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Order: $29.95
ISBN: 0913348287
Book Endorsements
" An original and stimulating piece of work, well argued and exhibiting sound scholarship. Dr Smith's medical-anthropological and cross cultural psychological work is excellent, and he succeeds in using this material for the advancement of his...argument."
-Sudhir Kakar. Visiting professor in the Social Sciences and South Asian Languages and Civilizations, the University of Chicago. Author of SHAMANS, MYSTICS AND DOCTORS.
" There is great need for such expressions....now that the field of psychiatry is so enamored of brain disorder and the medical model, in the extreme states, that the person and his/her experience is increasingly disqualified and neglected."
-John Weir Perry, M.D. Jungian Analyst and author of THE FAR SIDE OF MADNESS; and THE PSYCHOTIC PROCESS.
EXCERPT from the Book
CHAPTER 4
Manifestation of the Sacred in Transformative Ritual
This chapter builds on the previous descriptions of the sacred to investigate how the sacred becomes manifested or objectified in psychotherapeutic rituals in cultures where the sacred is part of the assumptive world. The first section describes three major elements of traditional sacred psychotherapeutics: (a) a sacred cosmology, (b) a conception of health and disease, and (c) a method of diagnosis and treatment. The next two sections then draw on the work of Mircea Eliade, Victor Turner, and Robert L. Moore to understand how these elements become integrated and effective within a transformative ritual structure and process. A final section looks at John Weir Perry's Jungian research for further insight into the psychotherapeutic process. Chapter 5 uses this typology to review four case studies that show how remediation of psychopathology resulted from the use of religious resources in various traditional Western and non-Western cultural settings that still presuppose the sacred. Chapter 7 uses the same insights to interpret a contemporary case where religious resources were used effectively.
THREE ELEMENTS OF TRADITIONAL SACRED PSYCHOTHERAPEUTICS
Sacred Cosmology. The healing systems of traditional societies take place within the cosmology of the culture in which the healer and the patient exist. Cosmology here refers to the view of reality and every entity within it that implicitly informs the assumptive world of any given society. A given society may, of course, contain many different world views, but it will typically subsume the alternatives within one overarching cosmology. Traditional and premodern societies largely articulated their cosmologies mythologically, so these cosmologies may be considered as revelations of the sacred (in Eliade's sense), objectified in the cosmogonic myths of the various traditional societies. Thus the system of myths in any given society provides the foundation for understanding its cosmology, and its views on human nature, health and disease, diagnosis and treatment, and the ritual context of the healing process.
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The traditional healer practices out of this cosmos, ordered by the sacred, and objectified in the myths of the local cultural context. For example, in shamanic healing rituals, the cosmogonic myth, or the myth of the origins of disease and healing, is often recited or chanted over the patient. This serves various purposes. It places the patient and the affliction in a context saturated with meaning and order, and thus soothes or comforts the afflicted and their loved ones. Disease is threatening, if not terrifying, and may be understood as an intrusion of chaos into the patient, the patient's family, and perhaps into the entire clan or tribe. Therapeutic use of the society's myths recalls the victory of the primeval forces of creativity, order, and health over those of destruction, chaos, and disease, and serves to reassure the afflicted that their disease or disorder will be overcome just as the chaos and darkness were overcome in the "beginning." Such reassurance and confidence in the availability and efficacy of supernatural help itself promotes an attitude of expectancy that is conducive to setting the healing process in motion.
Claude Levi-Strauss, the structural anthropologist, argued that myth also works to mediate social and personal oppositions. The shaman provides the patient with a mythical language for expressing the pain and confusion (chaos) undergone during affliction. In one example, Levi-Strauss described the shamanic cure of a woman with an unspecified psychosomatic disease. He noted the therapeutic efficacy of the myth recited by the shaman in performing the curing ritual. It seemed to matter little whether the mythical picture corresponded to objective reality. As long as the patient and her society believed in it, it had therapeutic value. All the many magical elements of the myth, with
its tutelary spirits and malevolent spirits, with its supernatural monsters and magical animals, all are part of a coherent system on which the native conception of the universe is founded. The sick woman accepts mythical beings or, more accurately, she never questioned their existence. What she does not accept are the arbitrary and incoherent pains, which are an alien element in her system but which the shaman, calling upon myth, will re-integrate within a whole where everything is meaningful. 1
Once the woman understands, she does more than resign herself; she becomes cured.
Levi-Strauss suggested that mere explanation would not be enough to effect a cure in the modem Western world, because, on the modem medical model, the relation of disease to germ is external. For the patient of premodern society, however, the relation between disease and demon or monster is internal (i.e., psychological). In using myth, the shaman provides the 'sick woman with a language to articulate unexpressed, and otherwise inexpressible psychic states. He also associates the introduction of order over chaos as a therapeutic move made possible by language, by verbal-mythical expression that enables the patient "to undergo
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in an ordered and intelligible form a real experience that would otherwise be chaotic and inexpressible - which induces the release in a favorable direction of the physiological process that is the reorganization, in a favorable direction, of the process to which the sick woman is subjected."2
To reiterate, myth and sacred cosmology provides the patient with a meaningful and ordering framework that both comforts and inspires a hopeful attitude, and thus contributes greatly to the therapeutic effect.
Conception of Health and Disease. A conception of health and disease presupposes a corresponding conception of human nature. Traditional societies provide understanding of their views through their ordering myths and cosmologies. Thus, to discover their views on human nature, health and disease, requires inquiry into those myths and cosmologies.
Eliade's phenomenological description of the structure of sacred cosmology elucidates the view of world and self held in traditional societies. An archetypical structure seems universally to underlie these assumptive worlds. The three-storied cosmos typically has an underworld below (hell), an overworld of celestial beings above (heaven, sky), and the world of humans in between (the earth). "Our world" is always situated at the center, the "axis mundi" at the intersection of heaven and hell, the meeting place of celestial and underworld beings. This structure is not only found in the religions of the Mediterranean but in societies employing a shamanic cosmology.
The same scheme describes the human individual. Each person stands at the intersection (in the world of humans) between the underworld (hell) and the overworld (heaven), and thus may be influenced by, or influence, various spirits, demons, and the like, from those realms. The person typically has a body, one or more souls, and a mind. In sacred or demonological idiom, the main soul is permeable and is open to invasion, possession, threat, or benign influence. Demons, angels, ghosts, spirits or animals, and ancestors are among the entities that can invade or affect the soul for good or ill.
Such a view sees health as the maintenance of order, and disease as chaos, disorder, or destruction. In a sacred cosmos, health is maintained by proper relations with the sacred, and this is associated with proper observance of taboo, performance of ritual (worship, sacrifice, etc.). Such observances constitute methods of maintaining relations with the sacred and its order and power-giving energies. Living in harmony with the will of the sacred may also require avoidance of loss of power through pollutions, contamination by evil objects, evil spirits, and the like (Otto, Van der Leeuw).
Historical and cross-cultural studies also support the widespread association of order with health. In ancient Greece, Plato and the Pythagoreans associated health with proper ordering of one's life, living in accord with the harmonious structure of reality. The Aristotelian "golden mean" found expression in the famous maxim for health and long life, "nothing to excess." For the Ayurvedic
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physicians of India, practicing out of a generally Hindu cosmology, the human person consists of "mind, soul, and body" in a social and metaphysical context. As a medical theory, Ayurveda emphasizes the equilibrium of the three humors: wind, bile, and phlegm. Imbalance of these humors equals disorder and leads to illness, whereas a balance of the humors leads to health.3
Theory of Diagnosis and Treatment. Therapeutics can only be effective after the nature of the disorder is manifest or known in terms meaningful to the patient. The proper treatment cannot be prepared until the specific cause or nature of the illness or disease is determined. Premodern and traditional societies conceptualize psychopathological or psychosomatic disorders in terms of the sacred worldview, that is, in terms of machinations of evil, ancestral, or animal spirits, demons, and imbalances in sacred energies (Kundalini, humors, breath, etc.). Therefore, the traditional healer must diagnose the cause of illness accurately in terms of the patient's worldview, and apply the therapeutic methods appropriate to that worldview. Table 1 presents Ellenberger's outline of shamanic diagnosis and corresponding treatment/cures, and illuminates the precise relationship between diagnosis/ disease theory and therapeutic method in traditional societies.
Thus there are three major elements of traditional sacred psychotherapeutics: a sacred cosmology, a theory of health and disease, and a theory and method of diagnosis and treatment. A review of the work of Mircea Eliade, Victor Turner, and Robert L. Moore will show how these elements become integrated and effective within a trans formative ritual structure and process.
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Table 1
Shamanic Healing: Theory and Practice
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Disease Theory
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Therapy
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1. Disease-object intrusion
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1. Extraction of disease-object
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2. Loss of the soul
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2. To find, bring back, and restore lost soul
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3. Spirit intrusion
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3. a. Exorcism
b. Mechanical extraction of foreign spirits
c. Transference of the foreign spirit
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4. Breach of taboo
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4. Confession, propriation
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5. Sorcery
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5. Counter-magic
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Source: Henry F. Ellenberger, The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry (New York: Harper and Row, 1970
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SACRED SPACE AND TRANSFORMATION (Eliade)
Each of the elements of traditional therapeutics relate to the others in a part-to-whole manner, so that each one makes sense only in relation to the others. Peter Berger argued that the reasons for this integration lay in the need to keep the forces of chaos at bay, the main task of sacred cosmology. Hence, sacred psychotherapeutics becomes a form of world maintenance or restoration. The category central to all of them is "the sacred," discernible nowhere more clearly than in the ritual structure and process of traditional psychotherapeutics. It is within the ritual structure, and in terms of the sacred mediated within that structure, that :he ordering myth is recited, diagnosis is made, and the method of treatment determined and applied.
In traditional therapeutics it is the sacred that has healing and transformative power, while human efforts constitute and maintain a ritual structure within which the sacred transformative energies can work. Eliade illuminates this relation of the sacred to space and transformation by documenting the universal "prestige of the center." The axis mundi provides a true orientation in time and space, whereas profane time and space are homogeneous, provide no fixed point from which to gain a true orientation, and offer no contact with that which is absolutely real, effective, and enduring. Sacred time and space, by contrast, are heterogeneous, having qualitative irruptions.
Thus, to homo religiosus, certain places and times are qualitatively "other" in that they manifest the sacred: they put humans in touch with the meaning-giving Center from which they may draw orientation and experience healing-transforming energies.4 It is this qualitative break in profane space that allows the world to be constituted, creates cosmos out of chaos, provides a reliable orientation, and allows the world to be regenerated. Drawing upon massive data from ethnology and the history of religions, Eliade notes that the manifestation of the sacred, a hierophany, permanently changes the quality of that space, even when the dominant culture or religious tradition constituted by it passes away or is relativized.
The Dome of the Rock in Jerusalem provides an example of the stability of sacred space amidst historical and cultural changes. Three different dominant cultures and religions have valorized its space as sacred during periods of historical ascendancy in that region-the Judaic, the Christian, and the Muslim. Thus manifestation of the sacred (hierophany) is continually repeated irrespective of historical and cultural changes. Eliade says, "In this way the place becomes an inexhaustible source of power and sacredness and enables man, simply by entering it, to have a share in the power, to hold communion with the sacredness ... But however diverse and variously elaborated these sacred spaces may be, they all present one trait in common: there is always a clearly marked space which makes it possible ... to communicate with the sacred."5
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Sacred space cannot be generated by an act of the human will. It can be provoked, invoked, and prepared for by questing, fasting, and by various ritual means, but it is beyond the power of human beings to force its manifestation. Human beings do, however, have important responsibilities in the consecration and maintaining of the boundaries demarcating sacred space, and this human function is of paramount importance. The boundaries demarcating sacred space serve as notice that a qualitatively "other" space is near, and that proper relations with the sacred require acknowledgment and respect for these boundaries.
Respect for the boundaries also serves as protection against the "high voltage" of the sacred, to use Van der Leeuw's expression. Naive contact with the sacred can be destructive without proper stewardship of its boundaries. Hence the enclosure around sacred space serves the function of protecting profane individuals from the danger of trespassing upon it without undue care. The need for ritualized relations with the sacred derives from the fact that the sacred "is always dangerous to anyone who comes into contact with it unprepared, without having gone through the 'gestures of approach' that every religious act demands."6
According to Eliade, it is one of the primary tasks of the shaman as a "technician of the sacred" to locate and effectively use the powerful deconstructive/ reconstructive transformative energies of the sacred for healing purposes. The shaman's primary function is to heal disorders of a spiritual-psychopathological nature, that is, disorders of the soul. Other types of healers may address other forms of disorder that do not need a strong ritual space for powerful transformative energies. Herbalists, naturopathic physicians, diviners, surgeons, and the like may diagnose physical illness, treat it medicinally or surgically, or make referral to a shaman. But disorders of the soul belong exclusively to the shaman.
Everything that concerns the soul and its adventure, here on earth and in the beyond, is the exclusive province of the shamans. Through his own pre-initiatory and initiatory experiences, he knows the drama of the human soul, its instability, its precariousness; in addition, he knows the forces that threaten it and the regions to which it can be carried away .... If shamanic cure involves ecstasy, it is precisely because illness is regarded as a corruption or alienation of the soul.7
The shaman, then, is the psychotherapist of traditional cultures par excellence who knows how to locate, utilize, and maintain sacred trans formative space.
In modem culture there has been a lack of knowledgeable technicians of the Sacred capable of locating, maintaining, and therapeutically utilizing sacred or transformative space. Although Eliade believes communication with the sacred requires a "clearly marked space," he is reluctant to say one can find such spaces in modem Western industrial culture, except in degraded or laicized form.8 Nevertheless, he is emphatic about the need for clear boundaries demarcating sacred space.
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TRANSFORMATIVE RITUAL PROCESS
AND RITUAL LEADERSHIP (Moore)
Robert L. Moore's work on the ritual aspects of contemporary psychotherapy builds on the work of Eliade and Victor Turner to formulate a theory of ritual structure that differs with Eliade on the key issue of sacred space in modem culture.9 He finds sympathy with Victor Turner's belief that even under the conditions of modem industrial culture the human experience of space is anything but homogeneous (132). Moore believes Turner made significant contributions to understanding the relationship between space and transformational process. He notes that Turner, like Eliade, gave considerable attention to the nature and meaning of heterogeneous forms of space discernible in human experience.
Turner's work on ritual process was influenced by Van Germep's pioneering monograph The Rites of Passage (Paris, 1908) which distinguished traditional rites of passages into three phases: separation, transition, and incorporation.10 The ritual phase of separation distinguished profane space-and-time from sacred space and-time. During this phase a special cultural realm comes into being as the locus of the intervening phase of transition. Van Germep used the term margin or limen for this second or middle phase, because ritual subjects pass through a time of cultural and social ambiguity in which they are relieved of their typical or previous social statuses, and undergo ordeals, painful trials and dismemberments, and receive instruction from their ritual elders in mythical lore relevant to their soon to-be-attained new status. The third phase of incorporation returns subjects to ordinary space and time, and reincorporates them, with their new statuses, into the social structure.
Turner's greatest contribution to understanding space and transformation, according to Moore, is his extensive elaboration of the middle or transitional phase of liminality. Turner distinguishes between ceremonial and ritual on the basis of the presence of liminality: ceremony is indicative, but ritual is transformative. Transformation, especially those forms respecting life crises, occur most completely in liminal seclusion where the cognitive schemata that give sense and order to everyday life no longer apply, but are, as it were, suspended - in ritual symbolism perhaps even shown as destroyed or dissolved. Gods and goddesses of destruction are adored primarily because they personify an essential phase in an irreversible transformative process.11
Whereas Turner, by Moore's account, “emphasizes” the “dangerous” aspect of “the liminal or ritual object,” he also realizes that it involves "much more than the destruction of the previous life-world" (134). Turner balances the danger of liminality, "respected by hedging it around by ritual interdictions and taboos," with its “regenerative" power. It resembles a “space- time pod” in which the individual "may be unbound" from social norms and conventions, and then ritually
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"rebound." "New meanings and symbols may be introduced - or new ways of portraying or embellishing old models for living, and so of renewing interest in them. Ritual liminality ... contains the potentiality for cultural innovation, as well as the means of effecting structural transformation within a relatively stable sociocultural system."12
Moore also draws attention to Turner's distinction between liminality and liminoid, a distinction crucial to Moore's own theory of ritual process and leadership. Liminal phenomena characterize tribal societies rooted in their "biological, calendrical, and other socio-structural rhythms" and naturally occurring "social crises." They organize typically around culture-wide symbols that "have a common meaning for all the members of the group." Liminoid phenomena, by contrast, typify "complex modern societies." They tend toward individual rather than collective expression, with meanings "marginal to the dominant [symbols and] cultural institutions," and not shared normatively or universally throughout the culture by all members of the society. Liminoid phenomena are "idiosyncratic and are usually generated by individuals or groups who are competing for recognition," and often associated with leisure time and play. For example, theatre, film, opera, ballet, art, poetry, and pilgrimage all exemplify liminoid phenomena (134- 35).13
Moore's own contribution to understanding transformative ritual process in religion and psychotherapy builds upon a critical use of Turner's work. Although giving Turner credit for mapping the distinctions between liminal and liminoid space, Moore argues that Turner gave too little attention to the relationship between boundary and space. Effective transformative ritual leadership requires concern for the establishment and maintenance of the boundaries to sacred space. According to Moore, the "distinctions between liminal and liminoid" result not from "the totality and comprehensiveness of ritual involvement in the social system," that is, on "whether the practice is 'society-wide' or not," but rather on "how the boundaries that delimit the space are constituted and maintained .... " Moore focuces the issue "on the nature and permeability of the boundaries of the space involved and on the relative importance of the leadership of ritual elders" in deciding how to utilize the sacred space.
Moore accurately perceives Turner's failure to isolate the key variable of ritual leadership, and he develops his own concept of the "ritual elder." He insists that "while liminal space requires ritual leadership, liminoid space does not. A ritual leader may be present in liminoid space, but must be present for liminal space to exist. Liminality ... occur[s] at or near the center in tribal society not just because the social processes are relatively 'simple,' integrated, or totalistic - but because of the availability of knowledgeable ritual elders who understand how transformative space is located, consecrated, and stewarded" (136). Moore's ritual elder (echoes Eliade's shaman as technician of the sacred, but Moore extends the concept far beyond shamanism to include contemporary psychotherapists, ministers, film
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and theater directors, civil rights leaders, and presumably any figure who can help an individual or group face powerful conflicts, oppositions, and competing energies and bring about relatively safe and creative transformation or resolution. The ritual elder knows how transformative space is "located, consecrated, and stewarded."
Modem culture shows a lack of knowledgeable and competent ritual leadership able to locate and effectively utilize such space for transformative purposes. Filling the vacuum is a plethora of liminoid spaces "not so much constituted by boundaries as it is on the boundary." Liminal space, by contrast, requires strong boundaries capable of "holding" the intensity of the energies released in the transformative deconstructivejreconstructive process. The availability of such effectively transformative space requires the conscious intentionality of its stewards in maintaining the boundaries. Whereas liminoid space does not require such leadership, liminal trans formative space does. A transformative life crisis or sociopolitical crisis requires the presence of a ritual elder, while a pilgrimage does not (136).
Moore uses his theory of ritual elder to describe ritually trans formative processes in the domains of psychotherapy and ministry. He urges recognition that psychotherapy, religious and secular, provides important ritual leadership to a certain sector of the population in times of crisis. Although he does not contend that all psychotherapy is effective transformative ritual leadership, where it is effective, such leadership is implied. Most forms of psychotherapy manifest ritualized submission, containment, and enactment. In order to facilitate a needed deconstruction of the old personality structure of the individual, the individual is offered an opportunity to surrender autonomy temporarily, to submit to a total process that has an autonomy of its own and enables the individual to maintain needed orientation and structure during this time of deconstruction. Built into the therapeutic process is the creation of a relatively safe psychosocial space in which this deconstruction and surrender of autonomy can occur. It is in this ritually constructed therapeutic space that the enactment, both playful and painful, of innovative new behaviors and styles of thinking can be tested experimentally before returning to the world of structure and its merciless demands for adaptive effectiveness (137),14
Thus Moore, in the midst of "many other ritual dimensions in therapy," emphasizes the issue of "containment," because it underscores the problem of boundary maintenance.15 He cites psychoanalysts Robert Langs and William Goodheart for using the analogous term "therapeutic frame" to suggest the strong boundaries that need to be maintained in an effective therapeutic "field." "Langs and Goodheart emphasize that the securing of a stable frame or boundary for the therapeutic space is more than just an expression of professional ethics. For them, it is the sine qua non that must be present for the facilitation of any truly transforma-
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tive therapeutic space" (139). Maintenance of an effective therapeutic frame is essential for containment. Without a strong enough frame the intensity and depth of the transformative processes become truncated. In such a situation, therapist and patient may collude in resisting truths that need to be faced, and the transformative truth becomes dissipated or extinct.
Extending his theory of ritual elder and transformative ritual process to contemporary Western religious life, Moore argues that institutional Christianity still has considerable potential as a containing vessel, a ritually transformative spacetime pod. The institutional church and its leaders can provide reliable psychosocial framing that facilitates deep structural change for individuals and groups. Moore agrees with British psychiatrist D. W. Winnicott that the church and its ritual elders can provide a liminal "holding environment" enabling individuals and groups to "tolerate the terrors of change, with its attendant painful truths and emotions. "16
Table 2 shows Moore's understanding of the three phases of ritual process as they apply to primitive initiation ritual, to psychotherapy, and to the institutional church and its pastoral ministry. This scheme illustrates the similarities in ritual structure between primitive religious rituals, secular psychoanalytic therapy, and the Christian worship service. (See page 65.)
THE SELF IN PSYCHOTIC PROCESS (Perry)
Further insight into psychotherapeutic ritual process is provided by the work of John Weir Perry, a prominent theorist of psychosis within the school of analytical psychology stimulated by the research and theories of C. G. Jung. The development of psychological methods for the treatment of psychosis is still, after about seventy years, in the pioneering stage. Currently, within the field of depth psychology that includes Freudian and Jungian schools, there are a variety of divergent opinions on what psychosis is, and how to treat it effectively. In spite of such divergences within the field, however, a few schools have definite theories and methods of psychological treatment. The Freudian camp contains names like Benedetti, Fromm-Reichman, Rosen, Sechehaye, Wexler, Sullivan, and Arieti, and the Jungian camp such prominent pioneers as Perry and Gianfranco Tedeschi.17
There have been roughly three periods in the history of the psychotherapy of schizophrenia, the major form of psychosis. After a long period of mere classification preceding the development of methods, there emerged a decade of interest in the interpretation of psychotic contents, especially symbolism and cognitions. The next decade brought a concentrated effort to achieve sympathetic contact and rapport with the patient. The third decade built on previous research for the purpose of achieving more effective therapeutic results.
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Table 2
Moore's Phases of Ritual Process
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Phase I
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Phase II
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Phase III
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Eliade
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Profane Time/
Space I
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....
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Sacred Time/Space (Journey to the Center)
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....
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Profane Time/Space II
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Van Gennep
Seperation
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Transition
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Incorporation
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Turner
Structure I
(preliminal state)
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Anti-structure/liminal
(liminal space/time)
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Structure II
(postliminal phase)
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Freud
Fixation,
Development,
Off Schedule
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Analytical Environment
(vessel, container, holding environment)
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Postanalysis Adapta
tion(after therapy session)
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Call to Worship
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Sacred Space/Time
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Reentry into Daily Life (renewed by encounter with the Sacred)
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Source: Modified from table in Robert L. Moore, "Ritual Process, Initiation, and Contemporary Religion," in Jung's Challenge to Contemporary Religion, ed. Murray Stein and Robert L. Moore (Wilmette, 111.: Chiron Publications, 1987), 150.
Jung's researches and writings on schizophrenia, rich, intuitive, and filled with implications as they were, have been largely ignored by the Freudians who have had far more clinicians working with psychosis, and have published more studies on schizophrenia than have the Jungians. This is a curious point, because Freud
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all but ignored the subject, especially schizophrenia, and what little he had to say about it had to do with his lack of hope that such conditions were curable. Jung, by contrast, spent about a decade in a major psychiatric asylum, and did extensive research on psychosis and schizophrenia (dementia praecox). Although he did not specialize in the treatment on psychosis, and was more interested in the treatment of latent psychosis, his work has considerable implications for the treatment of psychosis. Jung himself, however, remained skeptical of these possibilities through much of his life and work. He confined his interest in the subject largely to understanding the content of psychotic productions, to understanding the conditions that give rise to it, and to prevention of relapse.
Although Jung did not develop a special treatment method for schizophrenic and other psychotic disorders, John Weir Perry, a psychiatrist and Jungian analyst, did develop a treatment rationale and method based upon Jung's theories. Perry's practice and research in the therapy of acute schizophrenia extendec. beyond his private practice to government-endowed research programs involving multi-staffed treatment centers and hospitals. This discussion focuses exclusively on Perry's representation of the Jungian perspective on psychotherapy of psychosis.
In 1953 Perry described the psychotherapy of a young schizophrenic woman ir. a monograph entitled The Self in Psychotic Process. The book included a foreword. by Jung that amounted to his nihil obstat imprimatur on Perry's application of Jungian theory to the psychotherapy of psychosis. The Far Side of Madness in 1974 systematized Perry's views on the understanding and treatment of psychosis frorr. a Jungian perspective. These works urged the psychiatric profession to turn a sympathetic and understanding ear toward persons undergoing psychotic experience, rather than merely medicate and manage them as medical cases. They charged that psychiatry had developed a habit of "non hearing" in an era of "sane making drugs" (the phenothiazines), and had placed an "interdiction" against listening to the nonrational concerns of patients.18 The Far Side of Madness claimed that many patients over the years had reported that they began recovering from their psychosis only after they had found a sympathetic and understanding listener. Perry claimed, after two decades of research, that the therapist's attitude toward the patient was the most crucial factor in treatment, even determining the nature of the syndrome itself.
Perry was most interested in those schizophrenic cases that today are describe: as having "positive symptoms" (a term he did not use). Positive symptoms are the active or most grossly psychotic symptoms such as deep regression, delusions hallucinations, accompanied by the elaborate production of symbolic imagery ar.: ritualistic gestures. "Negative symptoms" include the loss of affect and the absence of active symptoms. The prognosis for negative types of schizophreria has been poor, but is better for patients with positive or active symptoms, accord
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ing to Perry, if the therapist's attitude toward the patient is sympathetic and respectful of these symptoms.
Against the belief that phenothiazine medication would improve a patient's chances for positive long-term recovery, Perry cited clinical research showing a 65-percent rehospitalization rate by the second post-hospital year.19 He cited a research project at Agnew State Hospital in which double-blind experimentation with placebos and thorazine showed that those patients treated with the medication did better only during their hospital stay. The three- year follow-up study showed that patients who received medication had a 73 percent recurrence rate, whereas those receiving no medication had only an 8 percent recurrence. Those with medication showed little continued growth curves on psychological measures, but those without medication showed continuing growth curves.
After the Agnew Project, Perry and Howard Levine established a residential treatment facility for the handling of acute psychotic episodes. It treated thirteen cases in the short span of the project. Perry said they had high expectations, gave no medications, and were astonished by the results. The most remarkable feature was the rapidity with which these persons recovered from their psychotic states. Recovery meant not only cessation of psychotic symptoms (e.g., hallucinations or delusions), but a restoration of healthy social relations, work, and "fruitful living." Most patients "came down" to a coherent, rational state of mind within five days. The longest anyone took was nine days. Of the thirteen cases, eleven made good recovery, an 85-percent recovery rate.
Perry admitted, in trying to explain the effectiveness of this program, that the factors were too complex and overlapping to provide adequate explanation. Nevertheless, he believed certain factors were essential. First was the attitude of the staff toward the patients. The staff agreed that labeling with psychiatric terminology had "destructive effects upon the clients in the form of disqualifying their experience and even their nature." They made special effort to permeate the residential atmosphere with a "demeanor of caring," "encouraging, supporting, and giving affection."20
The significance of the therapist's attitude toward the person undergoing psychotic disorder is the constant theme emphasized in Perry's writings. The justification for this phenomena arises from the nature of the psychosis itself, for the psychotic is a person who has undergone considerable damage to self-esteem and feels socially isolated. An attitude by therapists or treatment staff can either increase the sense of isolation and devaluation, or it can enhance the capacity to belong and gain self-esteem. Perry lamented that psychiatrists too often have fallen into the trap of a technical approach to their patients that devalues the person's experience:
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No one is more isolated than when withdrawn in an altered state of consciousness. When one is thus prey to every psychic force, one is in desperate need of the human response of empathy, for which drugs are so poor a substitute as to amount to a mockery. But when the psychiatrist resorts only to medication and management to stamp out the nonrational, the "patient" quickly senses that this is not a congenial atmosphere in which to open up or a safe relation in which to reveal his actual preoccupations.21
Perry concluded that the psychological factors giving rise to psychosis are essential to understanding and treating it. The psychotic self-image, in a state of disorganization, quests for a reorganization. Regardless of whatever biological factors may predispose the patient to illness, psychological causal factors are also discernable. Typically, a severe injury to the self-esteem emerges early in the development of the prepsychotic (schizoid) personality. Perry failed to state the role of the father in the etiology of psychosis, and gives a profile of the mother as one who was typically unable to "bring into play the attentive, caring, and even worshipful emotions" of a mother toward her child. Such a mother "tends to have the feeling, in regard to this particular offspring at least, that she is dealing with a child that she cannot wholeheartedly love with full acceptance."22 Frequently these children take on the image of "black sheep," and the mother's image of the child becomes internalized in a false self-image. Frequently the mother's image of the child is rooted in her own complexes. The mother's image of the child, Perry claims, becomes all-important to the child's welfare, because it determines the conditions for experiencing "warmth of feeling" or "painfulness."
Observations of the hallucinatory imagery of numerous psychotics convinced Perry that the psychotic syndrome itself is organized around the self-image. For the prepsychotic personality, sometimes referred to as "schizoid," the self-image is shaped by factors alien to itself and thus not naturally a part of the personality. Typically the self-image is shaped by the introjection of negative maternal and familial images projected from the outside, attended by feelings of unworthiness, of undesirability, and incapacity. Closely associated with these feelings will be compensatory ones of greatness, of superlative being, of genius, or divinity. Perry claimed that as the personal self-image becomes severely debased, the archetypal self-image becomes proportionately exalted. The discrepancy between these two self-images results in an unstable psychic equilibrium permeated by a sense of unreality and anxiety. With this discrepancy, the stage is set for a dramatic conflict that frequently emerges in psychotic imagery as a battle of the forces of Good and Evil. Thus the oppositions between the self- images can and do precipitate a psychotic process that strives toward resolution of the conflict. Perry referred to such a movement of the psyche as a teleologically aimed-at renewal process.
Perry suggested that when the psyche cannot progress in its development to the next stage of maturity, especially in times of increased vulnerability such as rejection or falling-in-love, a profound psychological transformation is initiated. The
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psychical libido is then attracted to the collective unconscious layer of the psyche, where archetypal images become activated with an unusually high-energy charge and begin activating the "central archetype" to begin reconstituting the self image. While the libido has regressed to the archetypal layer for the purposes of reconstituting the self- image, the higher levels of the psyche are depleted of their energy supplies. The result is a state of disorganization, a loss of reality testing, with archetypes bursting raw upon the stage in hallucinations and delusions, and with little ego-eonsciousness available to organize experience. The ego is left in a state of fragmentation.
For the patient to have a chance to heal and recover, the psychotherapist must understand and respect the role of images in the psychotic process. This issue is bound up with the issue of the importance of the therapist's attitude toward the patient. Typically the person engrossed in psychosis reveals the imagery in an attitude of reverence, as if revealing innermost secrets. In order for the patient to trust the therapist, the therapist must value and respect such imagery. Perry believes that therapeutic transformation is impossible unless the therapist enters into a sympathetic emotional field with the patient, a ritual "space-time pod," and respects the ensuing symbolic images. It would seem that this kind of attitude would naturally be enhanced for those therapists who can find meaning in the patient's imagery. This is exactly what Perry reported to be the case.
Only when the proper "emotional field" is established between therapist and patient will the image production process move forward toward the aim of transformation or creative reorganization of the personality. Thus establishing this emotional field is equivalent to establishing and maintaining the "therapeutic frame," the ritual boundaries mentioned previously in the discussion of transformative ritual process and ritual leadership. At any rate, when the teleological process is activated in this way, "one finds an astonishing regularity in the occurrence of motifs from case to case."23
Examining the imagery of persons undergoing psychosis, Perry noticed that certain typical themes frequently emerged. He first ferreted out a discemable ground plan, or ordering of these images, in a review of images produced by twelve psychotics he had treated. He found ten images that appeared most frequently.
Center. A location is established at a world center or cosmic axis (point where sky world, regular world, and underworld meet; between opposing halves of the world; center of attention).
Death. Themes of dismemberment or sacrifice are scattered throughout and make themselves evident in drawings (crucifixion, pounding or chopping up, tortures, limbs or bones rearranged, poisoning). A predominant delusional statement is that of having died and being in an after-life state
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(people look like living dead; in hell or in heaven; or in prison as equivalent to death).
Return to Beginnings. A regression is expressed that takes the person back to the beginnings of time and the creation of the cosmos (the Garden of Eden, waters of the abyss, early steps of evolution, primitive tribal society, creation of planets). There is a parallel regression, of course, to emotions, behavior, and associations of infancy (surrounded by parent figures; crawling, suckling, needs for touch and texture, oral needs).
Cosmic Conflict. There arises a world conflict of cosmic import between the forces of Good and Evil, or light and darkness, or order and chaos (surprisingly often expressed as democracy and communism; Armageddon, or the triumph of the Antichrist; destruction or end of the world, or the Last Judgment; intrigues, plots, spying, poisoning- for all to gain world supremacy).
Threat of Opposites. There is a feeling of threat from the opposite sex, a fear of being overcome by it, or turned into it (drugs to turn one into the opposite; identifications with figures of the other sex; supremacy of the other sex; moves to eradicate the other sex).
Apotheosis. The person experiences an apotheosis as royalty or divinity (as a king or queen, deity or saint, hero or heroine, messiah).
Sacred Marriage. The person enters upon a sacred marriage of ritual or mythological character (royal marriage, perhaps incestuous, marriage with god or goddess; as virgin mother, who conceives by the spirit).
New Birth. A new birth takes place or is expected of a superhuman child or of oneself (ideas of rebirth; divine child, infant savior, prince, or reconciler of the division of the world).
New Society. A new order is envisioned, or an ideal or a sacred quality (a new Jerusalem, lost paradise, utopia, world peace; a new age, a new heaven and new earth).
Quadrated World. A fourfold structure of the world or cosmos is established, usually in the form of a quadrated circle (four continents or quarters; four political factions, governments or nations; four races or religions; four persons of the godhead; four elements of states of being).24
In this scheme, which regularly occurs in the cognitive and affective dimensions of psychotic experience, Perry discerned an archetypal ground plan that had affinities with the myth and ritual of early antiquity. Although all of these themes do not come up in every case, and the sequences may differ somewhat, Perry believed there was evidence that this archetypally patterned imagery aimed at a purposive unfolding development of the psyche. However, in order for the purposive aims of the transformative psychotic process to be set in
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motion, the patient must be met with an attitude of emotional warmth and respect for his preoccupations and imagery.
Like the shaman, the therapist must also be at home with the unusual dimensions of human experience, without fear, mistrust, and with a "confidence that the psyche knows what it is doing."25 He must also assume that the patient has an ego worthy of respect, however submerged it may be in psychotic turmoil, and address it as if it were in its rightful position of mastery. When this happens, Perry says, "a coherent and natural response follows very soon."26
It is Perry's primary thesis that the psychotic process, at least in the case of acute or positive schizophrenia, is a natural trans formative response to a damaged, one-sided self-image. The best thing to do, it seems, is to trust the psychotic process and let it run its course with the aid of a sympathetic and knowledgeable therapist as guide. Rather than abort the process with the use of phenothiazines, the therapist should seek to facilitate the processes of psychic deconstruction and reconstruction. Joseph Campbell has interpreted Perry's thesis in quasi-mythological terms:
... a schizophrenic breakdown is an inward and backward journey to recover something missed or lost, and to restore, thereby, a vital balance. So let the voyager go. He has tipped over and is sinking, perhaps drowning; yet, as in the old legend of Gilgamesh and his long deep dive to the bottom of the cosmic sea to pluck the watercress of immortality, there is the one green value of his life down there. Don't cut him off from it: help him through.27
Persons undergoing psychotic experience need firmly established and safe boundaries within which they can undergo the profound transformations in self-organization they require. Perry found such boundaries in two places: (a) the orderly teleology of the pathologic processes themselves, and (b) the intervention of a therapist sympathetic with the struggle for meaning represented by those processes.
Notes and References
1. Claude Levi-Strauss, Structural Anthropology, trans. Claire Jacobson and Brooke Grund (New
York: Harper Torchbooks, 1963), 197.
2. Ibid., 198.
3. See Kakar, Shamans, Mystics, and Doctors, 231.
4. Mircea Eliade, The Sacred and the Profane: The Nature of Religion (New York: Harcourt, Brace and
World, 1959), 20.
5. Mircea Eliade, Patterns in Comparative Religion (New York: Sheed and Ward, 1958), 269.
6. Ibid., 269-71.
7. Mircea Eliade, Shamanism: Archaic Techniques of Ecstasy (Princeton: Princeton University Press,
1964),217.
8. Eliade, Patterns in Comparative Religion, 269.
9. See Robert L. Moore, "Space and Transformation in Human Experience," in Anthropology and the Study of Religion (Chicago: Center for the Scientific Study of Religion, 1984), 126-42. Page numbers in parenthesis in this section refer to this work.
10. Arnold Van Gennep, The Rites of Passage, trans. Monika B. Vizedom and Gabrielle L. Caffee (Chicago: University of Chicago Press, 1960.)
11. Victor Turner, From Ritual to Theatre: The Human Seriousness of Play (New York: Performing Arts Journal Publications, 1982), 84; cited by Moore, "Space and Transformation in Human Experience," 133.
12. Turner, From Ritual to Theatre, 84-85; cited in Moore, "Space and Transformation," 134.
13See also Victor and Edith Turner, Image and Pilgrimage in Christian Culture: Anthropological Perspectives (New York: Columbia University Press, 1978),253, cited here by Moore.
14. See also Robert L. Moore, "Contemporary Psychotherapy as Ritual Process: An Initial Reconnaissance," Zygon 18 (September 1983), 283-94.
15. C.G. Jung used the terms container and alchemical vessel to suggest the strong boundaries needed for deep psychological transformation. See his Collected Works, 2nd ed., ed. Herbert Read, Michael Fordham, and Gerard Adler, trans. R.F. Hull, Bollingen Series, no. 20 (Princeton: Princeton University Press, 1966-78), vol. 10, pars. 253, 255.
16. Robert L. Moore, "Ritual Process, Initiation, and Contemporary Religion," in Jung's Challenge to Contemporary Religion, ed. Murray Stein and Robert L. Moore (Wilmette, Ill." Chiron Publications, 1987), 154-55.
17. For an overview of various theoreticians of the treatment of psychosis, see John Frosch, The Psychotic Process (New York: International Universities Press, 1983), 433-86. For John Weir Perry's approach to the treatment of schizophrenia in a Jungian perspective, see his two works The Self in Psychotic Process: Its Symbolization in Schizophrenia (Dallas: Spring Publications, 1953, 1987), and The Far Side of Madness (Englewood, N.J.: Prentice-Hall, 1974). For Gianfranco Tedeschi's approach from the same perspective, see his article "Analytical Psychotherapy with Schizophrenic Patients," in The Analytic Process: Aims, Analysis, Training, ed. Joseph B. Wheelwright (New York: Putnam, 1971), 38-55.
18. Perry, The Far Side of Madness, 2.
19. John Weir Perry, "Psychosis as a Visionary State," in Methods of Treatment in Analytical
Psychology, ed. Ian F. Baker (Verlag: Adolf Benz, 1980), 194-95.
20. Ibid., 195.
21. Perry, The Far Side of Madness, 2.
22. Ibid., 26.
23. Ibid., 28-29.
24. Perry, The Far Side of Madness, 29-30.
25. Perry, "Psychosis as a Visionary State," 197.
26. Ibid., 195.
27. Joseph Campbell, "Schizophrenia: The Inward Journey," in Consciousness: Brain States of Awareness and Mysticism, ed. Daniel Goleman and Richard J. Davidson (New York: Harper and Row, 1979),195. The author acknowledges that the usage of Campbell and Perry does not meet the DSM IV criteria for schizophrenia. The more generic term psychotic better covers both schizophrenic and non-schizophrenic disorders. The religious ideation of which Perry and Campbell speak also occurs in the manic phase of bipolar disorder and in other atypical psychoses.
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