The soulful psychiatrist

A friend of mine was sectioned last year. They were in the psychiatric hospital for two months, given psychotropic drugs until their mania stabilized, then discharged, with a regular prescription for more drugs. I was struck by the fact they weren’t offered any talking therapy, in the ward or subsequently. Just the pills.

There are some psychiatrists out there who have a richer vision of the mind and how to heal it. One of them was a man called Arthur Deikman.

I came across his name while researching a central idea in Acceptance and Commitment Therapy (ACT) — the distinction between self-as-content and self-as-context.

Self-as-content refers to the content or objects of our consciousness — our thoughts, emotions, body-image, relationships, self-narrative and so on.

Self-as-context refers to the awareness beneath all that, which makes it all possible. In a favourite ACT metaphor, self-as-content are the constantly changing clouds, while self-as-context is the sky.

Where did Steven Hayes, the inventor of ACT, get this idea from? The obvious answer is Buddhism, but Hayes insists he wasn’t directly influenced by it. Instead, in what he says was the first ACT paper (‘Making sense of spirituality’, 1984), he credits the idea to Arthur Deikman’s 1982 book, The Observing Self: Mysticism and Psychotherapy.

So who was Deikman? He began his academic career studying physics at Harvard University, then switched to medical school. When he told a supervisor he was a fan of Yeats and Rilke, the supervisor suggest he specialize in psychiatry.

His interest in consciousness stemmed partly from his self-exploration. In his paper ‘A Functional Approach to Mysticism’ (2000), he recalls how, before starting medical school in the early 1950s, he had a mystical experience while camping alone beside a lake in the Adirondack mountains in New York state. He sat on a boulder for an hour every morning until, after a week or so, his consciousness shifted and he felt in touch with an energy in all things. The ‘perception was felt to be of paramount value’, and it continued, on and off, throughout the summer.

He then went to medical school, started to read mystical literature — particularly the Yoga of Patanjali — and set up an early meditation experiment by getting a group of people to meditate on a blue vase and note their experiences. He also conducted one of the first brain-scans of meditators, and wrote an important paper in 1963 suggesting mystical experiences involved a process of ‘de-automatization’ of usually habitual cognitive processes.

Strangely enough, in my account of my post-ayahuasca spiritual emergency last year, I drew on this very idea, noticing how my habitual expectations of reality had become ‘de-automatized’.

Two of his studies of meditation were included in Charles Tart’s ground-breaking 1969 anthology Altered States of Consciousness. Tart recalls:

Meditation was then largely considered a strange, possibly psychotic-making or psychotic-manifesting activity performed in more primitive cultures. Deikman began the exploration of what might actually occur when Westerners practiced a basic concentrative meditation exercise, interviewing subjects after each session.

Deikman clearly had a capacity to think for himself and challenge the blind-spots in psychiatry’s knowledge. One gaping hole, he noticed, was the lack of a theory for the ‘observing self’.

He wrote in The Observing Self (1982):

The fundamental questions, ‘Who am I?’ and ‘What am I?’ arise increasingly in the struggle to find meaning and purpose in life…Western psychology is severely handicapped in dealing with these questions because the centre of human experience — the observing self — is missing from its theories.

At the heart of psychopathology lies a fundamental confusion between the self as object and the self of pure subjectivity. Emotions, thoughts, impulses, images, and sensations are the contents of consciousness: we witness them; we are aware of their existence. Likewise, the body, the self-image, and the self‑concept are all constructs that we observe. But our core sense of personal existence ‑- the “I” — is located in awareness itself, not in its content.

The idea of the ‘observing self’ is central to wisdom traditions like Stoicism and Buddhism. In Hindu philosophy, especially, one finds the idea of two selves — the self absorbed in doing, and the observing self. The more we can explore and rest in this second mode of consciousness, the more we can discover the divine Self underlying our ordinary flickering ego-mind.

At this point, psychiatry merges into metaphysics, and we meet difficult questions. Can there really be a ‘pure consciousness’ beyond thoughts and words? What is the relationship of my consciousness to your consciousness? What is the relationship of consciousness to matter? And so on.

Yet on a much more practical level, the idea of the ‘observing self’ is hugely useful for therapy and for life.

We often cause ourselves suffering by over-identifying with particular thoughts and words, such as ‘I am worthless’. We ruminate on certain thoughts and wrap them around our consciousness, over and over, like masking tape. Eventually we end up completely constricted and stuck. Everything looks utterly black and we can’t even breathe, and we take this to be the fundamental nature of our self and reality, rather than a situation we ourselves have constructed.

But we can have moments when we suddenly realize, wait a second, I am not my thoughts. My thoughts and emotions come and go. If I can observe them, there must be something in me greater or more primary than my thoughts.

If we can wake up this much, then we can observe our thoughts, reflect on them, and detach ourselves somewhat from them. We can realize ‘I am doing this to myself! And I can stop doing it.’

That’s basically what happened to Eckhart Tolle, when he awoke suddenly from his intense depression. He realized:

If I cannot live with myself, there must be two of me: the ‘I’ and the ‘self’ that ‘I’ cannot live with. Maybe, I thought, only one of them is real. I was so stunned by this realisation that my mind stopped. I was conscious, but there were no more thoughts.

Mystical experiences can give us sudden intense jolts of realization, but — this is a very important point — there is nothing esoteric about this idea at all. The capacity to step back from our automatic thoughts is at the heart of our capacity to self-regulate our emotions. It’s at the core of being human.

In a 1971 paper on ‘bimodal consciousness’, Deikman suggested there are two modes of consciousness in the mind — a ‘doing’ mode, which evolved to help us survive and solve problems, and a ‘reflective’ mode, which can emerge when we are safe and at peace (like Deikman sitting by the lake). This bimodal theory of consciousness is central to mindfulness therapies, by the way, which make a similar distinction between the ‘doing mode’ and ‘being mode’ (here’s the founder of Mindfulness-Based Stress Reduction, Jon Kabat-Zinn, talking about Doing and Being).

Deikman’s bimodal theory influenced research in the 1970s into whether these two modes mapped onto the left and right hemisphere. The hypothesis was explored particularly by David Galin and Robert Ornstein, whose work influenced Iain McGilchrist’s magnum opus, The Master and Emissary.

Deikman, like McGilchrist, suggested our instrumental reason — the ‘doing’ mode of consciousness — has become over-dominant. In his 1977 chapter, ‘Sufism and Psychiatry’, he quotes a parable by Sufi teacher Idries Shah, called The Servants and the House, about a master who goes away and leaves his servants in charge of his house. They forget they are just the servants and the house falls into disorder. I think this is where McGilchrist got his title from — he says the parable comes from Nietzsche but he’s forgotten where. I think it comes from Shah, via Deikman and Ornstein, who were both students of Shah’s.

We see in Deikman’s work a willingness to ask the difficult central questions that psychiatry and psychology shy away from. What is the meaning of life? The sense of meaninglessness is at the root of many emotional and psychological problems, yet psychiatry and psychology struggle to give an answer beyond tautologies like ‘the meaning of life is to find a meaning’. He writes in ‘Sufism and Psychiatry’:

It may be that the greatest problem confronting psychiatry is that it lacks a theoretical framework adequate to provide meaning for its patients….Survival is a purpose but not enough. Working for the survival of others and to alleviate suffering is a purpose but it loses its meaning against a picture of the human race with no place to go, endlessly repeating the same patterns, or worse…The issue of meaning increases in importance as one’s own death becomes less theoretical and more probable…As former goals lose their significance, life can easily appear to be a random cycle of trivial events and the search may end in the most profound despair or a dull resignation.

So what is a better meaning of life then? In ‘Sufism and Psychiatry’, he puts forward the Sufi theory that the goal of life is the development of a spiritual mode of knowing, sometimes called ‘the heart’, which we can develop through becoming less egocentric.

But he insists that we shouldn’t directly seek mystical experiences. He clearly saw this mistake happening a lot, with the spread of psychedelics and ecstatic spiritual practices in the counter-culture of the 60s and 70s. In one paper, he warns that psychedelic research was over-estimating the mystical experience, both as an effective form of therapy and as an ethical goal.

In the 1970s, 80s and 90s, he warned that many of the spiritual and utopian groups that had mushroomed out of the counter-culture were harmful cults, and wrote two books on cults and de-indoctrination. He identified four signs of cult-like behavior — dependence on a leader, compliance with the group, forbidding dissent, and devaluing outsiders. These four behaviours were particularly strong in cults, he suggested, but existed throughout society.

They emerged, he suggested, from people embarking on the spiritual journey without having dealt with their family baggage. They seek a perfect happy family with a perfectly loving and all-knowing parent / guru. Charles Tart writes:

He described the transference-like inhibition of critical faculties and emotional satisfaction in such groups as being like the experience many of us had as children, riding home in the backseat of the family car on a rainy night with your parents driving — and the world was fine.

It must have been dispiriting, for someone who tried to re-introduce mystical wisdom into western culture, to see supposedly spiritual groups so often become toxic. He also thought Westerners were too quick to seize on mindfulness as an instant solution for everything, as if it were a vitamin. In fact, the ‘doing’ mind seizes on mindfulness as a life-hack, a means to greater success and productivity. We are also too impressed with foreign gurus and exotic costumes, terminology and techniques. Anytime a Westerner puts on a robe, he said, ‘they are apt to feel like Snoopy in a Peanuts cartoon — ‘Here’s the World War I flying ace’.

He believed the meaning of life can be found not in mystical experiences or exotic spiritual pursuits, but in service to others. ‘The forging of human love and human work is the labour of life’. And most of his life was spent as a clinical psychiatrist, doing research into states of consciousness, trying to oppose the arrogant reductionism of his profession, and working on psychiatric wards.

Deikman thought the psychiatric system was over-reliant on the use of tranquilizers, and neglected the importance of talking therapies, relationships, and the patient’s sense of meaning and efficacy. He tried anti-psychotics himself as an experiment, and said it was like walking around being covered by a heavy rug. He suggested psychiatrists over-relied on anti-psychotics as a subconscious defence against their fear of the psychotic state. Staff were also rewarded for keeping wards quiet, and for getting patients out quickly.

But the tranquilizers didn’t really treat the underlying cause of many mental disturbances — he questioned the idea that schizophrenia was always a biological illness. Instead, he suggested psychotic episodes were triggered by isolation, the break-off of relationships, and a low sense of meaning, self-worth and self-efficacy. Giving someone tranquilizers did nothing to resolve those underlying problems, and patients would often end up coming back to wards.

In the 1960s, he ran an experiment on a ward with a colleague, Leighton Whitaker, a psychotherapist who was a founding figure in university mental health. For nine months, they gradually stopping giving the patients tranquillizers, and tried to strengthen their capacity for self-determination. Every patient was offered an hour’s therapy a day, and all residents in the ward — staff and patients — met for daily meetings. The staff were also encouraged to share their feelings — this was difficult to achieve, Deikman noted, because they had been trained not to show their feelings and not to admit to feelings of anger for patients.

Rather than establishing strict chemically-policed barriers between patients and staff, there was a recognition of a human commonality in their experience and their meaning-directed behavior. Deikman later wrote of the similarities between mystical and psychotic states (he coined the phrase ‘mystical psychosis’), although he also insisted on the important differences between these experiences.

It was certainly a brave experiment. In one incident, the staff let the patients organize a Halloween party, in which each member of staff was subject to a ‘psychiatric review’ and subsequent punishment (usually placing their hand in cold water) before the entire staff were locked into a padded cell! This carnival-esque reversal of hierarchy led to a deepening of the group-feeling on the ward, he says, and staff and patients voted to unlock the ward. No one ran off. In fact, patients increasingly took charge of the therapeutic process themselves, trying to take care of each other.

Eventually, however, the experiment ended, the staff went to work elsewhere, and psychiatry became even more dependent on drugs, and even less reluctant to use talking therapies or to admit to any meaning to psychotic patients’ experiences. He only published an account of this experiment a decade after it finished — it was rejected from psychiatry journals, even rejected for review by some reviewers, because they considered any alternatives to psychotropic drugs to be malpractice.

Ah well. It takes a long time for things to change, but they do change, slowly. And they change largely thanks to the toil of good people like Deikman. His life reminds me of the closing lines of George Eliot’s Middlemarch, who writes of her provincial heroine, Dorothea:

Her full nature, like that river of which Alexander broke the strength, spent itself in channels which had no great name on the earth. But the effect of her being on those around her was incalculably diffusive: for the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been, is half owing to the number who lived faithfully a hidden life, and rest in unvisited tombs.