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Translating therapy

Depression is the leading cause of ill-health worldwide, but therapy is little known or practiced outside the West. If psychotherapy is going to become more popular in the non-western world, it needs to build bridges and find cultural parallels in local spiritual traditions. This is totally doable. 

The UK has had a good last decade when it comes to mental health awareness. The Brits don’t talk about our emotions? We never shut up about them these days! Not a week goes by without some official or celebrity – Theresa May, Prince Harry, Rio Ferdinand – saying we need to talk more about mental health. That’s a good thing. It’s good to talk, though it’s even better when that talk is backed up by increases in government spending on mental health services.

The situation is a lot worse elsewhere. As the World Health Organization highlights this Friday in its World Health Day campaign, depression is now the leading cause of ill health and disability worldwide, affecting more than 300 million people. While only around 50% of people with depression get therapy or medication in high income countries, in middle and low income countries, the percentage is closer to zero.

In half the countries in the world, there’s only one psychiatrist per 100,000 people. In India, where I spent the last three months, the country spends 1% of its GDP on health (the OECD average is 9%), and 0.1% of that on mental health services – one of the lowest figures in the world. There’s one psychiatrist for every 300,000 Indians, though in fact most psychiatrists are based in the big cities. In poorer rural regions, there might be one psychiatrist for every million people.

There’s a lot of stigma around mental illness around the world, and little awareness of psychotherapy. And there’s a cultural and language problem for both psychiatry and psychotherapy. Sadia Saeed Raval, who runs the Inner Space therapy centre in Mumbai, says: ‘Therapy in India is mainly Anglophone. The training is in English, the terminology is English, and the therapy techniques tend to be developed in the West.’ 

At a recent event I attended on mental health in India, the discussions were almost all in English, and even when a psychiatrist spoke in Hindi, he still used English words like ‘stigma’ and ‘depression’. The WHO’s own campaign posters, ‘Let’s Talk’, are also all in English. Imagine if we in the UK only had Indian words for depression, anxiety or other internal states.

This Anglicisation of therapy has limited its cultural dispersal in low and middle income countries to affluent, westernized elites. So how does everyone else cope with mental illness? In large part, by turning to religious or spiritual healing. This might sometimes work – it can help provide meaning, community support, meditation, and the powerful placebo of hope. But it doesn’t always work, and in some cases can be harmful.

What to do? Obviously, the best thing would be for countries to increase their spending on mental health services. I imagine the WHO is trying to get its member states to do that. But we shouldn’t assume that western psychiatry has all the answers to the meaning of life (look at suicide rates, where some Western countries do worse than many non-Western countries).

We can also try to help bridge the cultural gap between western psychiatry and psychotherapy, and non-western cultures. And here the medical humanities can help.

In the UK, the most popular and evidence-based therapy for depression and anxiety is Cognitive Behavioural Therapy (CBT). As I and others have researched, CBT has its roots in the ‘healing wisdom’ of Stoicism and, to a lesser extent, Buddhism.

That means that it is easily translatable into other cultural contexts, because the idea of ‘healing wisdom’ appears not just in Greek philosophy but also in Christianity, Islam, Judaism, Hinduism, Jainism and many other religious and spiritual traditions. Indeed, Stoicism was a big influence on therapeutic wisdom books in Christianity (Boethius’ Consolations of Philosophy, for example) and Islam (eg Al-Kindi’s On Dispelling Sadness).

There is also a great deal of similarity between Stoic-CBT therapeutic ideas and those found in the wisdom texts of Hinduism and Buddhism. For instance, Stoicism / CBT is based on Epictetus’ idea that ‘it’s not events, but our opinion about events, that cause us suffering’. Likewise, the Buddha taught: ‘We are what we think. All that we are arises with our thoughts. With our thoughts we make the world’.

Many different wisdom traditions recommend learning detachment, both from one’s own thoughts and desires, and from the ups and downs of fortune, and learning to accept the limit of one’s control over the world – both of which are central concepts in CBT and Positive Psychology. Many also recommend some form of mindfulness and techniques for improving it – Stoicism-CBT recommends keeping track of your thoughts and behaviour in a journal, Jesuits practice ‘recollection’ at the end of the day, Orthodox Christians practice ‘nepsis‘ or watchfulness, and so on. 

Many wisdom traditions also emphasize that changing the self takes repetition and practice (askesis in ancient Greek), as CBT does. Proverbs, in the Bible, talks about seeking wisdom, and inscribing wisdom on the ‘tablet of your heart’ through memory and practice. The Bhagavad Gita says: ‘It is difficult to curb the restless mind, but it is possible by constant practice and by detachment’.

There is some evidence that CBT works better when its basic ideas and techniques are connected and translated into local language and local culture. Here, for example, is a paper on Islamically modified CBT. Others have developed Christian CBT, and of course mindfulness-CBT now has a strong evidence base, although ironically it is barely known or practiced in India, the home of Buddhism.

Medical humanities scholars can help explore the cultural connections between western psychotherapy and various wisdom traditions around the world, and help to discover the local vernacular for local emotional states.This will help people overcome their suspicion of therapy. Speaking personally, for example, I’ve done workshops on healing wisdom for evangelical Christians, where you can describe the basic ideas of CBT purely using quotes from the Bible and Christian wisdom literature. That is helpful for an audience which has traditionally been wary of psychiatry and psychology, partly because of psychiatry’s long history of hostility towards religion.

At the same time, we should remind ourselves that cultures aren’t static and monolithic. There is no such thing as ‘Indian culture’, for example, there are many Indian cultures, all in flux. A 2013 article in the Indian Journal of Psychiatry calls for the ‘Indianization of psychiatry’ to take account of cultural differences such as the greater emphasis on traditional family structures. Fine – but Indian therapists also tell me of the stress and suffering caused to some Indian women by the traditional understanding that their role is entirely to support their husband and his family. Therapy can help people not just adjust to traditional roles, but also help them evolve into new roles, new identities, a new place in society.

Working with local spiritual healers

A second way that medical humanities researchers can help to bridge the cultural gap between non-western cultures and western psychiatry / psychotherapy is by working with local religious and spiritual leaders, facilitating dialogues of mutual respect to work together.

Aaron Beck, one of the inventors of CBT, with the Dalai Lama, who has spoken about the close similarity between CBT and Buddhism’s theories of the emotions

At my university, Queen Mary University of London, a team of psychiatrists are working with local Muslim spiritual healers, to try and improve relationships with a community that has traditionally been very wary of psychiatry. The latest issue of the WHO’s Panorama magazine has an article on psychiatrists working with Kyrgyz spiritual healers. In India, I think it would help to work with local spiritual leaders like Sadhguru, the best-selling yogi who regularly speaks on yoga as a means to mental health. We already know how fruitful the dialogue has been between western psychiatrists and psychologists and the Dalai Lama – it has helped western psychotherapy advance. 

Finally, I think technology has a role to play in improving global mental health. Governments are spending far too little on mental health services, and should be encouraged to spend more. But could the WHO or other organizations like the Wellcome Trust help to develop apps, websites and online courses, in local languages and local cultural terms, to disseminate basic therapeutic ideas and techniques? It would not be enough, but it would be something. And it would be cheap. 

I’m working with the WHO on a project called the Cultural Contexts of Health. Find out more about it here. 

New book on ecstatic experience (not by me)

There’s a new book out later this month on the psychology of ecstatic experiences, and why they’re good for us. It’s called Stealing Fire, by two performance coaches, Steven Kotler and Jamie Wheal. It might be disconcerting to have another book on ecstasy published two months before my own, but actually I’m glad others are walking the same path and coming to similar conclusions. I disagree on one or two points the authors make, however. The book isn’t out until later this month, but I heard them on The Psychology Podcast, here. Great podcast by the way.

So why did these two coaches, who specialize in teaching ‘flow’, start talking instead about ecstasy, or ‘ecstasis’ as they call it in the ancient Greek word. Kotler says that they started coming across similar experiences across a whole range of domains – meditation, psychedelics, the arts, sex, extreme sports. ‘It was a broader category of which flow is a subset.’ In fact, the Positive Psychologist Mihaly Czikszentmihayli developed his concept of flow (i.e moments where we’re blissfully absorbed into a challenging activity) out of the idea of ecstasy, as he told me in this interview.

Nomenclature is tricky for this domain of experience. William James and Alister Hardy wrote of ‘religious experiences’, defining them as ‘individuals standing alone in relation to the divine’ – but that ignored collective ecstatic experiences, and the fact atheists also have moments of self-transcendence. Durkheim spoke of ‘collective effervescence’ which sounds like a bubble bath. Abraham Maslow wrote of ‘peak experiences’, but that ignores the fact these experiences are often terrifying, and occur to people in life-crises. These days, the few psychologists who explore this terrain still haven’t agreed on nomenclature – some study ‘self-transcendence’, others ‘out-of-the-ordinary or anomalous experiences’, others ‘mystical experiences’, or ‘altered states of consciousness’. Not to mention the related research fields on hypnosis, trance and possession. The topic is so interdisciplinary – from aesthetics to sex to sports to politics – and the authors are to be applauded for recognizing that and not being deterred.

Personally, I’ve also gone for ‘ecstasy’ as my preferred term, because it’s got the longest history. But the risk of that is people think you mean either MDMA or ‘feeling very, very happy’. The authors make the mistake too of describing ecstasius as ‘north-of-happy states’. No! As Gordon Wasson, who reintroduced magic mushrooms into western culture, wrote: ‘In common parlance ecstasy is fun. But ecstasy is not fun. Your very soul is seized and shaken until it tingles. The vulgar abuse the word: we must recapture it in its full and terrifying sense.’ Another risk, which I may have fallen into, is that talking about ‘ecstatic experience’ makes it all about something happening within oneself, something one ‘has’, rather than something transpersonal happening beyond you, an encounter or realization rather than an experience (which sounds more like a thrill).

The altered states economy

The authors are coaches who make a lot of money giving talks and workshops to companies and CEOs on flow and peak performance, so they are quite focused on the practical business applications of ecstasy. They speak of the ‘altered states economy’, and suggest that today we spend around $4 trillion a year trying to get out of our heads and beyond our egos. ‘That’s insane, and no one’s talking about it’, says Wheal. To get to this figure, they added up all that we spend on, say, legal and illegal drugs, the alcohol industry, extreme sports, gaming, immersive arts like IMAX or festivals, gambling, self-help and psychology, and so on. It’s a bit rough-and-ready, but their basic point is right – the human desire for self-transcendence and ego-loss is fundamental, and late capitalism has found many ways to make money from it, including addictive behaviours like drugs and gambling. I’ve also written about what I call (in a nod to Joe Pine’s idea of the experience economy), the ‘ecstatic experience economy‘. There is also a political economy of ecstasy – states and empires use awe and wonder to increase their power, and now corporations like Disney, Cirque du Soleil and Magic Leap sell us enchantment and transcendence.

Tony Robbins and the human potential movement helped to instrumentalize ecstasy as a tool to capitalist success

The authors also want to convince us of how ecstasy leads to peak performance. This is very much in the tradition of human potential coaches like Anthony Robbins, who teaches how ecstatic or peak states can unlock our life-potential (hence his use of fire-walking, pumping techno, trampolines and so on in his seminars). They’re particularly interested in how Silicon Valley entrepreneurs like Steve Jobs used meditation and psychedelics to unlock their creativity. They quote life-hacking guru Tim Ferriss: ‘The billionaires I know, almost without exception, use hallucinogens on a regular basis.’ Tune in, turn on, get rich!

This weird fusion of the ecstatic and the capitalist goes back to Stanford Uni in the 1970s, when pioneers of the digital economy like Jobs, Stewart Brand and Douglas Engelbart mixed coding with Bay Area spirituality. Engelbart introduced LSD boot-camps at his Stanford research unit (after one trip he invented a toilet that played music when you peed in it). This led to the idea that the main route to ecstatic experiences would be the start-up, the dot.commune, the guru-CEO creating a new utopia in cyberspace. A great introduction to this is Fred Turner’s history, From Counterculture to Cyberculture.

I guess my issue with the selling of ecstasy as a way to peak capitalist performance is that, historically, ecstatic experiences have involved a revolution in the self and a revolution in values. St Paul is utterly transformed after his Damascene moment, his values are utterly transformed – he has died, someone new has been born. The instrumental use of ecstasy for conventional goals of success and power seems to me closer to the magic of Simon Magus or Aleister Crowley. But it’s often there in religion too – what is the Prosperity Gospel if not the instrumentalization of ecstasy for worldly aims?

The risk of the psychology or neurobiology of ecstasy is it leaves out the ethics. Most spiritual traditions emphasize that ecstatic experiences are at best a distraction and at worst a serious risk if they’re not grounded in strong ethics. Later psychologists have come to this conclusion too – William James suggested we evaluate religious experiences based on the ‘fruits’. I think the authors understand this, they speak of the ‘dark side’ of ecstasy, and warn it often leads to unbridled hedonism. But that’s not the main risk, historically. The main risk is that ecstasy without humility leads to pride, the feeling that you’re special, chosen, elite, Crowleian supermen. Kotler and Wheal’s book, talking about the special ‘Prometheans’ or ‘supermen’ whose ecstatic experiences prove how wise and advanced they are (and rich! did we mention they’re rich?), could feed this tendency.

The four drivers of ecstasis

The authors argue we’re at a special moment in history, when suddenly we understand ecstatic experiences better than ever, and can get them ‘at a flick of a switch’. Why now? Because of four drivers. Firstly, psychology. Kotler says that, after William James’ Varieties of Religious Experience in 1902, psychology took a ‘hundred-year detour’ and focused on psychopathology. Altered states of consciousness were dismissed or pathologized, but in the last decade psychologists like Czikszentimihayli and David Yaden have realized they’re actually good for us. This is not quite right – as co-author Jamie Wheal notes, ecstatic experiences were hugely studied in the 1950s, 1960s and 1970s, particularly through the human potential movement and transpersonal psychology. What’s really happened in the last decade is that transpersonal psychology has gone mainstream, thanks to the rise of contemplative science and the return of psychedelic science.

Secondly, neurobiology. Brain-scanning techniques have enabled scientists to take ecstasy more seriously. Before, it seemed a very flakey topic for research, that led into career cul-de-sacs like parapsychology or after-death-investigations. But look, a brain-scan – something really is happening! This was reassuring for the Doubting Thomases in academia. Now, there is interesting neurobiology on ecstasy done by scientists like Andrew Newberg, Richard Davidson and Robin Carhart-Harris, showing the neural correlates of states of ego-loss and deep absorption.

There is a danger that these very early insights are then uncritically seized upon to argue that ‘the mystical is now neurobiological’, as Wheal puts it, or that the mystical has now been ‘decoded’ as Kotler says. In other words, because something happens in the brain, mystical experiences are nothing but brain events. This would be a big mistake by psychiatry – it has a 300-year bad record of pathologizing and ignoring these experiences, to the great harm of many people and of western culture in general, for which no one has ever apologized. Now, when it starts seeing the positive side of these experiences, it again rushes to a triumphalist scientistic interpretation.

As the podcast presenter, Scott Barry Kaufmann, who researches in this field, points out: ‘Everything is biologically mediated, so that statement is not as exciting as you think. There’s so much we don’t know – we’re at the start, not the end point.’ He’s quite right. Andrew Newberg, for example, has found that ecstatic experiences involve the emotional processing areas of the brain. Well, no shit! How is that useful, besides as a way of getting sceptical scientists to take ecstasy seriously?

The third driver the authors outline is pharmacological – particularly the ‘psychedelic renaissance’ today. No arguments there, though again it’s very very early days in the research. And the fourth driver is technological. New technology makes ecstasy more widely available than ever before, they argue. For example? New amplification technology makes music concerts better. In the old days it was just the Grateful Dead, now we have huge EDM festivals. Uh huh. And new skis make powder skiiing easier. Right….I’m not entirely convinced. Just because electric guitars are more advanced now than the 60s, doesn’t mean people play them better than Hendrix did, or that the experience of the audience is more intense than it was at Monterey or Woodstock (who really thinks that?) It’s partly the shock of the new that creates the ecstatic – the shock of, say, the first use of the Roland 303 in acid house.  I’d say humans are constantly inventing new technologies and scripts for ecstasy, from cave paintings to virtual reality. Our age has developed some new scripts, but so did every age before us.

I also think that, like many secular psychologists and neuroscientists, the authors don’t entirely get the connection between ecstasy and ritual. Like Sam Harris, they’re impatient with ritual, which is all woo-woo. They want an entirely stripped-down, rationalist, flick-of-a-switch mechanistic ecstasy, one liberated from middle-men. Wheal says:

For folks who have mythological or mystical explanations and assumed [ecstasy] came from grace or adherence to religion, we can say, here are the mechanisms. It cuts out the middlemen, the priest class, those who presume to tell us how to get it. This is our human birthright. Mystical experiences can be demystified and we can create them a hell of a lot more often than when people are bowing and scraping to Mecca.

Kumbh Mela. Low-tech ecstasy

Never mind the casual insult to 1.6 billion Muslims, this fails to understand the power of rituals – including pilgrimages – to bring us to ecstasy. You think westerners now have more ecstasy than ever before? Compared to the Middle Ages? Compared to, say, Indian culture today? OK, Burning Man now attracts thousands and thousands of people…The Kumbh Mela in India attracted 120 million people in 2013, and they had no more technology than tents, chillums, bhang and a river. And what the Sixties showed us is you can do away with the ‘middlemen’ of Christianity, but often new middle-men rise up – gurus, artists, politicians, rockstars, dare I say it, even self-help coaches, who ‘presume’ to tell us how to find ecstasy and what it means.

I also think the authors miss out an important cultural driver for why we are talking about ecstatic / spiritual experiences today. The main reason, I think, is the decline of organized religion in the west. This has created a large group of ‘nones’ or ‘spiritual-but-not-religious’, who are just as hungry for spiritual experiences, perhaps even hungrier than before. Hence the fact that, while attendance at church is going down, the number of people who say they have had spiritual or mystical experience in the US and UK is going up.

But a spirituality based on ecstatic experiences and detached from moral dogma and community can mean we become overly attached to them, we fetishize them, we make them the goal of the journey, rather than something which may or may not happen along the way. So what then is a more appropriate goal? Love and awakening to our true selves, I would say. Transhumanists, life-hackers and human potential coaches always speak of ‘peak performance’, and rarely about love, vulnerability, openness.  ‘Though I speak with the tongues of men and of angels, but do not have love, I have become a noisy gong or a clanging cymbal.’

Having said that, there’s much that I agree with in Kotler and Wheal’s analysis, particularly their insight that the internet has allowed an open-source big data approach to ecstasy, a ‘crowd-sourced Bible’ – the exact phrase Ive used in my book! I didn’t copy you, guys, I swear. I’ll definitely give the full book a read when it’s out later this month.