Altered States of Consciousness and Psychotherapy
A Cross-Cultural Perspective*
The main physiological and induced Altered States of Consciousness (ASCs) are outlined, as well as methods of induction. The phenomenology of ASCs is described and related to psychopathology. A short commentary is given about ASCs used in some ethnopsychotherapies. Psychotherapies of Western origin using ASCs, especially hypnosis, Holotropic Breathwork, and Personalized Experiential Restructuralization Therapy (Past-Life/Regression Therapy) are outlined and discussed.
Mário Simões Psychiatric University Clinic, Lisbon, Portugal.
Altered (Waking) States of Consciousness (ASCs)
CULTURAL ISSUES were included, although in a limited fashion, in the diagnostic manuals ICD-10 (World Health Organization,1992) and DSM-IV (American Psychiatric Association, 1994). As Fabrega (1995) points out, the study of the cultural sciences as they pertain to psychiatry offers a necessary corrective to the increasing impersonality and reductionism that has come to characterize the neurobiological approach. A major enterprise in cultural psychiatry in recent years has been the integration of clinical science and anthropology (Minas, 1996).
This paper is also an attempt to make such an integration. It deals with a psychological phenomenon that is rooted in the cultural life of a wide variety of peoples and which has only recently come to the attention of Western researchers, in spite of a long European tradition in research on Altered States of Consciousness (Beringer, 1927; Stoll, 1947).
There is a current view that accepts the existence of different levels of reality, according to the state of consciousness (level) which an individual is in at the moment. Normal daily consciousness (the ordinary state of consciousness) gives access to an ordinary reality, but altered states of consciousness, for example, in dreaming, permit contact with a nonordinary reality. Less familiar forms of consciousness are those categorized under the general designation of altered states of consciousness (ASC). These should be understood as altered or modified in relation to the waking state of consciousness, since this ordinary state of consciousness can be considered, itself, an unusual state, impossible to maintain for long, and secured only by a modicum of perceptual intake and continuous interior discourse (Gowan, 1978). In fact, a discrete fluctuation in the ordinary state of consciousness exists, giving rise to what Tart (1975) calls discrete states of mind.
An ASC is present when there is a deviation in subjective experience or psychological functioning from certain general norms for that individual, recognized by the subject or observers
(Kokoszka, 1987; Ludwig, 1966). Some authors (Dittrich, von Arx, & Staub, 1986) add some other features to this basic definition:
1. Every ASC has certain verbally comprehensible features which occur only infrequently during the normal waking state. The number of such differential characteristics determines
the state of an ASC on dimensions ranging from the normal waking state to an extreme ASC.
2. ASCs normally last for only a few minutes to hours, which is an important difference from psychiatric diseases.
3. ASCs are self-induced, that is, they are usually voluntarily induced, or may occur in the normal way of life. They are not the result of illness or adverse social circumstances.
4. The various means of inducing ASC can be grouped into four types:
(a) hallucinogens of the first order (e.g., LSD, DMT, THC);
(b)hallucinogens of the second order (e.g., Scopolamine, nitrous oxide);
(c) reduction of environmental stimulation or contact in the broadest sense (e.g., sensory deprivation,
meditation, falling asleep, awakening); and
(d) increased environmental stimulation and contact (e.g., intense rhythmic stimulation, extremely variable stimuli).
Using the APZ (Abnorme psychische Zustaende) questionnaire (Dittrich, 1975) for scanning ASCs of the different types mentioned above, various authors in different countries (Dittrich, von Arx, & Staub, 1986; Simões, Polónio, von Arx, Staub, & Dittrich, 1986) found that some common characteristics of ASCs remained sufficiently stable under different methods of induction. Analyses on a dimensional level identified three primary subscales, positively intercorrelated, and designated as follows with regard to content: (1) Oceanic Boundlessness; (2) Dread of Ego-Dissolution; and (3) Visionary Restructuralization. The first subscale describes a state similar to mystical experiences; the second subscale contains features which indicate a very unpleasant state, similar to what is called a “bad trip” by drug users and similar to some symptoms in schizophrenia; and the third subscale includes items on visual (pseudo)hallucinations: visions, illusions and coenaesthetic hallucinations, or a change of significance of the surroundings. As Dittrich, von Arx, and Staub (1986) point out, referring to Huxley (1961), it could be said that the three primary etiology-independent aspects of ASCs correspond to Heaven, Hell, and Visions.
Altered States of Consciousness and Society
ASCs, even when recognized in Western societies, still possess negative connotations. They are labeled as different, irrational, strange, abnormal, or pathological. This is more likely to happen if these states emerge spontaneously, because the so-called “functional” psychiatric diseases also arise in an apparently spontaneous way. An acute paranoid syndrome triggered by marijuana, in its early stages, is very similar to an acute schizophrenic episode, giving some support to the classification of an acute paranoid syndrome as an ASC (Simões, 1995). The phenomenology included in the three subscales mentioned above can be present simultaneously in a psychotic and in a spiritual/mystical experience, but the degree of involvement of each subscale is different in the two kinds of experience (Dittrich, 1988). These data indicate the possibility that both experiences may have a common psychophysiologial basis, such as a common path of final expression. As Mandell (1982) admitted, this common path may “reflect the neurobiological mechanisms underlying transcendence, God in the brain,” or, metaphorically, the brain as a hologram of the all-one.
But the question remains whether a given ASC is to be considered pathological. Its classification as pathological is not strictly based on biological or phenomenological criteria, for the stigma of pathology can as well be seen as a measure of social control (Dittrich, 1996). Crombach (1974) believes that ASCs would lose their strange and “irrational” character if they were considered as “another” way of getting knowledge or “framing reality.” Pathological ASCs should be recognized as those that arise spontaneously and present the following characteristics: (1) they are a dominant experience in daily life; (2) they serve to enable the experiencer to avoid the necessity of finding adequate solutions for the problems of daily life; and (3) the context in which they emerge provides no cognitive or social structures with which those ASCs can be dealt with. The last situation, for example, is the case where societies, although used to spontaneous or induced ASCs, cannot integrate in their cultural frame the ego dissolution experienced by schizophrenic patients (Scharfetter, 1990). Ethnological studies (Bourguignon, 1973) indicate that in ninety percent of societies quoted in the Ethnographic Atlas (Murdock, 1967), ASCs are used for some social events, so one can speak of them as an anthropological constant. Earlier on, ASCs were thought to be an uncommon experience in Western societies, and those experiencing them did not talk about the subject, fearing to be considered psychiatric patients. But now, the results of a survey conducted by Hay (1982) have been confirmed (Kokoszka, 1989; Valla, 1992) and indicate fifty-four percent of the population experiencing a “deep” (mysticlike) ASC, whereas eighty-four percent referred to some form of “slight” (alteration in reality feeling and disturbance of cognitive process) ASC, occurring more often in religious situations than in everyday situations or during cognitive processes. The tendency to emphasize rationality and intersubjective communication makes an ASC more likely to be considered abnormal. It evokes fear of mental disease because it does not conform to experiential stereotypes. It should be noted that relaxation techniques, socially spread as meditation or autogenic training, can be followed by ASCs. In Western societies, mysticlike ASCs can be considered as a healing mechanism (Lukoff, Turner, & Lu, 1992; Valla, 1992).
Altered States of Consciousness in Ethnopsychotherapy
MANY NONINDUSTRIAL cultures employ ASCs in various spiritual and healing rituals. Anthropologists have used phrases such as trance or possession states to describe these practices. Psychologists have used other terms to describe them in Western cultures: hypnotic states, mystical experiences, and hysterical dissociation are some examples (Jilek, 1989). Differences among these states are considered to be more cultural than psychological or neurophysiological in nature. The capacity to enter into an ASC is common to all human beings, but frequency is a function of social and cultural variables. Among these, there is the possibility that an individual may be required to fulfill certain social roles in the culture, to practice certain permitted “roles” sometimes sought after in that culture to satisfy social, personal, or other healing needs.
Some cultures use ASCs in healing rituals that are similar to Western psychotherapeutic techniques. These rituals may employ psychoactive plants (Rios, 1989) or rhythmic stimuli such as dancing or drumming (Jilek, 1989) in the induction process, while in the Western psychotherapeutic context, other means (e.g., sensory overload or deprivation, with or without guided visualization) are generally preferred. There is no contradiction here because according to the current understanding of the interdependence of the mindbody, psychological processes affect biomedical changes and vice versa.
When we study ASCs in different cultural settings, the first problem we must face is whether these states are internally consistent or dependent upon social or cultural factors (Ward, 1989). The data indicate that these positions are not antagonistic. Although behavior during ASCs in some aspects can be different, ways of induction, and social and cultural objectives exhibit some similarities. There is not always social and functional equivalence, however, even when neurophysiological mechanisms are common. The greatest difference between what is observed in Western cultures and those of other cultures in relation to psychotherapy has to do with causal attribution (Lambek, 1989). It is interesting to note that in Western societies there are different schools of psychotherapy, each with its own etiological model of disease.
YOGA HAS been practiced in Asia for millennia, and has often been used therapeutically in contemporary times to treat insomnia and other psychological problems (Hehr, 1987). A practitioner of yoga strives to become aware of corporeal sensations and perceptions, while keeping this bodily awareness free of ego involvement. To attain this state, one uses visualization techniques as well as physical postures, or asanas, frequently in combination with controlled breathing. This state has neurophysiological correlates which are similar to those observed in opium smokers (Hehr, 1987)-thus leading to the endorphin hypothesis for explaining these sensations associated with Yoga.
Umbanda and Voodoo
HEALING CEREMONIES in Umbanda (Brazil) and Voodoo (Haiti) cults contain psychophysical techniques which manipulate consciousness. According to Umbanda, the etiology of disorders is centered on supernatural fluids that are prejudicial because of ethical-religious errors, magic, spiritual and karmic forces, or derived from an underdeveloped mediumship. Therapy is executed by a medium in an ASC under the influence of a spirit of a deceased person that blows away those fluids. Many clients themselves seek to become mediums, which brings them social prestige and assists in the cure. Voodoo technique is partly similar to Umbanda, and both aim to promote social and psychological integration (Pressel, 1987). The types of “spirit” that orient therapy, through the medium, which are the caboclo (handsome man), preto velho (old man), criança (child), and exu (a supernatural being), represent aspects of a socially well-adapted personality, which explains the frequency with which they appear in terreiros (ceremony playgrounds) (Pressel, 1987). Voodoo ceremonies are not principally for healing as in Umbanda-and animal sacrifice is often involved. The concept of supernatural fluids permits the medium an approach to modern neurophysiological and biochemical correlates on one hand and the social relations of the patient and other persons on the other hand. It can be seen as part of an organized, integrative effort by that society to satisfy the need of its members to know life’s meaning, as well as a biological need for a cure (Pressel, 1987).
Induction processes used are dance, mainly around the body axis, and rhythmic drumming and hand clapping. These belong to the category, listed earlier, of ASC induction by sensory overload with simultaneous rhythmic monotony. Both rhythms belong to the EEG theta frequency (4-7 hertz/second) which is the most common frequency found in ceremonies that lead to trance(Jilek, 1989) and is confirmed in ceremonies accompanied by rhythmicbatuque in Siberia, Haiti, Africa, and Indonesia (Neher, 1962).
American Indian Dance
HEALING CEREMONIES through dance have also been observed among North American Indians (Salish, Algonqians, Kiowa) (Jilek, 1989). The patient is brought into an ASC, following the instructions of an “initiator” and helped by the community. Production of these ASCs generally occurs without use of hallucinogenic drugs (e.g., peyote, psilocybin). These states are provoked through waking-sleep variations, hypo- and hyperventilation, or rhythmic acoustic and motor stimulation (Jilek, 1989). Considering this type of therapy from a Western point of view, various therapeutic parameters are clear: occupational and activation therapy, group psychotherapy, cathartic abreaction, psychodrama, suggestive support, and physical exercises. The psychosocial function of these ritualistic dances with healing properties can be interpreted as a way to obtain emotional and spiritual well-being and responsibility and self-esteem for autochthones, especially in modern times when they have difficulties in finding their identity in a society dominated by white North Americans (Jilek, 1989).
Altered States of Consciousness in Western Psychotherapies
Because hypnosis, bodywork, and so-called “image work” are currently popular, I will briefly consider them.
A WELL-KNOWN joke is that the first use of hypnosis was when God hypnotized Adam in order to take his rib for the creation of Eve. While this may be stretching things a bit, hypnosis is certainly an ancient technique, in use for millennia. Wefind the phenomenology of hypnosis in Egyptian sleep temples, for example, as well as in numerous other sites around the world. Many famous physicians were involved in the development of hypnosis in one way or another: among them, Paracelsus, Mesmer, Faria, Braid, Charcot, Freud, Pavlov, and Janet. The Portuguese Abade Faria is notable in that he was the first to consider hypnosis to be a state of autosuggestion. Interest in hypnosis is still strong (Burrows & Stanley, 1995; Walter, 1995; Araoz, 1998).
The hypnotic state (as opposed to the practice of inducing hypnosis) can be defined as an ASC characterized by attentive and receptive concentration with a relative suspension of peripheral awareness (Spiegel & Spira, 1993). To date, neurophysiological or clinical correlates have not been found to be specific to this state (Walter, 1995), which is why some authors claim that it does not exist at all (Barber, 1970; Wagstaff, 1981). Others see it as self-controlled behavior by individuals in response to demanding social roles, while being present as passive actors in a drama in which they could lose control (Spanos, 1989). Still others think that a true ASC is involved as well as learned responses to social roles (Hilgard, 1986; Tart, 1975). Experiences and behavior under hypnosis are associated with a subjective conviction similar to delusion, and with a sense of unwillingness similar to compulsion (Kihlstrom, 1985). These aspects have contributed to some popular misconceptions: that hypnosis is a dream; that it is passive (something one does to somebody else); that everyone is hypnotizable; that it is dangerous; that it is therapeutic per se; or that it is a special susceptibility or spiritual weakness. Hypnotic susceptibility can be evaluated through tests, and it is influenced by the rapport or trusting relationship that is established between the therapist and patient. In hypnosis, “resistance” does not come from the patient, as in psychoanalysis, but from a failure in rapport. The success of the session depends also on hypnotic susceptibility, which has also been shown to vary widely among different people, and to vary in individuals over their lifetime. Hypnotizability seems to be something that is inherited, in that parents who are easily hypnotized are more likely to have children who share this susceptibility (Matthews, Conti, & Starr, 1998).
Methods of induction are based on monotonous rhythmic stimuli in an environment of little or no other acoustic or visual input. Trance levels range from hypnoidal to somnolent states, and some of the different phenomena which can be observed include hallucination, anesthesia, age regression, and post-hypnotic suggestion. The spectrum of possible use is wide-ranging from the treatment of phobias and multiple personality disorder, to modern research on traumatic childhood memories (Kluft, 1995). Hypnotic-like procedures are found in Shamanism, and native practitioners utilize the same human capacities (Krippner, 1999; Richeport, 1987). Krippner (1999), as a cross-cultural psychologist, remarks that the human psyche cannot be extricated from the historically variable and diverse “intentional worlds” in which it plays a co-constituting part.
There is another therapeutic technique in some Western countries that also uses hypnosis-spirit releasement therapy-developed by Baldwin (1993). Such an approach will stretch or overstep the bounds of some therapists’ credulity and it is advised that psychotherapists who do this type of work have a working knowledge of metaphysics, spirituality, and nonphysical levels of reality (Wicker, 2000). There is some controversy about the use of hypnosis in recovering repressed memories (Yapko, 1995) that would not exist if therapists were more careful about verifyingsubjective “certainty.” Of course, material obtained under hypnosis must be considered as deserving further research-especially when suspicion of sexual abuse persists. Hypnosis can be considered an ASC similar to others common in daily life (e.g., relaxing, reading a book in deep concentration), but different from the normal waking state in relation to dreaming or sleep, where the distinction between these is stable both for humans and other mammals (Stengers, 1993).
THE NAME of this psychotherapy-holotropic- derives from the Greek, meaning both “whole” and “moving toward.” Developed by Grof (1979), this method facilitates altered states of consciousness by means of conscious breathing, evocative music, and focused bodywork. Grof’s research led him to a map of consciousness with three levels: the biographical, perinatal (related to traumas of biological birth), and the transpersonal (experiences supposed to happen in a time and space out of the ordinary frame). The holotropic approach is intended to bring into consciousness content from the unconscious that has a strong emotional charge and is relevant from a psychodynamic point of view (Grof, 1996).
In this therapy, symptoms are seen as the first stage of healing. Though the majority of emotional problems have their roots in childhood, others originate in the other aforementioned levels. A resolution of problems means letting the patient experience the other levels associated with the problems under treatment. Grof (1996) uses holotropic breathwork to activate the selfhealing potential guided by one’s own deep inner intelligence.
Personalized Experiential Restructuralization Therapy (Past-Life/ Regression Therapy)
THIS DESCRIPTIVE title is intended to summarize and integrate what in some circles is known as “Past-Life/Regression Therapy,” recent discoveries on imagery (Achterberg, 1985), and clinical applications of nondrug-induced states (Budzinski, 1986). In its early days, this therapy referred to a concept somehow strange to Western culture-the notion of reincarnation-the possibility that an individual could experience various lives in different bodies in different times and cultures through the agency of an immortal spirit or soul. This idea is not strange for many Eastern societies and can even be found in some Western cultural circles. Because it is beyond the scope of this work, I will not discuss reincarnation here, although there is a growing literature of rigorous scientific investigations into the matter (Stevenson, 1970, 1983; Andrade, 1988; Keil, 1994).
This brief introduction makes clear that it is more neutral to call the therapy “Personalized Experiential Restructuralization Therapy.” Being symbolic in nature, imagination permits representations of things that do not exist or which are approximations of reality. It is a capacity that allows elaboration of concepts or precognitions which would be impossible to realize in any other way. The graphic representation of mental disorder in a patient’s inner world is sometimes like a Bosch picture. In reality though, one’s world is more similar to daily life than to the representations of Bosch. There are cognitive distortions leading to fantasies, logically unsolvable, but able to be represented in consciousness. This imaginative potential can be used for healing purposes when combined with an ASC (Achterberg, 1985). This procedure is based on hypnosis, and has been used by Wambach (1978) in an effort to obtain answers to certain questions. For example, some seek proof of memories of a supposed past life or to discover areas in the mind able to be activated under hypnosis but not in the waking state. Others that have contributed to “regressive” therapy include Netherton and Shiffrin (1978), who called it “Past-Life Therapy.” The idea of exploring reincarnation is close to the therapeutic concept that a patient must reexperience the primal trauma to exhaust emotion tied to it. It is arguable whether or not hypnosis is being used since patients remain awake and in contact with the therapist in a dreamlike situation, oscillating in alpha-theta EEG frequency (Simões et al., 1998). It does not matter if experiences are true or not; what is important is that an event is experienced in a personalized way. These scenes can be dramatizations of unconscious material, facts experienced in a supposed past life or really in the biographic life-whatever they are, they are always accepted as they “happen” (Peres, 1992). It seems that believing in reincarnation is not important for success (Clark, 1995), and sometimes the contents of experiences have nothing to do with past lives (Baldwin, 1993). The growing importance of these issues is indicated by the appearance of several journals and a handbook devoted to the subject (Lucas, 1993). As in any psychotherapy, rapport is very important and is a very good clinical indicator in relation to the success of treatment.
Induction of the ASC varies, depending on the author or therapist in question; hyperventilation, minimalist music, autogenic training, or hypnotic suggestions can all be used. The experience must be accomplished in the evolutional stages (in the womb, birth, childhood, and adulthood) and involve experiences that the patient attributes to past lives. Some of these experiences are evoked through a bodily stimulus that lets the patient reexperience bodily sensations (Woolger, 2000).
According to Peres (1992), each session takes nearly two hours and passes through several phases, the core of which is the subjectively identified trauma and, afterwards, a cognitive restructuralization is done by the patient, helped by the therapist. As in hypnosis, a “hidden observer” (Hilgard, 1986) controls emotions and the patient experiences only what he or she can comfortably handle. In this procedure the patient acts as therapist and works as a helper of the therapeutic process throughout the session. Afterwards, a positive suggestion for the future concerning the problem is made and the patient is brought slowly back to a normal waking state.
Problematic personal relationships, phobias, and a lack of meaning and purpose in life have been the conditions most successfully treated with this therapy; addictions, weight problems, and depression have been cited as the least successfully treated (Clark, 1995).
Some Final Considerations
THE FACTOR common to Western and shamanic psychotherapies consists in a reconciliation with one’s destiny, social group, and the domain of the transpersonal. These objectives are attained with a modification of perspective in each of these three domains, within an ASC where there is an intense cathartic and dramatic experience conforming to the prevailing cultural concepts of disease, shared by patient and therapist. Use of ASCs in psychotherapy requires a change in the usual scientific paradigm (Kuhn, 1962) concerning Kantian logic and consciousness as exclusive products of the brain. ASCs warrant more research in terms of their psychotherapeutic application and will come to be seen as an important way to understand the mind of an individual in a cultural context.
I thank Christopher Ryan for help in the translation of the manuscript and for some suggestions about the
content. The elaboration of this manuscript was part of a research project supported by a grant from the Bial
Foundation (Porto, Portugal).
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