Psychiatry, Psychedelics & Meaning
8 Feb 2021
“Ultimately, man should not ask what the meaning of his life is, but rather must recognize that it is he who is asked. In a word, each man is questioned by life; and he can only answer to life by answering for his own life; to life he can only respond by being responsible.”
— Victor Frankl
The contemporary discipline of academic and theoretical psychiatry, as opposed to the practice of psychiatry, generally declares itself a scientific pursuit, even though compared to the other medical specialties, psychiatry lags way behind in scientific achievements and progress. To compensate, there is a great emphasis on diagnosis, on so-called evidence-based treatments, and on the reduction of complex human behaviours to simplistic biochemical and neurophysiological explanations. Such an emphasis leads to “epistemic arrogance” whereby psychiatry resolves its relative lack of scientific progress by squeezing life and the world into crisp commoditised ideas, reductive categories, specific vocabularies and prepackaged narratives, which in themselves may provide little assistance to patients.
But out in the field, things are different. Much good psychiatry is practiced in clinical settings, especially if the psychiatrist is a phenomenologist. The phenomenological approach does not start from prior theories or assumptions, either in relation to scientific concepts, therapeutics, or schools of psychotherapy. The practicing psychiatrist may favour certain medications or adhere to a particular psychotherapeutic technique. But a genuine phenomenologist primarily attempts to establish a worthwhile dialogue with a patient, in order to understand the unique meaning and experience of their illness or state of mind. From this shared understanding, positive changes may come. There is now good evidence that it is the non-specific factors in much of effective psychiatric treatment, such as the depth of the therapeutic relationship, patient expectations and the placebo effect (also called the meaning response), which account for many of its benefits.
No two people see the world in identical ways. Everyone interprets and understands their experiences in a unique way. For this reason personal meaning will always be idiosyncratic and impossible to standardise. The phenomenological approach allows for this by elevating the sufferers experience and actions to the focus point of treatment, which then metamorphoses into a joint project between patient and clinician to make things meaningful, and so transcend the distress and disorder of the patient’s existence.
In the recent history of psychiatry it was Victor Frankl, the famous Austrian existential psychiatrist, a survivor of several horrific years in a concentration camp during the Second World War, who attempted to integrate the concept of meaning into the basis of his psychiatric treatment. He emphasised the importance of what he described as “the will to meaning”. This did not involve the search for a specific meaning, nor was it something that occurred in isolation. Rather, Frankl spoke of the meaningful or responsible life, which included not only an obligation to oneself, but also the realisation of the benefits of genuine positive relationships with the other. By the other he implied other individuals, particular causes or creations, or society or the world in general. Ultimately for Frankl, it was the positive virtuous connection with the other that underscored the value of meaning. Thus Frankl emphasized the selfless over the ego-driven selfish approach to the responsible life.
Which brings us to the use of psychedelic drugs in psychiatric treatment. The so-called peak or transformative experience resonates with the idea of unification, of loss of ego, of profound connection between the outer material world and the inner mental world. Neuroscience increasingly shows us, what Buddhist psychology has been saying for a long time, that our conditioned personal subjective ways of experiencing reality can be upended and expanded, so that any temporary dissolution of boundaries between subject and object can give birth to greater understanding and profound new meaning.
This psychedelically induced process fits snuggly into Frankl’s approach to psychiatry as long as there is not an over emphasis on specific or personal meaning, although obviously this will always be considered in some detail as part of the therapeutic process. However ultimately it must be the therapeutic encounter, the shared responsible search for meaning, which remains the key to the delivery of a positive therapeutic outcome. The content of the meaning experience should never be more important than the form of that experience.
Current research in the Northern Hemisphere with psychedelics emphasizes that these drugs are there to assist and deepen the psychotherapeutic process. These medications are adjuncts, not the primary treatment. Taking a psychedelic trip may be interesting, even life changing, but that approach alone should never be a psychiatric treatment. What remains important is the supportive relationship between therapist and patient, the encounters and rituals they share, and the support provided to the patient in their search for meaning. Whatever the personal meaning, it must remain secondary to the actual quest for meaning.Danger lies in the exaltation of the meaning itself.
Of course it is fascinating to explore the content of the mystical experience. Who does not want to have a divine encounter? But if psychedelic therapy is to become mainstream, it must proceed with caution. Today, more than at any time in the past, the world suffers from the “fatal estrangement” – the modern war of the soul in which the pursuit of knowledge is at odds with the quest for meaning.
Psychedelic therapy offers a bridge between these warring worlds, but bridges are fragile and easily targeted when forces have positions to defend. Psychedelic psychotherapy should never attempt to re-insert religion into psychology. Psychology can objectify faith but it should never base its understanding of human existence on faith, on a blind acceptance of the existence of an ultimate truth without evidence apart from personal experience. No matter how profound is one’s sense of meaning, science (including it’s infant offshoot psychiatry), with all its strengths and weaknesses, must remain an objective discipline.
So if mainstream psychiatry is to accept psychedelic assisted psychotherapy, Frankl’s approach is the way to go. Meaning, especially personal meaning, will always be subjective and open to interpretation, and hence to manipulation and even abuse by ego, whose influence does not necessarily go away, just because someone has had a mystical experience.
By Dr Nigel Strauss