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Understanding Our Minds:
Where Religion and Psychiatry Meet
A Sermon Given
by Rev. Kenneth Torquil MacLean
on September 1, 2002
at Cedar Lane Unitarian Universalist Church
Bethesda, Maryland
Reading (from T. M. Luhrmann)
Luther here used an old religious distinction,
which I shall call the distinction between inessential and essential
suffering one can act on and suffering that, as a Catholic priest
might say, one must offer up to God. Essential suffering is what we
are not able to prevent but must survive if we can. Essential
suffering is the inherent difficulty of human life, our troubles, the
way we struggle in the world, being the specific people we are, of a
certain character, in this specific place and time. The particular
history of our pain molds our characters further into the people we
become. Human pain is inevitable, and all the knowledge and fervor in
the world will not wash it safe and pure.
Inessential suffering is the pain we can treat. We
can remove it because it is the result of some fact that can be
altered. When it is gone, it is inessential to us. It is not made us
who we are. Luther argues that illness that can be cured, hunger that
can be fed, and chill that can be warmed are inessential sufferings,
and it is our duty to remove them. He also argues that those fervent
worshipers who scourge and starve and otherwise torment themselves to
honor God are terribly misguided. Only suffering that is unavoidable
must be accepted. We must ask for God’s beneficence to our crops only
if we have tended the fields with love and care. "Fool!" remarks the
Talmud. "From your own work, do not understand that... even as the
plant, if not weeded, fertilized and ploughed, does not grow...so is
the body of man. The fertilizer is the medicine, and the farmer is the
physician."
As this distinction has been inherited by our
Judeo–Christian culture, medicine handles the inessential suffering,
religion the essential suffering, and intentional hurt falls into a
limbo, neither treated by medicine nor tolerated by religion. The
physician’s role is to treat what is treatable and to manage what is
manageable. Doctors are not trained to handle the patient’s
existential crisis or, in extremis, his confrontation with death. That
is why there are priests, ministers, and rabbis attached to hospitals,
and while doctors can hardly avoid the personal tragedy created by a
diseased liver, it is not their task to attend to it, and an emergency
down the hall preempts a patient who has been treated but in despair.
Doctors are taught how to understand disease processes and interrupt
them. A priest or rabbi is taught to help us through moments of the
irrevocable. We go to the doctors to solve the problem of our aching
joints and stuffed noses, as if the doctors were glorified technicians
of the body, and we go to church to solve the problem of our
loneliness in the infinitude of time and space. That, among other
reasons, is why people in their thirties and forties often begin to
feel a need for religion, because by then they have realized that life
is an accumulation of forced choices, with consequences that could not
be foreseen; that bad things happen to good people, sometimes in
terrible ways; and that to see life as good despite this can require
the kind of wisdom one finds in spirituality.
Sermon
One Friday, while my car’s brakes were getting fixed,
I was able to see the film, A Beautiful Mind at the Mary Pickford
theater, my first visit to that quite splendid addition to Cathedral
City.
The film would be unbelievable did we not know that
the story is true, based on the book by Sylvia Nasar, which has been a
bestseller. We are introduced to John Nash as he is entering Princeton
University as a graduate student in mathematics, something of an odd
stick, who admits freely that he doesn’t like people very much, and they
don’t like him. It takes him quite awhile to get started at Princeton,
since he does not find it necessary to attend classes, and he cannot
focus on a particular problem to solve. He is told that he will not be
recommended for any graduate placement–sort of an internship for
promising students. In another semester he has been able to produce some
work which his professor finds dazzling enough to assure him that he
will be able to pick any placement he desires, and he goes to the
Massachusetts Institute of Technology to pursue his studies.
The film is clever in introducing characters whom we
find believable and situations which we can accept as plausible, until
we gradually learn that they are delusions of John’s and they do not
exist. For John is a schizophrenic, and his brilliant mind is capable of
both great, original, leaps of logic and theory and also terribly
paranoid delusions which manufacture a close friend and a government
intelligence agent who assigns him the task of decoding messages from
the Russians in popular magazines.
John Nash is a professor at Princeton who falls in love with one of
his students and marries her. His mental breakdown comes both slowly and
imperceptibly and in dramatic episodes of lashing out and being
restrained forcibly. His wife is told the diagnosis: acute
schizophrenia. She sees him go through the horror of insulin shock
therapy; she lives with him when he is released from the hospital. His
therapy cannot banish the delusions; they still appear, but he is able
to learn to ignore them, to carry on his life in as normal a way as
possible. With regular medication, under the treatment of a skilled
psychiatrist, he makes great progress and is able to function as a
teacher.
Then comes the climax, which even Hollywood would not
dare to make up: for his work in mathematical theory, fifty years
earlier, he is awarded the Nobel Prize. We are told that his work has
had wide influence in economics, international trade, and government
regulation. And we believe the paradox, because it is so.
T. M. Luhrmann is an anthropologist who spent a
number of years studying an exotic group of people: American
psychiatrists. She got a number of study grants and went about her
project like Margaret Mead studying the Samoans; but Luhrmann did not
have to travel so far, and she was able to participate in the
training in some leading institutions and the practice of a number of
psychiatrists. She worked in hospitals, clinics, and universities like
Harvard and Columbia. She quickly became aware of the great split which has
taken place in the theory and practice of psychiatry in our country in
the last forty years, something we all need to understand, because it
affects anyone who is treated for mental illness.
While I was in Divinity School, I was asked to visit a man who had tried unsuccessfully to commit suicide. He was at one of the large state mental hospitals where thousands of patients were kept, and he provided me with my first contact with those institutions. They had very little treatment to offer; they were largely custodial, keeping these people off the street. I later had the experience of visiting such a hospital regularly in Tennessee, walking through ward after ward, shaking hands with each patient in turn, talking a little bit and then moving on to the next one. Several times I came to know individual patients from my church and
talking with their families as they coped with illnesses like
schizophrenia, manic depression, anorexia nervosa, and Alzheimer’s
Disease.
In the beginning, whatever treatment they got was
based on the theories of Sigmund Freud and psychoanalysis. But
two major developments took place in the 1960's which changed
the whole landscape in the American treatment of mental
illness.
Freudian psychoanalysis was an import from Europe,
hastened by the Nazi persecution of the Jews. A great many
European psychiatrists fled to the United States and became
involved in practice here and also in the training of our
psychiatrists. In the 1940's and 1950's Freudian psychoanalysis was
psychiatry. And then came a development in psychopharmacology,
i.e., treating mental illness with drugs. Gradually this came to
dominate the field, especially in terms of the money for
research. At the National Institute of Mental Health in Bethesda, Maryland,
the two approaches were called "the herbalists," and "the
verbalists." The degree of success in controlling patients’ symptoms
with the new drugs made possible the second great change: the
de-institutionalization of our mentally ill
population. From 1965 to about 1985, the number of mentally ill persons in
our state mental hospitals was reduced about 80%. The plan was that
there would be mental health centers in most communities which
would help families to keep former patients on their
medications and provide supportive services to enable them to function
outside the hospitals.
The mental health centers never materialized in
most places, and many of the former patients ended up living on the
street. In 1973 I was invited to join the Research Review Committee of the National Institute of Mental Health, reviewing proposals,
called protocols, for research on human subjects. I met weekly with that group for the next eighteen years, going over protocols and asking questions of the doctors doing the research. It was an unexpected glimpse into a different world for me, one for which I have been grateful. It was immediately apparent that what we were reviewing was almost totally studies in treating different kinds of mental
illness with medications and, sometimes, with shock therapy. The major learning for me was how slow and meticulous must be the process
by which scientists learn about such a complex reality as schizophrenia.
To go back to our anthropologist, T. M. Luhrmann, we
find a careful examination of the two schools and the great gulf which
has grown up between them. I think it is important for us to know that
these two routes to understanding and treating the human mind rest on
totally different concepts of what a person is. The scientist is
treating a human body, just like any other doctor. Mental illness is a
disease, and doctors treat disease by fixing what is not working in the
human machine. When the medicines work, as they have increasingly for
many patients, the total scientist may look on the doctor practicing
psychoanalysis as a witch doctor, dealing with mumbojumbo and
superstitious theories. The psychoanalyst may respond that the scientific doctors are not treating a whole person;
they are treating symptoms. The person is whatever category of symptoms
being exhibited: anxious, psychotic, schizophrenic, bipolar
or whatever.
What we discover is that each of the approaches has a function, and I think this goes beyond the treatment of mental illness; it
applies to how we think about ourselves and other people. Am I a body,
determined to a great extent by my genetic inheritance–the genes and
chromosomes from my parents–as well as by all the things that have
happened to change my physical makeup? Is that who I am? Or am I a
complex of memory and decision, a contradictory and dynamic mixture of
responses to all that has happened to me and of choices that I have made
and continue to make? Obviously, we are both, in our own minds, but my
guess is that as we grow older, the body becomes more important in how
we think of ourselves. The young person is often able to take the body
for granted; so long as its needs are, satisfied, it works, and the
person is what I want to do and achieve and how I react to the world
around me. As we get older, the body does not always work the way it
used to, and we become more preoccupied with its impact on our daily
lives.
The advantage of the scientific model is that illness and. disease
can be seen as incidental to who the person really is. He or she is not
just a schizophrenic, but a person who lives with schizophrenia. It is
not the person’s fault, and it is not their parents’ fault that they
have this illness. Early in my ministry, I encountered a number of
parents who knew that the doctors blamed them for their child’s disease.
One of them was asked by a physician, "Why did you make your son
schizophrenic?" Today it is understood, much better than it was thirty
years ago, that schizophrenia is a disease of the nervous system,
involving an imbalance of certain neurotransmitters, especially
dopamine. Though it can be triggered by certain kinds of stress, there
must be a genetic base for it to occur; i.e., the predisposition is
inherited.
It can be helpful in protecting some patients and
treating certain problems to consider them, as illnesses rather than as
moral problems. The disease concept of alcoholism is widely accepted in
such groups as Alcoholics Anonymous, and it helps to remove the stigma
from people who have trouble dealing with alcohol. It leads to an idea
of "diminished responsibility," which is very useful in helping people.
So long as they are only seen as "hopeless drunks," to the extent that
they accept that view of themselves, they see no hope and they do not
believe that they have the power to make difficult choices about not
drinking. When they see this as an illness, some of the weight of that
moral judgment is lifted, and they are sometimes empowered to make
better choices.
On the other hand, according to Luhrmann, the advantage of the
psychoanalytic, or talk therapy approach, is because it includes a sense
of human complexity, of depth, an exigent demand to struggle against
one’s own refusals, and a respect for the difficulties of human life.
Psychoanalysis teaches humility in the face of human pain. Its central
concept is the unconscious, and its burden is that less of life happens
by chance than we think and more of life is hidden from our awareness
than we imagine... Psychoanalysis teaches that to respect someone is to
respect how much he has struggled, how great the difficulties have
been.....Psychodynamics teaches a great deal about human sadness and
also about mastery and faith in human possibilities."
I am reminded of the quotation passed on by the teacher of a high
school sex education class from a student: "I am tired of the sperm and
the ovum; I want to know about me!" The right response is that both are
important, and that is the conclusion reached by the anthropologist, T.
M. Luhrmann, as she completes her study of psychiatry: while Freudian
psychoanalysis was dominant up through the 1960's, and scientific
psychiatry using drugs has captured the field since then, we need both
approaches, and the difficult task for new psychiatrists is to integrate
both approaches. Many problems of our mental life, especially depression
and the psychoses’ are most effectively treated with medicines, but we
sometimes need the empathetic help of a professional who can listen with
us, can feel the pain and take it seriously, can face the things that
are so overwhelming and so help us to see that we can face them too.
What does this teach us about how to understand ourselves? It seems
to me that it opens several pathways that we can explore. How do you
usually think of yourself? Strong? Helpless? Confused? Unable to cope
with all that you find on your plate? Scattered? Independent and wanting
to stay that way? Healthy? Young in an old body? Competent to deal with
what you have to? Dealing with a lot of pain that does not show?
The scientific approach teaches us to take the body seriously, as the
infinitely complex mechanism that it is. The study of the nervous system
in recent decades has uncovered an intricate balance of chemicals,
called neuro–transmitters, which determine a lot about our health, how
we feel, and how much control we have over our behavior. A psychiatrist
who had treated obsessive-compulsive cases of handwashing was aware that
some persons could not keep from washing their hands every few minutes
throughout the day. The Freudians had developed theories of the early
childhood experiences which they thought were at the root of this
problem.
A scientific psychiatrist had experimented with prescribing a certain
drug and had some success in eliminating this compulsion. That
psychiatrist visited a very remote area of China, totally cutoff from
any contact with Western culture, and he discovered some persons there
who had this same handwashing compulsion. Giving them the medication
seemed to work. What this story always makes me question is my own
freedom. Here I am, living my life, making choices and decisions every
day, feeling that I really have the power to decide how to live my life.
Some parts of my life seem completely under control, the way that I want
them. But I hate clutter, and I find myself creating it all the time. I
don’ t seem to be able to cope with all those papers in my home office,
all those files in the wrong places, and those leaflets and letters that
I can’t quite throw out, but I can’t push myself into organizing
properly. Is there a pill I could take which would change my behavior,
enable me to follow the first rule of administration: never put a piece
of paper in a temporary place? If there is such a pill, should I want to
take it?
How do you think about yourself and your life? Do you have some
serenity in facing each day? Are the things that are important to you
pretty well in place? Have you accepted the fact that real life is
always a struggle, however good it looks on the surface. We mostly work
pretty hard to maintain that surface. Luhrmann suggests that the role of
the doctors is to fix what can be fixed and the role of religion is to
help us to deal with the parts of life that can’t be fixed. She says,
"In church we come to terms with the life that circumstances have carved
out for us, and we learn to make the best we can of it and accept our
struggles as essential to ourselves. We learn to understand pain as part
of life, and, in some senses, as a spiritual lesson."
I might put it another way. I think that from the doctor's point of
view, the task of the patient is to get better. That is what the
treatment is all about, and that is what enables the doctor to feel that
he or she has succeeded. From the minister’s point of view, the task of
the patient is to figure out what this illness means in the context of
one’s whole life. Maybe the illness tells us what is really important.
Maybe it calls on reserves of strength we did not know we had. Maybe it
teaches those who have always been caregivers how to accept being cared
for.
Ultimately, we all face the fact that we must die, and that is a part
of our lives which religion deals with intimately. A good religion helps
us to come to terms with that reality, to accept it as an inevitable
part of the best life. The doctors do not have very much to offer us
there.
Learning about our minds is part of the life-long process of learning
who we are. We are bodies, and a central tenet of our Judeo-Christian
tradition is that the body is good. We do not look at life as a
pilgrimage to rise above all bodily concerns to some hazy spiritual
realm, as some religions do. We are also minds, minds that feel and
think and learn and remember and imagine. And in spite of all the
constraints imposed by our physical limitations–I will never be six feet
tall–and by our previous experiences, I believe we have some freedom,
freedom to decide, to act, and to respond to the world. And it is that
limited freedom that tells me that I am in charge of my life; no one
else is. It is that limited freedom that makes me responsible for what
happens to me. It is that limited freedom that keeps me glad to be
alive.
Office@CedarLane.org
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