World of Cults
B ion made his observations on peoples' need to seek out an omnis-

cient 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 ex-

amples of spiritually oriented groups that have been led astray by lead-
ers 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 di-
vine gift, and is defined as "great personal magnetism" or "divinely in-
spired 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 so-
cial 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 all-
knowing 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 be-
come 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

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 neces-
sary; 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 en-
gagement 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 previ-
ous 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 de-
gree 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 ex-
perience a sense of well-being.

This fit in with the relief effect I described before regarding earlier
studies on induction into the group: becoming affiliated with a charis-
matic group typically brings relief of distress, and continued affiliation
sustains it. This relationship can be said to reinforce continuing mem-
bership 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 on-
going 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 popula-
tion.10 These included experiences such as a change of residence, addi-
tion 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 emo-
tional experience. Altogether, the combined set of life events was asso-
ciated 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 (be-
lief and cohesion) and the negative impact of disruptive life events. The
score on affiliative feelings operated counter to the relationship be-
tween 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.

The members' life of privation was further underlined 3 years after
the engagement study. I was able to follow-up, reaching 209 of the orig-
inal 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 en-
gagement 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 signifi-
cant distress."
Living with Persecution
A 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 esti-
mated that he had between 20 and 60 million followers. Even the Chi-

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 member-
ship 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 com-
pound in Beijing, seeking official recognition for their group. Soon mem-
bers who congregated in Tiananmen Square in central Beijing every day
were carted off in buses, often not seen again. Some were held in psy-
chiatric 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 po-
tential 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 de-
scribed 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 appar-
ently bizarre spiritual ideology could generate intense conflict with the
surrounding populace and move its adherents to privation, suffering,
and even self-immolation.
Narcissism
I f a person becomes engaged in a spiritually oriented group, the wis-

dom of their joining may be judged by the culture of the group over-
all. 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

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 dis-
astrous, 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 exter-
nal 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 res-
toration of an earlier golden age, but for the feeling, the momen-
tary 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 stu-
dent at Stanford vulnerable to the psychological pressures in her en-
counter group.
People can seek relief and an illusion of transcendence in a transient
commitment to a conveniently available ad hoc tradition without rela-
tion 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 for-
ward by Gordon Allport's14 distinction between an extrinsic and in-
trinsic religious orientation. From his perspective the extrinsic orienta-
tion 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 waysto

provide security and solace, sociability and distraction, status and
self-justification. The embrace of creed is lightly held, or else se-
lectively shaped to fit more primary needs.
The intrinsic orientation is seen in people who find personal mean-

ing and direction in their beliefs:
Other needs, strong as they may be, are regarded as of less ulti-
mate 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 ac-

tive 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 jus-
tification for a preoccupation with one's own personal needs. As Ameri-
cans have been provided with leisure time and substantial economic re-
sources, 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 illus-
trated 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 en-
tity 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 prod-
ucts have become associated with rewarding individual accomplish-

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 col-
lective 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 adver-
tisements for the accoutrements of America's materially oriented soci-
ety 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 Ameri-
can culture of narcissism, wherein people attend to their egos and bod-
ies, 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 bro-
chure20 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

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 nar-
cissistic needs are met by alighting on one spiritual reserve for a tem-
porary 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 sur-
prised 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 re-
cently, she settled on tutoring wealthy high school students by combin-
ing 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

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 state-
ment. 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 narcis-
sistically grounded need of the moment.
Many of these new pursuits, representing people's grasping at spiri-
tual 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 Holly-
wood 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 narcis-
sistic 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 advo-
cate of this is Michael Berg, who opened Kabbalah Centres in Los An-
geles, New York, and London, and attracted a following (for whatever
reason, mostly women) including the likes of Elizabeth Taylor, Court-
ney 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 He-
brew 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 nissanAries," "lyarTaurus," 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

hiatus from her movie career, did during her shoplifting trial). In one
of his little books, The Secret: Unlocking the Source of Joy and Fulfill-
ment,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?

6
When Something Is Missing
Life's Transitions
E 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 prob-
lems 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 con-
verse in Swahili and found a congenial existence among the people
there, unfettered by pressures back home, but when he returned to col-
lege he found the trappings of materialism in the United States disillu-
94
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 medita-

tion 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 my-
self. 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 wor-
rying 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 year-
old kid. I've got a family to support and I'm dealing with a start-
up business. It was really helpful then. That was my past. I've
moved on.
When Something Is Missing 95

Some years before, Jim's distress might have left him open to an en-
counter 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 high-
est 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 per-
spective on where he fit in the world around him. It did this by em-
bodying 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 try-
ing 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 en-
counters. Such programs are sometimes run by a charismatic American-
born 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 Chris-
tian 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 Mys-
tery School that did not cost her much more than stays at an off-season

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 motiva-
tions 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, al-
though 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 Ameri-
can 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 every-
thing. 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 pro-
vide rich experiences embracing sacred psychology: a synthesis of

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, so-
cial 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 touch-
ing 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 mis-

sion. 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

make a wish, like three wishes from a genie. Then you have a pri-
vate 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 genie-
like 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 greet-
ing Mother Theresa, the psychiatric resident who described the bright
halo that appeared around a woman who was giving a religious ser-
mon. Such encounters seem to embody an air of transcendence, im-
plicitly conveying the spiritual message of the emotional healer.
We see with Jim and Mara that there are alternatives to therapy, as cur-
rently practiced, when life's circumstances leave a person in need of some-
thing more than the relief of "target symptoms." Our culture has achieved
a degree of ecumenism that offers alternatives to what traditional reli-
gion, psychoanalysis, or a comfortable family life once provided. Per-
haps these options reflect the secular spirituality of our time. These al-
ternatives 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
T 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 con-

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 spiritu-
ality in my division. She described how, much to her surprise, the insti-
tute had commissioned her to study the importance of "making mean-
ing" 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 physi-
ology 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 chil-
dren 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 per-
spective," 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 be-
cause the term spirituality evoked displeasure in contemporary Swe-
den, 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 con-
temporary psychiatry and people's need's for spiritual redemption.
Shortly after her visit I spoke in the Netherlands with Peter Geer-
lings, 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

their patrons and where prostitutes beckon to pedestrians through dis-
play 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 look-
ing 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 spiritu-
ally 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 re-
sistance 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, com-
munism, 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 ini-
tially 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 en-
countering people quite different from the proper folks with whom she

had grown up. The experience of one teenage girl whom she had evalu-
ated 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 experi-
ence 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 com-
pleting 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 al-
lowed her to do just this with regard to her uncertainty over the com-
promise 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 demand-
ing 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

positive course that he could sustain. Finally, while searching the Inter-
net, he came across the Hazelden Foundation in Minnesota, a mecca for
spiritually oriented rehabilitation through the acceptance of AA. Un-
like 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 edu-
cation 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 cul-
tural 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 stu-
dent, 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 spiri-
tual void without losing sight of a rational approach to their pursuits.
A person with a more deviant state of mind might have greater diffi-
culty in the face of this quandary. This was evident in Corrie, a physi-
cian who presented a puzzling and complicated response to her need to

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 ap-
preciated 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 tradi-
tional 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 be-
coming a physician, and she was pleased with the career she had cho-
sen. She was willing to describe for me the experiences she had kept se-
cret 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 un-
comfortable 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 worth-
while anymore in my life. And then when something like that hap-
pens, 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 Bud-
dhism, 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.

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 incompati-
bility 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 writ-
ings] . 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 mo-
ment. 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 de-
mands 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 sus-
tain 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 leav-
ing, 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.

She still wantedor neededa 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 mo-
ment I asked for a teacher in the spirit world, not someone walk-
ing 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 chan-
neling 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 alco-
holic 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 chan-
neling 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 en-
ergy 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 al-
lowed her to look back on former lives to gain a better understanding
of her current attitudes.

"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
A lthough quite different in character and intensity, Corrie's experi-

ence 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 long-
standing 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 re-
vealing. Corrie was a competent professional, not considered deranged
by her colleagues. So she said, "If I told people about this, the psychia-
trists I work with would think I was psychotic." People who harbor delu-
sions 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 Cor-
rie's experience. It would be simplistic to say that her initial transfor-
mation had brought her close to psychosis. Did the "core of all religions"
that she came upon reflect delusional grandiosity? To say so would be

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 associ-
ate 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 tomor-
row, but live in the moment instead." This does reflect the Hindu ethos
of relinquishing active striving and accepting one's karma. It is a phi-
losophy 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 As-
sociation's diagnostic manual,5 each "an enduring pattern of inner ex-
perience 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 giv-
ing 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 work-
shop had intense emotional experiences that led them to join a move-
ment 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 mem-
bers 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

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 eventswhether 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 ful-
fillment, 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 communityand it was ac-
tually 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

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 en-
vironment 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 dis-
order 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 con-
trast 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 profes-
sional 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 profes-
sional work.
no The Impact of Culture

PART III
Varieties of Spiritual Experience
T
he attempt to put the encounter between psychiatry and spiri-
tuality in perspective is quite daunting. We have looked at psy-
chological, biological, cultural, and even some economic as-
pects 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 anthro-
pology 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 psycho-
therapy 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 vio-
lating their own religious traditions. In America people trained for
hospital-based chaplaincy, because of the mantle of spiritual legitima-
tion they bear, can address the fears and anxieties of those who are
morally ill. And within the culture of Fundamentalists Christian psy-
chiatrists, attitudes range from sensitivity to what is meaningful in
people's lives, religiously related or not, to healing that involves chan-
neling the Spirit of Christ.
Each of these traditions can anoint a healer to address certain is-
sues 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.
112 Varieties of Spiritual Experience

7
Christian Psychiatry
T 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 glisten-
ing Marriott Hotel down the block from the San Francisco Convention
Center, I walked toward the city's downscale Tenderloin District, navi-
gating 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 pharmaceu-
tical 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
W 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 mem-
113
bers' complaints over problems with some small inpatient psychiatric
services that had become "Christian-oriented." It turned out that Chris-
tian 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 member-
ship of 7,500, 5% of whom were psychiatrists. Their membership ap-
plication 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 mak-
ing an explicit attempt to integrate a spiritual orientation into clinical
practice. Dr. David Larson, who was active in the group, had helped es-
tablish 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 popu-
lation (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 Chris-
tian psychiatrists felt that the Bible and prayer should play a role in

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 alco-
holism (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 strengthen-
ing the Christian psychiatrists' commitment to their religion. The relief
in symptoms of emotional distress they experienced in this process ap-
parently 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 psy-
chiatrists. This suggested how relief of emotional distress and a strong
identification with their Christian colleagues served as a nidus for a re-
doubled commitment to Christian doctrine and their acceptance of its
importance in their work.
"Stealth Christians" Meet Together
T 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 invit-
ing 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:
Christian Psychiatry 115

Dear Jesus
I can see now that I've been carrying this heavy burden by my-
self. . . 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 char-

acterize 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 south-
western 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 for-
mal 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 col-
leagues. 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 prac-
tices 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, imply-
ing less delineation between a therapist's religious views and the sepa-

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 under-
lying their emotional distress. The consensus was that Christian for-
giveness 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 "Chris-
tian" woman comes for consultation for chronic depressive symptoms.
In her third session she tearfully tells the psychiatrist of her deepest se-
cret, 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 psychia-
trist 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 sever-
ity of the woman's illness relative to the need for antidepressant medica-
tion, although one participant from France said he avoided using anti-
depressants.
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 rela-
tionship 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 reli-
gious 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.

Opinions varied in terms of the degree to which religion should play
a role in treatment. Interestingly, though, there seemed to be more re-
flection 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 cita-
tion. 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, de-
scribed 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 pe-
riod 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 daugh-
ter's death.
Three of the Christian psychiatrists who attended the meeting illus-
trated the degree to which their strongly held beliefs influenced their
treatment, from a flexible stance on to an intense commitment to doc-
trine. 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
F 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 en-

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 ori-
ented toward "the unity of all religions."
Robert spoke of his religious awakening while serving as a Navy phy-
sician. After a chaplain had asked him, "Who is the authority for the re-
ligion you practice?" he began to think more seriously about his Chris-
tian 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 par-
ticipants imagine themselves to be in Biblical settings, even to the point
of experiencing what it would have been like to encounter Jesus in Bib-
lical times.
Robert readily distinguished between his approach to Christian be-
lievers, 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 self-
punishment 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 ex-
pressing "What's the point?" My response is "Wonderful question.
What is the point? Let's find out. Let's talk about it. Let's under-
stand what endows your life with some meaning." So spirituality
to me may be God talk but it can also be about meaning and pur-
pose and finding a reason for whatever is one's next action.

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 Chris-
tian, 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 pointand 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 men-
tal illness," but he said that he was careful to avoid presenting an ex-
pressly 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 be-
cause 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, home-
less, 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 en-

couraged him to think about the possibility of getting a foothold back
in a community that would be meaningful for him. He told the resi-
dents 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 pa-
tient'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 hospi-
tal, the patient spent time alone in the nearby mountains trying to rec-
oncile 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 reconcilia-
tion 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 pa-
tient was now better able to go back to reunite with his family.
In his own private practice many of Robert's patients had an orien-
tation similar to his own. He said this allowed him to draw on his reli-
gious 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. Proba-
bly 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 feel-
ings of worthlessness.

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 de-
scribed 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 comfort-
able 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
U nlike Robert, Dwight had a lifelong commitment to his Fundamen-

talist 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 com-
promised 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 lit-
erature. 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 com-
mitments. Having been a long-standing member of the Christian Medi-

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 reli-
gious beliefs during his residency but dealt carefully with them and with
his supervisors to avoid coming into conflict with his program's non-
religious 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 con-
sultation, 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 mission-
aries 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 book-
sellers, but he often saw it placed in drugstores, airports, and groceries.
He commented wryly that this was not the kind of book that one usu-
ally 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 de-
pression: 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 acciden-
tal 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

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 ap-
plication 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,"

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 life-
line in other situations. The distinction may not be an easy one to draw.
Enoch: The Literal Role of Jesus
W 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 inte-
grating 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 psy-
chiatrist, 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 re-
lieve 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

education and family counseling from Southwestern Baptist Theologi-
cal 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. Lit-
erally 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 beha-
vior (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 consis-
tent. 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 confes-
sion 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, performance-
based-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 inter-
pretation of the sacred document to a flexible expression of its spirit;

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

8
Spirituality in India
M 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 out-
look 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 con-
temporary India see evidence of each of these episodes in the highly
varied styles of the country's holy sites. The Indian south, never pene-
trated 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, at-
tracts thousands of worshippers to its Friday services. St. Paul's Cathe-
128
dial in Mumbai (Bombay), with its steeple modeled after the one at
Canterbury, was completed in the mid-nineteenth century, only a mo-
ment 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, pre-
dates Christianity by a millennium and retains elaborate myths and cus-
toms that must be respected, if not fully understood, in order to appre-
ciate 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 elabo-
rated 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 high-
est 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, motor-
cycles are replacing bicycles, and bicycles, in turn, take countless Indi-
ans 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 un-
arguable. Nonetheless, the grand architectural monuments remain, the
temples are well populated, and, of some irony, Western interest in tradi-
tional 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 129

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 ap-
preciate 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
A s the spiritual center of India, Varanasi is the definitive embodi-

ment 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 devel-
oped settlement. Two and a half millennia later, Mark Twain, an invet-
erate 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 lead-
ing to the river, washes away sins. Cremations at the Manika, or burn-
ing 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,

whose worldly remains have departed here, will then go directly to
heaven.
Benares Hindu University was founded by a Hindu nationalist dur-
ing 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 sib-
ling. 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 sci-
entifically grounded, Westernized "modern" Indians.
Dr. Indira Sharma, a professor and head of the department of psy-
chiatry at the modern school, showed me a facility that was modest and
certainly economically compromised relative to its American and Eu-
ropean counterparts. Nonetheless, it housed a faculty and cadre of resi-
dent 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 tradi-
tional 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 consider-
able 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 knowl-
edge of the spiritual tradition from which yoga derived. It was quite

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 ex-
hausting 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 reflec-
tion 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 psychi-
atric problems. These patients were still treated with the medications
that their diagnoses required but also benefitted from the culture of tran-
scendence 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

care. Its director explained that the etiology of all diseases could be ex-
plained 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 psycho-
therapy 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 manu-
facturer 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 blan-
ket 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 psycho-
therapy 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 ex-
position, displaying a congeniality that was her nature. I asked her later

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 medi-
cine, 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
T 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 ap-
proaches 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 cer-
emonies 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 typi-
cally undergo pesi, a ritual trance, during the evening service while hun-
dreds of people sit on the floor singing hymns. While in trance the pa-
tients 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

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 regu-
lar 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 men-
tal 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 Heisen-
berg 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 pa-
tients who were, as he put it, "given the usual smorgasbord" of treat-
ments 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 elabo-
rate 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.

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 scien-
tifically minded practitioners in India. Satish Malik, a professor of psy-
chiatry, 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 aca-
demic ritual were assembled when he was informed that the outside ex-
aminer 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 ac-
ademic 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 occasionto 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 profes-
sor of high scientific standing.
Transcendence of the Family
T 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 val-
ues. In New Delhi I spoke with Taj Bahadur Singh, who established one
of the finest clinical psychology internships in India. He had begun his

studies in the physical sciences 40 years before and later turned to psy-
chology, hoping to apply his scientific experience to his new discipline,
but in time he learned that cultural sensitivity and intuition were un-
avoidable concomitants of his clinical practice. When I asked him how
spirituality played a role for his patients, he pointed out the transcen-
dent role of family ties in India, which he said served as "shock ab-
sorbers" 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 dis-
rupted 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 toler-
ated 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 re-
spected 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 mem-
bers 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 ex-
tended family, children, and grandchildren on the anniversary of his

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 govern-
ing 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 encoun-
ters between the betrothed are devoid of romantic choice. Sharma said
further that parents will actively disabuse their son of a romantically se-
lected 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 pro-
duce the most intense of psychiatric reactions. The very close-knit na-
ture of the family structure can be oppressive, particularly when anger
is repressed because of social convention. A resident in psychiatry pre-
sented 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 un-
folded 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 limita-
tions, 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 hav-
ing 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

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 onethe conver-
sion phenomenon. This phenomenon is well known to reinforce con-
version 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 hospi-
tal, where she also had some spells.
The psychiatrist's role among his patients was that of a parental au-
thority, 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 prac-
tically oriented agreement with the mother-in-law to return the retarded
boy to the patient's household. Family intervention coupled with a con-
temporary psychiatric approach successfully addressed the problem,
whereas a traditional healing, perhaps bizarre but sometimes effective,
had failed.
Integrating Tradition into Therapy
S 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 driv-
ing 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

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 dis-
charged. Singh pointed out that a request for respite from distress pre-
sented at a temple generally brings reassurance and comfort, more re-
liably 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 ap-
proach of psychoanalysis, which is typically value-free and oriented pri-
marily toward understanding the self. For Gandhi, committed to tradi-
tional 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 coun-
try's professional mainstream, as he had served as president of the Delhi
Psychiatric Society and had made a series of television shows explain-
ing 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 sym-
bolic meanings inherent in such patients' delusions and help them in-
tegrate them into a personal spiritual journey, rather than dismissing

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 partici-
pate 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 an-
cient texts are used to give meaning to contemporary life. When she felt
the mission was giving her enlightenment, he helped her resolve a grow-
ing 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 con-
siderable wealth as a corporate executive but suffered from chronic de-
pression 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. Transforma-
tions of therapists' practices based on intense personal encounters have
not been uncommon. In the early twentieth century analysands' regres-
sions on the couch did much to frame the nature of psychotherapy, and
this has happened with the response to drug therapy as well. Kay Jami-
son, an academic psychologist who was treated with lithium for manic

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 spiritu-
ality. In time, their work, producing a body of credible scientific find-
ings, can have a material effect on what is perceived as valid clinical
practice.

9
Liberal Islam
T 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 men-
tal 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 Mo-
rocco with its Spanish heritage, to Egypt, where contemporary agrarian
practices reflect pharaonic traditions, across to Iran, whose Persian in-
fluence 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 ad-
Din Rumi, played a role in the emergence of Sufism, a semimonastic Is-
lamic 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 con-
temporary 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 gi-
ants 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 con-
temporary 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 reli-
gious leadera cultural model typical of Eastern rather than Occi-
dental 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 de-
cision 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 cler-
ical 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

on the Cairo University faculty. She was wearing a business suit and
was sitting next to the shaikh. Her perspective served as an interest-
ing 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 fol-
low the word of God the more that person becomes spiritual.
Given his interest in psychiatric issues, I asked him how this perspec-
tive 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, psychol-

ogists, 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 re-
mind 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 ap-
parent in the calls to prayer one hears at those times all over Cairo. How-
ever commercial and secularized this city of some 10 million people
may be, however crammed with automobiles are its streets, the ambi-
ence 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 145

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 ex-
pressing 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 ritu-
als 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 rou-
tines to adhere to this spiritual injunction. This fortified her own family
ties, because during the other months of the year she would miss fam-
ily meals while working late into the evening.
She searched for an analogy in the United States and likened Rama-
dan to a month-long gathering for the Thanksgiving holiday. Even al-
coholics 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 ex-
pectation 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 expe-
riences 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 per-
son. She wanted to know whether it was acceptable to give it to the fam-
ily 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 other-
wise. 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 diffi-
culty and receive no respite, they may go to a Coptic Christian priest to
resolve the problem. Indeed, Coptic Christians, who constitute about

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 sui-
cide, 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 at-
tempted 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 tradi-
tion, amplifying what Mohit had discussed and further clarifying how
a spiritual tradition can lend weight to the psychological impact of a
Liberal Islam 147

guru-like figure when a person is distressed. He said that in the Egyp-
tian 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 ex-
pression: "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 trea-
tise 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 move-
ment 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.

10
Hospital Chaplaincy:
Confronting Illness and Death
T 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 en-
roll 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 depart-
ment of psychiatry and was in fact, virtually unknown to the psychia-
try 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 di-
rects 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
149
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 well-
being 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 him-
self to the chaplaincy. As a young man he had considered the priest-
hood 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 particu-
lar 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 over-
whelmed with grief and did not know how to respond. Looking hope-
less 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 reflec-
tion of the level of training my profession offered in religious tolerance?
The opportunity to speak with other chaplaincy trainees in the pro-
gram 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 equanim-
ity, the trainees had to struggle with issues that would carry an emo-
tional burden for themselves.
Harry served as a pastor in the Church of the Nazarene while en-
rolled in the chaplaincy program, and he described how his views had

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 Fundamental-
ist, 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 Catho-
lic 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?"
Hospital Chaplaincy: Confronting Illness and Death 151

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 stand-
ing 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 for-
mal 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 be-
lief in God as on her Jewish lineage.
Sara made clear how dealing with terminally ill patients could pre-
sent problems that taxed her ingenuity at times, not only her compas-
sion. 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 ordi-
nation, whatever the denomination, allowed them to make statements

and offerings that a mental health professional could not. I was re-
minded 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 sanc-
tion a grieving woman's expression of anger, and when Sara's sponta-
neous 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 spiri-
tuality 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 lis-
tening 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 some-
thing 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

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, some-
time 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."

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. Some-
times 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 understand-
ing, 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 chal-
lenge 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 evan-
gelizing 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-

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 profes-
sionals need to invoke something more transcendent than their clinical
training.
Also, Peter had learned that he need not always wear his clerical col-
lar, 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 man-
ner 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 bound-
aries that frame their need to maintain a certain remoteness from pa-
tients 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 pathol-
ogy? After the antianxiety agents, the antidepressants, and the anti-
psychotic pills do their job, when should "patients" become people?

PART IV
Spiritual Recovery Movements
O
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 re-
markable 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 ideologyas 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 alterna-
tive medicineoften the embodiment of techniques devoid of scien-
tific validationand 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.
158 Spiritual Recovery Movements

11
Alternative Medicine
T 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, medica-
tions have side effects, leaving people uncertain about the harm they
may be subjected to from treatment. They often live with the resent-
ment of having no option to express the fear that accompanies their
treatments.
Spiritually oriented treatments, on the other hand, steeped in reli-
gious and cultural tradition, may carry with them the promise of tran-
scendence 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 se-
rious 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 con-
ventional medical approaches.
Among the severely ill this was illustrated by a patient who was suf-
fering from a neurodegenerative disease. After a series of metabolic stud-
ies, 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 sup-
port, 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, sophisti-
cated New Yorkers on any count, had contemplated any medical treat-
ment 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 re-
sponded differently and stayed on with an alternative healer.
Among the healthy some people tailor their diets to conform to ex-
otic and ill-founded theories that are remotely related to primitive cul-
tures 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.
The Movements
S piritual recovery movementsas opposed to conventional medical

carecan be considered to have three primary characteristics. They
(i) claim to provide relief from disease; (2) operate outside the modali-
ties of established empirical medicine; and (3) ascribe their effectiveness
to higher metaphysical or spiritual powers. Christian tradition under-
standably serves as the basis for some of these movements, given that

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 va-
riety of inspirational books such as M. Scott Peck's The Road Less Trav-
eled,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 physi-
cian members of the Christian Medical and Dental Association avow
that their religious faith is "absolutely critical to their personal and pro-
fessional 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 orien-
tations 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 inter-
est 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 assump-
tion that mental and medical illness can be overcome by an ill-defined
Alternative Medicine 161

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 memo-
ries 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 mem-
bers 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 nar-
cotic 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 fac-
tors 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 depriva-
tion,15 and loneliness.16 Relationships can be observed in the laboratory

between psychological stress and hormonal responses from the hypo-
thalamus and the sympathetic nervous system,17 but clearly much study
needs to be done before the relationship between neuroendocrine fac-
tors 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 benefi-
cial 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 al-
ternative care first, and up to 72% did not even tell the doctor of that
alternative care.19 Even among cancer patients who went for question-
able alternative treatments, 17% did so before obtaining conventional
medical therapy.20
Subcultures
C 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 Ire-
land. 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 Gere-
bernus to death, after which Dymphna allowed herself to be decapi-
tated rather than submit to her father's demands. The legend continues
that the king's cruelties so frightened several "lunatics" who witnessed the

slaughter that they were cured. Dymphna, whose suffering had led to
this miraculous outcome, came to be known as the patron saint for re-
covery 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 char-
ity 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 peoplenow patientsin 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 contempo-
rary 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 recog-
nized 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 sys-
tem. 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 Al-
coholism 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 sub-
culture. In preindustrial societies established healing practices and spiri-
tuality were generally compatible with each other, as they derived from

the same value system. In many types of shamanism, for example, di-
vinely inspired healers provide meaningful care and relief of somatic
symptoms, if not actual cure. Tdng-ki healers in Taiwan address psycho-
somatic 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 tradi-
tional societies is apparent in healing rituals directed at mental dis-
orders, 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 es-
piritismo 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 pa-
tients 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?
I ll effects of spiritually grounded approaches have also been found.

For example, two studies carried out on alternative clinics prescrib-
ing 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.

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 cardio-
toxicity 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 re-
ligious 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 Patti-
son36 evaluated medically ill people in the Pacific Northwest in a de-
nomination 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 re-
vealed 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 sup-
portive 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 com-
ply with the orders given, even though phone orders ran counter to
hospital procedures. Such findings help us understand the harmful be-
havior perpetrated by members against recruits in some dubious move-
ments 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-

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
C onsider the onset of pain apparently due to illness. People gener-

ally 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 be-
comes engaged in conventional care, the model offered will be based on
available biomedical mechanisms. If she encounters an alternative heal-
ing movement, on the other hand, she may accept a spiritually grounded,
nonscientific perspective, even if it has limited credibility. This likeli-
hood 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 adher-
ents, 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, empiri-
cally 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 doc-
tor 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

thereafter a friend introduced her to a practitioner of Chinese medi-
cine, 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 con-
viction 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 asso-
ciated 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 move-
ment 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 ini-
tial relief from malaise and uncertainty due to accepting a new attribu-
tion. This can then continue providing an ongoing reinforcement of the
commitment to the group and its views. The sick person is thereby con-
ditioned (operantly) to maintain affiliation. This is because of the posi-

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 com-
mitment wavers. If more problems of illness later beset the patient, diffi-
culties can be rationalized and their explanation attributed to some as-
pect 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 ideologi-
cal 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 mu-
tual involvement and teaching them to suppress thoughts related to crav-
ing 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 dimen-
sion 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 appro-
priate 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 sub-
liminal issue is associated with how it is presented. A medication's ap-
parent propertyeven its colorhas been shown to enhance a patient's
conviction that it is effective. Elixirs that I was shown by a manufac-
turer of alternative medicines in Varanasi (Benares), India, all had the
same black color. They addressed indications ranging from liver prob-
lems to kidney disease and even brain disease. The latter medicine, called

"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 in-
clude Prozac, Paxil, Effexor, Celexa, Lexapro, Luvox, Zoloft.

12
Alcoholics Anonymous
T he redemptive potential of Alcoholics Anonymous can be under-

estimated, even by people acquainted with it in film and novels. At
Bellevue Hospital I interviewed Michael, one of the many patients pre-
sented to me by our psychiatry residents and fellows. Michael had been
living on disability payments for many years because of severe obsessive-
compulsive 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 hopeless-
ness. 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. How-
ever, 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 meet-
ing 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 simi-
lar 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 re-
hab center, but neither of them found the idea of accepting AA particu-
larly appealing. Knowing Harry, this was hardly a surprise, as he had suf-
fered 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 man-
aged to assume a controlling interest in it some years before. It was un-
settling 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 dis-
traught wife that the friend had died of an overdose of pills 2 days be-
fore. Harry was shocked and dismayed and could think of nothing else

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 remem-
bered 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
Y 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 de-
fines a moral code that originated in an intense religious experience re-
counted 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 173

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 mod-
eled ten of AA's Twelve Steps after its creed and added two more ex-
plicitly associated with alcohol.
After initial difficulties in securing a circle of adherents, Bill's fellow-
ship 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 detoxifi-
cation, and some settings were offering a period of retreat. However, al-
coholics 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 alco-
holic person can now turn to more than 100,000 of its local groups world-
wide 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 spiri-
tual 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 deci-
sion to turn our will and our lives over to the care of God as we under-
stood Him," has led some courts to prohibit treatment programs from
requiring AA membership of their patients because of a person's right

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 sen-
tence 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 non-
alcoholic 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 nondenomi-
national journey toward relief from the pain of alcoholism, a journey
characterized by the Serenity Prayer, in which members distinguish be-
tween 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 adher-
ents 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 sub-
clinical 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 denomi-
nation. 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 cog-
nitive level members are explicitly led to avoid "persons, places and
things" that would trigger a desire to drinka dictum that has been
clearly put into practice by cognitive-behavioral therapists in their de-
velopment of an approach to recovery couched in a structured set of
treatment encounters. Social support is carefully structured in AA, as il-
lustrated by the expectations that members will find a sponsor with es-
tablished sobriety to lead them through the adoption of the Twelve Steps
as well as attend meetings with a variety of well-established procedures.

These meetings are spiritual in nature but may be likened to religious
services because of their ritualized structure. They range from those as-
sembled listening to a speaker "qualify"or recount the experiences of
his or her personal struggle with addictionto 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 con-
sultant 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 mov-
ing to include nonmembers of AA in the General Services Board is illus-
trated by his having invited onto it Vincent Dole, the physician who de-
veloped methadone as a physiologically grounded treatment for heroin
addiction. Although Bill saw the fellowship's spiritual orientation as re-
quired 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 Tradi-
tions, 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 mem-
bers' use of the group for invidious gossip or personal aggrandizement.

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. Interest-
ingly, 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 fra-
ternal ones to experience the same degree of social support in their en-
vironment and were more likely to maintain the same degree of religious
commitment.6 Others have even found differences in brain metabolism

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 be-
come 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
S 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 evalua-
tion of patients from his treatment program, one oriented toward the
AA recovery format. I went to Atlanta, where he was running a work-
shop 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' cur-
rent 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 encoun-
tered 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 religioushowever much AA may
allow for a nonreligious orientation. One could easily see how such in-

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 alco-
hol 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 involve-
ment 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 commit-
ment 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 meth-
odological problem in studying AA is that this fellowship, deeply con-
cerned 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,

and the number of AA visits made by year three was positively associ-
ated 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 tech-
niques were evaluated: (i) a cognitive-behavioral approach, (2) a tech-
nique for enhancing patients' motivation for dealing with their alco-
holism, 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 engage-
ment 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 cohe-
sive 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 phi-
losophy, 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 acknowledg-

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 accept-
ance 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
O 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 her-

self, and it was the acceptance by people at that meeting that allowed
her to continue to come. Her identification with the group's spiritual-
ity 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 ap-
proach 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 af-

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 despairhe was in debt, increasingly isolated, and about to
be fired from his jobwas 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 even-
tually 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 cred-
ibility. 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 meet-
ing, a very emotional meeting. They asked everyone to say some-
thing 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 re-
late 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 liv-
ing 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 re-
vival meeting begging forgiveness of the Lord.

Because AA has become the mainstay of rehabilitation programs
nationwide, it has served as an effective medium and messenger for ex-
plicitly 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 occa-
sional alcohol withdrawal seizures that he experienced had never con-
vinced 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 im-
portance of absolute abstinence. His subsequent treatment in my hands
thereby benefited from this acceptance of the idea of abstinence, with-
out 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
P 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 bol-
ster 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 pa-
tient, Linda, how she related to the spiritual aspect of membership, and
she said quite explicitly that it did not make much sense to her person-

ally. She was quite content to use the meetings simply as a means of re-
minding her of the dangers of having a drink.
Linda illustrated as well how personal inhibitions, or character pathol-
ogy, tend to color a person's encounter with such a movement. She was
initially ambivalent about attending the meetings, given her early expe-
riences 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 im-
pulses. 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 au-
tonomy, 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 tele-
phone, 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
T he term evidence-based medicine has gained currency among aca-

demic physicians and hence the psychiatrists among them. It reflects
a desire to codify and apply only those medications and procedures that

have been validated by carefully controlled research techniques. Presum-
ably, the profession will consequently become more like a science (or
maybe an engineering job). This also will presumably enhance the com-
petencies of the practitioner, who will then be known to act on tech-
niques with scientific validation. Many in the general population, how-
ever, may not be impressed by the words of an engineer.
Spiritual recovery movements, on the other hand, are largely vali-
dated through personal ties with their leaders and fellow members. They
are much more susceptible to the vagaries of these people'sAA spon-
sors, for examplenatures. There is a downside to this relative to the
evidence-based approach. On the other hand, it does allow the move-
ment 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 pro-
fessional 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 coun-
try 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 at-
tendance. 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 bol-
stered 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 epidemio-
logic investigation, biological studies in the laboratory, or controlled
clinical trials. A spiritual recovery movement such as AA, however, can-
not be effectively evaluated by any such means. Because of this, bio-
medical models often suffer from incompatibility with a spiritually ori-
ented approach such as AA. This was made dramatically clear to me in
my work as program chairman for the medical-scientific conference of

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 propos-
als drew primarily on subjective aspects of recovery. Although each of
our meetings had a time apart from the scientific sessions for AA meet-
ings, these directors, typically in recovery themselves, felt excluded be-
cause 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 at-
tempts 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 asso-
ciated 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.

PART V
Therapy of a Different Kind
M
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 commu-
nity'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 main-
stream 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 psychologi-
cally grounded disorders. The approaches discussed here, quite differ-
ent in nature, illustrate that people have within them the ability to ac-
complish 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 fa-
cilitates 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 feel-
ings 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.
188 Therapy of a Different Kind

13
Rethinking Care of the Mentally 111
The Problem
T he nature-nurture dichotomy has long been played out in oppos-

ing views on the roots of mental illness and has also framed how
psychiatric treatment is provided. It was reflected in the nineteenth cen-
tury in the origins of our contemporary view of psychosis, as experi-
mental medicine was emerging as a science at that time led in France by
the physiologist Claude Bernard. A psychiatrist colleague of his, Bene-
dict 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 promi-
nent role in the course of schizophrenia. Hebephrenia, for example, is a
term introduced in the late nineteenth century for a form of schizophre-
nia 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 re-
habilitation of the mentally ill, this regressed form of schizophrenia is
seen less often nowadays. In actuality, the severe regression that charac-
189
terized it typically resulted from the isolation from normal social con-
tact 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 so-
ciety 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 observ-
ing 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 Hospi-
tal 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 coun-
try to feign mental illness in order to gain admission.5 These pseudo-
patients were instructed to arrive at the respective admission offices
complaining of hearing voices but otherwise to present their life histo-
ries 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 hos-
pital, 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 hal-
lucinations, were reinterpreted by staff to validate the origins of their
mental illness. Notes such as this framed the staffs understanding: "While

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 man-
ner by the staff, who took little time to speak with them in any meaning-
ful 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 di-
rectly at Dave. Rosenhan, in fact, tabulated the many times in which en-
counters 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 selfa similar 'moral
career."'6
In other circumstances, the converse could be true. A spiritually ori-
ented group can offer a sense of personal meaning and hope for the fu-
ture in the face of despair. We can therefore ask: Can a secular adapta-
tion 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 hopeless-
ness implicit in a "career" of mental illness. Hopelessness is a hallmark
in the life of most people suffering from mental illness, and the prob-
lem 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 com-
mon 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 addi-
Rethinking Care of the Mentally 111 191

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 sub-
stance 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 regu-
larly ignored in treatment. Alcohol and drugs are also more readily avail-
able on the street than in psychiatric wards, so that although the agita-
tion and delusions of schizophrenics or severely depressed people are
apparent after admission, their substance abuse problems do not re-
emerge until after they have left the hospital.
This issue of such "dual diagnosis," however, was becoming unavoid-
able 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 Man-
hattan's state psychiatric hospital. The state hospitals are less aggres-
sively 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 abil-
ity to produce addiction, only later appreciated, had led to its being out-
lawed 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

reinforced their addictive pursuit of the drug, as it gave momentary re-
lief from their unhappy lives, effectively conditioning them into an ad-
diction.11 We reviewed the charts of patients admitted to the general
psychiatric units and found that no less than 64% of them had a sub-
stance 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 data-
base 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 pri-
marily through promiscuous sexual activity. At low doses of crack, two

or three vials, men were aroused and could maintain an erection. (At
higher doses they could not.) Women turned to prostitution to main-
tain their habits, and, not surprisingly, they reported disliking sex and
feeling degraded.16 Diseased minds were leading these people to despoil
their bodies.
Deinstitutionalization
W 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 emer-
gence of the York Retreat in England under William Tuke, and in the
United States in the Bloomingdale Asylum in New York and the Hart-
ford Retreat in Connecticut. The movement was premised on the as-
sumption 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 psychia-
trist 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 after-
care. In this way a short-term inpatient stay would precede patients' rein-
tegration 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

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 com-
munity 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 medi-
cal director of the American Psychiatric Association, who in 1955 pre-
dicted 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 de-
velopment of medications to treat their deluded states. In fact, it was al-
ready 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 fac-
tor 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 livingbut many refused to livein single-room
occupancies or shelters that were infested with predatory alcoholic and
drug-abusing people, often mentally ill themselves. More recently, some

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
O ne way to approach this sad circumstance is to create a treatment

environment that shows that there is a meaningful path to recov-
ery, 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 com-
munity" (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 psy-
chological 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 ware-
housing them, with relatively little attention paid to their needs for ul-
timate 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, establish-
ing 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 pres-
sure 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 struc-
ture of the psychiatric hospital and Jones's concept of openness between
patients and staff. The approach did emerge more prominently, how-

ever, in the drug-free therapeutic communities such as Phoenix House
and Daytop Village designed to rehabilitate addicted people who suf-
fered 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 tellon an-
other who has been seen to violate expected behaviors, such as avoid-
ing 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 beha-
vior patterns of mentally ill addicted patients was supported by one study
we did. We looked at the impact of personality disorders that compli-
cated 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 evalua-
ted were significant factors in yielding a poorer outcome of treatment.
According to the psychiatric nomenclature, such disorders are charac-
terized 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 di-
agnosed 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 maladap-
tive 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 treat-
ment format: Why did the residents in the original drug-free TC toler-
ate demands to conform to the behaviors required of them? After all,

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 sup-
portive. There was a strong sense of commonality, with an almost spiri-
tual ideology of good versus evil (redemption from addiction versus the
drug-addicted life). This Manichean divide paralleled that seen in reli-
gious 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 respon-
sible 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 trans-
formed 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 de-
pressed under intrusive pressure to meet the program's demands. We
had to treat him on our unit for the depression that had been aggra-
vated by the traditional TC culture.
In order to merge the TC and general psychiatric format, we collabo-
rated 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,

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 psychi-
atric 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, trans-
formed into an acceptable model like AA, but adapted to the needs of
disordered psychiatric patients, including the progressive use of psycho-
tropic medications.
The Issue of Belief
H 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 illus-
trated 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 respec-
tive 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 ad-
dressed, just as the alcoholic's denial of her addiction can be under-
mined and then extinguished under the right therapeutic circumstances.
Reshaping of thought can also be successfully achieved in a support-
ive group situation, and the impact of AA on alcoholic denial has made
this clear many times over. Experiences that I witnessed in zealous reli-
gious sects, let alone the many religious conversions that have taken
place at revival meetings over the years, show that new beliefs can be in-

troduced into people's worldviews in the right group setting. Given
these observations, we can consider how a program to instill the con-
cept of personal renewal can be introduced into the thinking of the ad-
dicted mentally ill.
Some years back, Jerome Frank, a master clinician and researcher,
wrote about the commonalities among a variety of redemptive experi-
ences.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 de-
moralization 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 psychia-
trists in a positive light as life-transforming experiences. One of them,
R. D. Laing, espoused a philosophy (a belief, in fact) that his schizo-
phrenic patients, in withdrawing into their own deluded views, were re-
sponding in a reasonable, rather than pathologic, way to the disturbed
families andas he saw itpernicious 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 break-
through, divesting them of the constraints of oppressive social struc-
tures, and thereby offering the opportunity for personal renewal. He
did not dismiss the fact that the residents might have a genetic predis-
position 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

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 ex-
pect less from them. Their ability to move forward in a positive direc-
tion 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 con-
trolled study in Soteria House, a residence in San Jose, California. He
instituted a number of changes in Laing's model, though, and impor-
tant 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 nonethe-
less 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 lim-
ited 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 be-
lieved [italics mine] to have potential for reintegration and reconsti-
tution resulting in a more stable sense of self, if it is not prema-
turely aborted or forced into some psychologically straitjacketing
compromise. 9Q
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.

Mosher compared the outcome of his patients to some who were
treated on a conventional ward and at follow-up clinic where anti-
psychotic drugs were given routinely. He found that after discharge the
Soteria patients needed less outpatient care, achieved a better occupa-
tional level, and were more able to live independently than were those
given conventional treatment. His study supported the idea that the in-
stitution 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 de-
gree 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 pa-
tients 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 in-
terest in undertaking such a venture, given the reliance of psychiatrists
almost exclusively on drugs that target psychosis and severe mood dis-
orders and given the practice of labeling patients' identities that Goff-
man'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 symp-

toms, not the disillusionment of the mentally ill. In addition, the field
of medicine, from which psychiatrists fear exclusion, is, not surpris-
ingly, 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?
I t would be easy to see our Bellevue patients as interested in survival

and little more, and the numbers certainly reinforced this. When ad-
mitted 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 medi-
cal 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 pa-
tients 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 patientsas peoplesaw as a way out from their seemingly hope-
less condition. The promise of spiritual redemption was clearly an un-
tapped 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 compro-
mised 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.

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 spiri-
tual 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 hospi-
talized, mentally ill, substance-abusing patients that would employ the
spiritual orientation implicit in AA along with a commitment to trans-
forming their attitudes and personal identities to help them stay drug
free and look toward a more positive future.
The Program Evolves
B 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 re-
ports 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 gen-
eral psychiatric disorders plus substance abuse. The plus made these pa-
tients 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

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 rehabili-
tating the mentally ill was not uncommon in some communities (ap-
plied at least in theory), but we premised our format on promoting co-
hesiveness 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 con-
temporary 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 appre-
ciable extent in the psychiatric mainstream, but we had some advan-
tages 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 relation-
ships 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

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 back-
ground in Utah to homelessness on the Manhattan streets. The staff at
a shelter for the homeless had called the police when they found her be-
having uncontrollably and quite drunk. Her complaint on arrival at
Bellevue was typical of the paradoxical statements we had come to ex-
pect: "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 dis-
charged 2 weeks later after her mood-stabilizing medications were re-
instituted. 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 avail-
able) 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 fu-
ture, 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 pe-

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 mo-
ments of peace. She said "I was a hard nut to crack but they got me in-
volved." 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 for-
ward 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 imple-
mented 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 educa-
tional 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 ab-
sent from psychiatric units, even though a good half of patients in pub-
lic 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 attend-
ing 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

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 to-
ward 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 sec-
ular 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 ab-
sent from view in our psychiatric hospitals, as they leave the environ-
ment 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 ulti-
mately 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 rehabili-
tation during a 6-month residential stay. The program included an en-
hanced 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-

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 goo-
bed building and take over the unit's food preparation and housekeeping
functions. Acquiring this latter set of responsibilities was important be-
cause it enabled us to run the unit with the kind of work hierarchy typi-
cal 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 owner-
ship 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 resi-
dent 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 Green-
house 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 stigma-
tism [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.

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 re-
sponsible 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 think-
ing 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 in-
tensive 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 cul-
tic groups increase validation of their beliefs by generating a sense of

universality when members are brought together in large groups. At-
tendance at AA meetings in the community enhances this approach.
On the other hand, group sessions of six or seven peers are also or-
ganized. These capture some of the redemptive qualities of the confes-
sionals 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 in-
troducing 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 unitsthe ward, the

Greenhouse, and the Recovery Clinicand our findings lent clarity to
the impact of the programs. For example, we found that patients dis-
charged 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

The patients on our ward with multiple previous admissions were in-
deed 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 en-
hanced 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 incarcer-
ated. However, those with more arrests adapted to the Greenhouse struc-
ture 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 re-
tained better in the Recovery Clinic and were more likely to stay absti-
nent 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 prom-
ising. Methadone patients, effectively strait-jacketed by their depend-
ence 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 tra-
dition, 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" pro-
gram 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 mu-
tuality 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

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.

14
A Shaman in the Halls of Medicine
A 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 primi-
tive societies, but in doing this they can lose perspective on powers con-
sidered 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 psycho-
pharmacologists will typically avoid treating sociopathy because of socio-
paths' 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 en-
able its practitioners to access information that is not ordinarily avail-
able 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
214
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 pro-
viding meaning to symptomsissues 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 main-
stream? Or, put another way, could some of the more elaborate proce-
dures undertaken by physicians be replaced by shamanlike rituals that
are effective and perhaps more efficient?
In addressing this question, we can consider one physician embed-
ded 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 rehabili-
tation 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 suc-
cessful 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. Dur-
ing periods of difficulty, he tended to suffer from headaches rather than
from anxiety and depression. He had long experienced these head-
aches, 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 prob-
lems at a local teaching hospital, but had received no relief. I remember
A Shaman in the Halls of Medicine 215

thinking how close the relationship is between the mind and body
when Adam's headaches came to an end shortly after he decided to di-
vorce his wife, with whom he had been locked in seemingly irresolvable
conflict.
After the divorce Adam and I worked on problems he had in achiev-
ing 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 re-
lieved. 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 psycho-
therapy for some time and saw me again several years later. He contin-
ued 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 compro-
mised by anxiety and inhibitions. He had suffered from school phobia
as a boy, had later dropped out of high school, and had been hospital-
ized 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 im-
mobilized by back spasms. As he reported this to me over the phone, I
thought that perhaps he would have been best referred to an orthope-
dist, a neurologist, or some other physician who did not deal with back-
aches "lite," particularly because of his emotional vulnerability. None-

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 re-
markable personality that lay behind his seemingly magical clinical skills.
Questioning the Somatic Approach
F or the moment, let us consider how widespread is the problem that

Sarno addresses and some of the ways that the conventional medi-
cal 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 in-
ferences from these studies is that most adults will show some such ab-
normalities whether or not they complain of backache. Even half a cen-
tury 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 pos-
terior cervical protrusion demonstrated, if he happens to have a mye-
logram."7 Indeed, in one study of myelograms, no significant correla-
tion 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 Lithua-
nia, where there was no insurance coverage for such injury, no differ-
ences in neck pain were found between people involved in such acci-
dents and those who were not.9 Apparently, a pecuniary incentive can
produce a traumatic injury that some lawyers would send to a consult-
ing orthopedist.
Psychology certainly plays a role in how people respond to treatment
for back pain. It has been reported10 that people who tend to catastro-

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 con-
trol pain all tend to have poor treatment outcomes for their back prob-
lems. 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 under-
going 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
S 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 fire-
brand, 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

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
processwe were, after all, sitting in the faculty dining room of a major
research universityhe 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 pa-
tients 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 shamanismclearly never "evidence-based"
ones that psychiatry seemed intent on expunging from its armamen-
tarium. 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 dis-
cussion 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-

lowed by the patient's attending his lectures. He would refer some pa-
tients who he felt needed more intensive work to untangle their con-
flicts to a number of psychologists.
Sarno's office was in the main medical school building, a more gen-
teel setting than Bellevue Hospital. Nonetheless, he was eager to estab-
lish 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 con-
cerned 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 psy-
chiatric 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 ob-
scenity. 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 ram-
bunctious, and Sarno decided not to interview him. As he had told me,
he chooses those whom he thinks he can treat. The patient did, how-
ever, 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

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 psy-
chologizing were more the style of dealing with tension.
Even so, Sarno had never embarked on a controlled study to deter-
mine 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 refrac-
tory patients. I wondered whether approaches like his, in some ways
bearing as much similarity to spiritual healing as to contemporary psy-
chiatry, would find their place in the mainstream. If so, conventional
medicine might be able to take advantage of the techniques of sha-
manic healers without questioning their merit because they have not
emerged from randomized, controlled trials.
The shamans, including those in Balajithe town in India where
spiritual healing takes place for the mentally illwere wise to restrict
themselves to those conversion symptoms they could address. They
would be wise as well not to compromise their seemingly magical in-
cantations 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

mother-in-law and the young man who had experienced a sudden on-
set 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 asso-
ciated with mental health.

15
Meditation
T herapists can learn to address their patients with compassion in a

variety of ways. Some draw on their training in listening for un-
conscious 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 experi-
ences after exposure to some aspect of Eastern spirituality. My own en-
counter 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 profes-
sional status. He described how both he and the mission itself had
evolved over the years.
223
Zach had become interested in meditation while practicing psychol-
ogy 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 believeexperience. If you don't experience anything, for-

get 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.

"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 nec-
tar. 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 peace-
ful place.
His answers illustrated the role of mystification in the process of en-

gaging people in a cultic meditation. Transcendental Meditation prac-
titioners 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 en-
counter 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 re-
vealed. 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 an-
other 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,
Meditation 225
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 re-
sponse illustrated the way a mental health professional, even one fol-
lowing a guru, may be reluctant to veer away from what is considered
proper practice:
I always felt that there would be something unethical about pro-

moting 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 pro-
fession, 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 dia-
phragm 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 asser-
tiveness], 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.

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 expe-
rience, or it is considered not quite relevant to a profession that is sup-
posed 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 ownif they feel

itis revered, but that of others can be dismissed, even maligned. Of
course, this is nothing new.
Mindfulness Meditation
I 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 con-
flicts, 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 en-
counter. Another is that entry into the mental health field does not nec-
essarily 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 227
as popular options during the 19708. Maharishi Mahesh Yogi, who in-
sisted 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 in-
creases. 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 "cos-
mic consciousness." Some established a residential community of their
own in Fairfield, Iowa, with their own university, and raised their chil-
dren as devotees to their philosophy. Given all this, TM may be too cul-
tic 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 associ-
ated 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 ap-
proximate the standards for treatment that empirical researchers es-
pouse but would also touch on people's spiritual inclinations. To illus-
trate this we can consider the technique of "mindfulness meditation." It
is reasonably well defined and is applicable in the context of a conven-
tional 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 Deik-
man, 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

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 medi-
cal 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 aug-
ment the practice of psychotherapy or even supplant it in some respects.
He pointed out how this approach could allow for "being aware of ex-
actly 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-to-
moment 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 mindnot to change or disavow them,
but to avoid getting lost in them. They are therefore accepted as the natu-
ral 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 psychologi-
cal 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 gener-
alized anxiety and panic disorder and contrasted them with a group of
patients similarly diagnosed but not treated with the meditation tech-
nique. They reported reductions in symptoms right after the medita-
tion intervention6 and on follow-up 3 years later.7 Investigators at Cam-
bridge 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 ap-
proach, the more chronically relapsing patients' rate of relapse was cut
in half.
Meditation 229
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 pa-
tients 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 mo-
mentary 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 mate-
rial improvement in the patients' distress and pointed out the impor-
tance of uncoupling the sensory component from its cognitive and emo-
tional 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 character-
ized by widespread moderate pain, fatigue, and sleep disturbance. Al-
though 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 cri-
teria.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 pa-
tients applied a mindfulness meditation regimen. Similar success has
been achieved12 in treating patients with psoriasis, another physical syn-
drome 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 reduc-
tion 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 en-

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 com-
mon 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 medi-
cal setting and can be helpful as well. An approach such as this may
come to be used more widely as health practitioners respond to pa-
tients' growing interest in alternative medical techniques.
Meditation 231
16
Psychotherapy for Personal Meaning
T 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 com-
panies, many in the profession have lost track of what may make a pa-
tient 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 timefor half a century, in factpsychiatry tried

to interpret the human mind merely as a mechanism, and conse-
quently, the therapy of mental disease merely in terms of a tech-
nique. 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 impor-

tance 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 strength-
ened 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 under-
lay patients' pain to offer them relief. As he said, "In some way, suffer-
ing 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 bestI 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 therapeu-
tic 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?
R esearch has shown that the success of a given episode of psycho-

therapy in providing symptom relief may be more the product of
a sound alliance between therapist and patient than the particular theo-
Psychotherapy for Personal Meaning 233

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 say-
ing 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 releasedwithout ad-
mission 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 pre-
sented 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 ex-
plained that she was drinking heavily around the time of the incident.
The resident described Marilyn as uncooperative and having little mean-
ingful 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 be-
fore 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

to go to her mother's bedside as she lay in a coma in the final days be-
fore 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 an-

other $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 im-
portant 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 ad-
dress her depressed state, but indeed that was what was worrying her
most. It was easily lost under the pressure of the presumably larger is-
sues 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 pay-
ment 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 com-
promising. Often an intervention in a family situation is essential to

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 appoint-
ment, 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 prob-
lem 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 anti-
depressants 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, de-
pressed, and "miserable" over his demands that she continue in a busi-
ness career, which she had embarked on only because of continuing pres-

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 de-
mands, but Jeanne was concerned about the well-being of the dis-
advantaged, 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 iden-
tity, 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 drink-
ing. A psychopharmacologist might have chosen to relieve her depres-
sion with an adjustment in medication, not having the time to become
involved in the details of her family conflicts. He would have admon-
ished 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 op-
tions 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, act-
ing 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 comfort-
able office of a private psychiatrist. In both cases, though, some time

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 ap-
proach 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 accumu-
lation of behaviors, or symptoms, for that matter. Murray emphasized
the importance of biography in such studies and even hoped to see per-
sonologists do research on scientifically framed biographies.
Keeping Murray's perspective in mind, we can consider how a com-
promised engagement with life's challenges can be as disabling as dis-
crete 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 psy-
chiatric nomenclature, acknowledges the issue. The schizotypal per-
sonality 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 at-
tempts. Such people are frequently troubled by chronic feelings of empti-
ness, but their lives may be stabilized by treatment with antidepressants
or low doses of antipsychotic medications, again suggestive of a relation-
ship to a biological vulnerability.
People with alcohol problems may differ physiologically among them-
selves. 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

nonalcoholic parents from the earliest age. Their genetic makeup ap-
parently shows through.
On the other hand, nurture, not only nature, plays its role. Psycho-
dynamic 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 depend-
ency, 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 adap-
tation 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 psycho-
analytic therapy but allows for emphasis on achieving what is mean-
ingful, 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 thera-
pist'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 rec-
ognize 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

the onset of depression, he found that events experienced as humiliat-
ing, 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 perspec-
tive 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 di-
rected 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 rela-
tionships. 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 op-
portunity to consider what his very real talents at marketing might

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 ac-
cepted a subservient role in relation to her and did not gain a sense of
autonomy. The onset of moderate depression in his teen years aggra-
vated his feelings of inadequacy and left him uncertain about his abil-
ity 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 simi-
lar business activities. At work he operated with considerable skill, but
two earlier employers, each callous in his own way, recreated the pat-
tern of dominance established by his mother. His work, however suc-
cessful, 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 anti-
depressant medication had provided: He directed his talents to develop

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 pro-
vided 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 ther-
apy 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 Kend-
ler's findings on the impact of humiliating experiences in generating
depression. He might well have evolved into a less dependent and in-
secure 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 mini-
mized 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 adapta-
tion 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 symp-
toms. 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.

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 need-
ing 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 com-
pliance 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 alco-
holic 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 mar-
riage. 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 aggra-
vated 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 mal-
feasance 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 par-
ents, 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

holding a responsible position in his corporate niche and was well re-
garded 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 edu-
cation, 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 dis-
tinct identity and interests that would distinguish him from other can-
didates. 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 vali-
date 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 relationshipnot unlike our ownwith a professor in
college who was dissecting out historical issues related to the legal prerog-
atives 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 perform-
ance. 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 su-
periors 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 re-
lated to what he might see for himself as an attorney and an accom-
plished 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

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
I s it feasible to employ an approach to treatment that requires con-

siderable 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 men-
tal health system? Groups such as the Rand Corporation have carried
out analyses on the cost of full mental health coverage under current in-
surance 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 com-
plaints, 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 work-
ers 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

a factor of more than six.8 Federally funded programs have also demon-
strated 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 coun-
selors 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 con-
gruent with the approach described in this chapter, its history in the
United States illustrates the feasibility of disseminating a mode of prac-
tice 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 un-
happiness or unfulfilled potential? Is it really necessary to expunge this
goal from the domain of mental healing?

Epilogue
T 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, bio-
logical, and cultural perspectives.
Although the nature of spirituality maybe ambiguous, psychiatry it-
self 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 diction-
ary 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 mem-
ber of the profession insisted that the members of his profession had no
obligation to deal with "problems of daily living" and advocated defin-
ing 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 prob-
lems into a series of symptoms and socially defined misbehaviors. They
247
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 struc-
ture 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 be-
ginning to look like that profession's clinical hallmark, but like psycho-
pharmacology, it is a structured approach that addresses specific prob-
lems, 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
I 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"2discerning the realities they confront,
248 Epilogue
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 de-
limit what journey, hidden from expression, they may undertake to find
validation, but each patient deserves the opportunity toat least
consider that journey. Consequently, it will take a good deal of creativ-
ity 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 in-
spired 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 Psychi-
atric 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 psy-
chiatric research, but what is meaningful to a given person is largely an
issue of the mind rather than the brain. Academic psychology is in-
creasingly adhering to reductionist models of investigation drawn from
the physical world and is moving away from the subjective experiences
Epilogue 249
that can define the identity of a given unique person. In any case, it is
not possible to conduct randomized, controlled clinical trialsthe dar-
lings of treatment researchon the issue of spiritual meaning.
A more hopeful note derives from the trajectory of scientific inves-
tigation 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 par-
adigms of research do not necessarily arise because they prove estab-
lished ones wrong, but often just because the established techniques
employed in the normal science run out of useful questions to be an-
swered. A newly emerging paradigm is then accepted because it can
raise challenging issues and produce answers to a flurry of new ques-
tions. People's pursuit of alternative medicine and of spirituality sug-
gests that with all our medical advances, many important questions are
left unanswered, even unasked. Hence, we now have the option of ap-
plying a new research paradigm, one for understanding spiritually re-
lated 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 dif-
ferent cultures. What is needed now is an approach that integrates a
large variety of observations like these in a creative manner. No scien-
tific discipline will lay claim to having the one valid perspective on this
issue. Physiology can give us lessons about those aspects of brain func-
tion that support the spiritual experience. Social psychology can be used
to examine the way related movements and the cultures they are em-
bedded in can shape people's experiences, and so on for cultural an-
thropology, 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, loneli-
ness, 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 rec-
ognized 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 de-
limited 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 ori-
entation, 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 op-
portunity 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 ear-
lier 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 thera-
pist may have neither the time nor the inclination to address these ques-
tions. 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, re-
covery 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 mir-
ror and see what lies on the other side.
252 Epilogue
Notes
PROLOGUE
1. M. Galanter et al. 1972; M. Galanter et al. 1973; M. Galanter et al. 1974.

2. M. Galanter 1976.
4. M. Galanter, D. Talbott, K. Gallegos 1990.
5. M. Galanter et al. 1994; Galanter et al. 1998.
6. L. Goldfarb et al. 1996; D. McDowell et al. 1996.
7. G.O. Gabbard 2000, p. 103-123.
8. K. Hausman 2004, p. 2 ff.
9. M. Galanter et al. 2000.
10. 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. R.T. Hales and S.C. Yudofsky 1999.

2. American Psychiatric Association 1994.
3. G.H. Gallup 2002.
4. 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.
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. A. Newberg et al. 2001.
14. C-K. Peng et al. 1999.
15. C-K. Peng et al. 1999.
16. B.K. Anand, G-S. Chhina, and B. Singh 1961.
18. A. Newberg et al. 2001.
19. J. Borg et al. 2003.
20. J. Bowlby 1973; R.A. Spitz 1946.
21. B.M. Seay, E.W. Hansen, and H.R Harlow 1962.
22. S.J. Suomi, H.R Harlow, and W.T. McKinney 1972.
23. S.J. Suomi et al. 1978.
24. K. Kendler 1997.
26. A.D. Solomon and D.M. Johnson 2002.
27. C.R. Brewin, B.Andrews, and J.D. Valentine 2000.
28. N. Tinbergen 1951.
29. K. Lorenz 1966.
30. R.L. Trivers 1971.
31. E.O. Wilson 1975; 1978.
32. C.D. Batson 1983.
33. D.S. Wilson 2002.
34. A.R. Radcliffe-Brown 1939.
35. 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.
10. R.C. Kessler et al. 20013.
11. K.M. Fairneld et al. 1998.
12. R.C. Kessler et al. 20Oib.
14. N.K. Choudhry 2002.
15. M.B. Rosenthal et al. 2002.
Notes 255
16. M. Olfson et al. 2002.
17. J. Wesley 1960.
18. P. Starr 1982.
19. A. Flexner 1910.
20. Thomson Financial Datastream 2002.
21. M.B. Rosenthal et al. 2002.
22. KG. Alexander and and S.T. Selesnick 1966.
23. P. Starr 1982.
24. J.P. Feighner et al. 1972.
25. Washington Post 2002.
CHAPTER 5. PROBLEMS WITH SPIRITUALITY
1. W.B. Cannon 1929.

2. S.E. Asch 1956; S. Milgram 1974.
4. J.M. Weightman 1983, p. 116
5. H.F. Searles 1965.
6. G.W. Brown, J.L. Birley, and J.K. Wing 1972.
7. I.D. Yalom and M.A. Lieberman 1971.
8. W.R. Bion 1959.
10. T.H. Holmes and R. Rahe 1967.
12. New York Times 1999-2002.
13. C. Lasch 1979.
14. G.W. Allport and J.M. Ross 1967.
15. Saferparks Database 2003.
16. New York Times Almanac 2002.
17. Time Magazine: Inside Business 2003.
18. Time Asia 2003.
19. Quart 2003.
20. New York Open Center 2003.
21. Associated Press 2002.
22. M. Berg 2002.
CHAPTER 6. WHEN SOMETHING IS MISSING
1. T. Pettersson 2000.
256 Notes
3. V. DeMarinis 2003.
4. G. Andrews and S. Vinkenoog 1967.
6. T.H. Holmes and R. Rahe 1967.
7. E. Salib 2003.
8. M.J. Horowitz 1986.
9. I. Skre et al. 1993.
C H A P T E R 7. C H R I S T I A N PSYCHIATRY
1. M. Galanter, D. Larson and E. Rubenstone 1991.

3. D. Biebel 1998.
4. D. Carlson 1984.
CHAPTER 8. SPIRITUALITY IN INDIA
1. N.C. Chaudhury 1979.

2. B. Thomas 1997.
3. I. Sharma 1989.
4. A. Pakaslahthi 1998.
5. G. Edwards and G. Kissin 1977.
6. 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.

4. M.S. Peck 1985.
5. W.A. Fintel and G.R. McDermott, 1993.
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. R. Glaser et al. 1985.
16. D. Russell et al. 1980.
17. J.T. Cacioppo 1994.
18. J.M. McGinnis and W.H. Foege 1993.
20. A.A. Skolnick 1991.
21. W. Parry-Jones 1981.
22. E. Roosens 1979.
23. Project MATCH Research Group 1997.
24. A. Kleinman 1980.
25. A. Leighton and D. Leighton 1941.
26. J.G. Kennedy 1967.
27. J.A. Adetunji 1992.
28. M. Singer and M.G. Borrero 1984.
29. T.A. Maugans and W.C. Wadland 1991.
30. K.K. Trier and A. Shupe 1991.
32. B.R. Cassileth et al. 1984; F.S. Bagenal et al. 1990.
33. I.D. Yalom and M.A. Lieberman 1971.
34. I.J. Lerner and B.J. Kennedy 1992.
35. M.B. Eddy 1989.
36. E.M. Pattison et al. 1973.
37. C.K. Hofling et al. 1996.
38. A. Bandura 1986.
39. A.T. Beck 1976.
41. B.S. Siegel 1990.
CHAPTER 12. ALCOHOLICS A N O N Y M O U S
1. Alcoholics Anonymous 1957.

2. Alcoholics Anonymous 2002.
3. New York Times, August 2001, page Bi.
4. J.N. Chappel 1993.
5. E. Sifton 2003.
6. K. Kendler 1997.
7. J. Borg et al. 2003.
8. M. Galanter et al. I99ob.
9. K. Humphreys et al. 1997.
10. Project MATCH Research Group 1997.
258 Notes
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 Sta-
tistics 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.
13. G. Haugland et al. 1991.
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.
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.
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. Gold Award 1993.
37. H. Franco 1995.
38. H. Dermatis et al. 2004.
39. D. Mierlak et al. 1998.
41. 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.
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. V. Frankl 1984.
2. L. Luborsky et al. 1985.
3. H.A. Murray 1938.
4. B. A. Johnson et al. 2000.
5. A.E. Bergin 1980; 1991.
6. K.S. Kendler et al. 2003
7. R. Sturm 1997.
8. U.S. Substance Abuse and Mental Health Services Administration 2000.
9. R.C. Page and J.B. Bailey 1991.
10. M. Margolis 2001.
EPILOGUE
1. A.F. Schatzberg and C.B. Nemeroff (eds) 2002.

2. E.J. Khantzian, K.S. Halliday, and W. E. McAuliffe 1990.
3. R.M. Miller (ed) 1999.
4. American Psychiatric Association 2002,2004.
5. T. Kuhn 1962.
Notes 261
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Index
AA. See Alcoholics Anonymous membership, 175

AAAP (American Academy of Addiction origins, in spiritual experience, 157,
Psychiatry), 50-52 173-176
Academic psychology, 249-250 professional relationships and,
Addiction 184-186
to alcohol. See Alcoholism Project MATCH and, 180
Islamic treatment program, 147 redemptive potential of, 171-173
mental illness and, 209 spiritual recovery and, 6, 51,162
Minnesota model for treatment, subjective experience and, 177-178
65-66 Alcoholism
substance abuse, mental illness and, mental illness and, 192-193
192-193 sociopathic behavior and, 238-239
Adolescents, developmental norms, 9 suppression in early life and, 243-245
Adrenalin, 31,32 treatment. See also Alcoholics
Advertising revenues, drug manufac- Anonymous
turer, 57 absolute abstinence and, 183
Arafa, Magdy, 147 cults and, 22
Affiliation, group, 25,168 making meaning in life and, 100
AIDS/HIV, 193-194 Minnesota model for, 65-66
Al-Azhar mosque, 144 Rational Recovery program for, 169
Alcoholics Anonymous (AA) role of spirituality in, 102-103
denial of addiction and, 199 therapeutic community for,
different attitude of members and, 196-199
183-184 Allport, Gordon, 18,19
efficacy/success of, 176 Alternative medicine
encounters with members, 181-183 do no harm concept and, 165-167
evaluating participation in, 178-181 emergence of, 54-56
medical community acceptance of, popularity of, 159-160
164 spiritual recovery movements. See
meetings, 175-176 Spiritual recovery movements
279
Altruism, 20, 43-45 Asanas, 132
AMA (American Medical Association), Asch, Solomon, 70-72
59-60 Astanga yoga, 132
American Academy of Addiction Psychi- Attention-deficit/hyperactiivty disorder,
atry (AAAP), 50-52 243
American Board of Medical Specialties, Attribution theory, 25-26
60 Aum Shinrikyu, 20
American Journal of Psychiatry, drug Australopithecus, 46
manufacturer advertising rev- Authoritarian religious viewpoint, 19
enues and, 57 Autonomy, 89
American Medical Association (AMA), Awareness, 229
59-60 Ayurvedic medicine, 7,132-134
American Psychiatric Association (APA)
annual meeting, 64-65,113 Back pain treatment, 217-218
clinical care guidelines, 249 Balaji, religious/spiritual commitment
Group for Advancement of Psychiatry in, 134-136,221
and, 63 Batson, Daniel, 20
pharmaceutical companies and, 57 Beatitudes, 124
psychopharmacology and, 248 Behavior, evolutionary basis of, 43-45
American Society of Addiction Medi- Behavioral traits, biological factors
cine (ASAM), 50-52,65,66,186 and, 20
Anger Bellevue Hospital, New York, evolution
against God, 151-152 of mental health program,
intense, 79 204-213
toward father, 236-237 Benares Hindu University, 131
unconscious, 218-219 Bergin, Allen, 19,239
Anthropology, 46 Bernard, Claude, 189
Antibiotics, 133 Bible, 114-115,153
Anti-Communism, 8 Biomedicine
Antidepressants metaphor of, 56-58
for depression, 117,118,197, 241-242 research, 63-64
effectiveness of, 170 Bion,W.R., 81-82
meaning to life and, 96 Biopsychiatry, vs. problems of daily
placebo-controlled studies, 28-29, 215 living, 64
sales of, 64 Blue Cross and Blue Shield, 61
vs. social support for depression, 41 "Bollywood," 129
Antipsychotic drugs, 195, 201-203 Bone pointing, 68-70
Anti-Semitism, 8,15 Borderline personality disorder, 238
Anxiety disorders "Born again" Christians, 12-13,114,115
cultic religious sects and, 162 Bottoming out, 180-181
curbing, cults and, 22 Boundary crossings, 116-117,124-125
meditation for, 229 Boundary violations, 116,124-125
spiritual explanation of, 26 Brain
APA. See American Psychiatric electroencephalography of placebo
Association effect, 37-38
Apache shamans. See Shamans, Apache emotional energy and, 32-35
Applewhite, Marshall "Bo," 108-109 evolutionary adaptation of, 43-46
Archetypes, 15 meditation and, 38-40
Arthroscopic surgery, 29 memories and, 35-37
ASAM (American Society of Addiction metabolism, transcendence experi-
Medicine), 50-52,65,66,186 ence and, 177-178
280 Index
nonspecific stimuli and, 31-32 Christian Science, 166
social support and, 40-42 Church attendance, 161
Brainomed, 169-170 Cingulate gyrus, 33
Branch Davidians, 20 Classical conditioning, 36
Buddha, 130 Clerical collar, 154,155
Buddhism, 128, 229 Clinical practice, introducing spiritual-
ity in, 247-248
CAM (complementary and alternative Clinicians, spiritually oriented recovery
medicine), 55 and, 248-249
Cancer patients CMA (Christian Medical Association),
alternative treatments for, 163, 165-166 113-118
religious healing for, 161 Cocaine, 192-193
Cannon, Walter, 68-70 Codependency, 162
Cardiovascular system, psychosocial Cognitive-behavioral therapy, 248
factors and, 162-163 Cognitive dissonance theory, 26
Caregiver, judgment of, 166 Collective unconscious, 15-16
Catechisms, as "cultural genomes," 45 Community
Catecholamine hypothesis, for sense of, 109-110
depression, 52-53 support from, 162
Catholics, 8 Complementary and alternative
Cell assemblies, 37 medicine (CAM), 55
Cerebral cortex, 34 Compulsive eating, Christian psychiatry
Chaplaincy for, 122
clerical collar and, 154,155 Conditioned response, 35-37
dealing with anger against God, Conflict, in mental health field, 49-52
151-152 Conformity, 71
demands of, 76-77 Contraceptives, 9
listening style and, 155-156 Conversion symptoms, 138-139
therapeutic tools for, 152-153 Coordination, in religious groups, 45
therapist-spiritual mentor relation- Corpus callosum, severed, 32
ship and, 155 Corticotropin-releasing factor, 42
trainees, 149-151 Cortisol, 42
Charismatic groups Crack cocaine, 192,193-194
definition of, 83 Creative visualization, 162
psychological well-being of members Cremations, Manika, 130
and, 84,86 Cults
Children, praying with, 154-155 decreased stress in, 162
Chlorpromazine (Thorazine), 195,202 disasters, 108-109
Christian Medical and Dental group affiliation and, 44
Association, 77,161 leaders of, 74
Christian Medical Association (CMA), mass poisoning incident, 74-75
113-118 problems associated with, 82-86
Christian psychiatrists spiritually oriented perspective of,
with Fundamentalist orientation, 20-23
122-125 Cultural reintegration, beginning of,
literal role of Jesus and, 125-127 10-11
working with, example of, 118-122 Culture
Christians distortion of reality and, 72
beliefs of, return to, 10 impact of, 47-48
"born again," 12-13, n4> 115 sexual inclination and, 45
Second Advent, 59 Cupping, 161
Index 281
"Daily affirmations," 7-8 Eastern spirituality, 7,159,161,223,227
Darshan ceremony, 225-226 Economics, of medical practice, 61
Daytop Village, 204 Eddy, Mary Baker, 166
Deikman, Arthur, 228-229 EEC (electroencephalography), 37-38,53
Deinstitutionalization, mental illness Egotism, 19
and, 194-196 Egypt, spirituality in, 144-145
Dementia praecox, 189 Electroencephalography (EEC), 37-38,
Demonic possession, 165 53
Denial, of mental illness, 193 Emotion, perception and, 32-35
Depression Emotional control, 75-79
catecholamine hypothesis for, 52-53 Emotional distancing, 76-77
Christian psychiatry for, 117-118,122 Emotional distress, dealing with,
cognitive approach for, 199 Muslim religious persons and,
cultic religious sects and, 162 146-147
dealing with, hospital chaplaincy Emotional support, 160
training for, 150 Encounter groups, 80-81
drug therapy for. See Anti- Engagement, in cults, 23,25
depressants Enlightenment, 96-97
etiological factors, 27-28 Environment, in schizophrenia, 189-190
humiliating experiences and, 242 Ephedra, 166
management, cults and, 22 Epilepsy, 32,34
placebo treatment for, 28-29 Epistemiology, 91-92
psychotherapy for, 241 Epstein, Mark, 229
social support and, 40-41 Ethnicity, religion and, 8
treatment, integrating tradition into, Evidence-based medicine, 184-185
139-142 Evolution, 45-46
Dexamethasone suppression test, 53 "Experience of significance," 107
Diet therapy, 160,161
Distress, psychological Faith clinics, 165
cult members and, 96 Falun Gong, 20,86-87
improvement, social cohesiveness Family
and, 22 childhood interactions with, 239
relief effect, 24-27 transcendence of, 136-139
Divine Light Mission FDA (Food and Drug Administration),
meditation and, 223 56
"receiving knowledge" and, 224-225 "Feighner" criteria, for psychiatric
relief effect and, 24, 25 diagnosis, 64
Satsang, 13-14,108 Festinger, Leon, 26-27
spiritually oriented perspective of, Fibromyalgia, mindfulness meditation
20-22 for, 230
Do no harm concept, 165-167 "Finding oneself," 10
Dream imagery, importance/meaning Fluoxitine (Prozac), 28
of, 36-37 Food and Drug Administration (FDA),
Dreaming, biology of, 33-34 56
Drug culture, 101 Forgiveness, Christian, 117,123-124
Drug marketing, to physicians, 61-62 Frank!, Viktor, 232-233,240
Drug use, illegal, 9,22,192-193 Freud, Sigmund, 14-15,16
Dual diagnosis, 192-193,197,204-205 Fromm, Eric, 18
Dymphna, 163-164 Fulfillment, spiritual, 92-93
Dysfunctional parents, recovering Fundamentalist religion
from, 162 beliefs in, 10
282 Index
Christian Medical and Dental Society Herd instinct, 46
and, 77 Heroin, 175
Christian psychiatrists and, 111-112, Higher power, belief in, 6,182
122-125 Hindu spirituality, 108,128-129,135
conversion experiences and, 26 Hippocampus, 33
HIV/AIDS, 193-194
Gandhi, 140 Holistic medicine, 7,161
Ganges, ritual immersion in, 130 Homeopathic medicine, 59-60
GAP (Group for Advancement of Homicide, 191
Psychiatry), 63 Homo erectus, 46
Gautama, Siddhartha, 130 Hopelessness, mental illness and, 191,193
Gender roles, 9 Hormones, stress and, 163
Genetic studies, of social support, 41-42 Hospitals. See also Mental hospitals
Gifting, 98-99 historical overview of, 60-61
God Humanity, respect for, 19
anger against, 151-152 Hypersexuality, 116
belief in, 17,114,161,182 Hypothalmus, 33
conception of, 17
Grief, hospital chaplaincy training for, Id, 33
150 Immune system, psychosocial factors
Group for Advancement of Psychiatry and, 162-163
(GAP), 63 Inadequacy, sense of, 242
Groups, spiritually oriented, 20-24. India
See also specific groups Ayurvedic medicine in, 132-134
affiliation intensity, 85 contemporary trends in, 129-130
affiliation with, 25,168 Hinduism in, 108,128-129
charismatic, 83 integrating tradition into therapy,
disruptive life events and, 85 139-142
harm to participants and, 80 psychiatrists in, 111
induction process, 85 spiritual center of, 130-134
intense experiences in, 79-82 trance states and, 134-136
intense influence from, 68 transcendence of family in, 136-139
leadership of, 80-82 yoga in, 131-132
prayer in, 154-155 Individual identity, 100
Infantile drives, 16
Halfway house, 205,208 In-laws, 138-139
Hare Krishnas, 20 Inspirational books, 161
Healing, spiritually oriented, 25-26 Integrative psychiatry training program,
HealthCare Chaplaincy Program. 147
See Chaplaincy Integrity, 100
Health-related products, medical claims Intensity, of spiritual experiences, 13
for, 56 Interpersonal relationships, in shaping
Health status, psychological impact on, human experience, 16
162-163 Irrational personal unconscious, 15
Heaven's Gate, 108-109 Islam
Hebephrenia, 189-190 addiction treatment program and, 147
Heisenberg effect, 221-222 clergy, 146
Herbal remedies culture and, 143-144
Brainomed, 169-170 importance of "the word" in spiritual
for HIV, 55 discourse, 153,222
toxic, 166 intellectual capital of, 144
Index 283
Islam (continued) Maslow, Abraham, 14
prayer and, 145-146 Materialism, 89-90,94-95
radical terrorism and, 148 Maturation, 16
spiritual figures in, 144 Meaningful life, moving toward,
Sufism and, 144,147-148 245-246
suicide and, 147 Meaning of life
responding to spiritual void and,
James, William, 14-15,17-18,49 99-107
Jellinek Clinic, 102-103 search for, 95-99,100
Jesus, literal role of, 125-127 A Medical and Spiritual Guide to Living
Jews, 152 with Cancer, 161
Joint Commission on Accreditation Medical illness, spiritual approaches
of Health Organizations to, 7
(JCAHO), 61 Medical materialism, 13
Jones, Jim, 74-75 Medicine, scientifically grounded,
Jonestown poisonings, 74 59-60
Journal of Addictive Diseases, 57 Meditation
Jung, Carl Gustav, 15-16 brain during, 38-40
mindfulness, 188,227-231
Kabat-Zinn, Jon, 229 mystification process, 224-225
Kabbalah, 92 Transcendental Meditation, 35,38,
Kaiser-Permanente network, 61 227-228
Kendler, Kenneth, 239-240 Memory
Koran, 145,146 long-term, 33
Kotb, Shaikh Gamal, 144 of spiritual experiences, 35
Mental health field, conflict in, 49-50
Laboratory-based findings, over-reliance Mental hospitals
on, 53-54 deinstitutionalization and, 194-196
Last rites, 152 pseudo-patient experience in,
Leaders 190-191
of charismatic groups, 83 Mental hygiene concept, 194
group, vulnerability of, 80 Mental illness
omniscient, 82-83 belief issue and, 199-203
Lewin, Kurt, 80 deinstitutionalization and, 194-196
Life events, disruptive, 109 denial of, 193
Life transitions, 94-99 historical treatment of, 62-63
Limbic system, 33,34 hospital-based program evolution
Logic, definition of, 16 of, 204-213
Lord's Prayer, 178 interest in redemption and, 203-204
labeling of, 190,203
Macrobiotic diet, 161 program evolution, 204-213
Mahabharata, 129 substance abuse and, 192
Making-meaning, of life, 100-101 therapeutic community and,
Maladaptation syndromes, 238 196-199
Maladaptive behavior, 25 Mental state, neural stimuli and, 31-32
Malpractice, orthopedic procedure, 218, Methadone, 175
220 Methodism, 58
Managed care programs, 66-67, *59 Methodology fallacy, 53-54
"Marathon" groups, 79-80 Milgram, Stanley, 72-73
Marijuana, 9,100-101,104 Mind-body connection, 215-216
Marriage, support from, 162 Mindfulness meditation, 188,227-231
284 Index
Minnesota model, for addiction "Peak experiences," 14
treatment, 65-66 Perception, emotion and, 32-35
Mohit, Ahmed, 143-144 Perfection, need for, 219
Moonies. See Unification Church Persecution, living with, 86-87
Mother-in-law, 138-139 Personal change encounters, 80
Moussa, Souad, 144-145 Personal conflicts, dealing with,
Moxibustion, 161 maintaining spiritual role
Music, popular, 9-10 during, 76-77
Muslim Brotherhood, 148 Personality, biology and, 239-240
Muslims, 111 Personality disorders, 108,197,238
Mystery School, Houston's, 96-9 Personality traits
measurement of, 19
Narcissism, 87-93 of religiosity, 40
National Institute of Mental Health Personal meaning
(NIMH), 63-64 promise of, 96
National Institutes of Health (NIH), psychotherapy for, 232-246
63-64 spirituality and, 11
Navajo Indians, ritualized beliefs of, Personology, 238
29-30 PET (positron emission tomography),
Needs, hierarchy of, 14 39-40
Neocortex, 33 Pfister, Oskar, 15
Netherlands, absence of spirituality in, Pharmaceutical companies
101,102-103 drug advertisements, 57
Neurodegenerative disease, 160 drug marketing to physicians, 61-62
Neuroleptic drugs, 195 influence of, 57
New Age philosophies, 90-91,159 promotion of new drugs, 58
New Age programs, 96-97 Pharmaceutical sales, economics of, 57
NIH (National Institutes of Health), Pharmacological treatment, 141-142
63-64 Physicians
NIMH (National Institute of Mental drug marketing to, 61-62
Health), 63-64 as purveyor of unitary spiritual
Obedience, 19 message, 60
Ojha, 139 role, historical perspective of, 58-62
Operant conditioning, 36 underestimation of spiritual
Oppression, in close-knit family, 138 orientation, 186
Out-of-body experience, 141 Pinel, Philippe, 194
Oxford Movement, 174 Pir, 144
Placebo effect
Pain, somatic alternative medicine and, 55
alternative healing techniques for, description of, 27-30
167-170 electroencephalography of, 37-38
backache, 216-218 Hindu spiritualism and, 135
cultic religious sects and, 162 Positron emission tomography (PET),
illness and, 27 39-40
mindfulness meditation for, 230 Posttraumatic stress disorder (PTSD),
Panic disorder, 229 37,42,121
Parents, mate selection for children, 138 Practice guidelines, 57
Pastoral care, 149 Practitioners, definition of, 247-248
Patient, spiritually oriented recovery Pranayama, 132
and, 251-252 Prayer
Pavlov, Ivan, 35-36 in Alcoholics Anonymous, 175
Index 285
Prayer (continued) Racial segregation, 8
in avoiding conflict, 76 Ramadan, 146
in emotional healing, 114-115 Ramayana, 129
group, 154-155 Rational Recovery, for alcoholics, 169
Islamic, 145-146 Reality
power of, 53-54 denial of, belief in spiritual recovery
spontaneous, 152,156 and, 166
Premarital sexual intercourse, 9 vs. subjectivity, 16
Prescription drugs, direct-to-consumer Reciprocal altruism, 43
advertising of, 57-58 Redemption, 203-204
Primitive societies, spirits and, 8 Redemptive experience, belief in,
Problems of daily living, 247-248 199-203
Professional relationships, Alcoholics Redirection, need for, 109
Anonymous and, 184-186 Reframing, 233
Project MATCH, 180 Relaxation response, 227-228
Prostitution, mental illness and, 194 Relief effect, 24-27,168-169
Protestants, 8 Religion
Provo movement, 101 ethnicity and, 8
Prozac (fluoxitine), 28 secular viewpoint of, 17-19
Psychiatric disorders, with substance spirituality and, 165
abuse, 204-205 trance and, 134-136
Psychiatric hospitals, 63 vs. spirituality, 6-7,175
Psychiatrists Religious, as "cultural genomes,"
Christian, 114-115,116 45-46
community-based practice, 63 Religious awakening, 119
devoutly religious, 77 Religious experience
Fundamentalist Christian, 111-112 disavowal in psychoanalytic move-
in India, in ment, 15
Psychiatry meaningfulness of, 14-15
biology of, 52 Religious faith, psychological validity
spiritual perspective and, 149-150 of, 13
Psychoanalysis, 14-17,16 Religious groups, coordination in, 45
Psychoanalytic practitioners, 245-246 Religious intensity, 13,77-78
Psychodynamic psychology, 239 Religious orientations
Psychological damage, from group altruism and, 44-45
experience, 81 extrinsic vs. intrinsic, 88-89
Psychological perspective, 20,107-110 impulse toward, 45
Psychological well-being, measure of, intrinsic, 19
23-24 sanction of, 117
Psychopharmacology, 47,202 types of, 19
Psychosis, 107,193,200,201 Religious view, of spirituality, 17
Psychosocial factors Renewal, spiritual, 109
cardiovascular system and, 162-163 Research
immune system and, 162-163 biomedical, 56-58
Psychotherapy community, spiritually oriented
with medications, 147 recovery and, 249-250
nonspecific factors in, 214-215 Resiliency, no
for personal meaning, 232-246 Rights, individual, 89
spiritual experience and, 19-20,226 Ritualized beliefs, 29-30
therapeutic alliance and, 233-240 Rizzuto, Ana-Maria, 16-17
Psychotomimetics, 9 The Road Less Traveled (Peck), 161
286 Index
Rostam, 144 Spiritual experiences
Rush, Benjamin, 62-63 intense, 37
varieties of, 111-112
Samadhi, 39,132 Spiritual healers, 139
Sarno, John, 215-221 Spiritual healing, placebo effect and, 29-30
Satsang, 13-14,108 Spirituality
Schizophrenia brain and. See Brain
environmental factors, 189-190 contemporary perspective, 8
historical aspects, 189 definition of, 5-6
offering of prayers for, 140-141 in India. See India
recovery from, 202 as intense personal experience, 12-14
suicide attempts and, 191 origin of, 7-10
symptoms of, 21 personal nature of, 5-6
Schizotypal personality, 238 problems with, 68-93
Scientific research, validity of, 72 cults. See Cults
Scientology, 10,166-167 emotional control, 75-79
Second Advent Christians, 59 in groups oriented to professional
Secular viewpoint, 17-19 growth, 79-82
Self-absorption, 88 narcissism, 87-93
Self-actualization, 14 persecution, 86-87
Self-analysis, 140 thought control, 70-75
Self-care, 248-249 "voodoo death," 68-70
Self-efficacy, 168 religion and, 165
Self-justification, 19 in Sweden, 100
Self-liberating approaches, 161-162 vs. religion, 6-7,175
Self-realization, 19 Spiritually oriented recovery
Serenity Prayer, 175 clinicians and, 248-249
Serotonin binding potential, 40 patient and, 251-252
Serotonin reuptake inhibitor anti- research community and, 249-250
depressants, 28 Spiritual needs, validation of, 105-107
Sexual inclination, culture and, 45 Spiritual orientation
Sexual orientation, 9 evolution of brain and, 43-45
Sexual practices, 9,116 impulse toward, 45
Shahnameh, 144 Spiritual perspective, psychiatry and,
Shaikh, 145,146 149-150
Shamans, Apache, 214-222 Spiritual recovery movements, 157-158.
Sin, 126 See also specific spiritual recovery
Skinner, B.F., 36 movements
Social cohesiveness, distress improve- acceptance of, 164-165
ment and, 22 belief in, denial of reality and, 166
Social support caregiver's judgment and, 166
brain and, 40-42 characteristics of, 160-162
personal meaning from, 162 extreme, 20-21
Sociobiological model, 20 psychological engagement in, 167-170
Somatic approach, 217-218 subjective experience and, 177-178
Somatic hallucinations, 34 validation of, 185
Soteria program, 201 Spiritual renewal, 37
SPECT, during meditation, 39 Spiritual subcultures, 20-21
Spinal nerve root pressure, 219 Spiritual void, responding to, 99-107
Spirits, primitive societies and, 8 Spontaneous prayer, 152,156
Spiritual Exercises in Everyday Life, 119 Steinke, Paul, 149
Index 287
Stomach cancer, dealing with, 153-154 Transcendental Meditation (TM), 35,38,
Stress, hormones and, 163 227-228
Subcultures, spiritually oriented, 163-165 Transcendent experience, functional
conflicting messages in, 78-79 anatomy and, 34
reality, distortion of, 72 Transitional objects, 16
value distortions and, 72-73 Treatment, spiritually oriented, 159
Subjectivity, vs. reality, 16 Twelve-Step process. See also Alcoholics
Substance abuse, 9,22,192-193 Anonymous
Sufism, 144,147-148 adaptive behavior and, 45
Suicide belief in, 179
borderline personality disorder and, 238 at Hazelden Foundation, Minnesota,
hopelessness and, 191 102-103
Islam and, 147 liberal Islam and, 147
schizophrenia and, 191 spirituality in, 7,50-52,159,162
Suppression, as defense mechanism, 102
Surgery Unification Church (Moonies)
for back pain, 218 conformity and, 71
placebo, 29 group affiliation and, 44
Sweden, formal religion in, 100 induction process, 27,71-72,74,108
marital engagement ceremonies,
Tng-ki healers, 165 83-84, 86
Target symptoms, 206 mental health professionals and, 23
TC (therapeutic community), 196-199, relief effect and, 24,25
204, 208, 210, 212 Reverand Moon and, 83
Temporal lobe epilepsy, seizure locus, 34 spiritual orientation of, 20
Ten Commandments, 46 Universal spirit, belief in, 161
Terminal illness, 152 An Unquiet Mind (Jamison), 141-142
Terror experiences, 68-70
"T group," 79 Validation, of spiritual needs, 105-107,185
Theophostic Ministry, 125-127 Values distortion, by prevailing sub-
Therapeutic alliance, 233-240 culture, 72-73
Therapeutic community (TC), 196-199, Values orientation, 17-20
204, 208, 210, 212 Varanasi, India, 130-131,169
Therapeutic relationship, effect of reli- Varieties of Religious Experience
gious intensity on, 77-78 (James), 49
Thomsonians, 59-60 Visual hallucinations, 34
Thorazine (chlorpromazine), 195, 202 "Voodoo death," 68-70
Thought control, 70-75
Thoughts Without a Thinker, 229 Wesley, John, 58
Tiananmen Square suicides, 87 Whitman, Walt, 17-18
TM (Transcendental Meditation), 35,38, WHO (World Health Organization), 143
227-228 Winnicott, D.W., 16
Token economy, 208 Witch doctors, 30
Traditional values, without spiritual ties, World Health Organization (WHO), 143
101-102 World Trade Center disaster, 109-110
Tranquilizers, overreliance on, 235-236
Transcendence, spiritual Yoga, 131-132
belief in, 169 Yoga Sutras, 132
escape from worldly pressure and, 175 Yogi, Maharishi Mahesh, 228
feelings of, 40,141 Yoruba rituals, 165
illusion of, 88
need for, 8,10-11 Zakad, 146
288 Index

Marc Galanter M.D.-spirituality and The Healthy Mind - Science, Therapy, and The Need For Personal Meaning-Oxford University Press (2005)

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Printed in the United States of America

One man tells me that he used a meditation technique taught him by

This book benefited from the opportunity to videotape extensive inter-

PART I WHAT IS SPIRITUALITY?

PART II THE IMPACT OF CULTURE

PART III VARIETIES OF SPIRITUAL EXPERIENCE

PART IV SPIRITUAL RECOVERY MOVEMENTS

PART V THERAPY OF A DIFFERENT KIND

S o you're writing a book on spirituality. What is spirituality?" my

Where Did the Idea Come From?

T he term spirituality has now gained considerable currency in Ameri-

The Beginning of Cultural Reintegration

A s is often the case, the leading edge of a cultural transition can

M ainstream psychiatrists are, to say the least, reluctant to consider

Spirituality as an Intense Personal Experience

S piritual renewal clearly has a resonance for many people as impor-

Medical materialism finishes up St. Paul by calling his vision on

James drew on these awakenings and those of his students as evi-

Evolution of a Psychoanalytic Perspective

P sychoanalysts with a positive attitude toward spirituality have had

S pirituality can be experienced from either a secular or religious stand-

Acquiring a Group's Spiritually Oriented Perspective

C ertain group settings are quite effective in drawing people into a

The Relief Effect

O ne answer to the question of how people become engaged in such

i. Affiliation with a highly cohesive group should yield a signifi-

Now here is an analogy that can be drawn to movements that pro-

Placebos: The Potency of Belief

M ost medical treatments act directly by altering the body's physi-

Spirituality and the Brain

I f there is a spiritual side to people's thinking, clearly it must operate

Emotion Driving Perception

T hese two studies begin to suggest the complexity of what takes

Spirituality and the Brain 33

Institutionalizing Our Memories

A nother important component of this biological model is the way

Spirituality and the Brain y>

A Note on the Placebo Effect

P lacebos work because we believe in what they represent. Because of

Spirituality and the Brain 37

T he practice of meditation is an area of particular interest these days

Spirituality and the Brain 39

The Role of Social Support

P eople most often acquire a spiritual orientation in a supportive

Spirituality and the Brain 41

C ertain patterns of behavior that are found in all members of a spe-

Spirituality and the Brain 43

R eligious groups can be understood to function as large organisms

Spirituality and the Brain 45

The Impact of Culture

48 The Impact of Culture

The Apparent Conflict

A spiritual outlook implies a particular perspective on people's in-

50 The Impact of Culture