18

Psychotherapy and Integral Yoga Psychology

Michael Miovic

Introduction

In the last decade, a consensus has been reached that it is important to address existential, religious and spiritual concerns in the daily practice of clinical psychology and psychiatry (Richards & Bergin, 1997; Karasu, 1999; Josephson & Peteet, 2004), as well as in palliative care settings (Sulmasy, 2006). For not only are religion and spirituality pervasive cultural phenomena that can have both positive and negative effects on mental health (Shafranske, 1996; Koenig, 1998; Richards & Bergin, 2000), but it is also quite possible that soul and Spirit actually exist. That is, nothing in science or philosophy definitively disproves the existence of a divine reality, and therefore mental health professionals need at least to be acquainted with spiritual models of psychology (Miovic, 2004a). Even if they do not personally ascribe to such models, they will encounter many clients who do and find them useful.

The current author has detailed elsewhere the history and central issues of spiritual psychology, from both Western and Asian perspectives (Miovic, 2004a). With regard to Indian spiritual philosophy, there is a tradition in the West stretching from James and Jung through contemporary transpersonal psychology that has always been sympathetic to the experiential insights of Hindu and Buddhist psycho-spiritual practice (Jung & Jaffe, 1961; James & Marty, 1982; Scotton, Chinen & Battista, 1996; Cortright, 1997; Taylor, 1999). In addition, an increasingly compelling body of scientific research supports the veracity of various parapsychological phenomena, and has demonstrated that consciousness is non-local, that is, not limited to the confines of the brain (Byrd, 1988; Radin, 1997; Harris, Gowda & Kolb, 1999; Braud, 2000; Koopman & Blasband, 2002; Standish, Johnson, Kozak & Richards, 2003; Radin & Schlitz, 2005). Today, the convergence of these two streams of thought is leading to a growing interest in Indian psychology, which has always been interested in methods of expanding consciousness so as to find spiritual liberation and overcome suffering (Cornelissen, 2001; Rao, 2002; Joshi & Cornelissen, 2004; Rao, Paranjpe & Dalal, 2008). Indeed, the present book is proof of this renewed interest in the ancient tradition of Indian psychology, both in India and abroad.

Within this larger context, the aim of this chapter is to explore some of the concerns of clinical psychology, with special reference to the areas of overlap between psychotherapy and Sri Aurobindo’s model of Integral Yoga Psychology (IYP). Here, IYP is used as an organizing framework because Sri Aurobindo interpreted yoga as being primarily a psychological process of self-cultivation and ego-transformation, and expressed his insights in modern English. Like psychotherapists, Sri Aurobindo was deeply interested in the problem of how to change character structure and behaviour; only, he felt the key to this change was ultimately spiritual (Dalal, 2001a). Indeed, many of his letters discuss a variety of neurotic and even psychotic symptoms that today fall under the purview of clinical psychology and psychiatry (Sri Aurobindo, 1970; Dalal, 1987). Since IYP accepts the existence of a divine Being/Reality who supports the relative existence(s) of all subsidiary beings/realities, this chapter will present a more theistic model of spiritually informed psychotherapy. For readers who prefer other metaphysical orientations, Indian psychology is graciously broad and diverse, and other chapters in this book present various approaches to spiritual psychology based on non-theistic yet non-dualistic world-views.

Faith as a developmental milestone

As just highlighted, there are many legitimate conceptual frameworks for spiritually informed psychotherapy, and these can generally be grouped into one of three metaphysical orientations, namely theistic, non-theistic (or agnostic) and atheistic (as in non-local studies based on a quantum model of consciousness). Regardless of one’s personal orientation, however, it is useful to consider that if indeed there is a supreme Being/Reality, then to have faith in the existence of It is an important step in psychological development. That is, in a divinely constituted universe, to have spiritual faith is not regressive but progressive, and is a normal stage of psychological development to be followed by a subsequent stage in which one actually perceives, experiences and relates intimately with the supreme Being/Reality.

Perhaps an analogy may help illustrate this point: as Mahler showed, the development of object permanence around months 18−24 of a child’s life is a major developmental milestone that allows the infant to separate from his or her mother, because s/he now has the capacity to maintain an internal image of ‘mother’ despite her physical absence. Object permanence is therefore not a defence against separation anxiety; it is an improved perception of the nature of reality that helps the child to master separation anxiety (Gabbard, 2000). Likewise with faith in the Divine: the correct conviction that the Divine exists even when not physically visible allows adult human beings to master the larger anxieties of living based on an improved internal representation of the actual nature of reality. Thus, genuine spiritual faith is not a psychological defence against existential anxiety; it is a developmental achievement that allows one to master existential anxiety. Admittedly the analogy is not perfect, because the process Mahler described establishes the child’s ego as separate from the mother’s, while spiritual faith leads beyond the ego towards a relationship in which the ego experiences itself as merging into the Divine. Nonetheless, the analogy is good enough to establish why, from the perspective of a theistic model of psychology, the development of faith should be clinically supported (Miovic, 2001).

While no one has yet managed objectively to prove or disprove the existence of the Divine, it is important to understand the philosophical issue described above in order to develop a critical perspective on the literature about psychotherapy and spirituality. Thus far, most Western psychologists writing on the subject come from either a Judeo-Christian or Buddhist background. Not surprisingly, the Western literature on Buddhist psychology adopts a pragmatic and non-theistic approach to spirituality, much as did the historical Buddha (Molino, 1998; Michalon, 2001; Twemlow, 2001). Meditation and mindfulness practices are empirically noted to improve spiritual, mental, emotional and even physical well-being (Kabat-Zinn, Lipworth & Burney, 1985; Kabat-Zinn, Massion, Kristeller, Peterson, Fletcher & Pbert, 1992; Kaplan, Goldenberg & Galvin-Nadeau, 1993; Miller, Fletcher & Kabat-Zinn, 1995; Carlson & Garland, 2005); and fascinating new work is beginning to elucidate the neurophysiological basis of meditation as well (Newberg, & d’Aquili, 1998; Newberg & d’Aquili, 2001; Lazar, Kerr, Wasserman, Gray, et al., 2005; Cahn & Polich, 2006). Also, psychotherapists report that engaging in non-judgemental awareness of the moment during therapy sessions improves their effectiveness as therapists and facilitates the resolution of emotional suffering in clients, which is the main work of psychotherapy (Epstein, 1995; Finn & Rubin, 2000; Germer, Siegel & Fulton, 2005). However, the question of whether or not soul and Spirit exist, and whether clients might be having experiences or perceptions of such at times, is almost entirely avoided in this literature.

On the other hand, psychotherapists writing from the Judeo-Christian perspective have naturally grappled more with the issue of spiritual faith and the individual’s relationship with the Divine. This line of inquiry began with Jung’s work on archetypes and the phenomenon of a psychological ‘God-image’ (McLynn, 1996), although his views had little direct effect on mainstream psychoanalytic thinking because of the historic split between Freud and Jung. However, within the Freudian tradition, Winnicott’s notions of transitional objects and transitional phenomenon allowed various analysts to re-interpret what Freud called the ‘illusion’ of religion as a developmentally necessary need for human beings to find meaning and creative connections in the world around them. Subsequently, Rizzuto advanced this line of thinking by showing how the development of intra-psychic structures of God-representation parallels the development of other object relations and may complete an integrated sense of self (Rizzuto, 1979). Rizzuto stopped short of asserting that God is actually real, but Meissner advanced this trajectory by exploring how faith can be understood simultaneously in psychodynamic terms and as referring to a real Christ, a real God, and a real sacrament (Meissner, 2000). Still, he remained cautious about the following step in the sequence, Spero’s introduction of an ontologically real God as a factor both in the God-representation and in the therapy process (Spero, 1992). Meissner was concerned about the dangers of therapists wrongly presuming to know the Divine’s will in the therapy process, but others have gone on to address these legitimate concerns and articulate appropriate ways to conduct faith-based psychotherapy (Richards & Bergin, 1997, 2000).

This brings us to IYP, which synthesizes the experiential insights of yoga and Buddhist phenomenology with the spiritual faith of Western monotheistic traditions and the empirical insights of material science, so as to arrive at what we might characterize as non-dual evolutionary theism. That is, Sri Aurobindo proposes that Matter is a densely dormant involution of the infinitely conscious saccidānanda into a poise of apparent unconsciousness, and that evolution is the ordered process through which the Divine then progressively reveals itself across space and time under the conditions of matter. In this worldview, transpersonal and spiritual experiences represent the leading edge of the evolution of consciousness on earth, and presage the future emergence of a supra-human life form that will exceed the human consciousness even as human consciousness currently exceeds that of animals and lower life forms (Sri Aurobindo, 1970). Evidently, this interpretation of the aim of life and the ultimate nature of reality offers an interesting new perspective from which to conceptualize some of the central concerns of psychotherapy (Dalal, 2001b; Miovic, 2008).

Soul and ego

Sri Aurobindo uses the term ‘psychic being’ to refer to the individual soul, which he equates with the caitya puruṣa of classical Indian yoga psychology. In yogic terms, he defines the psychic being as an eternal but evolving aspect of the ātman (non-dual transcendent Self) that the jivātman (an individualized but non-evolving aspect of the ātman) puts forth into the phenomenal play of prakṛti (mutative substance of all the physical and supra-physical worlds of manifested existence). However, in contradistinction with traditional notions of reincarnation, Sri Aurobindo places a new emphasis on the evolutionary aim of the process. He posits that the purpose of reincarnation is not to prepare the soul to transcend the cycle of karma (as in the classical definition of nirvāṇa), but to increase the soul’s capacity to perfect life in the physical world, which, as previously mentioned, is itself a manifestation of the Divine reality. Indeed, he argues that this evolution of consciousness is the real force driving the physical evolution of biological forms that are increasingly able to express higher levels of consciousness, for example, the evolution of the animal into the mammalian brain, culminating currently in the human brain (Miovic, 2004b).

In terms of psychotherapy, this world-view implies that psycho-spiritual development consists of two broad lines of evolution, one the growth of an eternal psychic being or soul, the other the growth of a transient outer being or ego, which is a nexus of cognition, affect and physiology. Now the concept of the ego is the central, organizing principle among the diverse schools of Western psychotherapy. Although it is temporarily being under-used due to the ascendance of neurobiology and psychopharmacology, informed psychoanalysts have pointed out that the concept of the ego encompasses neurophysiology and can therefore still help to integrate the treatment of even ‘biological’ diseases such as schizophrenia (Diamond, 1997). In fact, the whole premise of the reigning biopsychosocial model of clinical practice is that biological and psychosocial therapies are both relevant to caring for the total human being. What Sri Aurobindo and others add to this proposition is that spirituality is a fourth dimension of consciousness that needs to be annexed to the biopsychosocial model. Even if one rejects the notion of reincarnation, as long as one accepts the reality of a soul that takes birth on earth at least once, the issues of psycho-spiritual growth outlined in this chapter remain fundamentally the same, the only difference being in how many lives the incarnating soul has to work them out.

So then, what exactly is the relationship between the soul and the ego according to IYP? And what are the psychological qualities and characteristics of each? We shall examine these two questions in order. First, there is the problem of what is meant by ‘transcending the ego’. In psychodynamic therapy, the whole aim is to strengthen the ego by repairing deficits (giving ‘corrective emotional experience’) and making unconscious conflicts conscious. In the vernacular of spiritual practice, on the other hand, people are enjoined not to have ‘big egos’ and to ‘be humble’ before God. How does one resolve this apparent antithesis? The key is that the vernacular ‘big ego’ in psychotherapeutic terms refers to narcissistic vulnerability, an ego deficit well-described by Kohut, which is compensated for with narcissistic defences of grandiosity (Mitchell & Black, 1995; Gabbard, 2000). Sri Aurobindo (1970, p. 1392) touches on the neurotic issues of narcissistic grandiosity vs. a punishing superego in the following letter to a disciple:

Humility is needful, but constant self-depreciation does not help; excessive self-esteem and self-depreciation are both wrong attitudes. To recognise any defects without exaggerating them is useful but, once recognised, it is no good dwelling on them always; you must have the confidence that the Divine Force can change everything and you must let the Force work.

The stable confidence that Sri Aurobindo prescribes here requires a well-integrated ego that allows for what Rizzuto and Meissner would call a mature object-relationship with God. Therefore, in spiritual philosophy, what is really meant by ‘transcending the ego’ is not to regress to earlier stages of ego development, but to complete the growth of the ego by adding to it another source of sustenance—the awareness of the soul. Thus, genuine spirituality does not erode individuality in a regressive fashion, as happens in different ways in schizophrenia and cults, but rather heightens and deepens true individuality by bringing out the soul, which is a unique manifestation of the Divine. In Sri Aurobindo’s words (1970, p. 1368):

There is individuality in the psychic being, but not egoism. Egoism goes when the individual unites himself with the Divine or is entirely surrendered to the Divine.… On the higher spiritual planes there is no ego, because the oneness of the Divine is felt, but there may be the sense of one’s true person or individuality — not ego, but a portion of the Divine.

This distinction between soul and ego is the theoretical foundation of IYP’s approach to spiritually informed psychotherapy. Sri Aurobindo acknowledged that childhood and adolescence are critical periods for ego development, and on that basis—for the most part—did not recommend taking up a serious spiritual practice until adulthood. He encouraged families and schools to accept that children do often have spontaneous contact with their souls (a phenomenon mostly overlooked by Western psychology), but he did not advise undertaking conscious efforts at ego-transformation until later. When people are developmentally ready, however, he described the process of transforming the ego as follows (1970, p. 1376):

Everybody has the ego and it is impossible to get rid of it altogether except by two things — the opening of the psychic within and the descent of a wider ego-free consciousness from above. The psychic being opening does not get rid of the ego at once but purifies it and offers it and all the movements to the Divine, so that one becomes unegoistic through self-giving and surrender … but it cannot happen in so short a time.

The complexities of how Sri Aurobindo classifies spiritual experiences according to their subjectively perceived somatotopic organization (that is, opening from within or descending from above) go beyond the purview of this chapter. What bears repetition here is that the final ‘unegoistic’ state he recommends is progressive and adaptive. While both psychosis and neurosis (to a lesser degree) increase fear and decrease the capacity for intimacy and generative love, spirituality as Sri Aurobindo defines it decreases fear and increases the ability to see reality as it is and love others as they are, because one is psychologically fulfilled in the Divine. As Erikson showed, the ego naturally broadens its scope of concerns to include more and more people as it matures, culminating in the healthy generativity of adulthood (Erikson, 1997). IYP would interpret this natural trend towards un-selfishness and individuation, which connects rather than separates one from the others, as due to the covert influence of the soul (psychic being) on ego development. This interaction effect accounts for the stages of faith development identified by Fowler in his research (Fowler, 1981). However, note again that IYP views the soul as ontologically distinct from the ego; hence, it is possible for people to have mature souls but immature or impaired ego-functioning (as happens, for different reasons, in spiritually gifted children, certain patients with psychotic disorders, and dementia in people with strong psychic development).

The second issue of concern, and one more apposite of the practical needs of psychotherapy, is how to distinguish the psychological qualities and characteristics of the soul from those of the ego. According to Sri Aurobindo, the soul’s influence is felt in all that leaves the impression of ‘sweetness and light’. By this, he does not mean any artificial pleasantry or niceness, but a deep and genuine inner ‘movement’ that flows purely from a spiritual fount. To name a few such qualities: sincerity, honesty, compassion, joy, love (in the sense of agape), forgiveness, patience, humility, courage, devotion, gratitude and the appreciation of beauty. Most people have felt the soul-touch at least once, if not frequently, in the charming innocence of children, in whom the psychic consciousness is often active, albeit in an unformed fashion. Many people also have openings to the soul when appreciating great music, literature, or art (Sri Aurobindo, 1992), or when communing with nature—flowers, for example, are especially full of psychic beauty (The Mother, 2000). For psychotherapy, the most important quality of the psychic being is that it is inherently joyful and free of ambivalence or conflict:

Let the sweetness and the happy feeling increase, for they are the strongest sign of the soul, the psychic being awake and in touch with us. Let not mistakes of thought or speech or action disturb you—put them away from you as something superficial which the Power and Light will deal with and remove. Keep to the one central thing—your soul and these higher realities it brings with it. (Sri Aurobindo, 1970, p. 1117)

Significantly, a new school of Western psychology, called ‘positive psychology’, has recently started to study the sources, benefits and sustenance of positive emotions and character traits such as gratitude, forgiveness, joy, love, courage, the appreciation of beauty, hope, curiosity, team-spirit, and so on (Seligman & Csikszentmihalyi, 2000; Snyder & Lopez, 2002; Fredrickson, 2004). Research in this field is beginning to empirically validate interventions that foster positive emotions (Seligman, Steen, Park, et al., 2005), and has found that such feelings often arise during ‘flow’ states in which the consciousness of the agent becomes one with the activity, as can happen sometimes during satisfying work, play, sports, prayer, meditation, or artistic expression (Csikszentmihalyi, 1990). From the perspective of IYP, all of the feelings and traits aimed at in positive psychology are due ultimately to contact with the psychic being (soul), and all methods for fostering them simply varieties of sādhanā. The main concern from the yogic perspective is therefore not theoretical but practical, e.g., actually finding and practicing the method that best helps any given individual or group increase the depth, duration and frequency of contact with the soul.

We have thus addressed the first half of the clinical problem—how to recognize and cultivate the soul-influence in human life. But the second half remains, namely the differential diagnosis of various levels of ego functioning, which is the bulk of what confronts practising clinicians. Therapists have all seen countless instances of false or inauthentic positive emotion, such as altruism that hides unconscious anger, faithfulness that avoids loneliness and fear, hypomanic happiness that distracts one from grief, forgiveness motivated by guilt, etc. What does Sri Aurobindo say about such instances in which apparently positive emotions are being used to defend against awareness of hidden negative ones?

Defence mechanisms vs. transformational processes

Before answering the last question directly, let us review the context first. The notion of defence mechanisms is one of the enduring pearls of wisdom gleaned from psychoanalysis. In his research following a cohort of Harvard graduates over several decades, Vaillant elegantly studied the interaction between defensive styles and Eriksonian stages of adult development across the life span. He found that in general, people tend to grow towards using more mature defence mechanisms as they age, and that those who are stuck behind are unhappy and fare poorly (Vaillant, 1993, 2000). The basic defence mechanisms cluster into four groups: psychotic, immature (borderline), intermediate (neurotic) and mature (see Table 18.1).

1 Psychotic	Delusional projection Denial Distortion
2 Immature	Projection Fantasy Hypochondriasis Passive aggression Acting out Dissociation
3 Intermediate (Neurotic)	Displacement Isolation/ Intellectualization Repression Reaction formation
4 Mature	Altruism Sublimation Suppression Anticipation Humour

Table 18.1. Mechanisms of ego-defence

1 Transitional	Witnessing Listening Going into Understanding (Mindfulness)
2 Spiritual	Aspiration (Invocation or Remembering) Surrender (Offering or Sacrifice) Rejection (Purification or Discrimination)

Table 18.2. Processes of ego-transformation

Now, in terms of Indian psychology, what Vaillant has demonstrated is an evolution of consciousness, a growth out of the darkness and turbulence of the inchoate ego to the relative stability and self-mastery of the well-formed ego. Over two millennia ago, the Bhagavad Gītā described the same sequence of ego development as in Table 18.1, only in less detail and without listing specific defence mechanisms. In his discourse on yoga to Arjuna, Kṛṣṇa described personality growth as proceeding from a tāmasic character structure (primitive/immature), through rājasic (immature/intermediate), to sāttvic (mature), and finally beyond into spiritual. Thus, both Indian and Western psychology agree that mature defences are necessary for the pursuit of happiness: people who know only how to deny and project live in raw misery, while those who can sublimate and deploy humour are much freer to find meaning and spots of joy in life, or, as Freud put it succinctly, ‘to work and to love’ despite the burden of normal human suffering.

IYP also recognizes the existence of defence mechanisms, but understands them within the larger context of the evolution of consciousness. Take, for instance, the following observation by Sri Aurobindo (1970, p. 1329):

The vital started in its evolution with obedience to impulse and no reason — as for strategy, the only strategy it understands is some tactics by which it can compass its desires. It does not like the voice of knowledge and wisdom — but curiously enough by the necessity which has grown up in man of justifying action by reason, the vital mind has developed a strategy of its own which is to get the reason to find out reasons for justifying its own feelings and impulses.

This passage clearly conveys Freud’s idea of the ‘id’ (although the Aurobindonian concept of the ‘vital’ is broader than that of the ‘id’), implies the existence of the unconscious, and cites the defence of rationalization. Sri Aurobindo did not explicitly catalogue the other defence mechanisms listed in Table 18.1 (although he alluded to some in other letters) because he was more interested in the fact that all of the defence mechanisms depend a priori upon the ego. His primary aim, therefore, was to transform the ego into a centre of individuality capable of manifesting the Divine. The only way to achieve this goal, in Sri Aurobindo’s opinion, is to evoke the psychic being (soul) through spiritual practice, and then infuse the psychic consciousness into the outer mental, vital and physical parts of the ego, so as to slowly effectuate a radical transformation of egocentric into soul-centric awareness. From the Aurobindonian perspective, cognitive behaviour therapy (CBT) attempts to change ego-functioning via the influence of the mental being, psychoanalysis via the vital, and psychopharmacology via the physical. However, while each of these approaches has its own relative utility, the problem is that the mental, vital and physical components of the ego are all inherently ignorant and in conflict with each other, and in any case no final solution to the ego is achievable at the level of the ego. Only the psychic being (true soul) is by its very nature capable of lasting harmony and unalloyed happiness, because it is a portion of the Divine, and therefore one must find and harness the psychic consciousness in order to definitively transform the ego. Hence the relevance of the psychic being to psychotherapy.

However, if the psychic being (soul) is real and can actually transform the ego function, then it must have modes or processes of operation that are distinct from the defence mechanisms listed in Table 18.1. Sri Aurobindo explained that such psycho-spiritual functions of the psychic being (soul) do indeed exist, and he named them ‘aspiration, surrender, and rejection’. He defines aspiration as a conscious remembrance of the Divine and invocation for It to transform all of one’s inner and outer awareness and action, while surrender is the inner movement of opening oneself entirely to the Divine will, and receiving and following its guidance without any reservations. Finally, rejection is the process of actively evaluating the source and quality of one’s thoughts, feelings and actions, and discriminating and discarding all that does not express the soul (that is, all that is motivated by the ego or by adverse forces of ignorance and falsehood that seek to oppose spiritual evolution). The essential impulse for these three movements comes from the psychic being; however, if the ego is willing, it can take them up and consciously elaborate them. To do so constitutes spiritual sādhanā or faith-practice, and thus, a deficiency in any of these psycho-spiritual movements, or an imbalance among them, leads to an incomplete practice of yoga.

Against this background, we can now expand the hierarchy of ego development in Table 18.1 by extending it vertically to add the ego-transformational processes listed in Table 18.2. The definition of transformational processes is that they are psychological movements that approach negative or otherwise painful content (drives, wishes, feelings, thoughts) directly and transmute it, instead of trying to ignore, disguise or divert it as defence mechanisms do. Sri Aurobindo named the ‘spiritual’ processes in Table 18.2; however, in order to integrate IYP with the existing knowledge of psychotherapy, I have created a bridging category dubbed ‘transitional processes’. Transitional processes are already used extensively in both CBT and dynamic therapy, and are synonymous with the analytic concept of the ‘observing ego’. These functions are classified here as transformational processes because they are not defence mechanisms per se, but rather adaptive capacities of the ego that derive ultimately from the soul’s covert influence on the ego (Miovic, 2004b). Although one does not have to be conscious of one’s soul in order to have a good observing ego, if the soul is entirely dormant (as in sociopathy), there will be a weak or absent observing ego.

In terms of definitions, to witness means to detach from and observe the flow of thoughts and feelings without interfering, controlling or altering them. Witnessing is taught formally in vipāssanā and other meditation techniques, and is used extensively in CBT to identify negative automatic thoughts and cascades of catastrophic thinking. Freud also sought witnessing in his method of free association, in which he enjoined the patient to ‘say whatever comes to mind, without holding anything back’. On the other hand, listening means to turn one’s awareness towards arising content so as to study and learn from it, while going into means to consciously experience a thought/feeling as much as possible, particularly if the experience is painful or difficult. Finally, understanding is the balanced process of practising witnessing, listening and going into over time, the result of which is that liberating awareness that analysts call ‘curative insight’ and Buddhists call ‘mindfulness’. Prototypically, in psychotherapy periods of witnessing allow painful content to arise, which can then be listened to and later gone into, so as to arrive eventually at directly experienced understanding. This cycle is repeated in miniature within each therapy session, and on a larger scale over time across many visits. Also, clients often initially delegate the transitional capacities of ego-transformation to the therapist, and it becomes the therapist’s role to gradually help clients learn and internalize these capacities over time (Miovic, 2001).

Practical implications

One good clinical illustration of the transformational processes listed in Table 18.2 is the 12-step method of Alcoholics Anonymous (AA). Much has already been written about AA from sociological, psychological and scientific perspectives, and we should briefly review these findings before proceeding to amplify this knowledge in the light of IYP. To begin with, AA is the single most used method for treating problem drinking in the world, and the scope of AA’s organization is now global. After more than half a century of debate regarding its efficacy, scientific research has recently established that participation in AA is not merely correlated with decreased drinking, but actually causes it (McKellar, Stewart & Humphreys, 2003). Research has also shown that while both professional treatment with CBT and non-professional treatment with AA are probably equally effective for light to moderate drinkers, for heavy and severe drinkers AA is more effective (Morgenstern, Bux & Labouvie, 2003); and that regardless of drinking intensity, more frequent and prolonged attendance at AA meetings yields greater rates of abstinence (Bond, Kaskutas & Weisner, 2003; Cloud, Ziegler & Blondell, 2004; McCrady, Epstein & Kahler, 2004; Moos & Moos, 2004b; Bottlender & Soyka, 2005). Finally, one of the important mediating factors of AA’s effectiveness involves opportunities for recovering alcoholics to help each other and help their communities (Pagano, Friend & Tonigan, 2004; Zemore & Kaskutas, 2004), and neither psychotherapy nor psychopharmacology has ever been shown to be more effective than AA (Vaillant, 2005). Thus, the best treatment for alcoholism probably entails a collaborative relationship between mental health professionals and AA, especially for patients who have severe mental illnesses (Brooks & Penn, 2003), and indeed data show that such collaboration can improve clients’ long-term participation in AA and thus improve outcomes (Kelly & Moos, 2003; Moos & Moos, 2004a).

As for the spirituality of AA, Vaillant has noted that the individual and group spirituality of AA probably taps into some of the same pleasure and reward circuits in the brain that addictions do, and much more powerfully than professional treatment can, so AA offers something invaluable to the alcoholic. Also, he has argued convincingly that AA is neither a cult nor a religion (Vaillant, 2005). Nonetheless, sceptics may still maintain that the ‘Higher Power’ invoked in AA may just be a useful fiction for eliciting a placebo response, and that the real benefits of AA derive from the solidarity of group membership, frequent and ubiquitous meetings to provide an alternative to drinking, confrontation by peers who challenge the drinker’s defences of denial and deception, and a series of tasks (the 12 steps) to restructure the alcoholic’s sense of self and overcome feelings of guilt. However, philosophically speaking, it is important to remember that the existence of such mechanisms of action does not negate the existence of a Higher Power, and if indeed the Divine exists, then these mechanisms of action are simply the channels through which the spirituality of AA works.

From the perspective of IYP, the effectiveness of AA re-demonstrates the perennial wisdom that spiritual groups (including āśramas, saṅghams and churches) help to propagate dharma. The more people convene to seek help from the Divine, the more the Divine answers through all available channels—provided, of course, that the inner call is sincere. Second, IYP would note that the proverbial ‘devil in the bottle’ is not just metaphorical, but real. Yoga has always acknowledged the existence of hostile forces and beings (rākṣasas, asuras) that seek to slay the spiritual seeker and retard or destroy spiritual evolution (Sri Aurobindo, 1970, pp. 393−398), and IYP posits that these hostile forces frequently use alcohol and other intoxicants as an entry into the vulnerable individual, because intoxicants cloud consciousness and undermine reasoning and judgement (Basu, 2004, and personal communication). Lastly, it is impressive that AA charges its clients no fees and most AA service positions are unpaid; that its organizational structure has no significant social hierarchy; and that its governing principles prevent members from gaining fame or consolidating power (Vaillant, 2005). Few other organizations in the world can claim an equal purity of process and dedication to egalitarian ideals. Also, the Big Book’s language is often quite beautiful, and the sincerity, honesty and lucidity of its thought and feeling substance reveals a psychic inspiration. Appreciate, for instance, the penetrating transparency of the following: ‘Anonymity is the spiritual foundation of all our Traditions, ever reminding us to place principles before personalities’ (Alcoholics Anonymous, 1976). That is pure eloquence of the soul speaking.

Likewise, consider the remarkable 12 steps themselves, which on paper read like yoga sūtras that teach the soul movements of aspiration, surrender and rejection. Step 1 begins with understanding, or the observing ego’s ability to hold a painful truth without enlisting defences to alter or distort perception, while Step 2 proceeds upwards with an aspiration to the Divine for transformation:

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.

Steps 3 through 7 focus on surrender, with aspiration and rejection in the background:

 

3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, ourselves, and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

7. Humbly asked Him to remove our shortcomings.

Steps 8 through 10 focus on rejection, or the psychic being’s conscious will to transform the faults of the outer personality. In this working-through process, the functions of the observing ego are enlisted and applied inter-personally:

 

8. Made a list of all persons we had harmed, and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

10. Continued to take personal inventory and when we were wrong promptly admitted it.

Finally, Steps 11 and 12 consolidate the work and provide a prescription for spiritual living based on the continued application of aspiration, surrender and rejection in all activities:

 

11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry it out.

12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

These last two steps, minus the passing reference to alcoholics, are as concise a definition of yoga as any written and integrate the three main approaches to the Divine described in the Bhagavad Gītā and reaffirmed by Sri Aurobindo in his Synthesis of yoga: bhakti (devotion, prayer), jñāna (knowledge, meditation) and karma (action, work). Thus, whatever the limitations of the human beings who seek the help of AA, from the perspective of IYP it is clear that the 12-step method is a spiritual discipline that seeks to re-awaken the psychic being (soul) slumbering in the alcoholic and save him or her from the devil in the bottle. It is a genuine spiritual inspiration.

A second area of IYP’s clinical relevance is in deepening clinicians’ understanding of the unconscious and resistance, which are primary issues in dynamic psychotherapy. Sri Aurobindo preferred to call the unconscious the ‘subconscious’ or ‘subconscient’, because in his view even inert matter is endowed with consciousness (1970, p. 1597):

For the subconscient receives impressions of all we do or experience in our lives and keeps these impressions in it, sending up often fragments of them in sleep. It is a very important part of the being, but we can do nothing much with it by the conscious will. It is the higher Force working in us that in its natural course will open the subconscient to itself and bring down into it its control and light.

The Aurobindonian concept of resistance encompasses the entire psychodynamic sense of resistance, plus more. This is why transformative spiritual practice is a life-long endeavour and takes even more time and discipline than psychoanalysis, because its scope is total and its final aim is to manifest the Divine in the world:

The mind resists with an obstinate persistency in argument and a constant confusion of ideas, the vital with a fury of bad will aided by the mind’s obliging reasonings on its side, the physical resists with an obstinate inertia and crass fidelity to old habit, and when they have done, the general Nature comes in and says, “What, you are going to get free from me so easily? Not, if I know it,” and it besieges and throws back the old nature on you again and again as long as it can (Sri Aurobindo, 1970, p. 1111).

Thus, we see that without reading a word of Freud or Jung, Sri Aurobindo developed a complex understanding of human psychology, including concepts of the ego, the importance of childhood development, defence mechanisms, the unconscious, the significance of dreams (alluded to above and elaborated elsewhere), resistance and the importance of biology. However, where Sri Aurobindo diverges from Western psychology and psychiatry is in his spiritual realism. The practical consequence of this is that he recommends that people find their souls before trying to work through the unconscious, because the psychic being is a more powerful agent of knowledge and action than the observing ego. This was the basis of his objection to psychoanalysis as a disciple explained it to him:

If one wishes to purify and transform the nature, it is the power of these higher ranges to which one must open and raise to them and change by them both the subliminal and the surface being .… But to begin by opening up the lower subconscious, risking to raise up all that is foul or obscure in it, is to go out of one’s way to invite trouble. First, one should make the higher mind and vital strong and firm and full of light and peace from above; afterwards one can open up or even dive into the subconscious with more safety and some chance of a rapid and successful change. (Sri Aurobindo, 1970, pp. 1606−1607)

Note that when Sri Aurobindo wrote this letter in the 1930s, he was criticizing the early analytic preoccupation with quickly unearthing childhood libidinal conflicts. However, since then psychoanalysis has evolved along the lines Sri Aurobindo recommended, such that today analysts are careful to strengthen the observing ego (that is, to ‘make the higher mind and vital strong and firm’) before exploring Oedipal issues. Also, there are many approaches to dynamic psychotherapy that avoid working directly with the unconscious and focus rather on the conscious, pre-conscious and real-time aspects of transference.

Case material

The following case material from a general outpatient psychiatry practice in the United States further illustrates the principles outlined in this chapter as they apply to psychotherapy:

A 24 year-old married Hispanic woman, with three young children, presented for treatment of severe panic disorder with agoraphobia, and moderate PTSD from childhood sexual abuse. She was grateful for education about her diagnoses, and obtained moderate relief after 3 weeks on clonazepam and citalopram. Based on this positive experience, she was eager to continue on in weekly therapy and medication management with a female resident, as I was leaving the clinic. At our third and final session, it struck me that the patient had consistently exuded an atmosphere of genuine sincerity, gratitude, trust, and an underlying joy of being despite her obvious anxiety. My counter-transference reaction to her was a peaceful feeling in my heart and the thought ‘what a lovely person, such a blessing to meet her.’ Further exploration revealed that she had an active Catholic faith but she had recently stopped going to church because she always ‘yawned and got sleepy’ during the services, and was worried that might be rude to her priest and to God. I asked if she felt bored by the sermons, and her face lit up as she replied to the contrary, ‘oh no, the words are sometimes so inspiring, they go right into my heart.’ I suggested that perhaps she got sleepy because she felt safe, and that maybe God could accept her sleeping in His arms ‘like a little baby.’ The patient visibly relaxed and replied, ‘Yes, I think He wants me back. Two of my kids have dreamed of the Cross recently. I think it’s a sign.’

Contrast that with the following vignette:

A 48 year-old divorced, Hispanic woman with an inactive Catholic faith, presented with moderately severe panic disorder and PTSD from sexual trauma as an adolescent. She spent 8 months of treatment not tolerating medications, resisting education about her diagnoses, and making me feel very frustrated and irritable. Dynamic exploration revealed many ways in which she had felt oppressed by her mother and was in turn oppressing her teenage daughter, but progress in therapy was painfully slow. During our last session before I left the clinic, she finally realized that she truly had panic attacks and agoraphobia, and expressed limited appreciation for my help.

The major difference between these two cases is the prominence of the psychic atmosphere in the first woman vs. a stubborn vital ego in the second. I would expect the first woman to be able to use spiritual processes of transformation (Table 18.2) to amplify the action of her observing ego in therapy. As she has active psychic movements, she might need help at times in differentiating these from ego defences. For example, she might confuse true aspiration with the defences of fantasy, reaction formation or altruism; or true rejection (a conscious will to change and grow) with the defences of repression or suppression. Her dreams might be rich and vivid, and one would need to distinguish between common dreams that reveal the subconscious and subliminal dreams that reveal the inner being (as happened when her children had dreams with a spiritual message for her). Naturally, resistances would arise at times during therapy and restrict the patient’s contact with her psychic being, but the working-through process could be accelerated by offering each session to the Divine in whatever way would be mutually agreeable to both the patient and the therapist. This could be done quickly and simply, with or without a particular theological overlay, but the key would be to do it with sincere aspiration and surrender.

Conclusion

This chapter has introduced Sri Aurobindo’s Integral Yoga Psychology (IYP) as one possible model for integrating the wisdom of Indian spiritual philosophy with the insights of Western psychotherapy. The primary focus has been on exploring the relationship between the soul (psychic being) and the ego, and understanding how the soul can transform ego functioning. It is proposed that the psychic (soul) movements of aspiration, surrender and rejection extend the range of ego-functioning from ego-defensive operations to ego-transformative processes. Also, the 12-step model of AA is interpreted as potentially evoking these movements of aspiration, surrender and rejection. While Buddhist psychology offers a valuable non-theistic alternative to IYP’s more theistic model of psychology, the strength of IYP is that it has a more richly developed concept of evolution and offers an orientation towards the future. Other frameworks for spiritually informed psychotherapy can and should be elaborated as well in order to suit the diverse needs and interests of patients and clinicians. Also, there is much work to be done in order to integrate culturally diverse understandings of spirituality into the mainstream of modern clinical practice.

References

Alcoholics Anonymous (1976). New York: Alcoholics Anonymous World Services (3rd ed.), 58−60.

Aurobindo, Sri (1970). Letters on yoga (3^rd ed.). Pondicherry: Sri Aurobindo Ashram Trust. (Original work published 1958).

Aurobindo, Sri (1992). Letters on art, literature and yoga. Pondicherry: Sri Aurobindo Ashram Trust.

Basu, S. (2004). Occultism and psychiatry: Implications in clinical practice. Journal of the World Psychiatric Association, 3(1), 194.

Bond, J., Kaskutas, L. A., & Weisner, C. (2003). The persistent influence of social networks and Alcoholics Anonymous on abstinence. Journal of Studies on Alcohol, 64(4), 579−588.

Bottlender, M., & Soyka, M. (2005). Catamnestic study on the efficacy of an intensive outpatient treatment programme for alcohol-dependent patients: Impact of participation in AA on the abstinence rates. Fortschritte der Neurologie-Psychiatrie, 73(3), 150−155.

Braud, W. (2000). Wellness implications of retroactive intentional influence: Exploring an outrageous hypothesis. Alternative Therapies in Health and Medicine, 6(1), 37−48.

Brooks, A. J., & Penn, P. E. (2003). Comparing treatments for dual diagnosis: Twelve-step and self-management and recovery training. American Journal of Drug & Alcohol Abuse, 29(2), 359−383.

Byrd, R. C. (1988). Positive therapeutic effects of intercessory prayer in a coronary care unit population. Southern Medical Journal, 81(7), 826−829.

Cahn, B. R., & Polich, J. (2006). Meditation states and traits: EEG, ERP, and neuroimaging studies. Psychological Bulletin, 132(2), 180−211.

Carlson, L. E., & Garland, S. N. (2005). Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress, and fatigue symptoms in cancer outpatients. International Journal of Behavioral Medicine, 12(4), 278−285.

Cloud, R. N., Ziegler, C. H., & Blondell, R. D. (2004). What is Alcoholics Anonymous affiliation? Substance Use & Misuse, 39(7), 1117−1136.

Cornelissen, M. (Ed.) (2001). Consciousness and its transformation. Pondicherry: Sri Aurobindo International Centre of Education.

Cortright, B. (1997). Psychotherapy and spirit: Theory and practice in transpersonal psychotherapy. Albany: State University of New York Press.

Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York: Harper & Row.

Dalal, A. S. (1987). Living within (pp. ix−xxxvii, 30−85). Pondicherry, India: Sri Aurobindo Ashram Trust.

Dalal, A. S. (2001a). Psychology, mental health and yoga. Pondicherry, India: Sri Aurobindo Ashram Trust.

Dalal, A. S. (2001b). A greater psychology: An introduction to Sri Aurobindo’s psychological thought. San Francisco: J. P. Tarcher.

Diamond, D. B. (1997). The fate of the ego in contemporary psychiatry with particular reference to etiologic theories of schizophrenia. Psychiatry, 60, 67−88.

Epstein, M. (1995). Thoughts without a thinker. New York: Basic Books.

Erikson, E. H. (1997). The life cycle completed, extended version. New York: W.W. Norton & Company.

Finn, M., & Rubin, J. B. (2000). Psychotherapy with Buddhists. In P. S. Richards & A. E. Bergin (Eds.), Handbook of psychotherapy and religious diversity (pp. 317−340). Washington, DC: American Psychological Association.

Fowler, J. W. (1981). Stages of faith: The psychology of human development and the quest for meaning. New York: Harper Collins.

Fredrickson, B. L. (2004). The broaden-and-build theory of positive emotions. Philosophical Transactions of the Royal Society B, 359, 1367-77.

Gabbard, G. O. (2000). Psychoanalysis. In B. J. Sadock & V. A. Sadock (Eds.), Kaplan and Sadock’s comprehensive textbook of psychiatry (7^th ed.), (pp. 563−607). Philadelphia: Lippincott Williams & Wilkins.

Germer, C. K., Siegel, R. D., & Fulton, P. R. (2005). Mindfulness and psychotherapy. New York: Guilford Press.

Harris, W. S., Gowda, M., Kolb, J. W., et al. (1999). A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Archives of Internal Medicine, 24(1), 79−88.

James, W., & Marty, M. E. (Eds.) (1982). The varieties of religious experience. New York: Penguin.

Josephson, A. M., & Peteet, J. R. (2004). Handbook of spirituality and worldview in clinical practice. Washington, DC: American Psychiatric Publishing.

Joshi, K., & Cornelissen, M. (Eds.) (2004). Consciousness, Indian psychology and yoga. New Delhi: Centre for Studies in Civilizations.

Jung, C. G., & Jaffe, A. (Eds.) (1961). Memories, dreams, reflections. New York: Random House.

Kabat-Zinn, J., Lipworth, L., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8(2), 163−190.

Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., et al. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149(7), 936−942.

Kaplan, K., Goldenberg, D., & Galvin-Nadeau, M. (1993). The impact of a meditation-based stress-reduction program on fibromyalgia. General Hospital Psychiatry, 15, 284−289.

Karasu, T. (1999). Spiritual psychotherapy. American Journal of Psychotherapy, 53(2), 143−162.

Kelly, J. F., & Moos, R. (2003). Dropout from 12-step self-help groups: prevalence, predictors, and counteracting treatment influences. Journal of Substance Abuse Treatment, 24(3), 241−50.

Koenig, H. G. (Ed.) (1998). Handbook of religion and mental health. San Diego: Academic Press.

Koopman, B. G., & Blasband, R. A. (2002). Two case reports of distant healing: New paradigms at work? Alternative Therapies in Health and Medicine, 8(1), 116−120.

Lazar, S. W., Kerr, C. E., Wasserman, R. H., Gray, J. R., et al. (2005). Meditation experience is associated with increased cortical thickness. Neuroreport, 16(17), 1893−1897.

McCrady, B. S., Epstein, E. E., & Kahler, C. W. (2004). Alcoholics Anonymous and relapse prevention as maintenance strategies after conjoint behavioral alcohol treatment for men: 18-month outcomes. Journal of Consulting & Clinical Psychology, 72(5), 870−878.

McKellar, J., Stewart, E., & Humphreys, K. (2003). Alcoholics Anonymous involvement and positive alcohol-related outcomes: Cause, consequence, or just a correlate? A prospective 2-year study of 2,319 alcohol-dependent men. Journal of Consulting & Clinical Psychology, 71(2), 302−308.

McLynn, F. (1996). Carl Gustav Jung: A biography (pp. 398−415, 459−509). New York: St. Martin’s Press.

Meissner, W. W. (2000). Psychoanalysis and religion: Current perspectives. In J. K. Boehnlein (Ed.), Psychiatry and religion: The convergence of mind and spirit (pp. 53−70). Washington, DC: American Psychiatric Press.

Michalon, M. (2001). ‘Selflessness’ in the service of the ego: Contributions, limitations, and dangers of Buddhist psychology for Western psychotherapy. American Journal of Psychotherapy, 55(1), 202−218.

Miller, J. J., Fletcher, K., & Kabat-Zinn, J. (1995). Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17, 192−200.

Miovic, M. (2001). Towards a spiritual psychology: Bridging psychodynamic psychotherapy with integral yoga. In M. Cornelissen (Ed.), Consciousness and its transformation (pp. 98−119). Pondicherry: Sri Aurobindo International Centre of Education.

Miovic, M. (2004a). An introduction to spiritual psychology: Overview of the literature, east and west. Harvard Review of Psychiatry, 12, 105−115.

Miovic, M. (2004b). Sri Aurobindo and transpersonal psychology. Journal of Transpersonal Psychology, 36 (2), 111−133.

Miovic, M. (2008). Therapeutic psychology and Indian yoga. In K. R. Rao, A. C. Paranjpe, & A. K. Dalal (Eds.), Handbook of Indian Psychology (pp. 449-470). New Delhi: Cambridge University Press India Pvt. Ltd.

Mitchell, S. A., & Black, M. J. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York: Basic Books.

Molino, A. (Ed.) (1998). The couch and the tree: Dialogues in psychoanalysis and Buddhism. New York: North Point.

Moos, R. H., & Moos, B. S. (2004a). Help-seeking careers: Connections between participation in professional treatment and Alcoholics Anonymous. Journal of Substance Abuse Treatment, 26(3), 167−173.

Moos, R. H., & Moos, B. S. (2004b). Long-term influence of duration and frequency of participation in alcoholics anonymous on individuals with alcohol use disorders. Journal of Consulting & Clinical Psychology, 72(1), 81−90.

Mother, The (2000). The spiritual significance of flowers. Pondicherry: Sri Aurobindo Ashram Trust.

Morgenstern, J., Bux, D. A., Labouvie, E., et al. (2003). Examining mechanisms of action in 12-step community outpatient treatment. Drug & Alcohol Dependence, 72(3), 237−247.

Newberg, A., & d’Aquili, E. (1998). The neuropsychology of spiritual experience. In H. G. Koenig (Ed.), Handbook of religion and mental health (pp. 76−94). San Diego: Academic Press.

Newberg, A., & d’Aquili, E. (2001). Why God won’t go away: Brain science and the biology of belief. New York: Ballantine.

Pagano, M. E., Friend, K. B., Tonigan, J. S., et al. (2004). Helping other alcoholics in Alcoholics Anonymous and drinking outcomes: Findings from project MATCH. Journal of Studies on Alcohol, 65(6), 766−773.

Radin, D. (1997). The conscious universe: The scientific truth of psychic phenomena. New York: Harper Collins.

Radin, D. I., & Schlitz, M. J. (2005). Gut feelings, intuition, and emotions: An exploratory study. Journal of Alternative & Complementary Medicine, 11(1), 85−91.

Rao, K. R. (2002). Consciousness studies: Cross-cultural perspectives. London: McFarland & Company.

Rao, K. R., Paranjpe, A. C., & Dalal, A. K. (Eds.) (2008). Handbook of Indian psychology. New Delhi: Cambridge University Press India Pvt. Ltd.

Richards, P. S., & Bergin, A. E. (Eds.) (1997). A spiritual strategy for counseling and psychotherapy. Washington, DC: American Psychological Association.

Richards, P. S., & Bergin, A. E. (Eds.) (2000). Handbook of psychotherapy and religious diversity. Washington, DC: American Psychological Association.

Rizzuto, A. M. (1979). The birth of the living God. Chicago, IL: University of Chicago Press.

Scotton, B. W., Chinen, A. B., & Battista, J. R. (Eds.) (1996). Textbook of transpersonal psychiatry and psychology. New York: Basic Books.

Seligman, M., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55(1), 5−14.

Seligman, M. E., Steen, T. A., Park, N., & Peterson, C. (2005). Positive psychology progress: Empirical validation of interventions. American Psychologist, 60(5), 410-21.

Shafranske, E. P. (Ed.) (1996). Religion and the clinical practice of psychology. Washington DC: American Psychological Association.

Snyder, C. R., & Lopez, S. J. (Eds.) (2002). Handbook of positive psychology. Oxford: Oxford University Press.

Spero, M. H. (1992). Religious objects as psychological structures: A critical integration of object relations theory, psychotherapy, and Judaism. Chicago, IL: University of Chicago Press.

Sulmasy, D. P. (2006). Spiritual issues in the care of dying patients: ‘It’s okay between me and God’. Journal of the American Medical Association, 296(11), 1385−1393.

Standish, L. J., Johnson, C., Kozak, L., & Richards, T. (2003). Evidence of correlated functional magnetic resonance imaging signals between distant human brains. Alternative Therapies in Health and Medicine, 9(1), 122−128.

Taylor, E. I. (1999). Shadow culture: Psychology and spirituality in America. Washington, DC: Counterpoint.

Twemlow, S. W. (2001). Training psychotherapists in attributes of ‘mind’ from Zen and psychoanalytic perspectives. American Journal of Psychotherapy, 55(1), 1−21.

Vaillant, G. E. (1993). The wisdom of the ego. Cambridge, MA: Harvard University Press.

Vaillant, G. E. (2000). Adaptive mental mechanisms: Their role in positive psychology. American Psychologist, 55(1), 89−98.

Vaillant, G. E. (2005). Alcoholics Anonymous: cult or cure? Australian & New Zealand Journal of Psychiatry, 39(6), 431−436.

Zemore, S. E., & Kaskutas, L. A. (2004). Helping, spirituality and Alcoholics Anonymous in recovery. Journal of Studies on Alcohol, 65(3), 383−391.