“In the Image and Likeness of God: Always?” Disturbances of the Human Mind 7

Home , Julio Licinio, Mario Francesco Pompedda, The Suffering of God, Vincenzo Di Nicola

Proceedings of the Eleventh International Conference

DOLENTIUM HOMINUM organized by No. 34 (Year XII - No.1) 1997 JOURNAL OF THE the Pontifical Council PONTIFICAL COUNCIL FOR PASTORAL ASSISTANCE for Pastoral Assistance TO HEALTH CARE WORKERS to Health Care Workers Editorial Board: + JAVIER LOZANO BARRAGÁN, Editor Rev. JOSÉ L. REDRADO O.H., Managing Editor Rev. FELICE RUFFINI M.I., Associate Editor Rev. GIOVANNI D’ERCOLE F.D.P. “In the Image Sr. CATHERINE DWYER M.M.M. Dr. GIOVANNI FALLANI Msgr. JESUS IRIGOYEN and Likeness Rev. VITO MAGNO R.C.I. Ing. FRANCO PLACIDI Prof. GOTTFRIED ROTH of God: Always?” Msgr. ITALO TADDEI

Editorial Staff: Disturbances Rev. DAVID MURRAY M.Id. Dr. MARÍA ÁNGELES CABANA M.Id. of the Human Mind Sr. M. GABRIEL MULTIER Rev. JEAN-MARIE M. MPENDAWATU

Editorial and Business Offices: Vatican City Telephone: 6988-3138, November 28-29-30, 6988-4720, 6988-4799, Telefax: 6988-3139 1996 Telex: 2031 SANITPC VA In copertina: glass-window Rev. Costantino Ruggeri Published three times a year Subscription rate: one year Lire 60,000 (abroad or the corresponding amount in local currency, postage included). The price of this special issue is L. 80,000 ($80) Printed by Editrice VELAR S.p.A., Gorle (BG) Paul VI Hall Vatican City Spedizione in abbonamento postale 50% Roma Contents

6 Cardinal Angelini’s 40 Mental Disorders Words of Greeting Around the World: for the Holy Father An Epidemiological Overview Professor José Manuel Bertolote 7 The Mentally Ill Are Also Made 44 Genetics and Environment in God’s Image Professor Yves Pélicier The Holy Father’s Address 46 The Man of the New Creation: From the Image of God 10 Introductory Remarks: to the Likeness of Christ A New Attitude Rev. Bonifacio Honings, O.C.D. Towards the Mentally Ill Cardinal Fiorenzo Angelini 52 Neuroscience Research and Mental Illness 11 WHO’s Response Professor J.J. López-Ibor to Current Challenges 59 Family and Society: in Mental Health Places of Pain Dr. Hiroshi Nakajima Dr. Anna Rosa Andretta 13 The Experience of Music Therapy 61 Autism Professor Mary Coleman 64 The Unfinished Project: Ethical Problems and Strategies for Action on Mental Retardation Professor Gian Luigi Gigli thursday november 77 Aberration in the 28 Natural Orders of Things Professor Bruno Silvestrini 81 The Acceptance of Mental Illness 16 Opening Address: Professor Carlo Lorenzo Cazzullo The Likeness of God in the Human Being Cardinal Joseph Ratzinger ROUND TABLE: 20 Introduction to the First Session THE MENTALLY ILL AND Professor Corrado Manni DIFFERENT SOCIAL MODELS 21 Basic Mechanisms of Signalling and Information Processing 86 Health: in the Brain An Invaluable Asset Professor Erwin Neher for a Robust Economy and Democracy 25 Algos and Pathos: Basic Moments Professor Eliot Sorel in Man’s Spiritual Growth Professor Pierluigi Zucchi 88 The Depressive Society Rev. Bonifacio Honings, O.C.D. Rev. Tony Anatrella 33 From Diseases of the Soul 93 Ideology, Politics, to Psychoneuroses and Psychiatry Professor Giuseppe Roccatagliata Professor Modest Kabanov 98 Culture and the Web of Meanings: 140 Psychiatry and Criminality Creating Family Professor George B. Palermo and Social Contexts for Human Predicaments 145 The Sickness and Death of Listening: Professor Vincenzo Di Nicola The Drama of Loneliness Professor Adolfo Petiziol 101 Family Reality in Regard to Mental Patients 148 Suicide: in African Countries Determinism or Freedom? Sister Andrea Calvo Prieto Professor Diego De Leo Dr. Paola Marietta 104 Society, Family, and Mental Health 155 Psychic Incapacity and Professor Amelia Musacchio De Zan the Sacrament of Marriage Monsignor Mario Francesco Pompedda 159 Intelligence, Freedom, and Holiness Professor Francisco Alonso Fernandez 164 The Intelligence of the Universe friday Dr. Ermanno Pavesi november 29 168 Man in the Nakedness of His Madness and the Meaning of His Delirium Professor Paolo Pancheri 109 Anxiety: 173 Accursed Circles: The Illness of All The Dantean Vortex of Madness Professor Gisela Crespo Rev. Mariano Galve 113 When Disquiet Invades the Body Professor Ferruccio Antonelli ROUND TABLE: PREVENTION, TREATMENT, 116 The Biology and Psychology AND REHABILITATION of Depression Professor Julio Licinio 178 Prevention in the Field 121 Abnormalities of the Mind of Mental Health in Schizophrenia Professor Pierre F. Chanoît Professor Malcom Lader 183 Integrated Therapies 125 The Dignity of Madness for Schizophrenic Patients Monsignor Ignacio Carrasco de Paula and Their Families Professor Janos Füredi 129 Creativity and Mental Disturbance 186 Psychotherapy Professor Antonio Fernandes da Fonseca Rev. Franco Imoda, S.J. 132 A Measureless Mind: 193 Psychosocial Therapies Manic-Depressive Illness Professor Eugene Wolpert Professor Dina Nerozzi Frajese 196 Rehabilitative Therapies 137 Nonhuman Man in Psychiatry Professor Wanda Poltawska Professor Driss Moussaoui ROUND TABLE: LEGISLATION saturday ON MENTAL ILLNESS november 30 218 Legislation on the Mentally Handicapped in Germany Ambassador Philipp Jenninger 199 The Image of the Mentally Ill in the Mass Media 222 Mental Health Law Dr. Joaquín Navarro-Valls And Mental Health Services in the Republic of China 202 Ethics and Psychiatry Ambassador Raymond R. M. Tai Professor Michele Schiavone 226 Legislation and Mental Health 205 The Role of the Church in Argentina in the Treatment of the Mentally Ill Ambassador Francisco Eduardo Trusso Rev. Pierluigi Marchesi, O.H. 229 Mental Health Law 208 Pastoral Care and the in the Gabon Spirituality of the Mentally Ill Dr. Michel Mboussou Most Rev. Hervé Itoua

The illustrations in this issue have been taken from Universitas Aromatariorum. Storia e documenti del Nobile Collegio Chimico Farmaceutico di Roma, published in a special edition by Merck Sharp & Dohme—Italy “I was sick and you visited me” (Mt. 25:36) 6 DOLENTIUM HOMINUM

CARDINAL ANGELINI’S GREETING TO THE HOLY FATHER

Holy Father: with that humanized and humanizing dimen- This Eleventh International Conference or- sion to which you, Holy Father, have so often ganized and promoted by the Pontifical Coun- called our attention so nobly. cil for Pastoral Assistance to Health Care The question which is contained in the title Workers marks a new milestone on the road of of our Eleventh International Conference does research, analysis, reflection, and practical not express a doubt. On the contrary, it seeks to conclusions traveled by this Council from its stimulate an ever deeper answer in the affirma- inception in connection with the fundamental tive—in the knowledge that every living hu- questions concerning the sanctity of life and man being is a celebration of the glory of God. the dignity of the human person. This compelling and Christian answer does Researchers, scientists, scholars in biomedi- not aspire to be merely scientific, nor can it be cine, theologians, psychiatrists, sociologists, a matter of a simple statement of principle. It and moral theorists have here addressed them- seeks, instead, to shake consciences—espe- selves to the various questions concerning the cially those of health care workers, but also of structure of the human mind, the dramatic facts all those who identify with the solicitude on the widespread presence of mental illness, which has always animated the Church’s ap- its direct and indirect causes, the places where proach to the mentally ill—so that these are disturbance occurs, the large number of social never forgotten and certainly not excluded, but reference models, the forms and the manifesta- come to be considered our very real brothers tions of its various kinds of pathology, and the and sisters. criteria and the means of prevention, treatment, The reception that this International Confer- and rehabilitation. ence has met with this year, too, is a source of With ethical and spiritual goals in mind, in- authentic hope that the ecclesial community in quiry has been carried out into the tasks and particular will become ever more sensitive to methods of helping and caring for the mentally the questions and problems of the mentally ill, ill—both from a strictly clinical point of view thereby giving rise in scientists, health profes- and in terms of pastoral assistance—in line sionals, and volunteers, to a growing spirit of service which is guided by the vocation and mission of the civilization of love. To sum up, this meeting with Your Holiness seeks to be an opportunity and a witness to faith in the guidelines laid down by the magisterium of the Church, that demonstrates and confirms—above all, in her care and concern for the sick and the suffering—that she is a loving and attentive mother. May your paternal and inspired words, which draw this international encounter for study and reflection to a close, accompany the hope that with enthusiasm and courage all of us here today will renew our commitment to serve those who suffer!

FIORENZO Cardinal ANGELINI President of the Pontifical Council for Pastoral Assistance to Health Care Workers “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 7

ADDRESS BY THE HOLY FATHER

The Mentally Ill Are Also Made in God’s Image

1. I am pleased with this meeting, which al- ture—seem severely limited and even imped- lows me to offer you my greetings, distin- ed by a pathological process. She therefore re- guished participants in the international confer- minds the political community of its duty to ence sponsored by the Pontifical Council for recognize and celebrate the divine image in Pastoral Assistance to Health Care Workers on man with actions that support and serve all the problem of mental illness, with the signifi- those who find themselves in a condition of cant title: In the Image and Likeness of God: serious mental illness. This is a task which sci- Always? Disturbances of the Human Mind. ence and faith, medicine and pastoral care, I affectionately greet Cardinal Fiorenzo An- professional skill, and a sense of common gelini, whom I thank for his cordial address. A brotherhood must help to carry out through an particular word of appreciation is owed to him investment of adequate human, scientific, and and to his co-workers, for their efforts in socioeconomic resources. preparing this symposium, which has brought together specialists from all over the world. 3. The title of the congress invites us to further examine this line of reflection which has 2. Distinguished Ladies and Gentlemen, pre- just been outlined. Indeed, while, on the one sent among you are researchers, scientists, spe- hand, it again offers an authoritative affirma- cialists in the field of the biomedical sciences, tion of the Bible, on the other, it raises a dis- theologians, moralists, jurists, psychologists, turbing question. sociologists, and healthcare workers. Together The conviction that man has been created in you represent a heritage of humanity and wis- the image and likeness of God is one of the pil- dom, of science and experience which can pro- lars of Christian anthropology. This is what is duce very useful advice for the understanding, written in the first chapter of Genesis (1:26). treatment, and care of the mentally ill. Philosophical and theological reflection has The Church looks on these persons with spe- identified in man’s mental faculties, that is, in cial concern, as she looks on any other human his reason and in his will, a privileged sign of being affected by illness. Instructed by the di- this affinity with God. These faculties, in fact, vine Teacher’s words, she believes that “man, enable man to know the Lord and to establish made in the image of the Creator, redeemed by a relationship of dialogue with him. In dis- the blood of Christ, and made holy by the pres- cussing this, St Thomas points out, “Person ence of the Holy Spirit, has as the ultimate pur- signifies what is most perfect in all nature, that pose of his life, to live ‘for praise of God’s glo- is, a subsistent individual of a rational nature” ry’ (cf. Eph 1:12), striving to make each of his (Summa Theologiae I, q. 29, a. 3). actions reflect the splendor of that glory” (En- It should be made clear, however, that the cyclical Veritatis Splendor, no. 10). whole man, not just his spiritual soul, including his intelligence and free will, but also his body, shares in the dignity of “the image of Man is created in God’s God.” In fact, the human body “is a human image and likeness body, precisely because it is animated by a spiritual soul, and it is the whole human per- The Church is deeply convinced of this son that is intended to become, in the body of truth, even when man’s mental faculties — the Christ, a temple of the Spirit” (Catechism of noblest, because they testify to his spiritual na- the Catholic Church, no. 364). “Do you not 8 DOLENTIUM HOMINUM know,” the Apostle writes, “that your bodies Christ is “‘the image of the invisible God’ are members of Christ? ...You are not your (Col 1:15). He is the perfect man who has re- own... So glorify God in your body” (1 Cor stored in the children of Adam that likeness to 6:15; 19-20). Hence the need to respect one’s God which had been disfigured ever since the own body, and also the body of every other first sin. Human nature, by the very fact that it person, especially the suffering (cf. Catechism was assumed, not absorbed, in him, has been of the Catholic Church, no. 10004). raised in us also to a dignity beyond compare. For, by his Incarnation, the Son of God has in a certain way united himself to each man” By grace man becomes (Gaudium et Spes, no. 22). a child of God 6. At this point we feel the whole weight of 4. Precisely because man is a person, his the disturbing question which appears in the dignity is unique among all creatures. Every topic: “Always?” This is a provocative ques- individual man is an end in himself and can tion which is not only asked at the ontological never be used as a mere means for reaching level—here faith and reason converge in rec- other goals, not even in the name of the well- ognizing the full human dignity of the mental- being and progress of the community as a ly ill—as much as at the deontological level: whole. By creating man in his own image, one can in fact ask whether the way a mental- God wished to make him share in his lordship ly ill person is treated by his peers in daily life and his glory. When he entrusted him with the corresponds fully and adequately to what he is task of caring for all creation, he took into ac- in God’s plan. count his creative intelligence and his respon- That question—“Always?”—must spur sible freedom. both the personal and the collective con- The Second Vatican Council, delving into the science to a sincere reflection on our behavior mystery of man under the guidance of Christ’s towards those persons who are suffering from words (cf. Jn 17:21-22), opened up to us hori- mental illness. Is it not true that all too often zons inaccessible to human reason. In the Con- these persons encounter indifference and ne- stitution Gaudium et Spes, “a certain parallel glect, when not also exploited and abused? between the union existing among the divine Through God’s grace, there is also another persons and the union of the sons of God in side to the coin: I stressed this in the Encycli- truth and love” (n. 24) is explicitly mentioned. cal Evangelium Vitae, recalling “all those dai- When God turns his gaze on man, the first thing ly gestures of openness, sacrifice, and un- he sees and loves in him is not the deeds he suc- selfish care which countless people lovingly ceeds in doing, but his own image, an image make in families, hospitals, orphanages, that confers on man the ability to know and homes for the elderly, and other centers or love his own Creator, to rule over all earthly communities which defend life” (no. 27). But creatures and to use them for God’s glory (cf. we cannot close our eyes to certain forms of ibid., n. 12). And this is why the Church recog- behavior which seem to ignore human dignity nizes the same dignity in all human beings and and to trample on man’s inalienable rights. the same fundamental value, regardless of any other circumstantial consideration. Therefore, regardless, too—and this is most important— The mentally ill always bear of the fact that this ability cannot be utilized be- God’s image and likeness cause it is impeded by mental illness. 7. We Christians, especially, cannot do so. In 5. This conception of man as the image and this regard the Gospel speaks clearly. Christ likeness of God is not only confirmed by the not only took pity on the sick and healed many New Testament Revelation, but supremely en- of them, restoring health to both their bodies riched by it. St Paul says: “But when the time and their minds; his compassion also led him had fully come, God sent forth his Son, born to identify with them. He declares: “I was sick of woman, born under the law, to redeem those and you visited me” (Mt 25:36). The disciples who were under the law, so that we might re- of the Lord, precisely because they were able ceive adoption as sons” (Gal 4:4-5). By grace, to see the image of the “suffering” Christ in all therefore, man truly shares in this divine son- people marked by sickness, opened their ship, becoming a child of God in the Son. hearts to them, spending themselves in various The Second Vatican Council teaches that forms of assistance. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 9

Christ took all human suffering on himself, or prevent relations of true Christian charity even mental illness. Yes, even this affliction, with those who are its victims. Indeed, it which perhaps seems the most absurd and in- should inspire a particularly attentive attitude comprehensible, conforms the sick person to towards these people, who are fully entitled to Christ and gives him a share in his redeeming belong to the category of the poor to whom the passion. kingdom of heaven belongs (cf. Mt. 5:3). Distinguished ladies and gentlemen, I have 8. Thus the response to the theme’s question recalled these fundamental and comforting is clear: whoever suffers from mental illness truths, well aware that I am speaking to people “always” bears God’s image and likeness in who fully understand them. I gladly take this himself, as does every human being. In addi- opportunity to express to you my full appreci- tion, he “always” has the inalienable right not ation of your valuable work and to encourage only to be considered as an image of God and you to continue a service with such lofty hu- therefore as a person, but also to be treated as manitarian importance. such. May the Lord bless your therapeutic work It is everyone’s duty to make an active re- and crown it with results that comfort your pa- sponse: our actions must show that mental ill- tients, to whom I offer my affectionate ness does not create insurmountable distances thoughts and the assurance of a special prayer. 10 DOLENTIUM HOMINUM

CARDINAL ANGELINI’S INTRODUCTORY REMARKS

A New Attitude Towards the Mentally Ill

The question expressed by the title of this in- ures relating to the presence of mental illness, ternational conference does not seek to raise a its direct and indirect causes, the places of such doubt about the truth that in every human per- disturbance, the various models of social refer- son there is a reflection of the image and like- ence, the forms and manifestations of the dif- ness of God. Its intention, rather, is to identify ferent kinds of mental illness, and the criteria and explore through the paths of reason, sci- and the means of prevention, treatment, and re- ence and experience itself—where all are illu- habilitation. From an ethical and spiritual minated by the faith—those traces of this mys- point of view, the tasks and methods of caring terious reflection of God which are present in for the mentally ill will be examined in strictly those who suffer from disturbance caused by medical terms and in terms of pastoral assis- mental illness in a variety of forms and in dif- tance. ferent degrees of intensity. Mental disturbance afflicts a fifth of What is of utmost importance and seeks to mankind and should not only be studied from be almost a provocation is not, however, a the- the point of view of its causes but in a very spe- oretical and abstract answer in the affirmative. cial fashion in terms of its consequences. We This would not be enough. Because the divine must do this if we want to face up to, treat, and image also shines within man when his facul- cure such illness, and to do this we must have a ties are compromised or limited in their use as conception and a vision of life which recognize a result of mental illness, the social communi- its origin in God; we must perceive the invio- ty—and Christians in particular—must recog- lable sanctity and the noble dignity which are nize and celebrate the divine image in man present in each and every human person. through service to those who suffer from such We constantly hear that before closing psy- illness. chiatric institutions we should provide alterna- The refusal and inability to perform this duty tive facilities and amenities in town and coun- become wrongdoing when they are expressed try, structures and amenities which in many rein indifference to the problem and in a total ab- gions do not exist or are inadequate. sence of practical commitment. This is a duty This is true, but it is not the whole truth. The which science and faith, medicine, and both structures and amenities are not sufficient if in natural and Christian morality are called upon their use and management human and Christ- to perform through the use of the increasing ian principles and criteria are not applied ele- advances in and demonstrated effectiveness of ments which involve seeing those suffering therapeutic methods and instruments. from serious mental illness as brothers to love The third international conference, held in and to serve. We are also dealing here with a 1989, was also dedicated to the “human mind.” problem in the current mentality, which, unfor- The subjects discussed by the conference this tunately, is becoming ever more closed and year represent from many points of view an selfish and tends to want to remove suffering updating of the work of its predecessor. and to marginalize it. Researchers, scientists, experts in biomedi- Now that science has achieved great steps cine, psychologists, theologians, and moral forward in the treatment of mental illness, such theorists—all of international fame—will ad- forms of treatment are clearly totally insuffi- dress during the course of this conference the cient if they are not infused with a renewed various questions and problems relating to the sense of social sensitivity. Experience shows structure of the human mind, the facts and fig- that one of the most serious problems in the “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 11 treatment and care of the mentally ill lies in mentality. Indeed, there can be no doubt that at their presence in families, which on their own the root of many and new forms of mental dis- are not able to help their afflicted relatives turbance there is a crisis in values and the dom- without risk and in an adequate fashion. Even inance of anti-values which propel man into in- the most modern facilities end up being like creasing loneliness. The step from this loneli- the infamous lunatic asylums when the human ness to mental disturbance is short—indeed, it heart is lacking. can be very short. The alliance between scien- In relation to the role of health care workers tific resources and spiritual resources is not a active in this area, all such workers should be mere question of possibility—it is a question psychologically, professionally, morally, and of duty. It is, therefore, the irreplaceable solu- spiritually trained and prepared for this form of tion when we come to consider that an increas- assistance and care. ing number of pathological phenomena in the This international conference will also dedi- field of mental illness spring from a lack of ac- cate itself to the study of the structural causes cess—in both preventive and therapeutic of mental illness within our society. The key terms—to the support of spiritual resources. point, however, remains that of the achievement and creation of a new sensitivity and FIORENZO Cardinal ANGELINI

HIROSHI NAKAJIMA

The Programs and Activity of WHO in the Field of Mental Health: A Response to the Challenges of Today’s World

The charter of the World Health Organiza- bral functions. For this reason we are very con- tion states that “health is a state of complete scious of the risks and consequences of nutri- physical, mental, and social well-being and is tional deficiencies; we thus seek to help our not a mere question of the absence of illness or member states to promote and implement pro- infirmity.” This definition gives the right grams which monitor and improve the diet of weight to the mental and relational aspects of mothers and their children. We also place great the health of human beings. Whatever may be emphasis on the fact that the child must be the mental incapacities or disturbances which loved and protected if his full development is afflict an individual, he still has the right to re- to be guaranteed. At the same time, however, ceive medical care and attention and the social, we place major stress upon the importance of psychological, and human support which will his receiving the means and instruments by allow him to achieve the highest possible lev- which to construct and develop his own free- els of independence and well-being. dom within a framework of responsibility. Since its inception fifty years ago, the World 2. The second axis. We encourage communi- Health Organization has developed programs ty participation in the debate about the psycho- and initiatives in the field of mental health. At logical origins of phenomena such as violence the present time, and in order to respond to the or suicide, the importance of the economic and challenges posed by our world and by the var- social environment in the emergence of these ious cultures which inhabit it, these responses forms of disturbance, and the possible role of revolve around four principal axes. this environment in prevention and treatment. 1. The first axis. We strive to promote a Attention is also drawn towards the violence healthy development of the child and in this which society itself perpetrates or provokes, a endeavor we also seek to understand his cere- process which acts to legitimate the law of the 12 DOLENTIUM HOMINUM strongest through the influence of the values of consultation when necessary by those who are money and success. in need of such a service and, on the other, that 3. The third axis. We seek to promote com- essential psychotropic drugs and essential psy- munity participation in care and treatment. chosocial help should always be available. This is especially the case in relation to the el- Mental illness must be dealt with both from a derly. Indeed, for elderly people loneliness is medical point of view and in psychological and far too often a primary cause of fragility and social terms. This form of illness involves suf- vulnerability, and this acts to aggravate their fering which must be treated and reduced to economic precariousness. A shift to new ap- such a point that the sick person can renew reproaches to mental health involves the intro- lationships, re-establish communication, duction or the strengthening of public policies and—where possible—engage in independent of social support which require substantial fi- work. Material and social support is necessary, nancial contributions. One thinks here of help but it is not enough. We need to treat and care in the provision of housing and a reform of the for the mentally ill person—that is, we must re- system of nursing care. It should also be point- duce his burden and help him to reconstruct a ed out that these approaches must increase will and an ability to live and to engage in rela- their reliance upon voluntary associations and tionships with other people. upon neighborhood support networks. As other psychiatrists have emphasized, re- In all these different fields we place great spect for the psychically disturbed requires emphasis upon the fundamental role which the both respect for their symptoms and a commit- family structures can and must play. This is ment not to abandon them to what would be a very evident in the case of elderly people who “chronic condition without hope, but which is are isolated and without financial resources. tolerable in social terms.” To these human be- But it is children and adolescents who are most ings, who in their differences from us reflect a marked over time by failings in their family part of the truth about ourselves, we must offer environment. Everybody agrees in theory that “health care facilities and not places of intern- every child should have the right to grow up in ment.” It is in this relationship—which should his or her own home and in good conditions. be marked at one and the same time by respect But we well know that at the present time, in and a suitable sense of responsibility—that the the situation as it is, the opposite often hap- image of our shared humanity will be formed pens. The break-up of families, poverty, and and shaped. war are other factors which impose the traumas Your Eminence, it is with emotion that I take of separation and violence on children. part in this eleventh international conference of The clinical studies carried out in war situa- the Pontifical Council for Pastoral Assistance tions demonstrate the essential role played by to Health Care Workers. Over the years Your the family in maintaining the psychological so- Eminence has confirmed your friendship to- lidity and health of children even in extreme wards me by inviting me to participate in your conditions. Equally, daily practice in the work and thought. I am infinitely grateful to sphere of psychiatric treatment shows the ben- you for what you have done for health in the efits in therapeutic terms that a child can gain world and in particular for the health of the from the active participation of his family. Ag- poor. Your Eminence has consecrated all your gression, the fragmentation of personality, energies to this field and has mobilized the net- crime, escape into drug addiction, the search work of institutions and health care workers for identity and membership in violent groups, under the supervision of the Church to this end. a lack of reference points, marginalization, and You were awarded the Sasakawa Foundation prostitution—these experiences are not a mat- Prize, and I myself had the pleasure and the ter of mere chance, but are directly related in honor to award the “Health For All Medal” to terms of risk to the absence or failings of the you in the name of the World Health Organiza- child’s family and the emotional and education. In a little while you will embark upon the tional role it plays in his life. path of retirement, which I hope will be long, 4. The fourth axis of the strategy of the happy, and sufficiently active to allow me once World Health Organization. We are in favor of again to have the opportunity to meet you and the development and integration of the ser- to work with you in the cause of improving the vices relating to mental health in all basic sys- health of all the peoples of the world. tems of health care. What we suggest in this area is that, on the one hand, experts in neu- Dr. HIROSHI NAKAJIMA ropsychiatry should always be available for Director General of the World Health Organization “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 13

The Experience of Music Therapy

During each session of the international conference a union between the interior subjective world and the ex- symphony orchestra conducted by Professor Adolfo Pe- ternal and relational world, represented a mechanism by tiziol (President of the Italian Society for Music Thera- which to remove and banish the suffering caused by re- py) played a number of musical pieces. A semiotic jection at the hands of a mother who loved music. analysis of each piece was carried out to detect which relevant symbolic elements represent and express the affective-intuitive, relational, emotional and at the same 2. Franz Schubert: time cognitive dimensions of the music of that piece. The Unfinished Symphony—First Movement These elements, which express the meaning of that mu- Music—and in particular this piece by Schubert: The sic, constitute the theoretical and practical basis for Unfinished Symphony—may be seen as an ally and a treatment involving music therapy. We are dealing here support in the process of individualization, a metaphor with archetypical or elementary images which corre- by which to represent and express the movements of the spond to the inner depths of human beings, their emo- spirit and to give sound to what is not expressed and tions, their suffering and their joy. The following pieces without form. Music stimulates the imagination in a sit- were played during the international conference. uation where all the senses can be used and be amplified in altered states of consciousness. This scenario follows 1. Wolfgang Amadeus Mozart: an idiosyncratic and symbolic logic and can be seen as The Marriage of Figaro—Overture the language of the self, of our inner world. Aristotle thought that music “not only imitates objects but ex- In the progressive construction of his reality as an in- presses the character of the passions themselves” be- dividual, man needs regularity, and because of this he is cause it lives out a relationship with reality which goes predisposed to the perception and recognition of beyond verbal language to embrace the emotions, joy, rhythms which are themselves necessary to the creation pain, fear and tranquillity which are immediate experi- of a nucleus of stability. Certain qualities which are pre- ences rather than mere concepts. Music is as complex as sent in the interaction between the mother and her child the self. Music can thus be considered as being—or fa- such as intensity, length, synchronization and form are voring—a projection of the individual psyche which is high-level characteristics which produce an affective made up of sounds, themes, harmonies and timbres syntonization. This spontaneous form of behavior, which are in conflict or which are complementary, inte- which on the whole reflects the character of the shared grated, consonant or dissonant. This also arises from the emotions of the relationship, is of fundamental impor- fact that listening to music favors a regression through tance in the emotional and cognitive growth of the child the emergence of states of less structured consciousness because it imparts subjective meaning and form to his which allow the overcoming of defenses and a coming inner world. into contact with the organization of the individual’s The structure of the music which we will now hear— own inner universe. namely the Marriage of Figaro by Mozart, which is In this composition by Schubert we can detect two melodically ordered, clear, and comprehensible, but al- levels of consciousness: one is made up of timbres and so has one or two joyous surprises—is well sustained by low sounds, the other consists of a melody which takes a regular rhythm. For this reason the experience it pro- place at a higher level. There is the use of violins and the vokes provides reward and pleasure similar to that of an creation of an intense and striking emotional space encouraging relationship with somebody who is mean- which takes place in the search for integration and mu- ingful for us—a relationship where we feel reassured tual support. The timbre of the instruments together and supported, free to play and to explore our universe. with the tonality set in a minor key and a melodic line Thus we encounter the innocence of the spirit of the which proceeds without ups and downs evokes intense artist, which is like that of a child, a spirit moved to cre- emotional responses which are nonetheless linked to ate but at the same time to ask fascinating questions and filtered by the character of each individual self. All about the nature of things. Music and science have the this takes place with a sensation of darkness and sadness divine right to respond to these questions because reali- which through a movement which is at times directed ty is many-faceted and holistic. Similarly, the route to its upwards, and a change of approach, produce a tempo- understanding involves a large number of levels and off- rary opening to hope and light. The harmony proceeds shoots. In a female patient who had psychic disorders slowly and gives a greater sense of intensity and reflec- the rejection of music, with its symbolic function of tion to the melody—something which deepens its emo- 14 DOLENTIUM HOMINUM tional meaning and significance. This piece, with its fea- verbal experiences are at the base of certain emotional tures of weaving and color, can favor an experience of responses which are provoked by listening to music. alteration in terms of time and/or regression towards the This is because in the perception of music subcortical past in addition to reduced distances from childhood (limbic) structures and functions are involved which are stages. In the process of individualization we should al- linked to cortical modulation and changes in emotions, so put ourselves into contact with, and become aware of, which are themselves caused by associative responses the dark sides, the shadows which are within each and and the emergence of memories. The form of this every one of us. The vibrant atmosphere of the sound of piece involves a sequential relationship between themes this piece enables us to experience the intensely dramat- and structural unities, as is the case in the use of the in- ic character of the mystery of our psyche. struments. It can produce the notion of “when something happens” in the imagination. The alternation of a 3. Ludwig van Beethoven: melody which has sweet and striking characteristics Symphony No. 7—First Movement with a melody which is festive in tone—which is followed by a more tranquil melody and then by a stormy The force and the practical energy which are devel- and agitated one—conveys a representation of life oped in this seventh symphony by Beethoven can be as- which is flexible and dynamic in character. Every mo- sociated with the development of the voice of the hu- tif—even if short—presents a kind of feeling, but how man spirit, which, through the evocativeness of the this is perceived depends not only upon the enigmatic sound, strives to give a meaning and a form to the expe- language of the music and the technical methods which rience of pain, doubt, will and subjective passions. The are employed, but also upon the individual self—some- search for a transcendent dimension above the terrestri- thing which is developed during infancy and which sup- al experience seems to express itself in the momentary plies each and every stimulus which has a personal stopping of the flowing of ordinary time in the compo- meaning. sition, an ecstatic silence of celestial spheres: “In excel- sis, in silentio” declared St. Augustine. This is inter- posed with the vigorous rhythmic and melodic elements 5. Helmut Laberer: of the piece which produce its internal cohesion. The es- Los Andes and Carretera Panamericana sential feature of Beethoven’s music and of this compo- The purified freedom of intuition and the emotion of sition as well is the constant and decisive search for ex- a victorious light of the spirit are here able to produce a pressive methods which are coherent expressions of his symbolic representation of a monotonous, repetitive and personal and tempestuous spiritual and mental attitudes. oppressive reality which is experienced without that Thus it is that in the ear of the listener the dynamic vari- creative liberty which is necessary to the bringing of ation of intensity and of timbres produce an emotional emotional variations to daily life—variations which be- reaction through the increase or decrease of energy stow subjective meaning on every experience. The which activates and motivates the emotions and at times rhythms are percussional and obsessive. They are simi- leads to the release of aggression. lar to those which are produced by patients suffering Even though the melodic line is accompanied by the from mental disorders where an affective levelling is to same movement of the base notes and sustained by a bi- be observed and where the other person as a human in- nary rhythmic structure which is regular and thus pre- dividual is denied, transformed into an object, or wrong- dictable, these features of violent timbre and dynamic ly imagined to be a dangerous and terrifying enemy. contrasts can disquiet and upset a psychically weak in- In this composition the heaviness of the journey and dividual who may experience a sense of anxiety-induc- the burden of a life lived in slavery can be felt physical- ing imbalance because of the force and the diversity of ly: the brief bursts of light are not enough to discover the emotions which are provoked. Indeed, intensity is very individual’s own identity. The sounds evoke mystery, marked in the musical expression of schizophrenic pa- depth and irrationality, and the changes in rhythm pro- tient. It does not, however, involve variations which voke a sense of dissolution and the fragmentary—ele- conform to his different states of mind—almost as if ments which can be noticed in people who suffer from these people were no longer able to control the ways and schizophrenia. The character of this work is marked by means of representing and recognizing affective states its intensity and its rhythm, which establish a strong in other people whether at a behavioral or a symbolic sense of energy and involve its release, taking place at a level. physical rather than mental level. This is because the impulses are tangible, hard and not accompanied by a 4. Gioacchino Rossini: melodic line which could provide an affective experi- L’Italiana in Algeri—Symphony ence of pleasure. When the melody appears in this piece it is expressed through a syncopated rhythm, a rebellion The happy tempo, the magic of the rhythm, and the against the authority of flowing time, which passes in- electrifying exaltation of the contrasts are elements exorably over experience without providing any lasting which we find in this symphony—L’Italiana in Algeri change. This is because there is no personal or group by Rossini. The sound and the rhythm of this piece are theological movement which can improve the quality of natural phenomena which are contained in the human life. Even joy is an artificial imposition, and for this rea- body and which the human being experiences from the son there is no integration with the texture of the com- time of his being in the maternal womb. For this reason position—the individual is left on his own, leaving him when he is born he is already impregnated with a special even more sad and worn out before a life which is emp- sound context, shaped by the heartbeat of his mother, ty of meaning. and made sensitive to frequencies which are like those Professor ADOLFO PETIZIOL of the voice of his mother. These early, sensorial, pre- President of the Italian Society for Music Therapy In the Image and Likeness of God

Disturbances of the Human Mind 16 DOLENTIUM HOMINUM

thursday 28 OPENING ADDRESS BY CARDINAL JOSEPH RATZINGER november The Likeness of God in the Human Being

The subject of this international come pathological because she was gated to itself the right to decide conference brings disturbing mem- always anxious about what the fu- who deserved to live and who was ories to my mind. Please allow me, ture would bring—perhaps she to be deprived of the right to exist by way of introduction, to give you would no longer have food to put in on the grounds of advantage to the an account of my own personal ex- her mouth. She was then defined as community or to the state, employ- perience. We return here to 1941, being mentally disturbed, placed in ing as a criterion the idea that an in- and thus to wartime and to the Na- an institution, and in this case as dividual could be eliminated be- tional Socialist regime. One of our well the news arrived that she had cause he was not useful to others or aunts whom we visited very often died from pneumonia. to himself. was the mother of a strong and A little later exactly the same This fact added a new and differ- healthy child who was a few years thing happened in our village. The ent kind of anxiety to the horrors of younger than myself. However, he small piece of property which was war, which were themselves be- increasingly displayed the symp- next to our house had previously coming ever more deeply felt—we toms of the Down syndrome. The been cultivated by three unmarried were touched by the chilling cold- simplicity of his clouded mind brothers to whom it belonged. It ness of a logic based upon criteria aroused affection and his mother, was alleged that they were mental- of utility and power. We felt that who had already lost a child who ly ill even though in actual fact they the killing of these people humiliat- had died early on in life, was bound were able to look after their house ed and threatened us, the human to him by sincere ties. But in 1941 and their property. They also disap- essence that was within us: if pa- the authorities of the Third Reich peared into an institution, and soon tience and love dedicated to the ordered him to be taken to an insti- afterwards it was made known that suffering are eliminated from hu- tution to receive better care and as- they had died. At this point there man existence because they are sistance. At that time it was not yet could no longer be any doubt about seen as a waste of time and money, suspected that an elimination of the what was happening—a systematic not only do we do wrong to those mentally handicapped was being elimination of all those who were who are killed, but those who sur- carried out, even though this pro- not considered productive was be- vive are themselves mutilated in gram had already been set in mo- ing carried out. The state had arro- their spirits. We realized that when tion. After a little while the news the mystery of God, his inviolable arrived that the child had died of dignity, which is present in each pneumonia and that his body had and every man, is not respected, been cremated. From that moment then not only are individuals threat- on news of this kind became ever ened, but humanity itself is endan- more frequent. gered. In the paralyzing silence, in In the village where we had pre- the fear which held everyone in its viously lived, we most readily used grip, Cardinal Von Galen’s con- to visit a widow who did not have demnation was like a liberation— any children and who was very he broke the paralysis of that fear in happy if the children in the neigh- order to defend man himself, the borhood went to see her. The little image of God, within the mentally piece of land which her father had disabled. left her only just provided her with The luminous word of God with a livelihood. She was in good spir- which Genesis begins the account its even though she was rather of the creation of man combats all afraid about the future. Later we threats to man caused by calcula- learned that the loneliness which tions about power and usefulness: afflicted her more and more had in- Let us create man in our image and creasingly darkened her mind. Her likeness—faciamus hominem ad worries about the future had be- imaginem et similitudinem no- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 17 stram, in the words of the Vulgate Epiphanius was right when he de- declare that only Christ should be (Gn 1:26). But what does this word clared—with reference to the vari- taught as being “the image of mean? What is the divine likeness ous attempts to give a precise defi- God.” Man, on the other hand, is present in man? The term, as used nition of the nature of this divine not the image but ad imaginem, by the Old Testament, is, so to likeness—that we should not “seek created in the image, according to speak, a monolith—it does not ap- to define the framework of the im- the image. He becomes an image of pear again in the Jewish Old Testa- age but recognize its existence God in proportion to the degree to ment, even though Psalm 8 demon- within man—if, that is, we do not which he enters into communion strates an inner connection with it: want to abuse the grace of God” with Christ and conforms to him. “What is man that thou art mindful (Panarion, LXX, 2,7). But in truth To put it in other words: the origi- of him?” The term is used again on- we Christians always read the Old nal image of man, which in turn ly in the sapiential writings. Sirach Testament within the context of the represents the image of God, is (17:2) roots the greatness of the hu- entire Bible, in its unity with the Christ, and man is created by start- man being in this fact without seek- New Testament. From it we receive ing from his image, with reference ing to give an interpretation of what the key by which to achieve a to his image. The human creature is is actually meant by this likeness to sound and accurate reading of its at the same time as being such a God. texts. Just as the creation account of creature also a preliminary project The Book of Wisdom (2:23) “in the beginning God created” rein anticipation of Christ—or, takes a further step forward and ceives its correct interpretation on- rather, Christ is the fundamental sees the state of being in the image ly in its re-reading in the “in the be- idea of the Creator, and he forms of God based in essential terms up- ginning was the Word” of John’s man with a view to Christ, starting on the immortality of man—what Gospel, so the same process is at from this fundamental idea. makes God God and distinguishes work here. The ontological and spiritual dy- him from created man is precisely Naturally enough, in this brief namism which is hidden in this his immortality and everlasting- introductory talk, I cannot dwell at conception of things becomes espe- ness. Created man is in the image length upon the rich and many- cially evident in Romans 8:29 and of God precisely because he partic- faceted treatment of the subject 1 Corinthians 15:49, but it is also to ipates in immortality—not because which is to be found in the New be found in 2 Corinthians 4:6. Ac- of his own nature, but as a result of Testament. I will confine myself to cording to Romans 8:29, men are a gift bestowed upon him by the exploring two aspects of the ques- predestined “to be molded into the Creator. The orientation towards tion. It should be observed first and image of his Son, who is thus to be- eternal life is what makes man the foremost—and this is a most im- come the firstborn among many created counterpart of God. This portant fact—that in the New Tes- brothers.” This conformity to the line of argument could be devel- tament Christ is described as being image of Christ is fulfilled in the oped, and one could also say that “the image of God” (2 Co 4:4; Col resurrection, by which he preceded eternal life means something more 1:15). us. Yet the resurrection—and this than mere eternal subsistence. It is The Fathers of the Church here should be made clear at this full of meaning, and only in this made a linguistic observation point—presupposes the Cross. The way is it life deserving and capable which perhaps cannot be really sus- First Letter to the Corinthians of eternity. tained, but which certainly corre- makes a distinction between the An orientation towards eternity, sponds to the inner direction of the first Adam, who became a “living therefore, is an orientation towards New Testament and its re-interpre- soul” (15:45; cf Gn 2:7), and the the eternal communion of love with tation of the Old Testament. They last Adam, who became a Spirit God, and the image of God thus giving life—”and it remains for us, bears the marks of its nature be- who once bore the stamp of earth, yond earthly life. It cannot be deter- to bear the stamp of heaven” mined in a static fashion and bound (15:49). Here we encounter a com- to some particular quality, but is a pletely clear expression of the inner prosthesis of time beyond earthly tension within the human being be- life. It can be understood only with tween clay and spirit, earth and reference to its tension regarding heaven, terrestrial origins and di- the future, in its dynamic impulse vine future. towards eternity. Those who deny This tension within the human the existence of eternity and who being in time and beyond time be- see man as a merely terrestrial crea- longs to the essence of man. And ture do not have any possibility— this tension determines what he is from the very outset—of penetrat- exactly at the center of life in this ing the essence of the likeness of time. He is always in a voyage to- God. But this is only touched upon wards himself or he distances him- in the Book of Wisdom and fails to self from himself. He is on a voy- be developed further. age towards Christ or he distances In this way the Old Testament himself from Him. He draws near leaves us with an unanswered ques- to his original image, or he hides it tion. We must recognize that and ruins it. The Innsbruck theolo- 18 DOLENTIUM HOMINUM gian F. Lakner has given fine ex- to disfigure the image, to achieve will always be the favorite children pression to this dynamic concep- an inner contradiction with it. At of our Lord and they will always be tion of the divine likeness of man this point, Lakner should be cited his image in a special way. Taking which is characteristic of the New once again: “The divine force the tension between the hidden and Testament in the following way: shines again precisely in the lacera- future manifestation of the image “Man’s being in the image of God tion caused by the contradictions.... of God as our point of departure, is based upon predestination to di- In this way, man as image of God is we can apply the words of the First vine filiation through mystical in- thereby crucified man.” Between Letter of John to the question we corporation into Christ.” The im- the figure of terrestrial man, have posed: “We are children of age being is thus an inherent finali- formed out of clay, whom Christ God even now, and what we shall ty of man from the point of creation with us has assumed in the incarna- be hereafter has not been made “towards God through participation and the glory of the resurrec- known as yet” (3:2). In all human tion in divine life in Christ.” tion, there is to be found the beings—but especially in those However, we thus come to the cross—the path of the contradic- who suffer—we love what they decisive question of the subject tions and the disfigurements of the shall be and what in reality they al- here under discussion: Can this di- image towards conformity with the ready are. They are already chil- vine likeness be destroyed? And if Son in whom the glory of God is dren of God—they are in the image it can, by what means? Are there manifested passes through the pain of Christ even though what they human beings who are not in the of the cross. Among the Fathers of will become is not yet manifest. image of God? In its radicalization the Church, Maximus the Confes- Christ on the cross likened him- of the doctrine of original sin, the sor most reflected upon this con- self in definitive fashion to the Reformation gave an affirmative nection between divine likeness poorest, the most defenseless, the answer to this question and de- and the cross. Man is called to most abandoned, and the most declared: Yes, through sin man can “synergy,” to cooperation with spised. And among these there are destroy the image of God within God, but has placed himself in op- those who are the topic of our dis- him and in fact has destroyed it. In- position to God. This opposition is cussion here today, those whose ra- deed, man the sinner—who does “an attack on the nature of man.” It tional soul is unable to express it- not want to recognize God and “disfigures the true countenance of self perfectly because of an infirm does not respect man, or, indeed, man, the image of God, because it or sick brain, as though, for one kills him—does not represent the detaches man from God and directs reason or another, matter were re- image of God, but deforms it, con- him towards himself, erecting sisting being taken up by the spirit. tradicts Him who is Holiness, thereby the tyranny of selfishness Here Jesus reveals the essence of Truth, and Goodness. Bearing in among men.” humanity, that which is its real ful- mind what was said at the outset, From within human nature itself fillment—not intelligence or beau- this can and must bring us to the Christ achieved the overcoming of ty, and even less wealth or pleasure, question In whom is the image of this contrast, his transformation in but the ability to love and to con- God more obscured, more disfig- communion—the obedience of Je- sent lovingly to the will of the Fa- ured, or more extinguished—in the sus, his dying unto himself, be- ther, however disconcerting this cold-blooded killer who is well comes the true exodus which frees may be. aware of what he is doing, strong man from his inner fall and leads But the passion of Jesus leads on and perhaps intelligent as well, him to unity with the love of God. to his resurrection. The risen Christ who makes himself God and de- The Crucified thus becomes the is the culminating point of history, rides God, or in the suffering inno- living “icon of love.” Precisely in the glorious Adam towards whom cent person in whom the light of the Crucified, in his flayed and the first Adam, the “terrestrial” reason glimmers weakly or is per- beaten face, man once again be- Adam, was directed. The end of the haps no longer discernible? comes the transparency of God, the divine project thus expresses itself: But such a question at this point image of God which shines forth every man is on a voyage between is premature. First of all, a key anew. In this way the light of divine the first and second Adam. None of point must be made—the radical love lies specifically upon suffer- us is fully himself. Each one of us thesis of the Reformation has been ing people, in whom the splendor must become himself, like the grain shown to be untenable, precisely of the creation has been externally of wheat which must die in order to when the Bible is taken as a point dimmed. Because these people are bear forth fruit, in the same way as of departure. Man is in the image of in a special way similar to the cru- the risen Christ is infinitely fruitful God because he is man. And as cified Christ, to the icon of love, because he has given of himself in- long as he is man, a human being, they have drawn near to a special finitely. he is mysteriously directed towards shared nature with him who, alone, One of the great joys of our par- Christ, to the Son of God made is the image of God. adise will undoubtedly be to dis- man—and, therefore, oriented to- We can say of them, as Tertullian cover the wonders which love has wards the mystery of God. The di- said of Christ, “However wretched worked within us, and which love vine image is bound up with the hu- his body may be..., it will always be has worked in each of our brothers man essence as such, and it is not my Christ” (Adv. Marc. III, 17, 2). and sisters, and in the sickest of us, within man’s power to destroy that However great their suffering may in the most unfairly treated, in the image completely. be, however disfigured or dimmed most afflicted, in the most suffering But what man can certainly do is their human existence may be, they of our brethren, while we did not “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 19 understand how love on their part utmost, certainly, but, above all, more fully bestowed upon ever was even possible, while their love images of Christ who are bearers of greater numbers of people. Every remained hidden in the mystery of an essential message about the step backwards in this movement Christ. truth of man. A message which we of expansion, every ideology or po- Yes: one of our great joys will be tend to forget too often: our value litical action which expels certain to discover our brothers and sisters in the eyes of God does not depend human beings from the category of in all the splendor of their humani- upon intelligence, stability of char- those who deserve respect, would ty, in all their splendor as images of acter, or the health which enables involve a return to barbarity. And God. us to engage in many actions of we know that, unfortunately, the The Church believes now in this generosity. These elements could threat of our barbarity always future splendor. She wants to pay disappear at any moment. Our val- hangs over those of our brothers or great attention to this and to em- ue in the eyes of God depends sole- sisters who suffer from an impedi- phasize even the smallest sign of ly upon the choice we have taken to ment or a mental illness. One of our this splendor which can already be love as much as possible, to love as tasks as Christians is to ensure that seen. This is because in the beyond much as possible in truth. their humanity, their dignity, and each of us will shine more brightly To say that God has created us in their vocation as creatures in the the more we have imitated Christ in his image means that he wanted image and likeness of God are fully the context and the opportunities each one of us to express an aspect recognized, respected, and promot- we have been given. of his infinite splendor, that he has ed. But I would like here to bear wit- a design for each of us, that each of I would like to take this opportu- ness to the love the Church bears us is destined to enter—by means nity which has been given to me to towards those who suffer mentally. of an itinerary which is specific to thank all those—and there are Yes, the Church loves you. She not him—into blessed eternity. many engaged in thought or re- only bears towards you that natural The dignity of man is not some- search, study or the promotion of “preference” borne by mothers to- thing which presents itself visual- different kinds of treatment—who wards the most suffering of their ly—it is neither measurable nor are committed to ensuring that this children. She not only adopts a quantifiable; it escapes the parame- image becomes ever more recog- stance of admiration towards what ters of scientific or technological nizable. you will be, but also towards what reason. But our civilization and our you are now: images of Christ. humanism have achieved progress JOSEPH Cardinal RATZINGER Images of Christ who should be only to the extent to which this dig- Prefect of the Congregation honored, respected, helped to the nity has been more universally and for the Doctrine of the Faith, Holy See 20 DOLENTIUM HOMINUM

CORRADO MANNI

Introductory Remarks

After the introduction by His chiatry as a discipline which can particular, has allowed us to delve Eminence Cardinal Angelini and perceive precise dysmetabolic deeply into the mechanisms by the magnificent address by Cardi- processes at the root of mental ill- which a nervous signal becomes nal Ratzinger, we now open this ness and then propose common transformed into a bioelectric event first session of those deliberations paths for treatment; (potential for action), a biochemi- and reflections which Cardinal An- Ð the socioeconomic relevance cal event (synaptic transmission), gelini, with esteem and benevo- of mental illness, one of the most and finally into an event of percep- lence, has asked me to chair. frequent and crippling illnesses of tion or a cognitive experience. I would like to thank him very this century; the causal mecha- We will now listen to the contri- deeply for this invitation, even nisms of mental illness, the etiolog- butions which the various partici- though other people, because of ical integration between genetic pants in this session are going to of- their special training and their cul- substrata and environmental influ- fer. I would like to thank them at tural interests, would perhaps have ences; the outset for what they will say— been more suited to this task than I. Ð the question of the dignity of which will certainly be of great in- Whoever has drawn near to the the mentally-ill person, who is cre- terest. central nervous system for reasons ated in the image and likeness of of professional duty or cultural in- God, a person who expresses the Professor CORRADO MANNI Director of the Institute terest has without doubt been fasci- suffering of Christ through his own for Anesthesia and Resuscitation nated by its functional and anatom- illness and his own socioenviron- at the Faculty of Medicine and Surgery ical complexity. Certainly the most mental disturbance; of the Catholic University extraordinary feature of the central Ð and, finally, the most impor- of the Sacred Heart, Rome nervous system is the transforma- tant advances in research in the Member of the Pontifical Academy for Life and of its Executive Council, tion of bioelectric and biochemical neurosciences. Consultor to the Pontifical Council events into higher cerebral func- The contribution of the neuro- for Pastoral Assistance tions which are in turn able to ex- sciences, over the last fifty years in to Health Care Workers press the will and the identity of each individual. In this miraculous integration of external signals and stimuli with mental processes there is to be found the very essence of the human soul, the person created in the image and likeness of God. During this session of this international conference and through the contributions of the expert speakers who are here present we will address ourselves to the questions and problems relating to: Ð the mechanisms by which the neuroanatomical structures support the very functions of the human mind; Ð the problem of physical pain (algos) and its transformation into emotional and cognitive experience (pathos); Ð the importance of modern psy- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 21

ERWIN NEHER

Basic Mechanisms of Signalling and Information Processing in the Brain

The central nervous system gath- nisms for regulation of metabo- tioned so far. In doing so, I will ers the information which is con- lism and those which govern the emphasize mechanisms mediated veyed by our senses. It constructs a formation and repair of tissues. by ion channels, because this has representation of the outside world While we know many of the been my own area of research over within us, and coordinates our principles underlying the action many years. I will then describe movements and our bodily func- potential, the synaptic transmis- some of the very fundamental tions. It is also the material sub- sion, the way by which a synapse principles of neuronal architecture. strate of the so-called higher brain can be strengthened and weak- I will do this by using the example functions like thought, memory, ened, and many of the general of the first few stages of informa- and consciousness. Research in the principles of the architecture with- tion processing in our visual sys- Neurosciences during the last cen- in our network of neurons, we tem—largely following the work tury, particularly during the last 50 know little about the higher orga- of Hubel and Wiesel. years, has revealed many mecha- nization, about how the individual nisms by which information is re- parts and subsystems cooperate in ceived, by which signals are propa- order to produce the so-called Ion channels underlie gated, and by which information is higher brain functions such as con- the propagation of the action processed and stored in the central sciousness, thought, emotion, and potential and the action nervous system. At the center of recollection. Regarding these is- of neurotransmitters these findings are the two basic sues, it seems, modern neuro- mechanisms: Propagation of the science is in a state where the best Neurons are specialized cells, action potential—the electrical progress can be achieved by for- which—like all other cells of our nerve impulse, and the mechanism mulating an appropriate question body—are surrounded by a mem- of synaptic transmission—the rather than trying to give an an- brane, separating the cell interior passing of the signal from one neu- swer. from the extracellular fluid. The ron to the next one. In this lecture, I will, therefore, nerve impulse is a wave of posi- We have learned that each of the try to explain some of the basic tive electric charge propagating 100 billion of our nerve cells is mechanisms which I have men- along the nerve axon, a cylindrical connected via synapses to about extension of the cell body. In 1952 1000 to 10,000 other neurons and Hodgkin and Huxley were able to that the strength, and nature of describe this electrical signal as a these connections is determined consequence of permeability both by genetic predisposition and changes of the nerve membrane to by our experiences. Most neurobi- the major cations of the body flu- ologists believe that our memories id, which are Na+ and K+. For a and many of our individual abili- long time it was not known what ties are laid down in the pattern of the molecular mechanism of this connections between neurons in permeability change was. In the our brain. Learning and acquisi- years 1976 to 1980 my colleague tion of new skills, then, require Bert Sakmann and myself were changes in these connections, so- able to show that membrane cur- called ‘plastic changes’. It has be- rent fluctuates in discrete steps. come clear over the last few years This was taken as proof that there that the central nervous system uti- are protein molecules embedded lizes and adapts the whole spec- in the nerve membrane, so-called trum of signal mechanisms which ion channels, which have an annu- have evolved in different parts of lar structure. They constitute our body in order to induce such membrane pores which open and changes. These include mecha- close when they are appropriately 22 DOLENTIUM HOMINUM stimulated. We developed a could be studied in detail. Subse- Furthermore, it was found that a method which allowed us to quently, it was found that various multitude of other types of chan- record membrane currents with types of such pore-like molecules nels operate in diverse cell types sufficient sensitivity so that dis- are operative both in action poten- fulfilling a variety of cellular func- crete step-like changes upon open- tial propagation and during synap- tions, such as in sensory transduc- ing and closing of these pores tic transmission (see Fig. 1). tion, regulation of fluid secretion, cell volume changes etc. Basically, all types of cells in our body are equipped with specific sets of ion channels. Of particular importance are channels which are permeable to the Ca++ ion. This is so because the concentration of free Ca++ inside the cells is orders of magnitude lower than its concentration in the blood and tissue interstices. Opening of these channels, resulting in Ca++ influx, leads to a sudden increase in cellular Ca++ with the resulting activation of a variety of Ca++-dependent proteins, such as contractile proteins (in muscle cells) or Ca++-dependent enzymes. Ca channels, which are regulated by membrane voltage, therefore, constitute the link between electrical signals of the nervous system and the metabolism and functions of effector cells. Ca++ channels and cells responding to Ca++ changes can be considered as the ‘output’ of the nervous system—if the latter is considered as an electrical signal processor. Ca++ signals, however, are also very important in forming and modifying the central nervous system itself, as will be detailed below.

Synaptic Connections Change in a Use-dependent Manner

Neurons utilize all known mechanisms of cellular regulation to ‘modulate’ electrical activity and to induce ‘plastic changes.’ It was mentioned above that neuroscientists consider the pattern of connections among neurons as the Fig. 1 - The mechanisms of action potential propagation and synaptic transmission. material correlate of memory. The action potential propagates along the nerve fiber due to the opening and Such memory includes both the closing of Na+- and K+-channels, which generate a sequence of inward and so-called ‘declarative memory’— outward current across the membrane. At the nerve ending Ca-specific ion the memory contents that we are channels—which open and close in response to voltage changes in a way quite + ++ aware of and can be described in similar to Na -channels—cause an influx of Ca . This, in turn, triggers the fusion words and the ‘procedural memo- of synaptic vesicles with the plasma membrane. The vesicles thereby release their ry’, the memory underlying the content (neurotransmitter) into the cleft between presynaptic nerve ending and postsynaptic cell. Neurotransmitter diffuses to the postsynaptic membrane where performance of tasks, and govern- t binds to specific receptors. The receptors, in many cases, are themselves ion ing unconscious reactions. If this channels which open upon binding of a neurotransmitter. This way an electrical is so, then learning of a task or an signal is generated across the postsynaptic membrane. Signals from a large acquisition of knowledge must go number of synapses are ‘integrated’ at the dendritic membrane of neurons, along with changes in this connec- generating a stream of action potentials, which, in turn, propagate to subsequent tivity. Therefore, neuroscientists cells. over the last 20 years have studied “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 23 mechanisms by which connec- image of the outside world onto The nerve fibers of the neurons tions among neurons (synapses) the retina. Here, a layer of neuron- in the geniculate body project onto are formed, severed or changed, like cells, the photoreceptors, layers of cells in the primary visu- depending on activity of the nerve transduce light intensity into elec- al cortex. Here cells are found cells involved and depending on trical signals. This is the only which no longer respond optimally the ‘use’ of a given synapse. One known place in the visual system to spots of light, but rather to lines mechanism, which received par- where there is a strict one-to-one or bars moving across the visual ticular attention, is the so-called correspondence (at fixed orienta- field. In one class of cells, the sim- long-term potentiation (LTP)— tion of the eye) between a given ple cells, a given cell responds op- the observation that certain cell and the light intensity of a lo- timally to a line of a certain orien- synapses are strengthened for cation in the outside world. The tation being moved through a cer- hours and longer, after having signals of the photoreceptors rep- tain position of the visual field. For been heavily used. Particularly in- resent a map of light intensity another more remote class of cells teresting is the finding that certain around us. (complex cells) again lines are op- forms of LTP were only observed Within the retina the photore- timal; however, they no longer if stimulation was effective, i.e. ceptors pass their electrical signals have to be localized precisely at a when the presynaptic stimuli actu- through a complicated network of certain position in the field of ally were successful and elicited neurons to another layer of neu- view. Still, the orientation of the postsynaptic action potentials. rons—the ganglion cells of the line is important, however. Such ‘coincidence’ of pre- and retina—which constitute the out- We can see, as we go step by postsynaptic activity is an impor- put elements of the eye. Each gan- step through the first stages of in- tant element of theoretical consid- glion cell sends an axon through formation processing in the visual erations on learning and memory. the optic nerve to the next stage of system, how the representation of In many cases it could be shown information processing within the the outside world is more and that the influx of calcium, going brain, the lateral geniculate body. more abstracted. At each stage one along with the postsynaptic action Although the ganglion cells repre- property or specificity is lost, potential, was necessary for sent again a map of the outside while another one is gained. So, longterm potentiation. Studying world, they no longer encode when we go from photoreceptors these phenomena, neuroscientists strictly light intensity, but rather to ganglion cells, absolute intensi- found that Ca++ as well as all other local light contrasts. Thus, for in- ty is lost while sensitivity to local so-called second messengers— stance, members of one class of contrast is gained. Stepping from which have been known for a long ganglion cells respond particularly ganglion cells to the cells of the time as regulators of cellular me- vigorously, if there is high light in- geniculate body, the property that tabolism—are involved in mediat- tensity at the center of their ‘recep- all information from one receptive ing LTP and in modifying ion tive fields’ and low light intensity field is represented by one area in channels as carriers of nervous in the immediate surroundings. the network is lost, while parallel signals. The modifications occur Uniform illumination, no matter processing in separate layers is on all levels: Covalent modifica- whether of low or high intensity, gained. Advancing to the simple tion of existing ion channels by evokes only minor responses. cells of the primary cortex, speci- phosphorylation, expression of In the geniculate body, again, ficity of point-location is lost new channels by activating tran- layers of neurons are found in while directional selectivity and scription, degradation of channels, which each cell responds to local edge detection is gained. Finally, enlarging synapses morphologi- contrast at a certain position in the when moving on to complex cells, cally, formation of new synapses outside world. The response char- the sensitivity for the exact posi- and elimination of entire cells by acteristics of a given cell are quite tion of edges is lost, while a given the process of programmed cell similar to those of ganglion cells. cell gains the capability of re- death or ‘apoptosis.’ This range of However, the fibers of the optic sponding to a wide part of the vi- mechanisms, in all of which Ca++ nerve are distributed between 6 sual field. We can see that at sever- forms links between electrical ac- parallel layers of neurons, each al early stages of visual informa- tivity and material changes, pro- layer giving rise to a downstream tion processing, our ‘view’ of vide options for alterations in the pathway which handles a certain things is primarily represented by connectivity among neurons aspect of visual perception, such edge contrasts. This may be the which can last over seconds to as color, form, or movement. Be- reason why we readily recognize minutes or else for hours, days, or sides, the cells of the geniculate objects of scenes, even if they are for the entire lifetime of the indi- body receive many inputs from only sketched as simple line draw- vidual. other areas of the brain, which are ings. believed to control the flow of information between the retina and Sensory Information the brain. In this way the brain Neuronal Networks Is Processed by Progressive may have a means to prevent being Can Perform Surprisingly Abstraction in Consecutive overwhelmed by huge amounts of Complicated Tasks Layers of Neurones information in situations when this information is not considered rele- The examples of visual informa- The lens of our eye projects an vant. tion processing outlined above 24 DOLENTIUM HOMINUM show that layers of neurons are ing complex ‘behaviour,’ despite tempts to simultaneously record perfectly capable of performing the fact that the interactions among from or to visualize the activity of complicated computations. Since their elements are restricted to the many neurons are even more re- we know many of the signalling most simple ones found for neu- stricted. On the other hand, all the properties of individual neurons, rons. Interactions among neurons evidence indicates that informa- we can ask the question, How do are orders of magnitude more tion processing is highly parallel the neurons of one layer have to be complex, so that it is not at all and distributed, and that most connected with the neurons of the proven that our brain works in any tasks of the brain are accomplished subsequent layers in order to way similar to the artificial ‘neu- simultaneously by large assem- achieve the particular processing ronal nets.’ blies of neurons. The two ap- between layers? It turns out that it Thus, it is fair to say that reproaches can definitely comple- is not difficult to design connec- search in the field of neuroscience ment and advance each other; tion diagrams—based both on ob- over the last 20 to 30 years has led however, it also has to be recog- served morphology and on knowl- to an understanding of many of the nized that there is a very large gap edge about functional properties— accomplishments of our central and currently no vision of how it which are expected to generate the nervous system. On the other might be filled. observed signalling pattern. In hand, it is also apparent that we are several cases, indeed, several alter- far from an understanding of the Professor ERWIN NEHER native schemes have been pro- higher brain functions, such as Winner of the Nobel Prize for Medicine posed which seem to be appropri- cognition, consciousness and emo- Director of the Biophysical ate, and it is currently not known tions. From the present point of Membrane Department at the Max Planck Institute which of them is used by the cen- view it is not even clear whether for Biophysical Chemistry tral nervous system. there is a path to improve under- in Gottingen, Germany The general architecture of lay- standing of these phenomena. The ered neuronal networks, observed approach which I have presented is in many parts of our brain, has giv- the ‘bottom-up approach,’ an at- en rise to a discipline—computa- tempt to explain some of the prop- tional neurobiology—which has erties of the system by studying its the ambitious goal to reproduce elements. The alternative is to con- Literature these mechanisms in computers sider the system as a whole, by D. JOHNSTON and S.M. WU: Foundation of and in control circuits for technical studying its accomplishments and Cellular Neurophysiology, The MIT Press, applications. In these studies ele- its limitations. Unfortunately, Cambridge Mass, 1995. E.R. KANDEL, J.H. SCHWARTZ, and T.M. ments are defined (either as ‘ob- there is no continuity between the JESSELL (Eds.): Essentials of Neuronal Sci- jects’ in a computer or as logical two approaches. Current method- ence and Behaviour. Prentice Hall Interna- elements on a circuit board) which ology in cellular research is quite tional, Inc. London, 1995. E. NEHER and B. SAKMANN: The Patch represent neurons. They are limited—even when restricting Clamp Technique, Scientific American, arranged in layers and are connect- study to only a single cell. At- March 1992, pp. 44-52. ed to ‘neurons’ of subsequent layers in a way similar to real neurons. It turned out, both in theory and in practice, that such an architecture can perform surprisingly complex tasks—not only spatial abstraction, as described above for the visual system. It can also be designed to display features such as associative memory, comple- tion of patterns stored in such memory after presentation of partial inputs, pattern recognition, detection of weak correlations between patterns, and control of robot arms. A very interesting property of such networks is that they can ‘learn’ or can be ‘trained’ in the sense that there are algorithms available which indicate how the connections between the ‘neurons’ of layers have to be changed (based on the response to trial pre- sentations of stimuli) so that the network will respond optimally to a set of input patterns. Such networks very often display surpris- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 25

PIERLUIGI ZUCCHI, BONIFACIO HONINGS

Algos and Pathos: Fundamental Moments in Man’s Spiritual Growth

As I was entrusted with a very itivity that involves, in interest if izing experience of pain leads complex and rich topic, I will im- not in consent, all men, both be- man to a better knowledge of his mediately come to the heart of the lievers and agnostics. In fact, only own self, whose identity and in- matter, trying to proceed schemat- a transcendent view can give sig- terpretation are often sought after ically in order to make the subject nificance to pain and suffering, breathlessly in such a difficult of my report more comprehensible. also in their relation with guilt, and complex articulation of so- I am going to divide my report into since, in this case, suffering is not ma-psyche. three parts: an ethical-philosophi- only interpreted as penalty and If he could not succeed in giv- cal introduction, an anatomico- punishment but rather as atone- ing a sense to what he is suffering, clinical part supplied with epi- ment and redemption. Thus pain no man would be able to live and demiological data, and a thera- is the real concealed energy in overcome his own suffering. peutic part in which the funda- man’s psychophysical heritage, Therefore, the Christian sets a mental role of prayer is pointed able to overcome the real lethal neoethical image of man against a out—together with the administra- effects of evil: it is the real point biologistic and immanentistic tion of drugs, it can bring the pa- of contact in solidarity between view: homo patiens, where pain tient’s life-quality great advan- God and men. tries to find a significance of its tages, as is stated in a recent sta- However, it is necessary to own, is set against homo sapiens, tistical study conducted with the think deeply over how, in every- who is set against homo faber. highly valued collaboration of one’s ethical-religious education, The aim of consecrating pain as a Professor Honings. only the conditions of physical sacrifice proves true in giving it pain and moral suffering lead significance. Every man’s pain man to think and raise himself to and suffering will make sense on- Ethical-philosophical God and, under these conditions, ly if they lead him to accept the introduction how God is able to instil Himself sacrifice these factors call for. completely in man. As Christianity taught first As far as their etymology is The individual and individual- through the suffering of God in concerned, I would like to give a Christ, it is only possible to un- definition of the two Greek terms, derstand pain and suffering better algos and pathos, whose meaning in the concept of sacrificial suf- is physical pain and moral suffer- fering—the bases to understand ing, respectively. the grammar of any act of love are The former—algos—repre- only laid through the Cross. In sents a physiological reaction to fact, as Cardinal Angelini states, nociceptive stimulations, e.g., a “a society of Love cannot exist trauma; the latter—pathos—is without giving pain a value, for considered a lacerating emotional the human condition is necessari- reaction subsequent to a psycho- ly accompanied by pain” (F. An- logical background the subject gelini, Quel Soffio sulla Creta, regards as negative, such as the A.M.C.I., Roma, 1990). loss of someone close or under Christian doctrine on suffering particular psychological condi- does not only call for a mild actions due to stress, anxiety, and ceptance of sufferings, but also depression. for a suffering endowed with In the grammar of suffering al- beatitude in which man can give gos and pathos are apparently two himself up to God so as to accept negative algebraical entities any pain and suffering, which are which, according to a religious to be loved and sometimes even perspective, always lead to a pos- searched for. As far as this out- 26 DOLENTIUM HOMINUM look on life is concerned, Chris- gesia System is a neurohormonal chemical—are received by organ- tianity opposes eudemonism. system consisting of a) afferent ules located in different dis- While eudemonists seek pleasure pathways carrying a nociceptive tricts—cutis, muscle, joints, vis- and find suffering, Christians un- stimulus from periphery (cutis, cera—which are called receptors dergoing pain try to interiorize subcutis, muscle, joints, viscera) (Fig. 1). this moment they regard as privi- to the upper centers; b) upper cen- An algogenic receptor or noci- leged, for it includes the beatitude ters as points of arrival of sensi- ceptor is the most distal histologi- and joy of their faith. bility and cognitive integration cal formation for stimulus trans- Now let me show you the im- interpreting a painful message duction, connected with two dif- portant function pain may per- and carrying out a responsive ferent kinds of fibers: Aδ myelin- form in the clinical field. strategy; c) systems modulating ic fibers, so named because they and reducing a nociceptive input. have a myelinic sheath, and C This schematization of the amyelinic fibers, not covered Anatomicoclinical part Pain-Analgesia System, where, as with a sheath. we will see, pathways and centers Experiments with electrical In the clinical-biological field, are morphologically identifiable, stimulation on nerves showed pain is certainly the greatest ally has only a didactic purport be- that these two kinds of nocicep- of man and all beings. In confir- cause clinically pain does not al- tive fibers conduct two different mation of this assertion, which ways follow the above-men- kinds of pain. In fact, while after a may sound very peculiar, unfortu- tioned typical course, but it may selective stimulation of Aδ fibers nately there is a very rare syn- arise in one of the three stations: there is an acute, stabbing, well- drome, namely congenital anal- peripheral algogenic receptors or localized pain, also called first gesia—the patient comes to nociceptors, nociceptive afferent pain, the activation of C fibers death, usually in his early years, pathways, or even the brain. evokes a diffuse, dull, burning because he does not have the no- One of the most important and pain, also called second pain, ciceptive system indispensable to current problems of neurophysi- which is typical of chronic prevent either situations of injury, ology is to understand and then to pathologies. e.g., a burn, or even more serious interpret its own physiopathologi- But which pathways transmit to dangers, e.g., an abscess or a vis- cal mechanism of passing infor- upper centers various kinds of no- ceral perforation. Apart from that mation from one cell to the other ciceptive noxae? very rare syndrome, in its contin- more and more completely. The characteristic anatomical uous and very slow phylogeny, Therefore, the physiopatholo- pathways, which conduct and nature devised extremely refined gist’s aim is to have the theoreti- modulate pain to the upper cen- and intelligent mechanisms cal and practical knowledge of ters, are: a) the Neospinothalamic which adjust themselves to the the pain neuroendocrine substrate changing environmental condi- he will have to deal with in the tions in order to defend itself near future. Fig. 2 - Schematic representation of against situations of injury. But where does the painful sen- neospinothalamic and There is also a clinical condi- sation start and where is it re- paleospinothalamic tracts. tion opposite to that of congenital ceived? analgesia, namely hyperalgesia Various kinds of algogenic or allodynia, in which any stim- noxae—mechanical, thermal, uli, even the most innocuous ones, are felt as pain. Both pain as a precious “alarm Fig. 1 - Schematic representation of bell,” so properly defined by sensivity receptors Descartes in 1600, and all the systems for pain control, i.e., analge- Pacini’s sia, are important for man’s sur- corpuscle PRESSURE vival. In order to obtain the homeostasis indispensable to the MESECEPHALON Meissner’s Reticularformation Neospinothalamic tract individual’s kinesthesia the or- corpuscle TOUCH ganism has at its disposal the PONS Paleospinothalamic sleeping-waking rhythm, ther- tract moregulation, and hunger and Ruffini’s HEAT thirst instincts. corpuscle These are fundamental and in- BULB alienable biological mechanisms Krause’s Spinothalamic in human beings’ life. corpuscle COLD tract Now we are going rapidly to examine one of the most important systems for the body’s de- Free PAIN fence—the Pain-Analgesia Sys- endings tem. Classically, the Pain-Anal- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 27

System, mainly consisting of Aδ vide for pain control and modula- very little mention of the other myelinic fibers, and b) the Pale- tion (Fig.4). two phylogenetically more recent ospinothalamic System, consist- But what is the basic situation brains—limbic and neocortex—in ing of C amyelinic fibers (Fig. 2). the individual begins to perceive which pain takes on the psychoaf- The pathways I have just de- pain in? fective features so proper to cog- scribed are the anatomico-physio- This condition is represented nitive and emotional experience, logical substrate of every al- by the algic threshold, which is that is, PATHOS. However, it is gogenic condition where all bio- determined by the slightest inten- right in these areas of the nervous electrical, ionic, and molecular sity felt as pain a nociceptive system that the most intelligent events take place. After a noci- stimulus can provoke in man or strategies of response and modu- ceptive stimulus, they appear in which evokes behavioral respons- lation for the pain phenomenon, the Nervous System from the re- es to pain in animals—the reflex learnt and memorized, take place, ceptor to the cortex and form no- of flight or vocalization. but only a few research groups are ciception. All the anatomicoclinical as- interested in them. As we have seen, the first event pects we have described so far are of nociception occurs at the re- the fundamental substrate to inter- ceptors level, so-called nocicep- pret the physiopathological mech- Cultural dynamics of pain tors; the second event of nocicep- anisms that are at the basis of tion consists of a transmission physical pain or ALGOS. Unfor- At this point, after identifying along the fibers—along the first tunately, even in the latest treatis- the anatomico-physiological ar- afferent neuron fiber, that takes es on physiopathology and pain eas where the mechanisms of the message from the receptor to therapy, the perspective you get is pain perception occur, we wonder the spinal cord’s posterior horn, limited as far as the neurophysio- what fundamental role the indi- where the second neuron fiber logical formulation of pain is con- vidual’s cultural elements play in leads to the thalamus, from which cerned. In fact, many researchers his psychological elaboration of the third neuron fiber leads to the are almost exclusively interested pain. cortex. There the integrative in the study of nervous pathways Everyone’s education plays a mechanisms of the algic condi- and centers in the reptilian brain, very important part in perceiving tion take place (Fig. 3). i.e., that brain which includes the a nociceptive noxa and respond- In addition to the nociceptive systems starting in the primary af- ing to it. system there is the antinocicep- ferent neuron and reaching the Concerning this, in order to tive system, which consists of all posterior horn, ascendant path- make you understand the prob- the neuronal networks and those ways, nuclei, mesencephalic bulb lem’s extent in a very simple way, of neurotransmitters which pro- pathways, and thalamus. There is I would like to report two exam-

Fig. 3 - Schematic representation of nociception stations (I neuron: receptor-spinal cord; II neuron: Fig. 4 - Schematic representation of antinociception main spinal cord-thalamus; III neuron: thalamus-cortex). stations.

intralaminar and limbic system medial thalamic nuclei

postero-lateral ventral nucleus

posterior thalamic nuclei hypotalamus

periaqueductal gray m. reticular formation

gigantocellular nucleus

spinal cord (I LAMINA)

RECEP- 28 DOLENTIUM HOMINUM ples from literature—the Couvade The suffering brought to matu- ing a real physiological meeting and the Initiation of the Chieftain. rity in physical pain may not be point of solidarity, availability, We well know that labour is the only a heritage of the patient’s and love—ethical qualities that most intense physiological noci- solely spiritual growth, but it may should be intrinsic and ingrained ceptive experience a human being involve his relatives and physi- within every family group. can feel. In their anthropological cian as well, establishing a mode In fact, the experience of phys- studies of some populations in In- of testing the three entities which ical pain and moral suffering the dia, South America, and the interact intimately. patient is involved with cannot be Basque Countries, Kroeber and A particular syndrome, namely reduced or reified within the con- Kosambi pointed out that in the Burn-Out Syndrome (Mayou, text of experiences from outside Couvade at a baby’s birth while 1987), hits some physicians who the human condition. On the con- the man is regarded as parturient, certainly have poor spiritual trary, they must be an indelible the woman goes on working in the training yet have to face very way-of-living in which pain is fields with no pain until the mo- stressing psychological situa- not levelled or emptied of its sig- ment of her delivery. The chief- tions, such as those occurring in nificance. tain’s initiation rite is another ex- pain therapy wards. Burn-Out Each patient’s pain-back- ample testifying how emotional, Syndrome is characterized by a ground, which is always a pain motivational, and affective factors depressive symptomatology with we can term global, due to its have a fundamental role in per- a tendency to ataraxy and often to constant involvement with man’s ceiving pain. In this rite steel sadness and a sense of reduced psychophysical sphere, cannot be hooks pierce through the back personal realization. His daily re- “banalized” or “psychologized” muscles of the man chosen to rep- lation to a patient affected with an as a period in his life which does resent God’s power among the in- algogenic pathology inevitably not represent, even for the agnos- habitants of the tribe. By ropes in- causes the physician to interior- tic, any contact with the super- serted in these hooks, he is lifted ize these sufferings, often leading natural or lead his mind to matu- up to the top of the wagon tower, him even to severe psychic con- rity and personal introspection. In where he is supposed to bless peo- sequences. fact, man, whatever his bent may ple in the nearby villages he is be- It is precisely in the patient’s be, tends to absolute truth, but it ing taken to. physical pain and moral suffering must not be regarded as an addi- Therefore, we can deduce from that the physician, if a believer, tion of partial truths, though mul- the two examples that psycholog- and the patient’s family, ethically tiplied to infinity; insufficiency ical conditions of great emotional well educated, find a special mo- and partiality will always be in- involvement can raise the physio- ment of spiritual growth and en- sufficiency and partiality. logical threshold of pain percep- richment. In fact, the family can- But let me show you the kind tion so that pain is not felt even in not be only a union among sound of dialogue the physician some- clearly algogenic conditions. and self-sufficient people; on the times may conduct, especially On the other hand, emotional contrary, it must set itself up as when an optimal relation has conditions psychologically oppo- the natural site of affective sym- been established with his own site to those examined so far— biosis, especially when one of its suffering patient and when his anxiety and depression—lower members becomes inactive or patient’s health is really precari- the algic threshold so that com- needs care. Only in this way will ous. monly painless nociceptive stim- it accomplish the main task of be- The physician, especially if a uli are felt as painful. As a conse- Christian, must feel called to take quence, a condition of pathos a “deacon-like” attitude towards which is often disproportionate to his suffering patient, establishing the algogenic noxa is created. a kind of communication identifying itself with a mystagogic pastoral approach, as Zulehner Psychological dynamics defined it. As a dialogical of pain method, mystagogy (from Greek mysterion agein = to initiate into As we have just seen, cultural mystery) gets the physician to es- and psychological elements can tablish a suitable intersubjective influence the individual’s psy- communication able to develop choaffective elements, raising or the intrasubjective communica- lowering his pain threshold. tion the growth of both interlocu- As we will see further on in the tors depends on. course of this report, both in the Respect for those who suffer psychologically-ill man and in requires of the physician a tactful the physically-ill man the physi- and sometimes silent approach as cian can establish different re- well. After serious mystagogic sponses to a therapy according to training, silence as a kind of dia- the patient’s ethical-religious and logue with his patient shows the cultural bents. physician’s great availability and “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 29 may be his most constructive re- Depending on circumstances, Epidemiological aspects sponse, for in these cases a silent then, to alternate words with si- of pain word is expressed by his total lence is the most significant kind presence. In fact, in the face of of language in the physician-pa- In order to understand better pain and suffering, silence repre- tient dialogue. how much the “pain-question” sents a mutual enrichment and Not surprisingly, sick people, may affect society, let me report plays the fundamental role of particularly those who suffer very the most important epidemiologi- spiritual development in the pe- much, are disturbing elements of- cal data published. culiar language which develops ten left to live alone with their Pain incidence with reference between the physician and his own miseries in a technocratic to pathology is 10% neoplastic patient. Leston Havens points out and thanatophobic society which pain and 90% non-neoplastic properly that it is precisely in his is only interested more than ever pain (Fig. 5); the problems asso- silence that the individual “takes in its output and production— ciated with neoplastic pain con- up an empathetic position” to- life-parameters tending to rise to sist of: 21.5% of cases cannot wards the sufferer, allowing him- “ethical values” of indivual refer- sleep, 7.4% can do nothing, self affective resonances, for it is ence more and more. 18.2% cannot sit longer than 15 in this agonizing circumstance But what is the delicate role of min., 11.7% cannot watch televi- that the physician identifies him- the physician in his relation with sion, 14.8% cannot read a book, self with the other’s suffering, his patient, especially in the light 26.4% cannot see other people though without losing his own of the present laws? (Fig. 6); handicaps associated identity. The silence of the physi- The physician happens to play with neoplastic pain consist of: cian, then, shows a full empathy the very important role of a 27.1% of cases cannot run or between him and his patient: by “path” between contrasting per- dance, 5.5% cannot look after this tactfully silent attitude the sonal and social necessities, espe- personal hygiene, 15.8% cannot believing physician and some cially when there are financial walk in the country, 5.6% cannot psychotherapy schools do not pressures to cut costs which have cook, 8.3% cannot go shopping, mean to stay behind or in front of, no sufficient cost-profit ratio. 13.5% cannot clean the house, but next to their patients, sharing The possibility of reconciling 10.9% cannot go upstairs and their condition. This dialogic si- often opposite positions between downstairs, 5.4% cannot get lence between physician and pa- the physician and hospital admin- dressed, 7.8% cannot walk on the tient, especially when a really istration could lie in following road (Fig. 7); in the United States empathetic relation is established the principle of helping those the incidence of pain compared between them, gets the sick per- who need more care. with the number of affected peo- son to introspect continuously so ple is 11 million for neoplastic as to revalue the language of his diseases and 86 million for non- own suffering in close diologue neoplastic ones (Fig.8); in the with his own life. United States the economic cost

PAIN INCIDENCE PROBLEMS ASSOCIATED WITH NEOPLASTIC PAIN (in relation to pathology) pain makes it difficult NEOPLASTIC PAIN (10.0 %) SLEEPING (21.5%) SEEING OTHER PEOPLE (26.4%)

DOING ANYTHING (7.4%)

READING A BOOK (14.8%) SITTING LONGER THAN 15 MIN. (18.2%) Fig. 5 NON-NEOPLASTIC PAIN (90.0%) Fig. 6 WATCHING TELEVISION (11.7%)

HANDICAPS ASSOCIATED WITH NEOPLASTIC PAIN PAIN INCIDENCE IN THE U.S. pain prevents data reported in millions of people GETTING DRESSED (5.4%) NEOPLASTIC PAIN (11) RUNNING (27.1%) RACHIALGIA (21) CLEANING (13.5%) WALKING ON HEADACHE (29) THE ROAD (7.8%) COOKING (5.6%) GOING UPSTAIRS AND DOWNSTAIRS WASHING (5.5%) (10.9%) PAINFUL ARTHRITIS (24) GOING SHOPPING Fig. 7 WALKING IN THE COUNTRY (15.9%) (8.3%) Fig. 8 MUSCULO-SKELETAL PAINS (12) 30 DOLENTIUM HOMINUM of pain calculated in millions of Medical-theological will. This passage from a biologi- missed working days is 58 mil- interpretation of pain cal to an ethical phase of pain lion for neoplastic pain and 375 and suffering leads man to a greater introspec- million for non-neoplastic pain tive activity of his own self. This (Fig.9). After examining these impor- condition leads man to have a The cost of direct medical as- tant epidemiological data, ac- better knowledge of God and sistance,—i.e., the utilization of cording to a medical-theological then to increase his faith—a fun- medical and paramedical staff, interpretation we will see what damental moment that enables hospital facilities, diagnostic ex- etiology might be assumed for him to accept even clinical situa- aminations, drugs—is 9 billion this clinical symptom, so incisive tions of very intense pain due to dollars every year for neoplastic and decisive in everyone’s life an increase in his physical en- pain, 4 billion for recurrent (Fig. 12). We learn that man’s durance that such an attitude of headaches, 11 billion for painful original guilt and so the resulting ethical introspection can estab- arthritis, 13 billion for rachialgia evil, leads to pain—a physical lish more in everyone who be- and 8 billion for musculoskeletal perception suffered by man as lieves in a Supreme Being. pathologies (Fig. 10); the yearly pure passivity. Man goes from indirect cost—i.e., missed work- this biological phase to an ethical ing days, claims for damages, le- phase where the initial physical Pharmacological therapy gal controversies—is 6 billion entity develops the moral affec- and ethical therapy dollars for neoplastic pain, 12 for tivity that leads the individual to recurrent headaches, 6 for painful an interiorization of his own pain Now let me show you how pos- arthritis, 7 for rachialgia, 3 for according to which suffering be- itively ethical therapy—that is, musculoskeletal pathologies (Fig. comes a moment of free and con- prayer—interacts on the suffer- 11). scious re-activity involving his er’s pharmacological therapy.

PAIN ECONOMIC COST IN THE U.S. millions of missed working days NEOPLASTIC PAIN (58) RACHIALGIA (120) GUILT—EVIL (original sin) RECURRENT HEADACHE (130)

PAINFUL ARTHRITIS (70)

Fig. 9 MUSCULOSKELETAL PATHOLOGIES (55)

PAIN DIRECT COST IN THE U.S. ALGOS or INCREASE in billions of dollars PHISICAL PAIN IN PHYSICAL (perception showing Ð Ð Ð AND PSYCHICAL NEOPLASTIC PAIN (9) MUSCULOSKELETAL PAIN (8) pure PASSIVITY: RESISTANCE BIOLOGICAL PHASE) RECURRENT HEADACHES (4) Ð Ð Ð gate RACHIALGIA + + control (13) + endorphins Fig. 10 PAINFUL ARTHRITIS (11) PATHOS or PAIN INDIRECT COSTS IN THE U.S. MORAL SUFFERING + + + + + + in billions of dollars (man’s free and conscious KNOWLEDGE INCREASE MUSCULOSKELETAL PATHOLOGIES (3) RE-ACTIVITY involving his of GOD of FAITH RECURRENT will: HEADACHES (29) ETHICAL PHASE) RACHIALGIA (7)

Fig. 12 - Medical-theological interpretation of pain and suffering. PAINFUL ARTHRITIS (6) Gate control of nociceptive afferences. NEOPLASTIC PAIN (6) Endorphins: opiate endogenic substances with an analgesic Fig. 11 action. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 31

Algos and pathos, fundamental resents an entity in God’s own being opened to a fundamental moments of spiritual growth in image, even if unconsciously. experience of introspection man, are surely influenced by which may be qualitatively simi- pharmacological therapy but al- lar even to a mystical experience. so by ethical therapy, i.e. prayer. Conclusions Thus, the sufferer cast out of a In a recent study by Zucchi and materialistic society finds the ca- Honings a blind sample of pa- To conclude I would like to say pability of thinking over and tients (i.e., their religious beliefs that pain and suffering, which are meditating all the same on a were unknown) was invited to such pressing and frequent ele- unique experience which read a Gospel passage and medi- ments in our lives, are, however, prompts him towards union with tate on it. A scientific and statisti- excluded from contemporary cul- the Absolute. cal analysis of these data proved ture, where everyone’s ego tends It is in pain that man finds a de- that this experience could stimu- to steer physical and psychic en- velopment of his own inner late every subject’s intimate her- ergy towards implementing ex- sphere with his spiritual feelings itage with very positive results on clusively hedonistic aims. when resources depending on his his pain. In fact, it appeared that It is from the wild and no-lim- bodily vigour and strength tend to a) the basic pain threshold is its hedonism that pain as enter- weaken, losing their intensities, higher in believers, i.e., they feel tainment appears, as can be often interests, and motivation. In fact, less pain; b) believers get better seen on TV, where pain is shown physical pain and moral suffering results from therapy than non-be- using violent, gruesome, and hor- are fundamental moments of lievers; c) agnostics who read the rifying scenes. It is in this esthet- man’s spiritual growth because Gospel passage compared with ic statement of pain that present they tend to improve his relation their control group, i.e., those neo-paganism tries to present an with his own inner-life in this ag- who do not read it, have a better ethical perspective on life exclu- onizing phase of life. Subse- response to the therapy. sively based on an immanent quently, the indvidual is able to On the grounds of this study concept of science, on seemingly transcend human events and the authors think that the phys- revolutionary and falsely innova- tends to a more synchronic iopathological mechanism by tive ideologies, on economics telegenesis with his soul. In these which faith in believers and the based only on profits. conditions pain, regarded as a stimulation of their intimate her- Therefore, man has to remem- fundamental moment in one’s itage in agnostics are able to ber that historically he comes lifetime, encounters its intrinsic modulate the perception of a from a culture able to transcend significance. painful stimulus consists: earthly things, even when he has It is only in contact with pain, a) neurophysiologically, of an no religious background, for this excluded from view in a society activation of descendant inhibito- need of the supernatural is his mythicizing productivity and sory tracts causing the gate closing first experience as a human be- cial value, that man can find a re- to nociceptive inputs and thus ing. lation with the transcendent again less pain perception, as in the No other condition like that the and get closer to spiritual behav- “Gate Control Theory” (Melzack individual affected with pain is in ior due to an imperative yet often and Wall, 1965); can urge him so intensely to- repressed need to search for the b) neuropharmacologically, of wards ethical-spiritual elements Absolute. However, all this a liberation of endorphins, endo- fostering either the capability of seems to be really difficult in a genic substances of an opiate transcending or the possibility of society where pain more and (morphinic) nature with anal- more easily becomes an etiologi- gesic action, localized at hypo- cal agent of affective mourning thalamus, nucleus of the great due to the debasement of the fun- raphe, and periaqueductal gray damental values whose loss pre- matter level (Hughes et al. 1985). vents reaching the transcendent This study, whose results am- and causes an annihilation of ply rewarded the efforts of the au- one’s own self. thors, points out that Faith, during fundamental periods of be- Professor PIERLUIGI ZUCCHI lieving patients’ lives—such as Director of the Institute for the Study pain and suffering—has a chief and Therapy of Pain, Florence (Italy) role as an etiological agent essen- Professor of the Semiology of Pain at the University of Chieti (Italy) tial to raising the pain threshold. Editor of Algologia Even concerning agnostic patients, the authors observed that Rev. BONIFACIO HONINGS, transcendent references, such as O.C.D. reading and meditating on a pas- Member of the Pontifical Academy for Life sage reminding them of a Consultor to the Congregation for the Doctrine of the Faith Supreme Presence to refer to, fa- and of the Pontifical Council cilitate raising of the pain thresh- for Pasto0ral Assistance old because every individual rep- to Health Care Workers 32 DOLENTIUM HOMINUM

References MORRIS H.R., Identification of two related del Dolore: attualità terapeutiche. Pathos, pentapeptides from the brain with potent suppl. 1(1994) 3-7. ANGELINI F., Quel soffio sulla creta, opiate agonist activity, Nature, 258(1975) TIENGO M., Nocicezione e dolore. In: M. A.M.C.I., Roma, 1990. 577-579. Tiengo, Cervello e mente nella terapia del BONICA J.J, Il Dolore, Vol. I, 1994, III KANDEL E., Principles of Neural Sci- dolore. Pathos, 4(1995) 4-9. Ed., pp. 605. ences, 3rd ed., J.H. Schwartz, T.M. Jessel ZUCCHI P.L., Compendio di Semantica CARTESIO, De Homine, 1665. (Eds.), Elsevier, New York, 1991. del Dolore, Vol. VI. ECCLES J.C., Come l’io controlla il suo KOSAMBI D.D., Living prehistory in India. ZUCCHI PL., HONINGS B., La fede come cervello, Rizzoli, Milano, 1994. Sci. Amer., 216(1967) 105. elemento trascendente e facilitante il risulta- FIELDS H.L., BASBAUM A.I., Endogenous KROEBER A., Anthropology. Harcourt, to terapeutico nel paziente sofferente. Studio pain control mechanism. In: P.D. Wall, R. 1948. controllato in cieco su un gruppo di soggetti Melzack (Eds.), Textbook of Pain, London, MAYOU R., Burn-Out. Br. Med. J. 295 affetti da patologie dolorose croniche. Do- Churchill-Livingstone, 1984, pp. 142 152. (1987) 284-287. lentium Hominum, in press. HAGBARTH K.E., KERR D.I.B., Central in- MELZACK R., WALL PD., Pain mecha- ZULEHNER PM., Passaggi. Pastorale delle fluence on spinal afferent conduction. Jour- nisms: a new theory. Science 150(1965) fasi della vita, Queriniana, Brescia, pp 304, nal of Neurophysiology, 17(1954) 295-307. 971-979. 1992. HAVENS L., Explorations in the uses of MORUZZI G., Sistema nervoso vegetativo language in psychotherapy: complex em- e sistema nervoso autonomo. Rass. Clin. pathic statements. Psychiatry, 42(1979) 40- Sci., 44(1968) 239. 48. TIENGO M., Il sistema dell’antinoci- Figs. 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 - 11 HUGHES J., SMITH T.W., KOSTERLITZ cezione. In: Report dal XVII Congresso from: Zucchi P.L. (Ed.), Compendio di Se- H.W., FOTHERGILL L.A., MORGAN B.A., Nazionale A.I.S.D., Giugno 1994. Controllo mantica del Dolore, Vol. VI. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 33

GIUSEPPE ROCCATAGLIATA

From the Diseases of the Soul to the Psychoneuroses

The soul is, in Pythagoras’ theo- Socrates’ opinion, coincide coming it and generating melancholic rization, the organizing principle pletely. illness. In Plato’s theory, the two of the organism, which, without its Plato also adopts a singular po- main ailments of the soul—hyste- harmonizing energy, would be a sition regarding the diseases of the ria and reactive depression—find mere assemblage of organic mat- soul. It issues from an original for- their origins respectively in the ter. There exists a “pivot” which mulation of the soul-body relation- dissatisfaction of the soul of the marshals and imposes order, bal- ship: the soul presumably entered genital apparatus and in the feed- ancing opposite forces, and which the body, starting from an origi- back of this rage onto the body. Heraclitus locates in “fire,” Hip- nary condition of “purity” and au- Other psychopathologies are pocrates in humours, Aristotle in tonomy. Once in the soma, it sup- caused by nonfulfillment of eros, a heat: it is the vital force which con- posedly differentiates itself by lo- pulsion which is by nature unhap- nects the organs, “moves” the or- calizing in the body’s various or- py because it is poor and voracious ganism according to a predeter- gans, cohabiting with them as a vi- and therefore in search of an object mined scheme, and is in close cor- tal energy and in turn receiving which might enrich it; a dissatis- relation with the cosmic soul. Ac- from them both physiological and fied eros underlies an existential cording to Bichat and Stahl, the pathogenic stimuli, hence losing state of suffering due to the lack of soul is active in controlling those its natural integrity, like an “am- the love object which might satisfy forces which might drive the or- phora which, lying on the sea-bed, the eternally pursued, primeval, ganism to become inorganic mat- becomes covered with mud and lost unity: an unsatisfied desire is a ter. It contains within itself the “via debris.” The noblest part of the cause of suffering for the eros, essentialis,” adaptive and final- soul is that which is localized in which therefore “withdraws, ized, qualitatively different from the brain, where it carries out supe- gloomy and sad, into itself.” If Pla- the so-called “natural” energy rior functions, consonant with its to holds that mania and melan- which is characteristic of each or- primary “divine” condition. choly are sustained by humoral gan and which is activated secon- Plato maintained that it is the disturbances due to the pituita and darily through the soul’s impulses, body which pollutes the soul, thus the black bile, he is nonetheless of according to automatic rhythms; deteriorating it and causing mental the opinion that some types of ma- this is the way in which body and disorders. Also, education, charac- nia, which he calls “enthusiastic,” soul exist. ter, and a disharmonious family are creative, because they express Socrate’s opinion on the biolog- life may exert a negative influence a “divine obsession.” Aristotle, ical model of mental disorders is upon the soul. likewise, was later to grant a posi- ironically negative. Referring to The coexistence of body and tive role to “atra bilis” in “gener- Hippocrates, he calls the humoral soul, according to Plato, lays the ous” melancholy. theory a “fairy tale.” The rigorous foundations for the origin of psy- It is probably, on the historical therapy of the soul’s ailments, chopathology: hysteria reflects the level, the soul-body dichotomy, as rigidly opposed to somatic dis- “wrath of the womb’s soul” due to formulated by Socrates and Plato, eases, is “maieutics,” a technique the lack of orgasm and pregnancy: which lays the foundations for a which brings one to know oneself the suffering thus caused “induces psychogenetic-passional interpre- through the revelation of the inner the womb to wander about the tation of some psychiatric condi- “truth,” thus “purifying” the sick body” and hence the symptomatol- tions: i.e, those in which, seeming- soul. The study of “nature” is, in ogy. Reactive depression is sus- ly, the soul’s passions—more than Socrates’ opinion, entirely useless; tained by “anger” which—because biological data — play a decisive the essential thing is to know the it is suppressed and not given vent role in their etiopathogenesis. By life of man, through the study of to, through psychosomatic out- reflecting themselves onto specific virtue, of good and evil, of truth lets—“contracts the canaliculi of organs, they trigger the surfacing and falsity. Ethics alone is funda- the black bile,” so that the latter ac- of symptoms, as this philosopher mental to obtain excellent men: cumulates in the blood and reaches typically believed for the above- virtue and mental health, in the brain in excess, thus deteriorat- mentioned disorders: hysteria, re- 34 DOLENTIUM HOMINUM active depression, and love melan- tive systems of the cerebral cortex, lect and the brain. The somatic choly. the hypothalamus, the brain stem, structures, such as the heart, mus- According to Aristotle, the soul the epiphysis, the hypophysis, and cles, glands, and lung would in is nothing but an “energy” activat- the vegetative system. These struc- themselves be inert, if they didn’t ed by an intrinsic force which aims tures are coordinated according to receive stimuli from acetylcholine, at creating forms; the soul is there- a plan aiming at self-balancing, for adrenaline noradrenaline and fore an “entelechia” which con- the prevention of possible derang- dopamine. In this model, an equi- trols behaviour: verbal, motor, ing mechanisms. The chemical en- librium within the homeostatic mental, imaginative, intellective. ergy contained in neurotransmit- system is at the basis of harmony The soul’s energy comprehends all ters gives rise to systems which, by between logos and soma; a lack of forms within itself; it receives stimulating the body, produce spe- balance caused by the neurotrans- nothing from other organs, but cific motor, mental, affective, mitters reflects upon the somatic, dominates the body and coordi- emotive forms. The dopaminergic visceral, and mental functions, nates its complex functions, cere- system, for instance, has different generating the symptomatology bral ones included. The brain is the functions, according to its varied which presents to the ego as a par- “instrument” of the soul, which us- anatomic connections: the hypo- asitic and disturbing phenomenol- es it according to a plan elaborated thalamus-hypophysis axis governs ogy. It has now been proved that by the intellect. The soul’s task is the discharge of prolactin, the ni- the neurochemical network (the the creation of forms which are ad- gro-striatal that of motor activity, soul for the ancients) is formed of equate to life: objects, operative the mesolimbic the emotions and molecules with specific functions: systems, scientific and philosophic affections, the mesocorticofrontal excitatory, inhibitory, and modula- models. In this perspective a har- imaginative activity. All neuro- tory, connected both with each monious soul will give life to suit- transmitters, such as NA, 5-HT, other, and with neuroendocrine able forms, a disharmonious one, DA, are balanced among them- and somato-vegetative systems, to psychopathological forms. The selves in a mutual control of in- i.e. with the visceral, sympathetic- soul is therefore the seat of all pos- hibitory, excitatory, and modulat- parasympathetic centres. NA stim- sible psychiatric symptoms; this is ing activities, in which the neu- ulates, GABA inhibits and 5-HT the sense in which one must inter- roendocrine, the neuropeptide and modulates—inhibiting hyperac- pret Kraepelin’s assertion: “The specific aminoacid systems take tive systems and stimulating hy- psychiatrist is concerned with the part. The complex system thus de- poactive systems—in order for the diseases of the soul.” scribed is formed of billions of in- balance of the organism to be A physiological bond exists, teractive cells, interconnected by maintained. If initially visceral sustained by the soul, between all specific neurotransmitters. Psychi- molecules, such as acetylcholine, parts of the organism: it modulates atric disorders express a lack of cortisol, cholecystochinine, reach “the more and the less,” with a balance in this “network” multi- the C.N.S. in excess, and if, for in- view to a harmonious balance system diffused throughout the stance in the brain and particularly which might impose unity upon body; if one single circuit is unbal- in the hypothalamus, there is a de- differences and prevent all possi- anced—becoming hypo- or hyper- ficiency of NA and 5-HT, they ble “discordance”: the soul there- active—this passes on, in a more destabilize homeostasis in such a fore contains within itself a plan or less diffuse manner, also to oth- way that specific symptoms will which it imposes upon the body, er meshes of the network. What appear: anxiety, panic attacks, de- and which, according to Philolaus, the ancients called “soul” coin- pression, coenestopathies and vis- is sustained by a transcendentally cides with the present-day model ceral dysfunctions; perspiration, established cosmic scheme—a of psychiatric disorders: a bal- nausea, diarrhoea. This explains term etymologically deriving from anced soul expresses “eutimia,” an why a stressful event, in an indi- “cosmos,” i.e. order. Oneness unbalanced one expresses the so- vidual with a deficit in NA and 5- takes shape through harmony be- called “storms,” i.e. “pathos,” HT, gives rise to a hypothalamus- tween all the energies of the organ- “aegritude,” caused by “one of its hypophysis-suprarene hyperactivi- ism, which, without the soul, movements against nature, from ty, plus an increase in cortisol, in would lack equilibrium, thus giv- which irrationality arises.” Order acetylcholine and in cholecysto- ing rise to a sickness of the soul it- deriving from equilibrium in the chinine. Nowadays it is document- self: a disorder of the soul brings “corporeal substance of the soul,” ed that this can also have an idio- about a complex symptomatology Galen held, sustains reason, while pathic origin; in any case the un- of varying levels, degrees and ex- a disorder in the “humoral constel- balancing is caused by the com- tension with proportionate somat- lation... (sustains) irrationality.” plex neurochemical system; the ic, visceral, emotive-affective and The brain-intellect problem is deficiency of DA causes inhibited mental disorders. always the crucial point in the ef- depressions, of NA, vital depres- The present-day biochemical fort to interpret the soul’s ailments; sions, of 5-HT, seasonal depres- model of psychiatric disorders is one is faced with a soul, a body sions and a high incidence of sui- based upon a perspective similar to and a structure called “hegemon- cides. In any case, whether the dis- the classic one. The soul in fact is ic”; the latter marshals the brain by turbance be psychoneurotic— to be identified with the biochemi- means of neurochemical systems. based on the confluence of stress cal energy of the neurochemical, Humors, like the modern transmit- factors upon a given tempera- neuroendocrine, and neurovegeta- ters, are the link between the intel- ment—or endogenous, the result is “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 35

“tempests of the soul, as the Stoics the discharge of prolactin, the mo- chemical data remain present even called them.” tor function, the affective tone and after recovery and can be the cause From a clinical-nosological mental representations; its hypo- of a relapse; namely, they consist point of view, in past times the ail- functioning will be expressed in a central constitutional hyper- ments of the soul, the so-called through inhibitions, abulic depres- sensitivity of the acetilcholinergic perturbationes animi—present- sion, and an increase in prolactin, neurons in the context of a 5-HT day psychoneuroses—were nearly with ideas of guilt, ruin, death. An deficit in the hypothalamus and a always considered, both by doctors excess of DA, conversely, will low content of NA in the “locus and by philosophers, only those of bring about an opposite condition, coeruleus,” so that a stressful a reactive origin, the consequence a manic state, with euphoria, motor event will favour a hyper-activity of a reaction to stress, on the basis and verbal acceleration and mega- of the hypothalamus-hypophysis- of a predisposed temperament; as lomania. Besides, the vitalistic suprarenal axis with a consequent to symptomatology, we do not find doctors, also, insisted on the fact appearance of somatic and affec- here the psychotic features present that a cold “pneuma” determines tive symptoms caused by the emis- in manic-depressive and schizo- melancholy and a “hot” one mania, sion into circulation of massive phrenic disorders; the latter—pre- and the followers of the atomistic quantities of cortisol and cholecys- sent-day endogenous psychoses— model believed that an acceleration tochinine. Hysteric, neurasthenic, were called alienationes mentis. of the movement of the atoms in hypochondriac, depressive, anx- This conceptualization has been narrow caniculi was at the basis of ious and obsessive symptoms sim- handed down, more or less unal- mania, while a slowing down of ply express the contents and the tered, until the second half of the the movement of the “corpuscola” form of the morbid mental image, present century, when a series of in broad caniculi was at the basis of as it is determined by the type and research efforts, initiated on the ba- melancholy. The biological model character of the underlying biosis of pharmacological data, yield- of psychiatric disorders, though chemical dysmetabolism. ed surprising results. The first in- varying in the choice of the basic In their nosological classifica- sight to be gained is how the diver- matter (humours, pneuma, atoms) tion, up until the 17th century, psy- sity of the symptomatology is con- implies that sickness of the soul is chiatric disorders comprised what nected with the degree and exten- due to either an excess or a lack of is now called psychosis; only hys- sion of the destabilizing process, energy, or to so-called “mixed” teria and love melancholy were and how, nearly always, a stressful conditions, where molecules with disturbances believed to be of re- event proves to be the triggering differing activities work simultane- active origin. In the 17th century cause of all psychiatric distur- ously; black bile with yellow bile, Pisoni and Willis held that all neu- bances, which later, due to a “sen- fast atoms with slow atoms, and so ropsychiatric manifestations, from sitization” phenomenon, may oc- on, determine psychopathologies epilepsy to mania, from apoplexy cur once more, even in the absence which are atypical, because they to hysteria, should be classified as of stress; whether the etiology be associate inhibited symptoms with “neuroses,” since they are always endogenous or exogenous, it is in- excitatory symptoms. A decisive preceded by a “chemical” distur- variably the homeostatic system factor is temperament, which in bance of the C.N.S. Perdulcis, on that is destabilized—in many cas- some cases conditions the arising the other hand, believed that neu- es, indeed, the system is found to of psychiatric disorders. Tempera- rological manifestations were to be genetically meiopractic. In fact ment, if disharmonic, sustains a be considered a part of general a deficiency of 5-HT and a hyper- constitutional predisposition called medicine, while psychiatric ones sensitivity of acetylcholinergic re- proclivitas by the ancients and “hu- were to be classified as “diseases ceptors remains even when the in- moral constellation” by Galen. of the soul.” At the beginning of dividual is clinically cured, thus The abnormal temperament pro- the 19th century Pinel—though in- becoming the basis for future re- motes the emergence of pathos fol- cluding in the concept of “neuro- lapses. Proclivitas plays a power- lowing a stressful event; though sis” both neurological and psychi- ful role, one which is the Gordian often, as Aretaeus of Cappadocia atric disorders—observes how knot of all psychopathologies, both maintained, a morbid state of psychoreactive mechanisms are on a primitive basis and, as the an- health is already present, as in love involved in the latter. However, in cients were wont to say, on a “sym- melancholy, which only comes to the sphere of cerebral neuroses, he pathetic” one. Nowadays it is doc- light when the tie with the love ob- identifies two sub-classes: one, umented that the neurotransmitters ject is broken. where tangible organic impair- control functions which, if im- Temperament is determined by ment of the brain is present, and paired, might present as symp- the physical factor which is domi- the other, vesaniae, where the dis- toms: 5-HT controls sleep, alimen- nant at the root of the dissymme- orders are caused by the intellect tary and sexual behaviour; its hy- try: if we have a slight constitu- and the affective functions. All the pofunctioning will generate bulim- tional excess of black bile, there psychopathological disorders, ia, insomnia, daytime sleepiness, will be a depressive temperament, such as melancholy, mania, and sexual dysfunctions. NA gov- if of yellow bile a choleric one, if catalepsy, acquired idiotism (mod- erns the life drive, energy and vis- of blood a hypomanic type, if of ern schizophrenia), hypochondria ceral stability; its dysfunction will pituita an abulic-apathetic tem- and panic attacks, belong to the involve asthenia, vital sadness, perament. Modern research also latter. He then isolated the so- vegetative disorders. DA controls has evidenced how abnormal bio- called “genital” section of the neu- 36 DOLENTIUM HOMINUM roses, which includes satyriasis vegetative pneuma is deranged. Indeed, Hippocrates had already and priapism in the male, and Only a domination “as firm as a identified two types of melan- nymphomania and hysteria in the rock” is able to control pathos, i.e. choly: one sine causa and the oth- female. For the genesis of vesani- the so-called “waves” of passion: a er cum causa, i.e. connected to ae he identifies the decisive role of domination that “turns” towards “motivated sorrows... in an indi- two factors: a primitive disposition the ideal sane reality can—as vidual with a depressive tempera- of the temperament associated Socrates, Plato, and Crisippo be- ment.” Humours are always at the with sorrow, fear, loss of love, al- lieved—manoeuvre pathos. core of psychopathology, but in cohol abuse and so on and stressful While medical theories believe the first case, it is actually they events. In the case of hysteria, that the derangement of the soul is that, originating from the viscera, Pinel acknowledges two factors: a brought about by visceral humours create a demissio animi in the thu- predisposition (“excessive physi- which modify the brain’s chemico- mos and indirectly derange the cal and sentimental sensitivity”) physical state (corruptio cerebri), C.N.S., thus generating the symp- and occasional events such as thus giving rise to the symptoma- toms; while in the second case a “lively emotions and the privation tology, the philosophic trend of predisposed temperament, along of amorous pleasures.” Towards thought, along with vitalistic doc- with a triggering event, underlie the end of the 19th century we tors such as Stahl, sees the process their dysmetabolism. The latter is have, with Dubois, a rigorous clas- from an opposite point of view: the a typical case of classic aegritudo, sification of all psychopathologi- morbid image favours congruous the sad and painful suffering of the cal disorders into two categories: thoughts and affections, which in- soul, in reaction to a triggering psychoses and psychoneuroses, fluence the logos, giving rise to the event. However, although nosolo- the latter being so called both be- visceral symptoms. Aristotle had gy might attempt to substantially cause of the absence of tangible previously correctly defined this discriminate, separate and identify organic damage, and because their problem in his “Physiognomica”: the basic symptomatology of each insurgence is due to a psycho- “the mind can operate on the body psychopathology—endogenous or genetic mechanism on a reactive and the body on the mind.” The reactive—as Galen declared, “fear basis. body-soul dichotomy has been and sadness”, cannot be eluded by At the beginning of the 20th handed down to the present day confirming interpretative and century psychoneurosis is thus and is currently elaborated accord- metaphoric symptoms. In his Se- considered as opposed to the psy- ing to two perspectives: “The tenth cretum, Petrarch calls aegritudo a choses; as Kraepelin asserts, it is a revision of the international classi- sickness of the soul, but is actually psychogenic disorder, while the fication of syndromes and behav- describing a major depression with latter are of somatogenic origin. iour disorders” confirms the psy- melancholia: “In this distressful Previously Dubois, while exalting chogenic origin of neurosis, while desolation everything is hard, the scientific medicine of the APA’s “DSM IV” excludes it, be- wretched, frightful; all leads to time—based on Virchow’s cellular lieving it to be an ambiguous clin- desperation and drives to ruin;... model, applicable, in his esteem, ical concept, and places it under this is no longer a time of light and to the psychoses—had maintained the generic heading of “disorder”: life, but is infernal night and cruel that “psychoneuroses” were a dis- anxious, obsessive, of conversion, death.” turbance of psychogenic origin and often ad dystimia and minor The morbid image created by the connected with “thought and the depressions. atra bilis evokes fear and sadness, imaginative processes,” wherefore bows down the ego and drives an their pharmacological treatment is individual to death; according to out of the question: a “psycho- Crisippus, this psychopathology moral treatment” is the most indi- finds its origin in an evil part of the cated; the psychiatrist must apply self which creates and agitates hor- himself to “man’s moral renova- rid spectres and incites to false tion.” Psychoneuroses, particular- judgments, and thence to delirium. ly reactive-neurotic depression, It is exactly in this context that coincide with the “pathos” of the Socrates and Plato believe an inner Stoics and are nosologically op- transformation to be therapeutic— posed to the psychoses, since they taking a new direction, turning are not triggered by humours but one’s gaze towards goodness and by erroneous thoughts, false judg- truth. This education, based upon ments and mental representations self-awareness, gives the ego such invalidated by passions. The a power that it becomes capable of “phantasm”, uncontrolled by the challenging every disease of the logos, agitates the body, thus pro- soul—as Socrates demonstrated in voking a perturbation with somat- the face of death. Lack of self- ic-vegetative repercussions: as awareness fosters sickness of the Zenon had previously maintained, soul; the foolish individual is op- it might be likened to the “convul- posed to the wise, who remains im- sive” flight of an alarmed bird, or perturbable when assailed by the to a storm of passions by which the waves of passion. The biological “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 37 trend believes that the morbid im- deficit or of a hyperactivity of the Hippocrates, causes an uteri trans- age is created by humours, while idiopathic energy of the soul; it is motio and its consequences, hence the philosophical model sees it as a evident that here the symptoms ex- called “hysteric” symptoms—a terrible spectre ensuing from pas- press nothing but an underlying theory which Freud had resumed sions or from the evil part of the biochemical mutation acting upon with an interpretation transferring self. Therefore, although the se- the energy of the soul. the emphasis onto the pathogenic meiologic design is identical, that The biochemical transformation role of a mental image full of li- which discriminates between the of the C.N.S. can therefore be de- bido which overflows into the two models in the role played by termined by an event whenever body—currently appears outdated; the etiological factor: humoral or there exists an individual disposi- conversion hysteria has disap- psychogenic. tion due to a central deficit of NA, peared and a clear accentuation of In its interpretation of the sick- DA and 5-HT along with a hyper- depressive disorders in women can nesses of the soul as minor psy- activity of the visceral molecules; be observed; that which, due to the chopathological structures, the whereas, in endogenous disorders, customs of the time, took on a psy- medical model borders onto the this unbalance is favoured by an chosomatic expression, today ap- philosophic one: in hysteria, innate familial/genetic disposition pears for what it is in reality: the hypochondria, love, melancholy, which can cause it in absence of phenomenic manifestation of a de- the symptoms are determined not triggering factors, via a phenome- pressive suffering of the soul. so much by humors as by “vapors”, non of sensitization called “Kind- Love melancholy, also, along i.e. by gaseous emanations which ling.” with Theophrastus’ lassitudo ten- the passions promote by “heating” The bridge between endogenous siva, or the panic attacks described the humours: fear, rage, sadness— diseases of the sound and psy- by Aretaeus of Cappadocia, Celius of reactive origin—cause the for- choreactive ones has been ade- Aurelianus’ aerophobia and Temi- mation of aeriform substances quately documented by both phar- son’s pantophobia are nowadays which act upon the viscera, the maco-therapeutic results and by believed to be symptoms associat- “thumos”, and the mind, giving experiments performed upon newed with a minor depression called origin to the symptomatology. An ly born rhesus monkeys preco- dystimia. Eutimia is not compara- analogous answer is nowadays ciously estranged from their moth- ble to Parmenides’ perfect One- given to psychopathologies with ers; a percentage of the latter pre- ness, but it is rooted in an optimal anxiety, panic attack, asthenia, resent depressive behaviour with ap- balance between opposed mole- active depressions, somatoform athy, abulia, refusal of food, and cules. It is well know how the in- and psychosomatic disorders, such isolation; moreover, there occurs tercellular relationship is founded as the irritable colon. In these cases also a reduction in liquoral NA, upon two receptors, one pre- and it is proved that a constitutional DA, and 5-HT. The symptomatol- the other post-synaptic; eutimia is deficit of NA and DA in the locus ogy recedes with antidepressive based on their well-balanced rela- coeruleus and in the nucleus ac- treatment; pretreatment with psy- tionship. The presynaptic receptor cumbens facilitates a destabilizing chotropic drugs prevents the de- with inhibitory functions controls of homeosthasis due to an irruption pressive reaction of abandonment. the discharge of the neurotransmit- into the central nervous system of In this perspective the concept ter in such a way that it be neither cortisol, acetylcholine, and, above of a “frustrated eros,” i.e. the excessive nor insufficient, and so all, of an intestinal neuropeptide, stressful event which, according to that the number of the post-synap- cholecystsochinine. tic receptors will be adequate to Moreover, triggering events are the stimulus. An excess or a defect to be found both in psychotic in pre-synaptic activity, caused by mood disorders and in dystimic a deficit of 5-HT with modulatory (psychoneurotic) disturbances, function, triggers an imbalance. If while in recurrent bipolar and the presynaptic receptor is more diphasic form one witnesses a sin- efficient in inhibiting, fewer neu- gular phenomenon already de- rotransmitters are discharged and, scribed by Galen and Aretaeus of in turn, the post-synaptic receptors Cappadocia: for a certain period increase. the patient is sad and frightened, Conversely, if it is less active, a he desires death and is overcome greater quantity of neurotransmit- by feelings of guilt caused by ters are produced, and the post-re- black bile, which “surrounds and ceptors decrease. This gives rise to smothers reason”; but suddenly, the imbalance and hence to the ap- due to a biochemical veering, he pearance of the symptomatology: becomes euphoric, active, he be- the sense of malaise, the aegritu- lieves himself a strong man, he do, epiphenomenon of a pre/post thinks he is a great poet, a very receptorial deregulation, with in- wealthy person, “he advances as if hibited or excited symptoms—just wearing a crown.” In these cases as the doctor friend of Lucretius, the sickness of the soul, according Asclepiades of Prusa, had hypoth- to Aristotle, is the result either of a esized, with an interpretative mod- 38 DOLENTIUM HOMINUM el deriving from the reductionism tive,” and which often make it im- seen as a divine curse; hysteric of Democritus. possible to adequately adapt the re- crises are not considered a sign of The answer of psychiatry to the quirements of life; the journey antisocial behaviour; the “hu- inclusive interpretation of all sick- from the subjective spirit to the ob- mours” (i.e. the soul) influence nesses of the soul as expressions of jective spirit to the objective and fi- both the brain and the intellect; psychopathology, is based upon nally to the absolute spirit, as the they are an intermediary which extremely reliable experiential da- classics had pointed out, is only for conforms mental representations ta; semeiological variations are the wise. Indeed, psychiatry does and supplies energy to the analytic correlated with co-morbidity phe- not assume the responsability of and synthetic activities of the lo- nomena: e.g. depression in the educating humanity; good and evil gos; if the soul is disturbed, the young presents with varied symp- express two moments of life, not body is disturbed, the logos is over- toms, often behavioural, not infre- infrequently social epiphenomena whelmed and loses its autonomy. quently with dependence on sub- of an imbalance which is not only The malaise of man, all that—as stances, in an attempt to control a individual but, indeed, arises from Bleuler asserted—makes humanity biochemical imbalance. Even biochemical derangements. unstable, can be traced back to the schizophrenia is seen nowadays as To summarize, the soul—ac- dissymmetry of the soul, to that an imbalance between 5-HT and cording to classic thought, from disorder which, if slight—as Aris- DA in a subject presenting a con- the philosophers of nature to Aris- totle and Ficinus thought—under- genital structural cerebral impair- totle and Galen—is endowed with lies “generous melancholy,” by ment caused by temporo-limbic at- a physical nature, an intrinsic ener- which the death drive is sublimated rophy. A 5-TH deficit might cause getic power, “it is the effector of it- in artistic, philosophic, and scien- suicidal behaviour, obsessive com- self” and activates the body; in tific forms “so that not all of me pulsive disorders and bulimia, be- physiological conditions the logos might have an end.” All that man sides seasonal depressions con- governs the soul. Logos, body and has created finds its origin in a nected with the decrease in dura- soul are in harmony with one an- slight biochemical dissymmetry of tion and intensity of sunlight. other, in the sense that the guide, the soul which, if rigidly symmet- Janet’s psychasthenia, deriving the active system and the body are ric, would become monotonously from mental weakness, Charcot’s finalistically coordinated with one and physiologically contented and hysteria, called “traumatic neuro- another. The soul lives in a cosmic blissful, wholly absorbed in placat- sis,” Bead’s neurasthenia—attrib- system, by which it is influenced, ing desire with the object of desire, utable to the stress of the convul- because it is made up of the same and then waiting for a new urge to sive life of big cities—prove to be elements as nature. When inter- appear, just for the pleasure of sat- psychoneuroses from a phenome- preted, in this way, the soul coin- isfying it. nological point of view but, bio- cides completely with the neuro- As regards therapy of the disor- chemically, mere dystimias. It is chemical and neuroendocrine sys- ders of the soul, strictly speaking, well known how heroin, alcohol, tems and its relationship with cog- i.e. present-day psychoneuroses, cocaine are made use of in an—al- nitive and somatic functions takes the ancient physician would gener- beit vain—attempt to balance an place as outlined by Aristotle. The ally accomplish it by prescribing underlying aegritudo of a depres- cosmic influences upon the soul drugs such as hellebore, mandrake, sive type. It is also the case of psy- are widely proved also on the level opium—the latter especially in chopathic personalities such as in- of psychopathology: let it suffice cases of hysteria because, as Galen veterate gamblers, aggressive to mention the variations of aminic believed, it is the eutimic tranquil- characters, and obdurate philan- metabolism in relationship with lity medicine. In the case of love derers, who achieve, by means of the duration and intensity of sun- melancholy, the first stage is char- their behaviour, an increase in light, and how certain types of de- acterized by advising the patient to their cerebral NA and hence a pression and mania are correlated travel, thus removing him from his chemical euphoria. with variations in 5-HT which oc- habitual context, or suggesting that The course of life is complex, cur in autumn and in summer. he take up pastimes, or other dis- and not infrequently hampered by The ailments of the soul, when tractions, which might lessen ten- mental and physical disturbances released from astral hypotheses— sion of the mind and the memory which make it difficult and danger- one might recall Saturn and melan- of the loved one, such as reading, ous; Plato has referred to the philo- choly, pseudoreligious configura- physical exercise, convivial meet- sophic “life-raft” one needs to go tions, such as the myth, which con- ings; medical therapy is centered through life, and St. Augustine has siders them as indicators of a di- on a moderate use of wine, opium, observed how only Christ can be of vine curse, or the sociologic model and hellebore, which is considered valid assistance in the existential which sees the symptoms as signs an antidepressive substance. In journey of man. The philosophic of antisocial behaviour—are seen straightforward reactive cases, ail- answer to the soul’s ailments as by Hippocrates, who acquires the ments of the soul are dealt with by given by Crisippus and Seneca, by way of thinking of Heraclitus and means of a supportive psychother- Socrates and Kierkegaard, by of Anaxagoras, as the “epiphenom- apy called consolatio. Kant, Hegel and Nietzsche have enon” of a humoral imbalance. If we look at Dubois and Freud, not always attributed the proper Melancholy is no longer an indica- this psychotherapeutic approach is value to the biological factors, tor of Saturn’s influence, nor is the centred upon an educational which Morel called “degenera- desperate weeping of Bellerofon strengthening of the self, in the “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 39 first scholar’s opinion and, with in the symptomatology, though trast to the psychiatric tradition— Freud, in the effort to reach-by supported by an associated cogni- supported by a grossly mistaken means of free associations and the tive or relational psychotherapy. view of the basic structure of the interpretation of dreams the core Considerating that the neuro- soul. The latter is seen, according of the conflict, the “hidden” image chemical derangement proves to to some interpretative models which nurtures the symptomatol- be the final common outcome pro- (such as the one based on the ethic ogy. In both cases the consolatio ceeding from a series of pathogen- rationalism of Socrates or modern of the Stoics and the Socratic ic factors—somatic, familial/ge- idealism) as something immaterial maieutic method may be recog- netic, exogenous/stressing—and and impalpable, while for classic nized: the more one understands that it is the symptom which ex- medico-philosophic thought and of oneself, the more one is freed presses it, a re-equilibrium of “the for all the vitalistic scholars, the from the symptoms. Today—from power of the soul,” in Alcmeon’s soul’s substance is completely ma- a psychiatric point of view, given words, may be reached through terial and intrinsically autonomous the results of biological re- the biological route, by acting on as the derivability of its own ener- search—neurotic, obsessive, pho- the pathogenic mechanism; this gy, just as we find it in the activity bic, hypochondriac, bulimic, might seem to be a reductionistic of the so-called biogenic amines. anorexic, anxious and neuras- approach, but one might also re- thenic disorders are all treated call how Epicurus emphasized with the same therapy prescribed that a “narrow model” always Professor GIUSEPPE for the treatment of humour disor- gives excellent results. ROCCATAGLIATA Associate Professor of Psychiatry ders, i.e. smaller doses of drugs We believe, with this modest at the University of Genoa which have an effect on the specif- contribution, to have cleared up a Member of the National ic systems believed to be involved crucial misunderstanding—in con- Research Council, Italy 40 DOLENTIUM HOMINUM

JOSÉ MANUEL BERTOLOTE

Mental Disorders Around the World: An Epidemiological Overview

Introduction cenna left us an excellent example place during that period. Under the of clinical work with remarkable influence of the prevailing scien- The origins of psychiatry descriptions of meningitis, melan- tific climate set by giants such as cholia and dementia. Darwin, Claude Bernard, Pasteur, Before we start to say how many During the Middle Ages, mental Comte, and following the paths people there are with mental disor- disorders were seen mostly as con- opened by masters such as Kock ders and where they are, we must sequences of sins, of demoniac and Virchow, the knowledge and say who people with mental disor- possession and of witchcraft, be- practices which constituted Psy- ders are today; or, in other words, ing treated accordingly. Neverthe- chiatry as a special branch of Med- what the currently prevailing con- less, this period also witnessed the icine were structured by what cept of mental disorders is. establishment of the first hospitals could be called the Fathers of What we consider today as ma- exclusively dedicated to people Modern Psychiatry: Pinel and jor mental disorders have always with mental disorders. The names Kraepelin. and everywhere been perceived as of Father Juan Jofré and Joao This new, scientific and modern something beyond normalcy, Cidade (later known as Saint John psychiatry was basically an insti- something which caused suffering, of God) must be remembered in tutional psychiatry, based in men- awe, fear. Admittedly, explana- this context. tal hospitals, paralleling what was tions on the cause and meaning of happening in medicine as a whole. these phenomena have varied However, psychiatrists of this peri- across time and place. Neverthe- The birth of scientific psychiatry od were acutely concerned with less, there is solid documentary the well-being of patients and the evidence that the ancient. Egyp- Despite all the rich tradition so question of Human Rights recently tians already identified and devot- far mentioned, it was not until the raised by the French Revolution. ed their attention to hysteria, 18th century that scientific psychi- In addition to the humanization of proposing the displacement of the atry developed. It came on a par psychiatric care represented by the uterus as its cause. This was also with the development of the clini- removal of chains and shackles of seen in ancient Greece, where Hip- cal and basic sciences which took patients and a policy of “open pocrates, the Father of Medicine, door” hospitals developed by Ellis also described melancholia and and Conolly in the UK, a concern where some forms of psychothera- with broader social issues is repre- py (e.g. catharsis) were already sented by the promulgation of the employed. In old India the roots of landmarking French Mental psychopharmacotherapy can be Health Law of 1838, whose influ- found in the use of preparations of ence extended until the present in Rauwolfia, Papaver (opium) and some places. Here, the name of Es- Cannabis (marihuana) for the con- quirol must be mentioned as an ex- trol of different forms of human ample of a psychiatrist who ex- suffering. celled as both a clinician and In the Talmud we can find early nosologist and as a social re- references to current principles of former. During this period, Char- mental hygiene, and in the Islamic cot was one of the most remark- world we have the first examples able neuropsychiatrist, as psychia- of institutional care of people with trists were then considered. mental disorders, in maristans, Drawing from the experience of madrasas and tekkes. From the the past, and like the dwarf on the Arabs we also inherited examples shoulders of the giant, psychia- of community care for people with trists of the present century have mental disorders. The great Avi- greatly expanded and extended the “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 41

benefits made available by succes- The frequency TABLE No. 6 sive generations of clinicians, re- of mental disorders searchers and administrators. In Looking specifically at mood fact, Pelicier considers that in the Now let us move to some data on disorders, epidemiological studies 20th century, psychiatry has the magnitude of mental, behav- anticipate that there are 335 mil- reached the age of maturity. ioural and neurological disorders lion people with major depression In 1892 a first International in the general population. I should (which emerges as the most fre- Nomenclature of Diseases was start by saying that the frequency quent of all forms of mental disor- adopted which contained some 13 of these problems are counted in ders) and 23 million cases of bipo- categories related to what we con- millions, which already gives an lar disorder. sider today as mental disorders. idea of its size, and that roughly one in every four or five inhabi- TABLE No. 7 TABLE No. 1 tants of this planet is affected by BERTILLON’S NOMENCLATURES some form of mental disorder. In terms of dependence on a OF DISEASES, 1892 psychoactive substance, we have 1,100 million cases of nicotine de- 56 Acute or chronic alcoholism TABLE No. 3 64 Apoplectic dementia pendence, 250 million cases of al- 65 Brain necrobiosis (softening) PEOPLE WITH MENTAL DISORDERS cohol dependence and 15 million 67 General paresis AROUND THE WORLD cases of dependence on other 68 Other forms of mental alienation drugs. Epilepsy cases are counted 69 Epileptic dementia as over 40 million. 73 Choreic dementia 74 Hysteria 120 Uremic dementia (Bright’s desease) Mental and psychological 140 Puerperal madness problems in PHC settings 154 Senile debility 26 % 173 Fatigue (surménage) TABLE No. 8 179 Delusion In a study conducted by WHO That Nomenclature was the in 14 countries during which forerunner of the WHO Interna- 25,916 people seeking care in pri- tional Classification of Diseases mary care facilities were exam- (ICD-10), currently in its 10th Re- Globally speaking, we estimate ined, well-defined mental disor- vision, with more than 300 types that there are more than one and a ders were found to be frequent in of mental disorders, which makes half billion people with some form all the general health care settings: the ICD-10 chapter on Mental and of mental disorder, if tobacco de- 24%. This means that one in four Behavioural Disorders the longest pendence is included in our calcu- persons seeing a doctor had a cur- one in the whole ICD—10. All lations. rent diagnosable mental disorder. these disorders are grouped under In addition, a significant propor- ten major categories, as indicated tion of the patients (9%) suffered in Table 2. TABLE No. 4 from a “subthreshold condition” that did not meet the diagnostic As for mental disorders sensu TABLE No. 2 criteria for research but neverthe- strictu, we have, approximately, less had two or more clinically sig- WHO’s ICD-10, Chapter V, 1992 more than 480 million cases of nificant psychological symptoms F0 Organic, including symptomatic, anxiety disorders, 350 million cas- (e.g. sleep, fatigue) and dysfunc- mental disorders es of mood disorders, 250 million tioning in their daily lives. F1 Mental and behavioural disorders cases of personality disorders, 60 due to psychoactive substance millions cases of mental retarda- use TABLE No. 9 F2 Schizophrenia, schizotypal and tion, 22 million cases of schizo- delusional disorders phrenia and 29 million cases of de- DIAGNOSES FOUND IN PRIMARY F3 Mood (affective) disorders mentia. HEALTH CARE SETTINGS F4 Neurotic, stress-related and Current Depression 10.4 somatoform disorders Generalized Anxiety Disorders 7.9 F5 Behavioural syndromes TABLE No. 5 Neurasthenia 5.4 associated with physiological Harmful Use of Alcohol 3.3 disturbances and physical factors In relation to anxiety disorders, Alcohol Dependance 2.7 F6 Disorders of adult personality and specific disorders represent 154 Dysthymia 2.1 behaviour million cases of generalized anxi- Panic Disorders 1.1 F7 Mental retardation Somatization Disorders 2.7 F8 Disorders of psychological ety disorders, 80 million of panic Agoraphobia with Panic 1.0 development disorders, 66 million of post-trau- Hypochondriasis 0.8 F9 Behavioural and emotional matic stress disorder (PTSD), 58 Agoraphobia without Panic 0.5 disorders with onset usually million of obsessive-compulsive Two or More Mental Disorders 9.5 ocurring in childhood and disorders (OCD) and 57 million adolescence cases of somatization disorders. Total 24.0 42 DOLENTIUM HOMINUM

TABLE 4 - PEOPLE WITH SOME MENTAL DISORDERS AROUND THE WORLD It is legitimate, then, to conclude that among primary care at- Anxiety disorders 480 tenders at least one third requires Mood disorders 360 careful attention for psychological problems. Given the huge num- Personality disorders 250 bers of people attending PHC Mental retardation 60 everyday, we are confronted with Dementia 29 a real major public health prob- Schizophrenia 22 lem. We cannot overemphasize the importance of primary health million 0 100 200 300 400 500 care settings for the control of mental disorders. Although many practitioners at TABLE 5 - PEOPLE WITH ANXIETY DISORDERS AROUND THE WORLD PHC settings were aware of the nature of psychological disorders, many patients with psychological Generalized 154 problems were not recognized by Panic 80 doctors. Doctors identified one PTSD 66 quarter of PHC attenders as having a psychological problem, OCD 58 whereas the research instrument Somatization 57 (CIDI-PHC), identified one third; however, the agreement between million 0 50 100 150 200 the two modalities of identification was not sufficiently high. There was also evidence that TABLE 6 - PEOPLE WITH MOOD DISORDERS AROUND THE WORLD many cases who were adequately identified were not properly treated. Major From other WHO studies we al- depression 335 so know that no more than one percent of all people with mental disorders become psychiatric in- Bipolar patients. Therefore, in the commu- disorder 23 nity remains an “invisible majority”; as is the case with an iceberg, million 0 100 200 300 400 as psychiatrists we usually only see the tip.

TABLE 7 - PEOPLE WITH SUBSTANCE USE DISORDERS AROUND THE WORLD The social burden of mental disorders Tobacco dependence 1100 We can look at these facts from Alcohol dependence 250 another perspective, and measure the impact of mental disorders through the burden of the disabili- Drug dependence 35 ty created by them. The World Bank did this, in collaboration million 0 200 400 600 800 1000 1200 with WHO, and came to the conclusion that mental disorders cause 8.1% of the burden due to all diseases. TABLE 8 - PSYCHOLOGICAL PROBLEMS IN PRIMARY HEALTH CARE SETTINGS TABLE No. 10

Current mental disorder 24% The disability caused by mental disorders is markedly higher than Subthreshold 40% disability associated with chronic physical disorders such as dia- No psychological symptoms 36% betes, back pain, hypertension and arthritis; all types of cancer, for instance cause 5.8% of all disability. If we extend our definition of cas- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 43

TABLE 10 - ECONOMIC BURDEN DUE TO DISEASE AROUND THE WORLD es to include behavioural disorders (such as those associated with 8% Mental disorders substance abuse, violence and sui- All other diseases cide) we reach a proportion of approximately 45% of the burden. 55% 37% TABLE No. 11

If we look at the social burden Behavioural disorders from a more humanitarian rather than economic perspective, the number of affected people jumps TABLE 11 - MENTAL DISORDERS AROUND THE WORLD from 25% of individuals suffering from mental disorders to an aston- Individuals with ishing 78%, which also include 26% mental disorders their relatives. 74% TABLE No. 12

From this perspective three- quarters of mankind is directly or indirectly touched by mental disorders, which is more than a good TABLE 12 - MENTAL DISORDERS AROUND THE WORLD reason to give them a high priority from both a public health and a so- 22% cial development perspective.

78% Professor JOSÉ MANUEL BERTOLOTE Director of the Department of Mental Disease Control at the Division for Mental Health and Prevention of Substance Abuse People affected by mental disorders (individuals & family members) at the World Health Organization Geneva, Switzerland 44 DOLENTIUM HOMINUM

YVES PÉLICIER

Genetics and the Environment

It seems to me that the observa- pendently of such human activity, for men and for nature. This is often tions which have been made now whether this activity is deliberate or forgotten not least because of the require a brief consideration of the a question of chance. These damaging and negative impact of question of the relationship be- changes are such that it is difficult power—and we often have to pay a tween genetics and the environ- to distinguish between “natural” heavy price for this error. ment. nature and a “natural” product The history of biological inheri- The environment is not only that which has been used, modified, al- tance began with Haeckel who which surrounds the individual in a tered, or improved by man. The hu- demonstrated that the development physical sense. It is also that which man environment develops side by of an embryo contained within it exists for him at a moral and physi- side with or against nature, or ph- the development of its species—its cal level. Husserl here is referring ysis. The plant or animal species, phylogenesis. Later Mendel de- to Umwelt. Von Uexkull employs the directions which rivers take, scribed the classic features of re- the term Umgeburg to refer to an and the quality of water should di- production in plants and the laws overall material environment. He rect human work within a frame- which can be deduced from the me- defines Umwelt as this field of pres- work of respect for all the objects of chanics of that reproduction. In ence—the environment within this work and for the ethical needs 1903 Sutton advanced the chromo- which man expresses himself. which are revealed in this site and somic theory of inheritance (chro- The way in which the world is location. mos—color). Morgan studied the conceived establishes the concepts What the problem and the threat development of the drosophila of which refer to a set of empirical re- of pollution serve to do, for exam- vinegar. De Vries (1880) and Dar- alities. The living being maintains ple, is to place things and words in win analyzed pangenesis—that is, his contact with the environment, a place of primary importance in the existence of elements which are Jaspers maintains, but subjects this the questionings and anxieties of separate from inheritance. The pan- life to a knowledge which is both modern man. How can we with- genes (Johannsen) have four prop- physiological and psychological. draw from the imposing responsi- erties: replication (that is, the abili- The real world—which is objec- bility of having avoided the adop- ty to form copies of themselves); tively empirical—is the world of tion of ethics which have no weak- functions (the capacity to determine technology, society, the economy, nesses and no false appearances? a given characteristic); recombina- and politics. The world of nature, like that of hu- tion (the ability to form typical The environment is the outcome man activity, does not escape the bonds); and mutation (the ability to of complex and intricate actions range of this constant question change the environment on their which at the same time force and which will either protect us against own). Bateson invented the term impel the individual to defend him- human evils or lead to us being “Mendelism” and explained the re- self. Jaspers goes on to say that the overwhelmed. sults that Mendel had achieved with individual must defend his history, In an etymological sense reference to the fact that every char- the opportunity to experience his “progress” is what describes and acteristic depends on a gene which liberty—that liberty from which his explains forward movement. Ever involve two alternatives or states— personal continuity springs, a world since the nineteenth century the alleles. The somatic cells have which is also the temporal “progress” has been a key word. It two similar examples. One of the dwelling-place of an existence. is true that the reality of progress chromosomes comes from one par- This existence is at a fundamental cannot be disputed but questions ent and the other from the other. level the site and location of tran- can be raised about its value. It can- There are two types of chromo- scendence. not be affirmed that safe progress somes—those of gender and the au- We can define the environment exists merely because the history of tosomes. Thus one can observe that as a set of natural and cultural con- the world seems to demonstrate the male has one chromosome— ditions which are likely to act upon such progress. What can be said is chromosome XY—whereas the fe- living organisms and upon human that such progress exists when it is male has two XX chromosomes. activity. Nature is what exists inde- useful, productive and beneficial The number of chromosomes “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 45 varies according to the species. The electrons, but with a tree which de- tion carried out by the OSI (Bureau human genome (or genic structure) scribes the functional and ancestral pour l’Integrité de la Science) has has twenty-two pairs of autosomes affinities which exist between hu- not yet been finished. The whole and two sex chromosomes. Some man genes.” He goes on to explain episode brings out the risks that are ferns have five-hundred chromo- that “in the same way as chemists involved in high science. Given the somes. An intestinal worm has two can recognize atoms from their consequences for research and for chromosomes. One species of mon- mass and their charge, so biologists patients, it is clear that prudence is key has forty-six chromosomes and will be able to create systems by of the essence. a gorilla has forty-eight chromo- which it will be possible to recog- But we also have to guarantee somes. nize every gene from an examina- medical secrecy. In 1995 New What is called gene chemistry tion of a characteristic fragment.” Hampshire was the first state to has been a subject of study for some Cancer of the ovaries involves a prohibit employers and insurance fifty years. Deoxyribonucleic acid hereditary predisposition in 5-10% companies from carrying out genet- (or DNA) is a molecule composed of victims. The genetic link is ic tests to achieve a diagnosis and of four nucleotides with an azoic found through the BRCA1 locus on make an assessment. During a con- base and a phosphoric group. The chromosome 17qA1. The average ference held in Berlin the Associa- letters A, B, G and T are used to de- age is lower in instances of this tution Internationale du Barreau fine the DNA sequence. DNA ex- mor (forty-one as opposed to sixty- called for limitations to be placed ists in the form of a double line one). One is dealing here primarily on access to an individual’s genetic which forms a double helix. with a serious kind of cancer whose dossier in the same way as refer- The DNA of a living creature potential evolution is more favor- ence cannot be made in certain situ- contains the genetic information of able. The prognosis is better. The ations to a person’s religion, politi- that species. Each locus is the site same kinds of results have been cal beliefs, ethnic group, or sexual of a gene on the chromosome. We found in relation to colon-rectum preferences. know how to transcribe genes, cancer. However, legal experts have cer- translate them, clone them (that is, 10% of prostrate cancer cases al- tain doubts as regards insurance insert a fragment of DNA into a so display a hereditary predisposi- and the premiums to be paid! Each vector), use hybrids, and so forth. tion and often involve genetic risk. illness involves genetic risks, but In 1990 the genome program was Ethnic differences have an im- their evaluation is not always easy set in motion by the United States portant role to play in the presence or precise. This explains the diffi- of America and other countries of cancer. However, this does not culties in such measures, whose im- which have the research facilities apply to breast cancer and womb portance in the life of a man cannot and resources which allow them to cancer. Black Americans are seven be disputed. support such an initiative. The aim times more likely to fall victim to In this way the use of genetic da- of this program or project is to con- prostrate cancer than Koreans. Rare ta is not relevant when information struct a genetic and physical map of kinds of tumor are to be found is provided about the possibility of the human genome. In this way it is among the Eskimos (cancer of the a tumor many decades before it oc- hoped that many illnesses caused bladder); the American Red Indians curs! by genetic factors would be discov- (thyroid cancer); and the Chinese Should we speak out or keep qui- ered and understood in their work- (nose and pharynx cancer). et? We should assess the direct risks ings. It appears that in the case of which are involved, but we should This program and the mapping of CADASIF (cerebral autosomal also examine the consequences for the human genome rely to a great dominant artheriopathy with neu- a person’s way of life. Quite apart extent upon computer methods and roencephalopathy) which is marked from genetic risks, there are also techniques. Various approaches are by early and returning cerebral he- certain risks in the consumption of employed. For example, there are morrhage, the gene is connected to alcohol or other toxic substances, in the genome studies of the hybrid ir- chromosome 19. However, here the the excessive intake of food, in ex- radiation phenomena which take mapping process is not yet com- aggerated exposure to the sun place when fractures occur. At the plete. (melanomas), in the absence of present time new genes and the way We already knew how to tell the treatment for benign conditions they work are studied. But this is truth, or what was believed to be the which can degenerate into more se- neither sufficient nor decisive for truth. We also know how to lie and rious forms, and so forth. our purposes. to falsify. Man has responsibilities which A researcher at the Massachu- Should we be surprised that the we should meet with medicine, ed- setts Institute of Technology (MIT) human genome project has in- ucation and charity. This is the has called for a new program which volved fraud at the very highest lev- meaning of the Christian message studies chromosome 17 and its role el? Collius Francis, the director of from which we cannot depart. It is in the inheritance of diabetes. the project, has revealed that one of our duty to know this message and “The human genome program his assistants modified the data and to uphold it—we have before us an tends to produce a periodic biologi- invented a mass of work over a pe- opportunity to be men among men. cal classification involving not a riod of two years. The seventh stage hundred elements but one hundred of work involved an error of rea- Professor YVES PÉLICIER thousand genes. Not with a rectan- soning which suggested the pres- Emeritus Professor of Psychiatry gle which reflects the values of the ence of a deception. The investiga- at The René Descartes University, Paris 46 DOLENTIUM HOMINUM

BONIFACIO HONINGS

The Man of the New Creation: From the Image of God to the Likeness of Christ

In his first letter the apostle St. must also think of the man created ment of the constitutive act “in Peter writes: “If, after all, you by God in paradise and, above all, paradise” and its loss; and 4) the should have to suffer in the cause he must also acknowledge fallen moment of the new creation “in of right, yours is a blessed lot. Do man or man the sinner, the man the likeness of Christ.” not be afraid or disturbed at their who abused the freedom of his The man of the new creation threats; enthrone Christ as Lord in paradise at the beginning of histo- finds his origin in Christ, the your hearts. If anyone asks you to ry. In other words, the man of the Anointed of the Father, who be- give an account of the hope you new creation is the same man came man like us so that every cherish, be ready at all times to an- whom God—after creating him in man could become once again swer for it, but courteously and his image, both male and female— “like” God—that is, a new crea- with due reverence.”1 These revo- established in a state of grace. ture in the likeness of the Risen lutionary words of the first Vicar An argument based upon bibli- Christ. of Christ challenged, and still chal- cal theology, such as that which I lenge, men of all times and of all present in this paper, must for this places, and they are words which, reason take as its point of depar- 1. The Three Moments above all, challenge the men of the ture the divine project of the cre- of the Divine Project third millennium. ation. At a more specific level it of the Creation of Man The title of this international must begin with the first of the conference is “In the Image and three key moments of that creation If we read closely what God in Likeness of God: Always? Disor- and then go on to examine them in Genesis reveals about man, we can ders of the Human Mind.” This detail. This paper is thus organized perceive at the outset the act of conference seeks to give an inter- into four separate subsections, creation. In the symbolic presenta- disciplinary answer to this “his- which indeed correspond to this tion of the work of God as a series toric challenge” of the Christian endeavor: 1) the three moments of of six days of divine “work,” there faith. My contribution, which goes the divine project of the creation of is nothing which does not owe its under the title “The Man of the man; 2) the moment of the creative own existence to God. The world New Creation,” is thus one of the act of “in the image”; 3) the mo- began when it was created from answers which this international nothing by the Word of God. All conference seeks to give to those existing creatures, the whole of na- who pose questions about this ture, and the whole of human his- faith. I hope that it is an answer tory find their roots in this primor- which will give a solid base to the dial event. Every creature has its trust of all those who suffer but al- own goodness and its own perfec- so, and above all, to those whose tion. The various creatures whose spiritual soul experiences the “or- specific being was willed by God ganic” limits of its own faculties or received their own character, truth, finds itself impeded in the exercise goodness, their own laws, and of those faculties. their own order at this precise mo- In order to explain the organiza- ment. For this reason, every creation of this paper in clear and con- ture reflects a ray of the infinite cise fashion, I would like to ob- wisdom and goodness of God in its serve at the outset that this answer own particular way. However, the is based upon the divine project of concept of the “six days” not only the creation. Indeed, the person seeks to express the interdepen- who refers to the man of the “new dence of the created beings, but al- or second creation” cannot but so, and above all, communicates have in mind the man of the “old their hierarchy, their structured or- or first creation.” Furthermore, he der from the least perfect to the “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 47 most perfect.2 “The sun and the visible creation.”8 Thus the moments of the creative project of moon, the cedar and the little Church, in giving an authentic in- God and in this endeavor especial flower, the eagle and the sparrow: terpretation to the symbolism of attention will be paid to the mo- the spectacle of their countless di- biblical language in the light of the ment of the new creation. versities and inequalities tells us New Testament and Tradition, that no creature is self-sufficient. teaches that our progenitors, Adam Creatures exist only in dependence and Eve, were created in an “origi- 2. The Moment of the Divine on each other, to complete each nal state of holiness and justice.”9 Act Creating of Man other, in the service of each oth- Such is the second moment of the “in the Image of God” er.”3 The order and the harmony of divine project of the creation of the creation spring from this diver- man. All, whether believers or not, sity of beings and the relationships But “this entire harmony of agree that everything that exists on which exist between them. We can original justice, foreseen for man the earth should be seen in the con- grasp that the beauty of the cre- in God’s plan, will be lost by the text of man, and that man is its ation reflects the infinite beauty of sin of our first parents.”10 Howev- center and its summit. But the an- the Creator. er, and here we encounter the third swers to the question What is However—and this is what moment of the creative project of man? vary and are also contradic- most interests us in this paper—the God, after this fall man is not tory. Indeed, man often exalts him- inspired account of the creation abandoned by God. On the con- self to such an extent as to become clearly reveals that man is at the trary. God calls him11 and informs an absolute rule or, on the other summit of the creation. Indeed, the him in mysterious fashion that evil hand, debases himself to the point Creator clearly distinguishes be- will be defeated and that man will of desperation only to end up, as a tween the creation of man and the rise above the fall.12 “This passage consequence, immersed in doubt creation of other beings and organ- in Genesis is called the Protoevan- and anxiety. The Church feels this isms. The formation of man is de- gelium (“first gospel”): the first difficulty very keenly and believes scribed in a way which is peculiar announcement of the Messiah and that she can give an answer which to him even though it is clear that Redeemer, of a battle between the comes from the teaching of divine man, like other beings, has his ori- serpent and the Woman, and of the revelation. This teaching describes gins in a divine act of creation. The final victory of a descendant of the real condition of man, gives a oldest account that we have tells us hers.”13 Such is the announcement reason for his sufferings, and helps that man was taken from the dust to man of the new creation. The him to achieve a just recognition like other animals and is thus mor- Magisterium of the Church speci- of his dignity and vocation.15 tal in the same way as they are. fies that this creation exceeds the With the authority of the Coun- However, his breath of life comes original holiness and justice of cil Fathers, the Church answers from the breath of God, something man in paradise. “The first man man’s question about his identity which does not apply to the cre- was not only created good, but was with the statement that he is creat- ation to any other animal.4 The also established in friendship with ed “in the image of God.” This most recent account of the creation his Creator and in harmony with means that man is able to know thus presents man as the work of a himself and with the creation and to love his own Creator and to solemn divine decision: “Let us around him, in a state that would rule over all creatures, over which, make man in our image.”5 Because be surpassed only by the glory of indeed, he has dominion, for the of this special form of divine cre- the new creation in Christ.”14 We glory of God.16 This is the reason ation, and, therefore, because of will now consider the individual why “man expresses within him- his resultant special nature, man self, because of his very corporeal occupies the central and summit condition, the elements of the ma- position of the visible world. Such, terial world, with the result that indeed, is the first moment of the through him they reach their sum- divine project of the creation of mit and take on a voice to freely man. praise the Creator.”17 In the same Against this background of the way, man is a being “in the image creative act of God, the Old Testa- of God” because he has the dignity ment revelation enables us to un- of a person. He is not something, derstand not only that God created but somebody, or, rather, he is an the first man as good, but that He individual human who is capable also wanted to create him in an of knowing himself, of possessing original state of holiness, and thus himself, of giving himself freely, in a state of original justice. The and thus of entering into a commu- sign of friendship between man nion of life and of love with other and his Creator lies in the fact that people.18 God places him in a garden where Among the visible creatures, he lives “to till it and keep it.”6 man is the only creature made “in Work is not a heavy burden,7 “but the image of God” and he is thus rather the collaboration of man and able to enter into dialogue with woman with God in perfecting the Him, to know Him, and to love 48 DOLENTIUM HOMINUM

Him. Man is a “subject aware of ated “in the image of God” pre- may live.”28 This is what St.Paul himself, free, and open to the infi- cisely as a “unity of soul and means when he declares: “So may nite. He knows himself, he asks body.” the God of peace sanctify you himself questions, he possesses Moreover, he is also the “image wholly, keep spirit and soul and himself, and he gives of himself. A of God” when male and when fe- body unimpaired, to greet the corporeal and sexualized subject, male. This does not mean that God coming of our Lord Jesus Christ he receives and transmits life in a is in the image of man. God is nei- without reproach.”29 It should be fabric of relationships.”19 This is ther man nor woman. “God is pure observed at this point that the why man is not in error when he spirit, in whom there is no place Apostle does not introduce a dual- perceives himself as being superi- for the difference between the sex- ity into the soul with this distinc- or to mere corporeal entities and es. But the respective ‘perfection’ tion. “Spirit” means that from the why he sees himself as something of man and woman reflect some- moment of his creation man is des- more than a mere particle of nature thing of the infinite perfection of tined for a supernatural end30 and or an anonymous element of the God: those of a mother25 and those that his soul is able to be freely el- human city. “Indeed, within his in- of a father and husband.”26 Man evated to the communion of life ner self he transcends the universe. “in the image of God” is a corpore- with God.31 Man, therefore, in the It is to this profound interiority that al and sexualized subject who re- divine project of the creation, was he returns when he turns to the ceives life from God and he him- from the outset ordained to a su- heart where God is waiting for self, as male and female, transmits pernatural end. As a result, his soul him, God who sees into hearts, it in the form of responsible col- was capable of being elevated there where he decides upon his laborators of the Creator.27 But through grace to sharing in the life own destiny under the watchful what has been hitherto observed of love of his Creator. gaze of God. For this reason, in about man created in the image of Here we encounter the theologi- recognizing that he is an immortal God is not all that there is to be cal reason why God created our and spiritual soul, he does not al- said on the subject. On the con- progenitors in a state of original low himself to be deceived by fal- trary. There is an action on the part holiness. “The eternal Father,” ex- lacious fictions which derive sole- of God the Creator which is even plain the Council fathers, “created ly from social and physical condi- more sublime and more elevated the universe with a most free and tions, but comes, rather, to touch in character. arcane plan of wisdom and good- the truth of things at their deepest ness. He decreed the elevation of level.”20 men to sharing in his divine life.”32 At this point, it is very important 3. The Moment of the Because it well characterizes the to dwell upon the symbolic lan- Establishment of Man second moment of the divine pro- guage of the biblical account of the “in Paradise” and Its Loss ject of the creation, attention divine creation of man. In order to should be paid here to this grace of reveal that the human person creat- Man came into the light as a pro- original holiness or, rather, this ed in the “image of God” is a being ject to be carried to its conclusion sharing in the divine life which po- made up of both body and spirit, because God called him to cooper- tentiated through its radiance the sacred author employs the fol- ation. This is what is well revealed every dimension of the life of man. lowing terms: “Then the Lord God by the words of God: “I have set The force of this radiance of the di- formed man of dust from the before you life and death, a bless- vine innerness of man by God ground, and breathed into his nos- ing and a curse; therefore, choose meant not only that man did not trils the breath of life; and man be- life, that you and your descendants suffer but even that he did not die. came a living being.”21 This clearly The Church teaches that “by the reveals why the body of man takes radiance of this grace all dimen- part in the dignity of being in the sions of man’s life were con- “image of God.” It is, indeed, “a firmed. As long as he remained in human body precisely because it is the divine intimacy, man would animated by a spiritual soul.”22 For not have to suffer33 or die.34 The in- this reason “spirit and matter in ner harmony of the human person, man are not two natures united, the harmony between man and but, rather, their union forms a sin- woman,35 and, finally, the harmony gle nature.”23 This unity of the soul between the first couple and all and the body is thus so deep as to creation, comprised the state render the soul the “form” of the called ‘original justice.’ ”36 body. It should be observed here, However, the sharing of man in and the point is most important, divine life “was realized, above that “the Church teaches that every all, within man himself: self-mas- spiritual soul is created immedi- tery. The first man was unimpaired ately by God—it is not ‘produced’ and ordered in his whole being be- by the parents—and also that it is cause he was free from the triple immortal.”24 Therefore, and here concupiscence37 that subjugates we encounter the great dignity of him to the pleasures of the senses, each and every person, man is cre- covetousness for earthly goods, “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 49 and self-assertion, contrary to the sin, and it brings condemnation we enter to the full into the answer dictates of reason.”38 The second upon all; one man makes amends, to the question posed by this inter- moment of the divine project of and it brings to all justification, national conference, which is at the creation, therefore, consists in that is, life.”45 The Apostle of the the same time an answer to the the fact that the man and the gentiles is convinced that this is “lighter-flint” challenge of our woman found themselves in a state the third and last moment of the bearing witness to hope. To the of friendship with God from which creative project of God. He says question whether a man with a dis- sprang the happiness of their exis- so in explicit terms when he re- order of the mind is always in the tence in paradise. The life of man veals the divine plan of salvation image and likeness of God I reply: in paradise was marked by a three- to the Ephesians: “Blessed be that he is certainly always “in the im- fold harmony—the religious, the God, that Father of our Lord Jesus age” but he is also in a certain way intra and inter personal, and the Christ, who has blessed us, in always, and to a greater extent, “in cosmic. This man, it should be ob- Christ, with every spiritual bless- the likeness of Christ.” For the served with care, “was destined to ing, higher than heaven itself. He sake of clarity and to avoid misun- be fully ‘divinized’ by God in glo- has chosen us out, in Christ, be- derstanding, I would like to ob- ry.”39 fore the foundation of the world, serve that I am not entering here This would have happened were to be saints, to be blameless in his into the question of the state of it not for the fact that, when tempt- sight, for love of him; marking us grace of individuals or of what reed by the devil, man “let his trust out beforehand (so his will de- ligion they belong to. I am refer- in his Creator die in his heart40 and, creed) to be his adopted children ring here to every human person abusing his freedom, disobeyed through Jesus Christ. Thus he who suffers from a mental disor- God’s command.”41 “In that sin would manifest the splendor of der. man preferred himself to God and that grace by which he has taken In part the answer is based upon by that very act scorned him. He us into his favor in the person of the doctrine of the Church that chose himself over and against his beloved Son.”46 The victor man “Disfigured by sin and God, against the requirements of over evil and the raiser of man death..., remains ‘in the image of his creaturely status and therefore from the fall predicted by the Fa- God’...but is deprived ‘of the glory against his own good... Seduced ther of the Book of Genesis, there- of God,’52 of his ‘likeness’.”53 But by the devil, he wanted to ‘be like fore, is Christ. Indeed, Christian in part also, and above all, upon God,’ but ‘without God,’ and not tradition perceives in the Protoe- the fact that the divine promise in accordance with God.”42 The vangelium47 the announcement of “made to Abraham inaugurates the dramatic and immediate conse- the “new Adam”,48 who, through economy of salvation at the culmi- quence of this first sin of disobedi- his obedience “until death on the nation of which the Son himself ence was the loss of original holi- cross”,49 “makes amends super- will assume that ‘image’ and re- ness and, as a result, of original abundantly for the disobedience of store it in the Father’s ‘likeness’ by justice as well.43 The Fathers of Adam.”50 The Apostle is right giving it again its Glory, the Spirit Vatican II clearly lay down that all when he refers to superabundant who is ‘the giver of life’.”54 The men are involved in the sin of amends because the original holi- answer of our hope is that of hope Adam. “Indeed, if man looks into ness and justice of paradise are against all hope of the descen- his heart, he finds himself inclined greatly surpassed by the glory of dance that God promised to Abra- also towards evil and immersed in the new creation in Christ.51 ham, namely Christ. In Him the many sufferings which certainly I would like to point out that outpouring of the Holy Spirit was cannot derive from the Creator, with this salvific mission of Christ to reunite “the children of God who is good... In refusing to accept who were dispersed”.55 Indeed, God as his principle, man frac- God undertook by an oath56 that he tured due order in his relationship would make the gift of his Chosen to his end and at the same time the Son57 and the gift “of the Holy whole of the order towards him- Spirit; a pledge of the inheritance self, both towards other men and which is ours, to redeem it for us towards the other created forms.”44 and bring us into possession of it, But in line with a promise made and so manifest God’s glory.”58 by God towards our progenitors, The Chosen Son, therefore, took his project of the creation also has on our flesh: “And the word was a third moment. The universality made flesh, and came to dwell of the salvation of Christ follows among us; and we had sight of his on from the universality of sin and glory, glory such as belongs to the death. Father’s only-begotten Son, full of grace and truth.”59 However, and this is a very important point, the 4. The Moment of the man for whom Christ made him- New Creation of Man self man was lacking in original in “the Likeness of Christ” holiness or rather the Glory of God, of the “paradisal” likeness to Indeed, “one man commits a God. This is why in his letter to the 50 DOLENTIUM HOMINUM

Galatians St. Paul writes: “God cause Christ lives it together with is for this that we sigh, longing for sent out his Son on a mission to us. you, shares your ill-destiny and the shelter of that home which He took birth from a woman, took your well-being, as if they were heaven will give us... For this, birth as a subject of the law, so as his.”69 From the “ likeness to nothing else, God was preparing to ransom those who were subject Christ” it follows that Christ, pre- us, when he gave us the foretaste to the law, and make us sons by cisely because he is the “perfect of his Spirit.”72 adoption.”60 In other and more in- man,” is the model of life for each In the light of this faith I feel cisive words the Word became and every man. myself authorized to declare that flesh so that we would become par- St. Paul declares proudly and every suffering person, and above ticipants “in the divine nature.”61 quite rightly that he does not all every person who suffers from “Indeed,” observes St. Irenaeus of preach his own cause but that of a mental disorder, not only resem- Lyons, “this is why the Word was Jesus Christ the Lord. For this rea- bles the Crucified One, but be- made man, and the Son of God, son his words and above all his life comes in a special way a person Son of Man: so that man, entering bear witness to a force which is “in the likeness of Christ” because into communion with the Word present, in specific fashion, in the he shares in the suffering and the and thereby receiving divine filia- fragility and the suffering of man. death on the cross of Christ. This tion, could become a son of As St. Paul writes to the Corinthi- reply, obviously enough, leads to a God.”62 St. Athanasius of Alexan- ans: “Always we, alive as we are, reflection upon the salvific value dria writes in a similar vein: “The are being given up to death for Je- of the mystery of the cross. What- Son of God was made man to sus’ sake, so that the living power ever the circumstances involved, a make us God.”63 And St. Thomas of Jesus may be manifested in this person marked by the cross of a Aquinas declares in the same way: mortal nature of ours. So death mental disorder challenges us to “The Only-Begotten Son of God makes itself felt in us, and life in judge the cross that he bears: either wanted us to be participants in his you.”70 it is madness or it is strength. It is divinity and took on our nature so We should observe with very really true that this person more that, when made man, he could great care that St. Paul intrinsically than any other can pose to the men make men gods.”64 connects the death of Christ which of today the provocative questions Christ, therefore, restored “that he (the Apostle) carries in his mor- of St. Paul: “What has become of likeness to God” which is “specif- tal flesh with a transcendent force the wise men, the scribes, the ic to Him” to fallen man—that is, of life which is inherent in suffer- philosophers of this age we live man deprived of his likeness to ing and death. In the light of faith in? Must we not say that God has God. Indeed, “Christ’s human na- St. Paul does not hesitate to write turned our worldly wisdom to fol- ture belongs, as his own, to the di- about this nexus of “power” be- ly?” vine person of the Son of God, tween suffering/death and life and And the person suffering from a who assumed it. Everything that to observe accordingly: “He who mental disorder, more than any Christ is and does in this nature de- raised Jesus from the dead will other person, has the right to an- rives from ‘one of the Trinity’. The raise us too, and summon us, like swer: “When God showed us his Son of God therefore communi- you, before him... No, we do not wisdom, the world, with all its cates to his humanity his own per- play the coward; though the out- wisdom, could not find its way to sonal mode of existence in the ward part of our nature is being God; and now God would use a Trinity.”65 And given that each one worn down, our inner life is re- foolish thing, our preaching, to of us has been taken on by the freshed from day to day.”71 save those who will believe in it. Word66 we can observe and under- The suffering and death of hu- Here are the Jews asking for signs stand that all of the riches of Christ man existence on earth precisely and wonders, here are the Greeks “are for every individual and are because they are able each day to intent on their philosophy; but everybody’s property.”66 renew this existence are able to be- what we preach is Christ crucified; This is true for every human per- come effective factors—and even to the Jews, a discouragement, to son, but it is also and “always” endless sources—of looking for- the Gentiles, mere folly; but to us true—and here we touch upon the ward to eternal life. This hope who have been called, Jew and title of this international confer- which will never be disappointed Gentile alike, Christ the power of ence—for the individual who suf- not only is never discouraged but God, Christ the wisdom of God.”73 fers from a mental disorder. The directs its gaze beyond the visible And thus we come to the con- Catechism of the Catholic Church and the ephemeral world. For this cluding observations of this paper. makes it clear that: “We are called reason the man of the new creation The people who suffer from a only to become one with him, for becomes evident when he profess- mental disorder are like every oth- he enables us as the members of es and confesses with the absolute er person, always beings “in the his Body to share in what he lived certainty of the faith of St. Paul image of God.” And from a certain for in his flesh as our model.”68 and all those who believe in Christ point of view they are such to a Furthermore, to every man, wher- that: “Once this earthly tent- greater extent because the Son of ever he may be, the Church has the dwelling of ours has come to an Man took upon himself man suf- following good news to announce: end, God, we are sure, has a solid fering because of sin, pain, and “God loves your life, whether building waiting for us, a dwelling death. In the same way, the people healthy or sick, happy on unhappy, not made with hands, that will last who suffer from a mental disorder virtuous or disfigured by sin, be- eternally in heaven. And indeed, it are, more than any other person, “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 51 always beings “in the likeness of suffering servant, united himself to 28 Dt 30:19. 29 I T 5:23. Christ” precisely because they every person suffering from a 30 Vatican Council II: DS 3005. challenge all to express them- mental disorder. For this reason we 31 Cf PIUS XII, Encyclical Humani Generis: selves in relation to the salvific can understand that Christ took on DS 3891. See also CCC, n.367. 32 Lumen Gentium, n. 2. value of the mystery of the suffer- their suffering. There follows from 33 Cf Gen 2:17; 3:19. ing and death of Christ on the this—and here we come to a wit- 34 Cf Gen 3:16. cross. nessing to hope and the reply to the 35 Cf Gen 2:25. 36 CCC, n. 376. Every person who suffers from a question posed by the title of this 37 Cf 1 Jn 2:16. mental disorder, therefore, is “in International Conference—a ques- 38 CCC, n. 377. the image of God” because one has tion about the term “always,” for 39 CCC, n. 398. 40 Cf Gen 3:1-11. before one an “anthropological-re- on the day of the resurrection 41 CCC, n. 397. ligious” title which does not de- every person suffering from a 42 CCC, n. 398. pend upon having or knowing, or mental disorder will share in a 43 Cf Rom 3:23. 44 GS, n. 13. upon the more or less “effective very special way in the glory of the 45 Rom 5:18. capacity” of a sound mind, but up- Risen Christ precisely because he 46 Eph 1:3-6. on their “being-a-person”—that is, will have shared in and expressed 47 Cf Gen 3:15. 48 Cf 1 Co 15:21-2, 45. their unity of body and soul. Their through his body—and in a very 49 Phil. 2:8. being as an image of God depends special way—the “re-animating” 50 Cf Rom 5:19-20; CCC, n. 411. exclusively upon the fact that their power of the suffering and death of 51 Cf CCC, n. 374. 52 76 Rom 3:23. corporeal-being has a spiritual Christ. In finishing this paper, I 53 CCC, n. 705. soul. Their body, their mind, and would like to stress the witness to 54 CCC, n. 705. their will are “in the image of hope that is offered to us by all per- 55 Jn 11:52. 56 Cf Lk 1:73. God” precisely because they are sons suffering from a mental disor- 57 Cf Gen 22:17-19; Rom 8:32; Jn 3:16. animated by their spiritual soul der: they are a disfigured image of 58 Eph 1:13-14. which is created directly by God God offering the divine guarantee 59 Jn 1:14. 60 Gal 4:4-5. and not produced by their parents. that all men have already been re- 61 2 Pet 1:4. It is not the use of their mental ca- stored to the likeness of the trans- 62 ST. IRENAEUS OF LYONS, Adversus Haere- pacities which makes them be “in figured Christ. ses, 3, 19, 1. 63 ST. ATHANASIUS OF ALEXANDRIA, De In- the image of God.” It is certainly carnatione, 54, 3: PG 25, 192B. true that this use would demon- Rev. BONIFACIO HONINGS, 64 ST. THOMAS AQUINAS, Opusculum 57 in strate their being but it is not the O.C.D. Festo Corporis Christi, 1. Cf CCC, n. 460. 65 CCC, n. 470. cause and it is emphatically not the Member of the Pontifical Academy for Life 66 Consultor to the Congregation Cf GS, 22. conditio sine qua non. 67 JOHN PAUL II, Encyclical Redemptor Ho- People who suffer from a mental for the Doctrine of the Faith minis, 11. and to the Pontifical Council for Pastoral 68 CCC, n. 521. disorder are from a certain point of Assistance to Health Care Workers 69 CEI, La Verità vi Farà Liberi, n. 1015. view even more “in the likeness of 70 ST. PAUL, 2 Co 4:10-12. God” because they all in varying 71 Ibidem, 4:14,16. degrees bear the “prophetic” char- 72 Ibidem, 5:1-2, 5. 73 1 Co 1:20-24. acteristics of the suffering servant 74 Is 53:2; 52:14. of Yahweh: “He had no form or 75 GS, n. 22. 76 Cf Col 3:3-4; Eph 2:26. As an unmistak- comeliness that we should look at able and unequivocal confirmation, I quote a him, and no beauty that we should Notes reflection in a discourse by St. Athanasius: desire him... His appearance was “`For this reason Christ died and came back to so marred, beyond human sem- 1 1 Pet 3:14-15. life—so as to be the Lord of the dead and of 2 Cf Gen 1:1-25. the living’ (Rm 14:9). Indeed, for no other rea- blance, and his form beyond that 3 Catechism of the Catholic Church (here- son did he come down to the earth, enchained of the sons of men.”74 However, after CCC), n. 340. by an ancient bondage, except to break the beyond this what we might term 4 Cf Gen 2:7. bronze gates and split the iron bars of death 5 Gen 1:26. and draw our lives out of corruption to him- “external configuration with 6 Gen 2:15. 7. Cf Gen 3:17-19. self, giving us freedom to replace slavery. If Christ” there is a likeness which is 8 CCC, n. 378. 9. CCC, n. 375. the work of this divine plan does not yet ap- of a more interior nature. The fa- 10 CCC, n. 379. pear to be finished (as men indeed go on dying 11 Cf Gen 3:9 and their bodies decay in death), this fact must thers of Vatican Council II de- 12 Cf Gen 3:15. not become a motive for lack of trust. In ad- clared that: “By the incarnation the 13 CCC, n.410. vance we have already acquired a pledge... As Son of God united himself after a 14 CCC, n. 374. St. Paul says, `He has raised us up along with 15 Gaudium et Spes (hereafter GS), n. 12. him and caused us to sit in the heavens, in certain fashion with every man. He 16 Cf Ibidem. Christ Jesus’ (Eph 2:6)... In addition, the worked with the hands of a man, 17 GS, n. 14. Apostle says that this fact, well known to him, 18 Cf CCC. n. 357. will become a reality for the whole human race he thought with the mind of a man, 19 75 CF CEI, La Verità vi Farà Liberi. Cate- by means of Christ, `who will transfigure our he acted with the will of a man.” chismo degli Adulti (Rome, 1995), p. 188. wretched bodies to conform them to his glori- Now if it is true that the mystery of 20 Ibidem. ous body’ (Ph 3:21). If, then, the transfigura- each man in reality finds true light 21 Gen 2:7. tion is a changing into the spiritual body and 22 CCC, n. 364. this body is in conformity with the glorious only in the mystery of the Word, 23 CCC, n. 365. body of Christ, Christ certainly rose with a this is true, above all, of each and 24 CCC, n. 366. spiritual body, which is nothing but the lowly every man who suffers from a 25 Cf Is 49:14-15; 66:13; Ps 131:2-3. body which is sown [cf. 1 Co 15:43] and then 26 Cf Hos 11:1-4; Gen 3:4-19. Cf CCC, n. changed into a glorious one” (ST. ATHANA- mental disorder. 370. SIUS, Fifth Discourse on the Resurrection of This is because Christ, as the 27 Cf Gen 1:22. Christ, 6-7,9; PG 89, 1358-1359; 1361-1362). 52 DOLENTIUM HOMINUM

JUAN J. LOPEZ-IBOR, JR.

Research in the Field of Neuroscience and Mental Illness

Over the last few years countries gle banner of neuroscience arises aware of the fact that the indirect such as the United States of Amer- naturally from the important fact of costs are higher than those of direct ica, Japan and the members of the personal suffering; the influence health care, and that we should European Union have developed that such suffering has in the social place in the balance such factors as and promoted research programs to field; and the economic impact of the personal suffering of these sick study the human nervous system. illnesses which are in truth wide- people, the distress of their rela- These initiatives have taken place spread in their incidence. We tives, and the suffering caused to under the general title of “the should also add that the increase in those members of society who are decade of the brain” or “the decade life expectancy involves a greater directly affected by the presence of of research into the brain” (Euro- incidence of dementia (such as mental disturbance in others. pean Commission, 1992). Their Alzheimer’s disease), of distur- By extrapolation it may be calcu- aim is to improve our knowledge bance of the cerebral-vascular sys- lated that in Europe the annual cost of the most complex, intricate, and tem, and of motility, and of the of such illnesses is probably around characteristic organ of the human short- and long-term effects of such 109 million ECU; of this sum 43 being, and at the same time to dis- chronic illnesses as epilepsy and million ECU are allocated to direct cover practical solutions by which mental retardation. health care. The rest is taken up in to tackle and treat various kinds of The notable increase in depen- secondary expenses (European illnesses and their connected psy- dency forms of behavior finds its Commission, 1992). It was calcu- chosocial problems, including all most fertile terrain in modern-day lated that in Germany in 1988 14% the malfunctions and pathologies consumer society. This means that of the population—that is, 11.5 which are associated with them. pathologies of the nervous system million people—suffered from one Later in this paper I will discuss produce individual problems, fam- form or another of psychiatric dis- and consider the most important ily tensions and—in terms of the turbance. In the same year 18.9 achievements and discoveries of community at large—an impact of million work-days were lost as a re- these initiatives. major social dimensions, the loss sult of the same kind of disorder At the same time we should also of productivity, and other negative (Bundes Minster fur Arbeit, 1991). discuss and debate the limits and consequences of a markedly high Overall, it is calculated that in the limitations of scientific research in profile. countries of the European Union this field, and reflect upon the im- When we talk about a prevalence the costs of caring for illnesses of portance which should be attrib- of such disorders, in many cases the nervous system amount to 20% uted to ethical principles in this we are talking about millions of of the total health care budget. whole area. These two aspects are people who are afflicted by mental Mental illnesses involve those of essential significance if we want illness in such medium-sized coun- who are afflicted by them—and to reach the basic goal of the in- tries as France, Italy, or Spain. The those who fight against them— quiries and investigations carried data published by the National coming up against one of the great- out by men of science—the Foundation for Scientific Research est and most intimate mysteries of achievement of improved knowl- (1989) indicate that the total cost of human nature. His Holiness John edge of human nature and the hu- these forms of illness in the United Paul II drew attention to this reality man condition in order to help States of America exceeds $400 in his address to a delegation of the those who suffer because they are billion every year—that is, 7.3% of members of the American Psychi- afflicted by illness. the gross domestic product of atric Association and the World America. Of this sum, $ 136 billion Psychiatric Association in January are lost because of psychiatric dis- 1992: The Challenges of Mental orders, 104 because of neurologi- “By its very nature, your work Illnesses and the Brain cal disturbances, 90 because of al- often brings you to the threshold of coholism, and 71 because of drug the human mystery. It involves a The need to coordinate the work abuse. In order to understand these sensitivity to the often tangled of various disciplines under the sin- statistics to the full we should be workings of the human mind and “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 53 heart, and an openness to the ulti- a branch of study which enables us 3. The development and the plas- mate concerns which give meaning to perceive individual signs within ticity of the nervous system, in- to people’s lives. These are areas of the neurons; to new forms of elec- cluding: the way in which the ner- great importance to the Church, tronic microscopy; to the construc- vous system, its cells and intracel- and they call to mind the urgent tion of images through the employ- lular organs develop, how the ner- need for a constructive dialogue ment of radioisotopes and magnet- vous system regenerates itself, between science and religion for ics—elements which enable us to growth factors and cell transplant. the sake of shedding greater light have an ever clearer idea of the Here we should also include stud- on the mystery of man in its full- structure and the function of the ies into cell damage and cell death ness. brain in live individuals operating (including spontaneous death), “Only by transcending them- in normal conditions or performing normal and pathological ageing, selves and living a life of self-giv- certain tasks; to the culture of live and neurotoxicity (the influence of ing and openness to truth and love cells and tissues; and to computer exogenic and endogenic toxic ele- can individuals reach fulfillment technology and automatic electron- ments on neurons). and contribute to building an au- ic instruments—discoveries which 4. The behavior of the individ- thentic human community”. pave the way for techniques and ual. We should lay especial empha- The World Bank has published strategies by which to produce sis upon cognition, learning and certain data which enable us to drugs and medicines which are memory, motivation, the emotions, evaluate—albeit in a rather approx- ever more effective in their impact. intelligence, and upon the disci- imate way—the level of disability The most important subjects of plines of psycholinguistics, psy- produced by certain illnesses. The research conducted in the field of chology, neuropsychology, aetiolo- index employed in this study is that modern neuroscience can be gy, and artificial intelligence. of years lost because of this disabil- placed within the following five 5. Pathologies. This heading in- ity (Disability-adjusted life years, major categories: cludes psychiatric, neurological or DALYs). 34% of these years lost 1. The neuron—that is, the nerve and cerebral-vascular illnesses, the are caused by behavioral problems; cell. Here we are dealing with such mechanisms of pain, drug abuse 8.1% by mental illnesses in the areas as: and addiction, and pathologies strict sense of the term; and 3.2% a) the chemical elements which connected with the phenomena of by vascular-cerebral illnesses. It transmit the signal of one neuron to growth and ageing. should also be stressed that 45% of another (neurotransmitters, neuro- the DALYs are connected in one modulators, neuropeptics, and hor- way or another with the workings mones); its receivers, channels, Examples of Research of the brain, or the brain itself— transporters and messengers all of with an Overall Approach that primary organ which is at the which play a role in communicat- core of all human activity. ing between neurons and the ner- Two examples illustrate very vous system and such other sys- well what are, and what could be, tems as the endocrinal system and the forms of progress and advance Developments in the Field the immunological system; in this whole field. The first con- of the Neurosciences b) the protein structure and the cerns research into the origins of biophysical and biochemical as- schizophrenia—a very serious Neuroscience has four principal pects of these signals; form of mental illness which af- objectives: c) the genesis and migration of flicts 1% of the population (Tsuang 1. To study the brain and the ner- neuron particles, the cell skeleton, et al., 1991) and which only a few vous system in general. the interactions between neurons decades ago was very likely to con- 2. To inquire into the various re- and other cells, the structure and demn those who suffered from it to lationships between the brain, the function of synapsis, and the struc- live within the walls of a lunatic mind, and human behavior. ture which links one neuron to an- asylum. Today, however, treatment 3. To create bridges between bi- other. results in a success rate of at least ology, the human sciences, sociolo- 2. The brain considered and ana- 50%. gy, and computer science. lyzed in overall terms through: Over a long period of time psy- 4. To explore the origins, and Ð examination of how this organ chiatrists have studied the influ- produce a diagnosis and treatment, constructs its perception of the ence of biological factors (whether of the illnesses connected with the world beginning with elementary genetic or acquired), psychological brain and the nervous system. sensorial signs; inquiry into how factors, and family and social fac- The discipline of neuroscience the brain engages in visualization tors, in the outbreak and emergence has created a broad variety of in- (cerebral imagination) and into the of schizophrenia. In recent years a struments by which to conduct re- workings of its metabolism in liv- model has emerged which is search and these have become ever ing beings; and the study of how termed “the vulnerability model” more sophisticated over time. In drugs and medicines which act on and this allows us to explain—al- analyzing these instruments special the central nervous system actually beit in approximate fashion—what reference should be made to mole- function—something which is of actually takes place during the cular biology—a discipline which vital importance in the discovery course and development of the ill- studies how genes express them- and identification of new pharma- ness. The model is based partly up- selves; to genetics; to biophysics— ceuticals. on the presence of a certain genetic 54 DOLENTIUM HOMINUM inheritance—the rate of presence viral outbreaks—factors which and evolution of the illness in- of the illness in identical twins is could leave subtle traces and effect volved far fewer difficulties and 50% whereas in non-identical the development of the brain. problems for those who had to treat twins it is about 10%, the same rate The vulnerability model explains it. as occurs in siblings (Tsuang et al., the interaction between cerebral In this study, an examination of 1991)—and partly upon environ- factors and other factors of a bio- biographical data and cerebral mental factors. Within this last cat- graphical character. In general, the damage showed that such factors egory a broad range of psychoso- illness emerges during adolescence were more influential in schizo- cial and biological factors are pre- but manifests itself earlier in males phrenic patients than in those who sent, some of which affect the indi- than in females (Beiser et al., did not develop any illness at all or vidual and his brain at very early 1990). It is often connected with in those who were schizoid. These stages of his or her development. very evident stress factors which data suggest that the schizoid indi- Others, however, act during the pe- are provoked by situations of rapid vidual inherits a genetic predispo- riod of adolescence when the ill- social isolation (as for example oc- sition to the illness but that he leads ness first emerges. curs in the phenomenon of emigra- an exceptionally favorable life Brain-image techniques such as tion). These factors can provoke which protects him against its out- computerized axial tomography the emergence of schizophrenia in break and emergence. Exactly the (Nasrallah et al., 1982; Messimy et individuals who have a natural vul- opposite may be said of the schizo- al. 1984) and magnetic resonance nerability to the illness. The distur- phrenic individual. In his case such (Andreasen et al., 1986) reveal bance of development and growth protection is not present or opera- anomalies in the development of which has already been mentioned, tive. the brain, especially in relation to manifests itself in specific expres- This kind of hypothesis opens asymmetries. What is very interest- sions of the personality which in- the door to the prevention and the ing is that cerebral asymmetry is volve a tendency towards emotion- treatment of this malady. This is accompanied by a parallel asym- al isolation and impoverished because schizophrenia is not a pro- metry in the cranial bone (Messimy forms of interpersonal communica- gressive illness but an illness which et al., 1985; Falkai et al., 1992) and tion. At the outset these phenome- has a specific period of risk—that this means what has happened na permit the individual who is af- is, the period which runs from the within the brain took place within flicted by them to live at a cer- ages of fifteen to twenty-five in the first months of life—that is, be- tain—albeit limited—level but males and a few years later than fore the cranium had completed its subsequently they create an inabili- this in females. process of ossification. These ty to manage and tackle new situa- The second example is to be anomalies are not progressive and tions and requirements. found in patients who have a limit- are not connected to the develop- The Danish study referred to ed kind of disturbance (borderline ment of the illness. This is a factor above took a set of children all of disturbance) of the personality and which plays a part in the early ori- whom were seven years old and all who display an impulse towards gins and not the evolution of such of whom ran the risk of falling vic- suicidal behavior. In such people anomalies (Andreasen et al., tim to schizophrenia because their we have discovered (López et al., 1986). mothers suffered from the illness. 1990), through the use of a tech- The other data available which Because of this family back- nique involving neuroendocrinal sustain this thesis of early origins ground,it was expected that 10% of stimuli (the phenylfluramine test), are the studies upon cohorts—that these children would develop the presence of very high basic is, the monitoring of a specific set schizophrenia. The probability rate concentrations of cortisol (some- of people over many years or was therefore ten times higher than thing which suggests a very high decades. A good example of this is in the rest of the population. This level of stress) and a very flat re- the Danish study on schizophrenia study, which was carried out over a sponse to stimuli (something which (Parmas et al. 1982; Mednick et period lasting some decades, iden- suggests a reduced ability to react al., 1987). Such studies demon- tified certain individuals who de- to external stimuli). The same phe- strate the presence of such different veloped schizophrenia, others who nomena are present in individuals factors as cerebral damage at an were normal, and a third group of who are addicted to heroine and early age and negative conditions people who demonstrated a schizo- who as a result are undergoing nal- during the growth and develop- phrenia disturbance which is trexone treatment. ment of the individual (broken termed “schizoid disorder.” The The key by which to understand families, orphanages, negative members of this third group dis- these results is to be found in the conditions, and an impoverished played certain symptoms associat- work of Sapolsky (1990). In the upbringing) during his or her child- ed with schizophrenia such as iso- African savanna of the Serengeti hood. The virus theory of schizo- lation in communication with oth- this scholar studied the stress adap- phrenia (Adams et al., 1993) is ers, difficulties in the formation tation systems of a certain species supported—but not always demon- and maintenance of social relation- of monkey (papiones). The strated by—a relationship between ships, problems in relation to their colonies of these monkeys live in the illness and individuals who are personal identity, and emotional in- very favorable conditions and cir- born during the winter (and thus stability. But they did not display cumstances, distant from the threat more exposed to viruses) or in cer- symptoms of delirium or forms of of predators and largely protected tain years when there are greater hallucination and thus the course against irregularities in the quantity “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 55 and quality of their food supply. The Problem of Truth though it belonged to those who re- The privileged society of the mon- in Psychiatry buke him, to those who search him keys of the Serengeti is highly hier- in a physical sense or send out bolts archical. The dominant males The classic definition of deliri- to injure his body or invade his reach their position of dominance um—that proposed by Esquirol at thought and his inner self. through a system of alliances, be- the beginning of the nineteenth The tandem of falsehood and the trayals and struggles which when century—of a false idea which is irrefutability of logical argument reached is then maintained through imposed pathologically and inex- proposed by Esquirol reminds us of the employment of a series of con- orably over logical thought is one the concept of madness adhered to ventional gestures. The males of which has been criticized by many in classical Greece—the arrogant the lower levels constantly have experts in the field, most notably negation of reality. This arrogance, high concentrations of hydrocorti- by Jaspers (1955) and by Schneider that which cannot be refuted by sone—the stress hormone—in (1930, 1949). The proposition that logic, is the delirious certainty their bodies whereas the high-rank- delirious ideas are pathological be- which also imposes itself on the ing males have low levels of this cause they are imposed pathologi- sick person himself. substance. However, the concen- cally is a line of reasoning which is For a long time psychiatry found trations rise rapidly within the locked into its own vicious circle. itself in a position of unease in rela- high-ranking males during mo- The truth or falsehood of a deliri- tion to the question of truth, even ments of stress only to diminish ous idea can be tested every day though, as is more than evident, immediately afterwards. For this through an observation of ideas this difficulty was built into the reason one can easily perceive that which are accepted in certain cul- very definition of the delirious the low-level males, who indeed tural contexts and not others. From idea. It was for this reason that the live in a permanent state of stress, this point of view, the boundary be- removal of the classic definition are not able to bring other re- tween delirium and belief becomes was followed by a definition of the sources of adaptation into play a more than evident matter of de- delirious idea which began with its (such as an increase in the secretion bate. structure and its content. This line of hydrocortisone) when new In an attempt to expand and of approach adopted by the Heidel- stress-inducing situations arise and deepen our knowledge of delirious berg school (Jaspers, 1955; Schnei- present themselves. ideas, Kunz (1954-55) sought an der, 1930, 1949). According to this That one is dealing here with the idea model of the psychology of a approach, the fidelity of the wife is consequence of rank rather than its healthy individual which had a in a certain sense irrelevant in un- cause (the alternative explanation structure similar to the delirious derstanding the delirious idea of is that the monkeys that are better ideas of people afflicted by schizo- jealousy. Nothing prevents the equipped in a physiological sense phrenia. However, he found only delirious person from being certain reach the highest positions as a re- one such idea—the idea of death. of what he believes. Treatment of action to stress-inducing situations) In this idea the same mechanisms the delirium of the jealous person was demonstrated by what hap- of defence are manifest as those does not have anything to do with pened after the revolution of 1981. which are to be found in delirious whether the other party is really be- During the revolutionary period the ideas. traying him. In the same way, it is members of the colony came to oc- One of the central and dominant not of importance whether the cupy different roles and even characteristics of the delirious per- hypochondriac really suffers from though there was always a high-up son is his inability to tolerate ambi- a serious illness. This line of ap- monkey which managed to affirm guity, and this is something which proach reached its culminating and uphold his privileges, the mon- leads him to fall into an unalterable point in Schneider (1949), who ar- key-society itself lost its stability. certainty. The human being lives in gued that delirium expresses itself By this route the characteristic two worlds—that which is shared in two forms—the delirious per- physiology of the dominant males (koinos cosmos) and that which is ception and the delirious idea. which was marked by adaptation to his own (idios cosmos), this latter In my opinion this line of ap- stress was also lost. Furthermore, being made up of fantasies and illu- proach is no longer valid or sus- these males, like the rest of the sions. This ambiguity also applies tainable. Schneider himself (1951) monkeys, had very high concentra- to his body (as was observed by announced the end of psy- tions of hydrocortisone in their Meleau Ponty, 1942, 1945) of chopathology and dedicated his bodies throughout the revolution- which at one and the same time one last years to the study of theology. ary period. When peace was re- can say that he is it and that he has Indeed, we can see that the analysis stored, the normal results to be exit (Marcel, 1955). Ambiguity is a of the question of what truth is be- pected from the hierarchical posi- radical feature of human existence came the means by which the crisis tion of each monkey were ob- and thus of human knowledge as of psychopathology could be over- tained, regardless of what the se- well. This intolerance which is ex- come. cretion levels of cortisol and tes- perienced by the delirious person To express the point very simply, terone of each of them had been be- leads him to alienate an important it is possible to affirm that truth is fore the revolution. This means that part of his psychic life which there- not a one-sided concept. A logical the hormonal changes were a con- by ceases to belong to him. To put truth exists which is in opposition sequence and not a cause of the so- it another way: he lives his body as to falsehood and a metaphysical cial position of each male monkey. though it were not his own, as truth exists which is opposed to the 56 DOLENTIUM HOMINUM illusory, to the unreal (Ferrater Mo- the jealous person which prevents structure of evil, has been seen as ra, 1979). From Aristotle onwards, him from going beyond his own the fundamental question of sci- truth was seen as the adaptation of state of jealousy. ence, or at least of social science the intellect to the thing. Despite We should not neglect the fact (Becker, 1980). This means that this fact and tradition, Heidegger that these ideas have very impor- science of necessity has an agnos- (1953, 1964) explored the concept tant practical implications. The tic root. of truth along the lines adopted by McNaughton norms (West and This statement clashes with the the pre-Socratic philosophers. He Walk, 1977), for example, have point of view advanced by T.H. saw truth as a process of discovery, lain behind the evaluation of penal Huxley, the thinker who coined the a means by which to unveil the hid- responsibility in mentally ill people term “agnostic.” Huxley believed den as it opens itself to us (that is, for many decades in Anglo-Saxon that agnosticism was an essential the truth as aletheia). In Heideg- countries. They are based upon the characteristic of science: “It merely ger’s thought this concept of truth rigid application of an erroneous means that a human being does not is similar to the process of the concept of truth. In other words, if say that he believes or does not be- search for, and the revelation of, the man who lives as a slave to his lieve in something which cannot be the hidden meaning of neurotic jealousy kills his wife or her proved scientifically.” But this def- symptoms, which is promoted in lover—whether actual or pre- inition bears within it an obvious psychotherapy. sumed—he must have the punish- dualism—that which can be known But there is yet more to be said ment that he deserves. Indeed, even scientifically on the one hand and on this point. In Heidegger’s sys- in cases where infidelity is certain that in which every human being tem truth converges with freedom. the crime cannot be justified. This believes (Huxley uses the term in- The essence of truth is freedom— it is that McNaughton, a young correctly) or does not believe on the freedom to leave things (and schizophrenic who spent almost the other. The first is accessible to men) to express themselves the whole of his life in the Bethle- the realm of technology, the second through that which they are, to en- hem hospital in London, would belongs to the realm of mystery, able them to become what they re- have been hanged if the norms enigma and imagination. This is ally are. Truth, therefore, has an in- which bear his name had been ap- very near to the two concepts of terpersonal character. It is a process plied to him. truth advanced by Ferrater Mora between kindred elements. The The approach adopted by Hei- (1979). Modern science, therefore, question of truth in medicine thus degger has very important implica- is at one and the same time both becomes reduced—or expanded— tions for the discipline of psychia- gnostic and agnostic. to the authentic relationship be- try. It is obvious that the process of Freudian thought is not only tween the doctor and his patient, to unveiling, of the revelation of truth, gnostic because it is scientific. It is the process which unveils the is achieved through the psychoana- also gnostic because it is connected meaning of the symptoms, the lytic process and that in this and linked to a Jewish mystical tra- meaning of inquiry into negative process it is the interpersonal rela- dition (Bakan, 1964). It is interest- and self-destroying practices, the tionship which is the effective basis ing to observe that the process of meaning of the revelation of the of knowledge. At the same time it the reading of the sacred texts of meaning of the existence of the ba- should be observed that this ap- the Jewish religion is based upon sis of mutual trust, and (finally) the proach has strong links with the re- an interpretation which becomes an meaning of the wish and the effort ligious tradition which in his day act of re-creation. Why is this? He- to achieve an improvement—a Heidegger perceived as being of a brew, like other Semitic languages, treatment which in the most favor- New Testament orientation (1988). does not have written vowels. The able of cases involves striving to However, there are even deeper re- reading of a Hebrew text thus achieve a level of authenticity ligious roots and these should re- obliges the reader to introduce the which is higher than that previous- ceive special—albeit brief—treat- vowel sounds which render its un- ly reached and which in essential ment in this paper. derstanding possible. In this terms involves greater freedom, The religious roots of Freudian process, at the same time, an at- namely a freedom to be a patient or thought have not passed unnoticed. tempt must be made to be loyal to to cease to be a physician. From López Ibor (1975) has drawn atten- the original text and to the meaning this point of view the falsehood of tion to the connections of the of the text taken as a whole. The the delirious idea becomes clearer. Freudian system with the agnostic reading of the text, therefore, is an It becomes evident that it is a false thought which is latent in many re- exercise in unveiling, it is a revela- truth which—taking the form of a ligions and in various forms of reli- tion of the word. lamb—is imposed by isolation into giosity. The Manicheanism implic- Zarader (1990) has published a being a certainty and an agreed re- it in agnostic dualism offers an ap- very profound book on Heideg- ality. It is an autistic truth which parently solid ethical basis in as ger’s thought which draws our at- cannot be reached by shared forms much as it permits the existence of tention to certain roots of that of research without reference to a two natures—one of which justi- thought which have hitherto been recognition of contingency, of the fies evil and can be—indeed must ignored, or to put it in more precise ambiguity which is present. The be—finally overcome or redeemed terms, denied. This philosopher problem is not whether the idea of by the other, even though certain demonstrates that the principal as- jealousy is certain or uncertain—it battles during the war will be cer- pect of Heidegger’s system is that is the lack of mutual trust within tainly lost. The question of evil, the the whole of an individual’s “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 57 thought is due to what is latent without wanting to make a person- We should also hope to be the first within him and which has never al criticism, should we not apply to discover such errors. Once such been formulated. The idea that the reason in favor or against our dif- errors have been identified, we man who traced back modern ferent (and criticizable) theories? must bear them in mind and exam- thought to its roots in classical This critical approach to which we ine them from all points of view in Greece, to the time and the place of adhere precisely because we are order to discover why they were the logo, of spoken thought, might obliged to do so, forms a part of the committed. “not think” or “not say” the essen- intellectual responsibility that we 8. The adoption of a self-critical tial elements of his approach—that must assume. stance towards ourselves which is is, the least surprising. Zarader’s 3. The principle of approaching both honest and frank forms an im- thesis is that the thought of Heideg- the truth through the support of de- portant part of our task and pur- ger has a very deep Jewish basis. bate. We can always approach truth pose. The texts go beyond analogy. For with the help of critical, imperson- 9. Given that we should learn this reason, the poet Heidegger is al (objective) discussion. In so do- from our mistakes, we must also none other than a prophet along the ing we can nearly always improve learn to accept them when others lines of those of the Bible and his our understanding, even in cases point them out and even in so doing poetry is an interpretation because where we do not actually reach adopt a stance of gratitude. This it is a reworking of a previously cit- agreement. does not mean that our errors are ed text. It is extraordinary that these generally excusable—we should three principles are of an epistemo- always be vigilant in the search for logical character and at the same mistakes. Towards a New Ethical System time are also ethical principles. 10. We need other people in or- Amongst other things, they imply der to discover and correct our mis- The most important task we have and encourage an attitude and ap- takes (in the same way as other before us is to understand from reproach based on tolerance. Later people need us) and we need peo- flection on these considerations in this piece Popper adds certain ple who have been educated with that in scientific inquiry involving new principles for new profession- different ideas in worlds which are the process of knowledge there is al ethics based upon the following culturally different from our own. always a personal element which twelve principles: 11. Self-criticism is the best form must develop within a specific con- 1. Our conjectural objective of criticism but criticism of others text—that of the knowledge and knowledge continues to increase is also necessary. the thought of other people. This and this distinguishes it from what 12. Rational and nonpersonal (or process of acquiring knowledge, one individual can understand. For objective) criticism must always be therefore, is a shared process. this reason authority is not present. specific. We should be governed by These ethical roots of knowledge 2. It is impossible to avoid all er- the idea of drawing near to the ob- have received a major impulse rors, even those which in them- jective truth. It is in this sense that from what is now termed bioethics. selves are inevitable. criticism must be impersonal but at This discipline is able to offer 3. It is our duty at all times to go the same time it must also be guidelines and provide rules of on striving to avoid errors. But to benevolent and constructive. conduct for those engaged in pro- avoid errors we must above all else fessional activity but it should also be aware of the difficulties that this be emphasized that each action of involves and be conscious of the The Madrid Declaration knowledge is in itself the subject of fact that nobody manages to avoid of the World Psychiatric ethics. Perhaps Karl Popper (1992) errors—not even the most creative Association is the thinker who has given best of scientists guided by intuition. expression to this truth in recent 4. Errors can remain hidden from The World Psychiatric Associa- years in his description and analy- the knowledge of everyone, and tion has just published certain ethi- sis of the ethical principles which can be present even within the most cal guidelines under the title of should govern the search for truth. accredited theories. As a result, the “The Madrid Declaration” (World Popper formulates those principles specific task of the scientist is to Psychiatric Association, 1996). in the following way: look for these errors. These replace the previous ethical The principles which are at the 5. We must therefore change our guidelines which went under the base of every rational dialogue— attitude and approach towards our name of “The Hawaii Declaration” that is, of every discussion con- errors. (World Psychiatric Association, cerning the search for truth—are 6. The new basic principle lays 1977, 1983). This latter declaration necessarily ethical principles. down that to avoid making mis- was made in the context of the These ethical principles may be takes we must learn from our er- abuse of mental illness and psychi- outlined as follows: rors. An attempt to conceal the ex- atry in totalitarian regimes, and in 1. The principle of fallibility. istence of errors would be the particular in the Soviet Union. In Perhaps I am wrong and perhaps greatest sin that we could possibly the USSR political dissidents or you are right but on the other hand commit. people with other ideologies or perhaps both of us are wrong. 7. We must be continually on the having forms of religiosity which 2. The principle of rational dia- alert to identify and perceive er- were different from Communism logue. Obviously enough, and rors, especially if they are our own. were diagnosed as being mentally 58 DOLENTIUM HOMINUM ill and were even placed in psychi- sion: to explore the innermost ta, Buenos Aires, 1955). Pope JOHN PAUL II, Discurso al la Del- atric institutions. depths of the human being and to gación de la Asociación Psiquiátrica Ameri- This kind of abuse has almost examine his most characteristic cana y de Asociación Mundial de Psiquiatría, disappeared, but the stigmatization features, with a view to reintegrat- (Rome, 1992). H. KUNZ, “Zur Frage Nach dem Wesen der of mental illness and discrimina- ing him into that world of human Norm,” Psyche, 8, 1954-55, pp. 241 and 321. tion practiced towards those who beings which has distanced him be- J.J. LOPEZ-IBOR, Psicopatología y Fenó- are afflicted by such illness are pre- cause of his illness and its related menos Religiosos. En Riesgos Psíquicos de la Experiencia Religiosa, (Eds.: Benzo, Pinillos, sent in all countries, even in those consequences. Garcia-Monge, Fernández Martos, Barcia and which are the most developed. We López-Ibor, Fundación Universitaria San find evidence of this in laws and Professor JUAN J. Pablo CEU, 1988). J.J. LOPEZ-IBOR, F. Lana and J. Ruiz Saiz, customs, in general attitudes, and LOPEZ-IBOR JR. “Conductas Autolíticas Impulsivas y Seroti- in commonly-held opinions. There Head of the Department of Psychiatry, na,” Actas Luso-espanolas de Neurología is no institution in which they do The University Hospital of San Carlos, Psiquiatría y Ciencias Afines, 18, 1990, pp. not in some way make their pres- The University of Madrid, 316-327. Member of the Royal National Academy J.J. LOPEZ-IBOR, Freud y sus Ocultos Dios- ence felt. of Medicine es (Planeta, Barcelona, 1975). The Madrid Declaration begins G. MARCEL, Etre et Avoir (Paris, Mon- taigne, 1955). S.A. Mednik, J. Parnas and F. with the principle of equality in hu- Schulsinger, “The Copenhagen High-Risk man relationships, beginning with Project, 1962-1968,” Schizophr. Bull., 13, that of the relationship between the 1987, pp. 485-495. J. MERLEAU-PONTY, La Structure du Com- medical doctor and his patient. The portement, (Paris, P.U.F., 1942). most significant paragraph relating J. MERLEAU-PONTY, Phénoménologie de la to this subject reads as follows: Perception (N.R.F.Gallimard, Paris, 1945). “The patient must be accepted in R. MESSIMY, J.J. LOPEZ-IBOR, H. LOO, P. METZGER, and P. DENIKER, “Tomodensitome- the therapeutic process as an equal trie (CT Scanner) au Cours de la Schizo- in his own right. The relation be- phrénie. Confrontation aves ses Résultats avec d’autres Investigations,” L’Encéphale, tween the patient and the physician 10, 1984, pp. 69-77. must be based upon mutual trust H.A. NASRALLAH, M. MCCALLEY-WHIT- and respect, and it is this which al- TERS, and C.G. JACOBY, “Cortical Atrophy in Bibliography Schizophrenia and Mania: A Comparative CT lows the patient to take free and Study,” J. Clin. Psychiatry, 43, 1982, pp. 439- responsible decisions. The duty of W. ADAMS, R.E. KENDALL, E.H. HARE, and 441. the psychiatrist lies in providing P. MUNK-JORGENSEN, “Epidemiological Evi- National Foundation of Brain Research, dence that Maternal Influenza Contributes to The Cost of Disorders of the Brain. Prepared the patient with relevant and mean- the Aetiology of Schizophrenia,” Br. J. Psy- by I.C.F. Lewin, 1992, (USA, 1989). ingful information so that he can chiatry, 163, 1993, pp. 522-534. J. PARNAS, F. SCHLUSINGER, T.W. TEAS- make rational decisions which are N.C. ANDREASEN, H.A. NASRALLAH, V.D. DALE, H. SCHLUSINGER, P.M. FELDMAN, and in line with his norms, his values DUNN, S.C. OLSON, W.M. GROVE, J.C. S.A. MEDNIK, “Perinatal Complications and EHRDARDT, J.A. COFFMAN, and J.H.W. CROS- Clinical Outcome within the Schizophrenia and his preferences.” SETT, “Structural Abnormalities in the Frontal Spectrum,” Br.J.Psychiatry, 140, 1982, pp. Only if one begins from this System in Schizophrenia: a Magnetic Reso- 416-420. principle is it possible to combat nance Imaging Study,” Arch. Gen. Psychia- K. POPPER, Una Nuva Etica Profesional. try, 43, 1986, pp. 136-144. Discurso de Investidura como Doctor Hon- stigmatization and discrimination. D. BAKAN, Freud et la Tradition Mystique oris Causa (Universidad Complutense, One must begin from the starting Juive (Payot, Paris, 1964). Madrid, 1992). point of a deep and true human re- E. BECKER, La Estructura del Mal. Un En- R.M. SAPOLSKY, “Arenocortical Function, sayo sobre la Unificación del la Ciencia del Social Rank, and Personality among Wild Ba- lationship, as indeed has already Hombre (Fondo de Cultura Económica, Mex- boons,” Biol. Psychiatry, 15, 1990, pp. 862- been pointed out in this paper. In ico D.F., 1980). 878. this way it will be possible to adopt M. BEISER and W.G. LACONO, “An Update K. SCHNEIDER, Die Psychologie der Schiz- on the Epidemiology of Schizophrenia,” ophrenen (Leipzig, 1930). a positive approach to a very broad Canadian Journal of Psychiatry, 35, 1990, pp. K. SCHNEIDER, “Zum Begriff des Wahns range of situations arising from 657-668. des Whans,” Neurol., 17, 1949, 26, (Also in: obligatory admissions, research Bundes Minister fur Arbeit und Sozialord- Die Whanweltern, edited by E.Strauss and nung, Arbeitsundfaigkeit und Krankenhaus- J.Strauss). and treatment. behandlung nach Krankheitsarten 1988 Zutt. Akademische Vg. (Frankfurt, 1963), If psychiatry and neuroscience in (1SSN 0937-4930, Bonn, 1991). p. 108. general are able to overcome the European Commission, European Decade K. SCHNEIDER, “Interpretación Especulati- of Brain Research. Programme for the First va de la Psicosis,” Actas Luso-Esp. de Neurol. barriers erected against mental ill- Five Years. First Draft from the C.E.C. Task y Psiquiat, 10, 1951, p. 1. ness, to establish communication Force, 28 June 1992. M.T. TSUANG, M.W. GILBERTSON, and and relationships with the most J.E.D. ESQUIROL, Von den Geisteskrank- S.V. FARAONE, “The Genetica of Schizophre- heiten (H. Huber, Berne, 1968). nia: Current Knowledge and Future Direc- alienated of the alienated, and to P. FALKAI, B. BOGERTS, B.U.P. GREVE, B. tions,” Schizoph. Res., 4, 1991, pp. 157-171. search for truth with those people MACHUS, B. FOLECH-REETZ, C. MAJTENJI, and D.J. WEST and A. WALK, Daniel Mc- who are dominated by autistic I. OVARY, “Loss of Sylvian Fissure Asymme- Naughton, his Trial and the Aftermath try in Schizophrenia. A Quantitative Post- (Gaskell, Ashford, 1977). truth, then it will be possible to en- Mortem Study,” Schizophr. Res., 7, 1992, pp. World Bank, World Development Report gage in authentic research. But if 23-32. 1993: Investing in Health (New York, Oxford all this is not achieved, then the dis- J. FERRATER MORA, Diccionario de Filoso- University Press, 1993). fia (Alianza Editorial, sixth edition, Madrid, World Psychiatric Association, The cipline and practice of psychiatry, 1979). Hawaii Declaration (1977, 1983). will disappear and neuroscience it- M. HEIDEGGER, Sein und Zeit, (7th. edition, World Psychiatric Association, The self will find itself in great difficul- Tubinga, 1953). Madrid Declaration (1996). M. HEIDEGGER, Qué Significa Pensar?, M. ZARADER, La Dette Impensée. Heideg- ties. This last discipline will have (Nova, Buenos Aires, 1955). ger et l’Heritage Hébraique (Editions du lost sight of the purpose of its mis- K. JASPERS, Psicopatologia General, (Be- Seuil, Paris, 1990). “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 59

ANNA ROSA ANDRETTA

Family and Society: Places of Pain

I must first of all express my spe- which arise, trusting only to their morbid curiosity, and of flight cial gratitude to His Eminence Car- instincts as each problem presents when faced with the reality of dinal Angelini, who with his sensi- itself. madness. tivity as a man and as a careful stu- There is an attempt to avoid Notwithstanding the present at- dent of social and healthcare ques- such situations and at the same tempts to treat the mentally ill per- tions has not remained indifferent time a desire to meet them. The re- son within the community rather to a great and imposing reality— actions are feared. There are mo- through a process of exclusion, that experienced by those who are ments when it is not clear whether these feelings of repulsion contin- involved in the tragic condition of the intention is to meet the reality ue to hold sway even when a kind- mental disturbance. He has also head on as soon as possible or to ly hand is extended to him. Even demonstrated marked solidarity to- avoid it. though the gesture is full of chari- wards the mentally ill and their rel- There is a great need to reduce ty, the face of the helping person is atives, people who are all too often one’s time and one’s space and ac- turned in another direction. the very least among men. cept the inevitable destiny. One Tranquillity and good con- The title of this international feels harassed, gripped by a desire science are greatly shaken when conference invites us all to engage to flee which amounts to a wish the walls of separation which are in a reflection. Who is a mentally not to be present, to cut one’s ties, both material and virtual come ill person? What explanation can to disappear. One becomes drawn tumbling down. Archaic fears we give for his behavior? into contradictory feelings of ha- come out again and the terrible For my contribution to this con- tred and love. power of madness springs out of a ference I have chosen the title— Then everything falls back into past full of rites and magical prac- ”Family and Society: Places of place again. One’s own despera- tices. Suffering.” This is a subject which tion is hidden through a covering The unconfessed and unconfess- would involve great difficulties if up of the feelings of intolerance able conviction that the mentally it were not applied to personal ex- which are an element of existential ill are different, useless, expensive perience. falsehood. The way in which men- and disruptive gradually gains For the mentally ill person and tally ill people are forced to live ground. Seen as a strange species his family a frontier disappears, a upsets us. Thinking about their which should be looked at rather frontier which led on to a serene fate worries us because our fears than approached, these people and peaceful life. At one time it are very similar to their forms of even become a reason for shame was easy to cross that frontier for delirium. There is an attempt to be- on the part of their own families. anybody who knew how to do so. lieve that the sick person is dan- People do not hesitate to talk Then terrible times arrive, full of gerous, but the unsettling feeling about a son who is a drug-addict, fear, and the road of life becomes a which society feels when faced but who manages to speak without labyrinth without an exit. There with the mentally ill person shows embarrassment and in clear terms follows the gradual dissolution of only too well that at the innermost about a relative who suffers from the prospect of a tranquil daily life. level the danger does not come mental illness? The extreme and Great struggles occur before the from the mentally ill person but irrational attitude of a family when towel is thrown into the ring and a from the idea that we might be or faced with the hospitalization and surrender is made. might become like him. treatment of their sick relative, the There are different reactions— The great characteristic of our refusal that they express, and the the mentally ill person seems to time is a metamorphosis in the insistence with which they ask for enjoy his condition, but the family physiognomy of mental illness. such an approach as a form of pun- no longer has the energy or the This gradual drawing near of the ishment which can eliminate strength to strive for an even par- normal man to the alienated man blame—all these elements well tial recovery. There are no doubts by small steps has not, however, demonstrate how the world of af- about a reality which forces people been able to eliminate an atavistic fections is powerfully assailed by to deal with the painful situations approach of superstitious fear, of the phenomenon of mental illness. 60 DOLENTIUM HOMINUM

The feeling of opprobrium siders and sees a person is the re- demned to a social death. which we encounter here arises sult of a complex of relations in I would like to finish my contri- from ignorance and from the wide- which the individual lives and re- bution to this international confer- spread conviction that mental dis- lates to the structure of society in ence with a reading of some short turbance can be transmitted from relation to his ability to be active verses written by a mentally ill one generation to another. Society within that society. The most fre- person: “When you think that becomes a place of suffering be- quent and immediate objection to things are finished, that is life; cause the mentally ill become an this kind of line of reasoning re- when you feel oppressed, sick, and oppressed and defenseless minori- volves around a questioning of the marginalized, that is life; when ty, and the phenomenon of mad- myths of productivity and func- you feel alone, that is life, because ness becomes pushed to the mar- tionality. life belongs to you and to me and gins in the field of medical care as And thus the question arises: to God my brother.” well. can the mentally ill person manage My conclusion after these lines The “madman” who is blame- to live without suffering in a social thus becomes easy. I would like to less and unable to resist the tide of context which refuses to accept invoke the subject of this confer- rebukes which assail him and to him with all his limitations? ence—“In the Image and Likeness defend himself against the suspi- The answer when in the affirma- of God: Always?” I reply: “Yes! cion with which he is treated be- tive is of a utopian character. His Always!” comes that which people want him reduced or nonexistent productive to be—the hideous expression of capacity lies upon him like an irre- Dr. ANNA ROSA ANDRETTA madness. movable stain which deprives him National President of DI.A.PSI.GRA The way in which a society con- of his respectability. He is con- (Defense of the Seriously Mentally Ill) “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 61

MARY COLEMAN

Autism

I wish to give thanks to the Pon- mal babies is often completely which help diagnose a child with tificium Consilium and Fiorenzo lacking. The autistic child does not autism. Usually from a very early Cardinal Angelini for inviting me usually come to his parents, broth- age, the autistic child shows major to the beautiful ancient city of the ers or sisters—or anybody else for problems in the comprehension of Vatican. I am here to speak about that matter—for help or comfort. human mime, gesture and speech. one of the most mysterious of hu- As the child grows older, the ab- Approximately one out of every man diseases. It is one that affects normalities of social relatedness two autistic children fails to devel- the thinking and behavior of become less immediately obvious, op useful spoken speech. Of those young developing children—the particularly if the child is seen in that do develop speech, all show syndrome of autism. It occurs in his familiar surroundings. The re- major abnormalities of speech de- approximately one out of 2,000 sistance to being touched and held velopment. Another problem is live births. usually decreases with age, even that a majority of autistic children The concept of infantile autism though rough and tumble play is demand that certain routines be ad- represents a comprehensive diag- often preferred to gentle stroking. hered to in a pathologically rigid nosis, somewhat along the the Unfortunately, the inability to play fashion. Also, they often form same lines as cerebral palsy or reciprocally with age peers re- bizarre attachments to certain ob- epilepsy. Autism is not a single mains sadly unchanged through- jects, such as stones, curls of hair, disease entity. There is now over- out the years in most cases. In chil- pins, pieces of plastic toys or met- whelming evidence that the behav- dren with autism, the inability to als. Food fads are the rule rather ioral syndrome of autism repre- reciprocate and the tendency to than the exception. The self—de- sents the final (common?) expres- treat other humans as anything but structiveness (head banging, wrist sion of various etiological factors. objects remains evident. These biting, chin knocking, cheek In 1943, a child psychiatrist, hallmarks differentiate them from smashing, clawing, hair tearing, Leo Kanner of Johns Hopkins superficially similar behavior seen etc.) seen in many autistic children University in the U.S.A., reported in emotionally deprived children. has been proposed as concomitant eleven cases in a scientific journal There are other symptoms to the mental retardation, but in introducing to the world medical fact could not be, since such be- literature this group of children he havior is often seen even in nor- labeled “autistic.” (Kanner 1943) mally intelligent autistic children. The central feature of this distur- Why do these children have all bance seem to be a lack of reci- these strange behaviors? We do procity in social interaction with not know enough about brain other humans and an apparent fail- function to be sure exactly where ure to recognize the uniqueness in the brain the problems lie but we and “specialness” of other human do know that these children have beings. The typically autistic child abnormal sensory responses. By avoids eye contact from before the and large, clinical experience sug- end of the first year of life, gazes gests that perceptions relating to out of the corner of the eye and auditory and tactile stimuli are gazes only very briefly, does not more impaired in autistic children show anticipatory movements than are the perceptions of visual when about to be picked up, resists and especially olfactory stimuli. being held or touched, and does Autistic children often want to not “adjust” himself to “fit” in a smell people and objects, probably hug or something similar. Autistic for purposes of identification. Fi- infants often seem to lack initia- nally, it is well established that tive; and interested curiosity and some autistic children, though not exploratory behavior seen in nor- all, show “islets of special abili- 62 DOLENTIUM HOMINUM ties,” particularly in the fields of possible to overemphasize the im- to be totally prevented. root memory (e.g. numerical portance of early, individualized The first is rubella autism, skills), music, art and visuospatial education as a treatment for chil- caused when a pregnant mother is skills (or skills with jig-saw puz- dren with autism. Today for most infected with rubella—or German zle). We call such children “autis- of these children, education is their measles—at the beginning of the tic-savants.” best hope. second trimester of pregnancy. If Studies in the neuropathology of The second way to help children all the girls in a society are vacci- the brain show no abnormalities of with autism is to find out exactly nated against rubella before they gyral configuration or myelina- what is causing the infant brain of reach the child—bearing years, tion, and no evidence of signifi- each child to express such bizarre this form of autism disappears. cant gliosis. (Bauman and Kemper symptoms. This involves a de- This is now what is happening in 1994). However, compared to con- tailed medical work—up because many countries and needs to be ex- trols, the brain in autism often there are many different underly- tended to every country in the shows increased cell packing den- ing diseases—all of which injure world. sity and reduced cell size in the the brain and are expressed The second preventable form of hippocampal complex, the en- through the final common path- autism is phenylketonuria autism torhinal cortex, the selected nuclei way we call autism. In fact, autism or PKU autism for short. PKU is a of the amygdala, the mammillary is a syndrome of many etiologies. metabolic disease that can be de- body and septal nuclei which pro- [Gillberg & Coleman 1992 (Eng- tected by newborn screening of all ject to the hippocampus. In addi- lish)]; [Coleman & Gillberg 1986 infants. For all newborns in many tion, loss of Purkinje cells are seen (French)’] [Gillberg & Coleman in countries, a bit of blood is rein the neocerebellum. The embo- press (Italian)]; [Coleman & Gill- moved from the heel and submit- liform, globose and fastigial nuclei berg 1985 (Japanese)]; [Coleman ted to special testing. Today, chil- show small neurons reduced in & Gillberg 1989 (Spanish)]. dren with PKU can be identified in number. There are lesions in the There are so many different the first week of life and then forebrain in areas related to memo- causes we group them into cate- placed on a special infant formula ry. Imaging studies have tended to gories as follows: which prevents both the other— confirm the neurophatological 1. Infectious etiologies wise inevitable mental retardation studies. In summary, in the anato- 2. Metabolic disease entities and the autistic behaviors. The my of the brain, there are subtle 3. Chromosomal aberrations children must stay on the special but probably significant changes. 4. Structural lesions of the cen- food, which is missing the amino What can be done to help these tral nervous system acid, phenylalanine, throughout little children who live in a world 5. Sensory handicap associa- their childhood. But is certainly of loud noises and confusing infor- tion—deafness, blindness worth it because they become nor- mation all around them? There are 6. Double syndromes (autism mal adults instead of severely im- two major areas where we can help plus another syndrome in the same paired and handicapped retarded them and make a significant differ- child) and autistic individuals. ence in their future lives. One is 7. Idiopathic We may soon have additional special education techniques Of course, regarding any syn- preventable forms of autism. which need to be available to all drome, the best approach of all is There are a several metabolic dis- children with autism; the second is to prevent it in the first place. Two ease entities where research thera- a medical evaluation which some- forms of autism are currently able pies are under intense investiga- times can be followed by a med- tion at present. If this research ical therapy which reverses or im- leads to an established medical proves the symptoms. Because of therapy which reverses symptoms, this, developing techniques for the then it is possible that testing for earliest possible identification of these additional diseases might be children with autism is now a high added to routine newborn screen- priority for researchers in this ing test. field. One of these diseases in purine Special education techniques autism. Purine autism is diagnosed differ from country to country but when a child with autism is found all good programs have in com- to have too much uric acid in his mon that the child needs to receive urine. Purines are very important individualized teaching based on in brain function—they are in- that child’s particular constellation volved in neurotransmissions, in- of symptoms. Many children with formation processing on DNA, en- autism, who are started in good ergy production and antioxidation. educational programs under three Three studies have shown that years of age and who develop lan- many children with autism excrete guage, improve sufficiently that too much uric acid. The figures in they are able to be mainstreamed Italy are 26% of children with into classrooms with normal chil- autism who excrete excessive uric dren by six years of age. It is im- acid; in France they are 28%; and “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 63 in the United States, they are 22%. diagnosed by imaging studies; One heart-breaking cause that has So far, two enzymes of the purine PKU and purine autism, which can been documented occurs when pathway (adenylsuccinate lyase be diagnosed by blood and urine mothers are exposed during preg- and PRPP synthetase) have been studies; the fragile X syndrome nancy to toxic substances. Benzo- found to be abnormal in children which can be diagnosed by chro- diazepine, excessive alcohol and with autism and current research is mosomal studies; and Rett syn- thalidomide have all been indicted demonstrating additional en- drome—a form of autism seen on- in some cases of autism. Also, zymes. Because there are overpro- ly in girls—which can be diag- there are cases where the most ex- ducing, rather than underproduc- nosed only by clinical observation. tensive examinations fail to reveal ing, enzymes, it is likely that a This discussion of seizure re- the etiology of the autism—these treatment may be found for purine minds us that many children with children are said to have “idio- autism, and soon. other syndromes have autistic fea- pathic” autism, which is the doc- A rare form of autism is known tures; in fact, they may have two tors’ way of saying that “we sim- as hyperlactatemia autism. Here syndromes—autism plus another ply don’t know.” the error is in the carbohydrate syndrome. Some examples of Finally, I wish to draw attention pathway affecting the brain and these double syndromes are: to the sufferings of the parents of the treatments under study are the 1. deLange syndrome children who have autism. These ketogenic diet and vitamin B1 (thi- 2. Fetal alcohol syndrome children have a type of handicap amine). 3. Hypomelanosis of Ito that often does not allow them to Another disease causing autism 4. Infantile spasms sequelae show affection to their attentive recently identified is infantile syndrome parents. In contrast to Down syn- manic—depressive disease which 5. Joubert syndrome drome children, for example, who is manic—depressive disease in 6. Lyan—Fryan syndrome often are very loving to parents, the parents expressing itself in the 7. Moebius syndrome some children with autism actually child at an infantile age. The treat- 8. Neurofibromatosis experience pain when the mother ment under investigation is lithi- 9. Rett syndrome looks at them or when she hugs um, a classic treatment used in 10. Sotos syndrome them. Children with severe forms adult manic—depressive disease. 11. Tourette syndrome of autism may use the mother’s Some children with autism have 12. Tuberous sclerosis hand as an object to turn the door- food faddism resulting in very 13. Williams syndrome knob rather than relate to her as a poor diets and a common result is As noted above, some patients person. In our work to help chil- that they have inadequate amounts have autism as a result of infec- dren with autism, we must include of calcium in their brains. Low tions either in utero or early in in- support for their heroic parents. levels of calcium, as measured in fancy—rubella, CMV and herpes Thank you. their urines, can be associated with virus are the best established at a prevention of language develop- this time. Bacterial infections, MARY COLEMAN, M.D., ment and/or self—abuse of their such as Haemophilis influenza Emeritus Professor eyes. This is something easy to meningitis, also have led to the de- Georgetown University School check and easy to correct by calci- velopment of autism. As if one of Medicine, Washington, D.C. USA um diet supplements in such an tragedy were not enough, children autistic child. This raises the im- who are blind or deaf are at higher portant point that if an individual risk of having autistic features. with autism is self—abusing, a biochemical evaluation of the person is always in order. Seizures are often a problem in children with autism—in fact, they are more likely than retarded children to have a seizure disorder. Re- cent research has shown that if a baby has a EEG focus for infantile Bibliography spasms on both sides of his brain, BAUMAN M.L., KEMPER T.L., The Neurobi- that child is more likely to develop ology of Autism. Baltimore: The Johns Hop- kins University Press, 1994. autistic symptoms afterwards. COLEMAN M., GILLBERG C., The biology of Seizures should always be aggres- the Autistic Syndromes. Prima edizione. sively treated and suppressed in Tokyo: Tuttle-Mori Agency, Inc., 1985. COLEMAN M., GILLBERG C., Biologie des any individual with autism; some- Syndromes d’Autisme. Prima edizione. Paris: times the behavior symptoms also Maloine s.a., 1986. improve with the drug treatments. COLEMAN M., GILLBERG C., El Autismo: Bases Biologicas. Prima edizione. Barcelona: Certain underlying disease entities Ediciones Martinez Roca, S.A., 1989. are more likely to be associated GILLBERG C., COLEMAN M., La sindrome with seizures in autistic children— Autistica, Roma: Omega Publishing, in corso di stampa. they are tuberous sclerosis and KANNER L., Autistica disturbance of affec- neurofibromatosis, which can be tive contact. Nervous Child 2, 1943, 217-250. 64 DOLENTIUM HOMINUM

GIAN LUIGI GIGLI

The Unfinished Project: Ethical Problems and Strategies for Action on Mental Retardation

A Word on Terminology surprise us: nothing is more amazing fold. In a certain sense mental retar- than to observe the progressive intel- dation can be seen as a sort of cumu- The term “mental retardation”, lectual development of a child to the lative joint outcome of a large num- which belongs to North American point where it begins to acquire the ber of pathological conditions which nosography, often has negative con- characteristics of adult rational intel- affect the central nervous system be- notations and can be offensive in ligence—that stage described by Pi- fore birth or in the first early years of some cultures, as indeed is the case aget as being operative-formal life outside the mother’s womb. in Great Britain. The terminology thought. Amongst the biological causes which is employed in relation to this In large measure this process is the which are at work there are such whole area varies from country to outcome of a project far greater than chromosome malfunctions as tri- country. Mental retardation, intellec- ourselves which is written into our somy 21 syndrome or Down’s syn- tual disability, learning disability, de- inner selves and over which we have drome and weak X syndrome (which velopment disability, and mental only a marginal influence. Our influ- are the two most frequent causes of handicap are terms which can refer ence is only able to render this mental retardation caused by genetic to the same thing or to things which process more evident when its im- factors); other forms caused by local- are very different. An obvious confu- pact is negative. ized mutations of chromosome X; sion can thus occur when the results At times, however, this delicate and other conditions found more of epidemiological surveys are as- process can become interrupted. We rarely amongst the population such sessed and when precise reference is see the child continue on his path of as Prader-Willi’s syndrome and An- made to the results of different strate- physical growth until he reaches gelman’s syndrome (caused by the gies of intervention to resolve certain adulthood but his behavior and his deletion of chromosome 15 by pater- problems. intelligence remain rooted in child- nal or maternal paths). There are, in It would be very useful to have a hood. We realize that we are faced addition, many congenital alterations terminology which had the same with a strange individual whose of the metabolism usually inherited meaning for everybody and which chronological age does not corre- through autosomic recessive trans- involved a positive vision of disabled spond to his mental age. The process mission (such as phenylpyruvic people. From research conducted in has stopped or advances with frus- oligophrenia, Taysach’s disease or English-speaking countries (Fernald, trating slowness and the project of Niemann-Pick’s disease) but also 1995) it seems that there is a certain man remains unfinished. We realize linked to chromosome X (such as the degree of consensus about the suit- that we are dealing with a person sphingolipidosis of Fabry’s disease, ability of “intellectual disability”—a who is afflicted by the condition of the mucoplysaccaridosis of Hunter’s term which is seen as understand- mental retardation. Quite apart from disease, and adrenoleucodystrophy). able, sufficiently clear in its mean- its negative connotations, the term Obviously enough, diseases which ing, and not offensive in its implica- suggests a general intellectual per- cause metabolic alterations do not tions. In this paper I will often use formance well below the average cause specific encephalopathies— the concept of intellectual disability, which begins before the age of eigh- that is, conditions where mental re- interchanging it with the term “men- teen and which is characterized by tardation is a permanent conse- tal retardation,” and this latter phrase substantial limitations in the individ- quence—but progressive forms of will be employed without any nega- ual’s capacity to adapt to the needs encephalopathy where the intellectu- tive connotation. and requirements of the environment al defect becomes worse over time. which surrounds him. There are also hereditary forms transmitted by dominant autosomic Introduction paths which express themselves in a The Causes variety of ways (such as Although the phenomenon occurs of Mental Retardation Bourneville’s disease and neurofi- repeatedly without any apparent ef- bromatosis). We also encounter al- fort during the period of growth, its The causes which can lie behind terations in the development of the miraculous character never ceases to this check to development are mani- embryo or foetus caused by maternal “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 65 infections (such as toxoplasmosis, the use of a scale of assessment referring here to such elements as the the rubella syndrome or herpes sim- which explores the subject’s intelli- home background, the school and the plex), by ectogenic toxicants such as gence in very general terms. The district where the child lives. alcohol, drugs or environmental pol- most commonly used kinds of test The measuring of intelligence lution, by pre- or post-natal hypoxia, are the WISC, the Standford-Binet through the use of IQ tests involves a by malnutrition, or by traumas expe- test and the Kaufman test. There is number of difficulties. The IQ result rienced during the course of the always a certain margin of error in is not able to give an adequate de- pregnancy. The dangers for the intel- the employment of these IQ tests. In scription of the abilities of the indi- lectual development of the child are, the same way, they cannot be applied vidual who has been tested when the however, also present after birth. In- to individuals who suffer from results obtained through different deed, traumas, infections, malnutri- chronic forms of mental retardation. tests vary a great deal and when there tion, poisoning, and the toxic effects The other criterion of assessment is a marked divergence between the of drugs can all have devastating ef- which is used in the diagnosis of results obtained in the oral section fects during childhood even though mental retardation is that of function- and those which emerge from the on the whole these damage the brain al adaptation. Indeed, it is the prob- tests on performance. less severely than those factors lems of adaptation to the environ- In addition, there are conceptual which interfere with the development which first raise the possibility criticisms relating to the numerical ment and growth of the embryo. of the presence of mental retardation. assessments of IQ tests. They must In addition to these biological The parents become aware that their take account of the linguistic aspects causes it should be pointed out that child is not able to live at the levels of the case, possible neurosensorial psychosocial factors can also bring of independence which are normal deficits, and the general sociocultur- about mental retardation. The lack of for his age. On the whole doctors and al background of the person who is suitable forms of stimulus during the educators come to the same conclu- tested. first stages of the relationship with sion, and the same may be said of the But with all these problems which the mother (especially if the mother results of suitable assessment tests. are latent in this kind of approach— is absent, incapable or negative); the In cases where other independent ob- problems which cannot be fully ex- lack of social forms of stimulus; the servers and assessment tests on a plored here—the definition of intelli- poverty of linguistic forms of stimu- broad scale detect the same problems gence quotient enables us to define lus; sensorial deprivation (something of functional adaptation, it is very individuals in relation to their effec- which also takes place when there is probable that one is in the presence tive levels of mental retardation. The natural blindness or deafness)—all of a case of mental retardation. concept of intelligence quotient these are elements which can help to However, it should always be real- means that we can categorize indi- bring about a state of mental retarda- ized and kept in mind that other fac- viduals in terms of light, moderate, tion. To conclude this section on the tors can artificially aggravate or re- serious or very serious levels of men- origins of intellectual disability, it duce the detection of adaptation tal retardation. These four categories should be pointed out that mental re- problems. For example, the presence differ greatly from each other with tardation can also be caused by of physical handicaps or connected regard to numerical importance and forms of serious mental disturbance forms of mental disturbance, or the correspond in practical terms to very which can interfere with the develop- impact of a culturally under-devel- different levels of performance even ment of the cognitive functions. oped environment, can impinge on though, obviously enough, distinc- Despite the important advances in the perception of the presence of dif- tions tend to become rather blurred our knowledge about mental retarda- ficulties of functional adaptation in a when the intelligence quotient is on tion which have been brought about child. On the other hand when a child the borderline between one category by scientific research, it should be is institutionalized even such forms of retardation and another. observed that even in the most expert of behavior as passiveness and de- The vast majority of forms of and up-to-date centers of study a pendence can come to be seen in a mental retardation (about 85%) for- goodly proportion of individuals (at favorable light, elements which in tunately enough belong to the cate- least 30% of the total) do not lend other contexts would be seen as ex- gory of light deficit—we are dealing themselves to a clear etiological di- pressions of problems of adaptation. here with an intelligence quotient of agnosis. The concept of the reversibility of a between 50-55 and 70. Precisely be- Even though the causes of mental diagnosis is implicit in any analysis cause their problems are not very retardation, its pathogenesis and the of functional adaptation. If the adap- great, children belonging to this cate- set of symptoms by which it express- tation improves, the individual con- gory are often not perceived as being es itself, can vary from case to case, cerned may well no longer come retarded until they reach the school- there is an element common to all within the diagnostic definition of going age because even with this forms of mental retardation which mental retardation. deficit they are able to acquire suffi- permits a clear diagnosis of this con- As the American Association on cient levels of communication and dition. An assessment of overall in- Mental Retardation (1992) correctly socialization. Fittingly enough, these tellectual functioning and perfor- points out, adaptation must be under- children are often seen as being mance carried out by IQ tests always stood and assessed within the context teachable given that they able to shows the presence of deficits in of the environment of the child con- reach the standard of a child of the those individuals suffering from cerned and with reference to the lin- fifth year of elementary school even mental retardation. The intelligence guistic and cultural frame of refer- though they do so rather late in their quotient is calculated by means of ence of his contemporaries—one is educational careers. On the whole, 66 DOLENTIUM HOMINUM and especially if the environment can Lack of Interest pressing the problem arising from give them some form of supervision on the Part of Psychiatry the different criteria employed in ad- and support during difficult mo- mitting people to institutions and ments, they manage to perform so- For a long period the discipline of programs of rehabilitation. This phe- cially useful work, achieve a mea- psychiatry displayed a marked lack nomenon is also the outcome of the sure of economic income, and live of interest in the phenomenon of in- employment of diagnostic methods independently. tellectual disability. The problem and instruments which vary greatly The category of children who have was that intelligence was considered in their levels of sensitivity and mon- a moderate level of retardation—that a prerequisite of humanity. In more itoring. is, those who have an intelligence specific terms, the discipline of psy- Although it is clear that intellectu- quotient of between 35-40 and 50- chiatry employed a concept of mind ally disabled people are more vulner- 55—make up about 10% of all cases which attributed a leading role to in- able to psychiatric disturbance in of mental retardation. Although it is telligence in the decisional process, comparison with those who do not very rare for such children to go be- in behavior, in the development of suffer from mental retardation, it is yond the second year of middle the ego, and based a great deal of its nonetheless evident that such forms school, they can look after them- action on individual psychothera- of disturbance continue to be diffi- selves with a minimal amount of su- py—a process for which a capacity cult to diagnose. The criteria em- pervision, move independently with- for introspection and verbal expres- ployed in the diagnosis of psychiatric in their family environments such as sion are more than necessary. illness in mentally retarded individu- a village or small urban district, and In addition, and perhaps for the als are difficult to establish and those carry out general forms of work al- same reasons, until a few years ago suggested by the usual textbooks on beit in protected environments where there was no recognition of the pres- classification are difficult to apply. an especial respect for social conven- ence of psychiatric illness in those One problem which remains very ev- tions is not required. afflicted by intellectual disability. It ident is that relating to the kinds of Those children with a serious lev- was only with great difficulty that the service which should be offered to el of retardation constitute about 3- symptoms of classic psychiatric ill- mentally handicapped people who 4% of all cases. It is only after a nesses such as depression or obses- also suffer from connected psychi- marked period of time that they ac- sive-compulsive disturbance were atric illness. quire the capacity for oral communi- recognized as being present within At this point special reference cation and independence in manag- mentally retarded people, and as a re- must be made to problem behavior, ing their own basic bodily needs. Al- sult it was very unlikely that people something which is frequent and per- though such children are not able to suffering from intellectual disability sistent in those who suffer from men- reach the standards of normal had the right to receive specific treat- tal retardation and is a factor which schooling they can acquire the most ment for these kinds of mental illness greatly disturbs the environment of basic elements of mathematics, read- in the same way as every other psy- the individual concerned. Antago- ing and writing (one is referring here chiatric patient. Only recently have nism, lack of co-operation, aggres- to certain key words). Despite their researchers begun to direct their at- sion, self-wounding, hyperactivity— limitations, such children are able to tention to carrying out inquiries into all these are forms of behavior which carry out simple and repetitive tasks how psychopathological problems may be seen as a challenge to a fam- in environments which are intensely can be diagnosed and treated in the ily, to a school, or to a health care in- supervised and controlled. In the case of people suffering from intel- stitution. In addition to the damage same way they can be integrated into lectual disability, and into establish- which is done to the possible provi- community life within a family or ing what biological, psychological sion of personal affection and other protected groups, as long, that is, as and social factors might lie behind factors, and to the subsequent risk of these children with serious levels of the psychopathology of mentally re- further disability, forms of problem retardation do not suffer from other tarded people. In other words, only behavior greatly increase the bur- forms of serious disability or handi- in recent times have psychiatrists be- dens of care which the family must cap. gun to study the question of psychi- bear. This raises the risk that the fam- Most of the children suffering atric illness experienced by those ily nucleus will become severely dis- from very serious levels of intellec- who are already afflicted by the rupted, reduces the prospects for tual disability (about 1-2% of all cas- handicap of intellectual disability. school integration, promotes the es) are afflicted by serious neurolog- likelihood of the need to institution- ical deficits which in conjunction alize the child, and as a general result with intelligence deficits compro- Psychiatric Illness increases the general economic costs mise their neurosensorial perfor- in Mentally Retarded People that society will have to bear. mance or motorial capacity. Such A large number of theories have children need an environment which The incidence of psychiatric dis- been advanced to explain the high in- is specially constructed for their turbance associated with intellectual cidence of forms of problem behav- needs and they require individual- disability varies greatly, ranging be- ior in those who suffer from mental ized forms of treatment and care tween 10% and 65%. Obviously retardation (Matson and Sevin, which alone are capable of enabling enough, this high level of variability 1994). Most of these theories are them to achieve progress in terms of is a result of problems of definition, based on ideas about learning. In- motorial capacity or communication different criteria of definition and de- deed, in many cases of intellectual skills. tection, and different ways of ex- disability deviant behavior has a “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 67 functional origin. This means that flicted by the condition of mental re- us. A society which wants to remove the reaction of the mentally retarded tardation. suffering and death from its field of person’s environment reinforces the In Western societies, whether they vision, although rationally aware of symptom and helps to promote the are industrial or post-industrial, great the fact that such elements in the end continued presence of pathological emphasis is placed upon the produc- touch us all, is led towards hiding the forms of behavior. For example, the tion of goods. In this way the value problem of mental retardation within mentally retarded person may learn and worth of a man is often identified health care institutions or through a that certain forms of behavior lead to with his social function. He is valued policy of eliminating the problem at certain kinds of attention being paid not for what he is but for what he its roots through a denial of the right to that individual or that certain situ- does. In this framework of reference to existence. ations which the environment re- the value and dignity of man no This mentality has corrupted the quires but which the mentally retard- longer constitute an absolute but are very meaning of words, not least in ed person dislikes can be avoided. heavily influenced and molded, in the field of medicine and scientific On other occasions it is the sensorial particular by economic factors and research. By this route the preven- or neurochemical consequences of considerations. The person suffering tion of mental retardation has ended the deviant behavior which can lead from mental retardation thus ends up up by meaning in current language a to an automatic reinforcement of by being perceived as a useless bur- mere ability to identify the problem pathological kinds of conduct. The den, involving very high costs, and during the stage of prenatal life and fact that these are more frequent in the great aim then becomes to ensure then to resolve it through a policy of individuals with demonstrable neu- that further cases of such a condition abortion. ropathological alterations, in con- do not come to oppress the social In order to justify the results of eu- junction with the results of pharma- body. genic selection, authoritative reviews cological research (a subject which There are also other forms of cul- on epidemiology have been used to will be discussed later in this paper), tural influence and direction which link the incidence of abortion with gives great weight to the theory that have a negative effect on how people levels of infant mortality and levels these forms of behavioral distur- afflicted by mental retardation are of maternal deaths caused by child- bance have a biological basis and perceived and treated. The models birth. The author of such an article origin. Some authorities believe that subscribed to by the young people of (Puffer, 1993) draws attention to the it is very probable that in the future this society of material prosperity are decrease in infant and maternal mor- many of these forms of problem be- those of success and immediate satis- tality and an accompanying rise in havior will be shown to be of a phys- faction. Any kind of sacrifice what- the incidence of abortion in the Unit- ical nature (Reid, 1994). It is also soever is understood and accepted ed States of America after the very likely that the behavioral and bi- with marked difficulty. For this rea- Supreme Court decision of 1974 ological elements overlap and inter- son it is with even greater difficulty which legalized abortion. This article act and that they will require dual that an intellectual disability can be is a clear example of an ideological forms of treatment. accepted, a disability which from the use of scientific information. In real- very outset presents a family with the ity, the same graph shows how the prospect of a long-lasting period of decrease in infantile and maternal An Integral View sacrifice which will have to be dealt mortality began well before the le- of Mental Retardation with in a spirit of total giving and galization of abortion and continued without any possible advantage be- after the number of legal abortions Hitherto I have sought to outline ing gained. Most of the time this sac- reached its peak in 1980. In addition, and analyze the clinical difficulties rifice is asked of families which are there is no attempt to take into con- and problems of the person suffering often in a state of difficulty and for sideration the fact that the decrease from the condition of mental retarda- whom the birth of a mentally retard- in levels of mortality could have tion. It is more than clear that care for ed child can constitute a potent factor been caused by an increase in the mentally retarded people involves a of disintegration. Furthermore, these quality of obstetric and neonatal heavy burden for their families, for kinds of families are not helped by care. schools, for health care institutions, the character of the economic organi- and for society as a whole. This bur- zation of society in giving space to a den is not only economic in nature new child even when that child is The Ethical Problems but also involves time, dedication, healthy. of Mass Screening humiliation, psychological disquiet, In addition, more than is the case and difficulties in the formation and with any other kind of disability, a For certain causes of the condition maintenance of personal relation- child afflicted by intellectual disabil- of intellectual disability we now ships. ity wounds the expectations of the have systems of screening which en- The commitment and the energy family it is born into and damages able us to identify the healthy carri- which families, institutions and soci- the self-image of the parents them- ers of genetic alterations. These sys- ety are able to give to people suffer- selves. This disability compels the tems have margins of imprecision ing from intellectual disability de- family and society as a whole to pose according to the disease which is be- pends upon the conception of man questions about the weakness of our ing investigated. In cases of reces- that lies behind their actions and in existence, about what could happen sive autosomic transmission, the di- particular on the value that is be- to all of our children, and about what agnosis of healthy carriers can be stowed upon the person who is af- only by pure chance has not befallen used to positive effect for pre-mar- 68 DOLENTIUM HOMINUM riage and pre-conception coun- would be the case in a screening of burden which the presence of the selling. But in cases where the trans- all women over the age of thirty. The needs of mentally retarded person mission of the illness is linked to achievement of this meager result implies, and the tendencies towards chromosome X, the screening of the would mean that in addition to the disintegration which such a presence genetic make-up of mothers who are death by abortion of children diag- involves must be converted into an healthy carriers is used in deciding nosed as suffering from the Down impulse towards unity. In this way whether to carry out an amniocente- syndrome, there would be the cost of less use will be made of the policy of sis. When this leads to the presence 4,500 useless tests, the anxiety in- institutionalization. Obviously of illness being diagnosed in the foe- volved in 200 false positive results, enough, the enjoyment of the above tus the mother becomes placed in a the distress caused by an equal num- mentioned rights must take place, as sort of perverse spiral which leads al- ber of amniocenteses, the loss of 1-2 is made clear by the declaration of most inevitably to abortion, in part normal children through amniocen- the United Nations, “to the greatest because at the present time there are tesis, and the cost of these amniocen- degree possible.” Only by being able no means by which this condition teses and of the personnel involved to offer the mentally retarded person can be treated in the womb. in counselling (a figure estimated at services which are in line with his ca- The weak X syndrome occurs at a 90,000 pounds sterling). pacities will it be possible to avoid rate of about 1/1200 in men and It is more than clear there should school or work becoming elements 1/2500 in women and is the most be a correspondence between the re- which act to underline his diversity common cause of intellectual dis- sources that are allocated and the val- even further rather than promoting ability rooted in genetically inherited ue that is attributed to a human be- his well-being. However, the diversi- factors. Recently a rapid antibody ing. Perhaps with sufficient econom- ty implicit in mental retardation test for the purposes of diagnosis has ic support it would be possible to en- should be respected and recognized been brought into being (Willemsen sure that the Down child is accepted as a right, the right to fragility and in- et al., 1995). Its application is envis- and that 1-2 normal children are not firmity, in order to avoid falling into aged in terms of mass screening and rejected in error, and this is a situa- the trap of eugenic temptations remi- this fact has raised a large number of tion where the economic costs would niscent of previous sad racist experi- objections. The almost inevitable re- be no higher than if such screening ences. sult of a positive diagnosis achieved were carried out. All modern research into mental by this test would be a policy of retardation is an invitation to em- abortion, and this even when there brace this more human perspective. are difficulties in predicting the seri- A More Human Perspective Indeed, in the light of present-day ousness of the illness in female foe- scientific knowledge a mentally re- tuses subject to chromosome alter- The “Declaration on the Rights of tarded person is not only an individ- ation. Phenotypical conditions of the Mentally Handicapped” pro- ual with a development deficit but is less clinical relevance are also possi- claimed by the United Nations on also a human being with certain abil- ble in such cases. It has also been Dec. 20, 1971 lays down that “the ities and capacities which enable him suggested that if such screening was mentally handicapped person must to live, to love, and to learn. He is carried out on a large scale it would have the same rights as other human first and foremost a person whose be impossible to ensure that all beings to the greatest degree possi- potential for development should be women interested in obtaining genet- ble.” Amongst these rights are cer- recognized. This means that fami- ic counselling support would receive tainly to be found the right to life, the lies, health care workers, and society such support. As a result states of right to be recognized as a person as a whole have a clear task before anxiety and worry would arise to and treated as an individual rather them—they should not resign them- which nobody would be able to sup- than as a member of a category, the selves to what they see as unavoid- ply an effective remedy. right to have a family, the right to the able. They should refuse not only to Forms of screening for Down’s best possible forms of care and assis- say but also to think that nothing can syndrome also now exist which en- tance (whether medical, involving be done. They should for once and able a possible diagnosis of such a rehabilitation, or through an institu- all stop seeing mental retardation as a condition to be made when the preg- tion), the right to schooling, the right condition of subhuman life, a source nancy is already underway. This too to work, and the right to participate of terror, a defenseless object to be leads to a policy of amniocentesis in the life of the community (at a re- pitied, or an innocent witness to the and abortion. One of these methods ligious, recreational and political presence of the sacred. On the con- involves three biological tests (al- level, to name the most obvious). trary. Efforts should be made in favor phafoetoprotein, chorionic go- These rights imply corresponding of every kind of action and initiative nadotropin, and unjoined estriol) and duties unless, that is, we want them which can promote and favor the po- this method seems to be especially to remain mere rhetorical declara- tential of development and growth reliable. The large-scale use of this tions. For example, when we recog- outlined above—and all this form of screening also seems to in- nize that the mentally retarded per- notwithstanding the evident difficul- volve paradoxical consequences. son has the right to have a family this ties which lie in the way of perform- Fletcher and others have calculated means that there must be support for ing this important task. that the offer of serological screening those families which have a mentally Today we must and we can act—at to all women in a city of half a mil- retarded member. Through the usual the level of prevention, diagnosis, lion inhabitants would only lead to mechanisms of social solidarity there treatment, education, health care in- the birth of one less Down child than must be a lightening of the heavy stitutions, the family, the social envi- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 69 ronment, the relationships between on young members of the Ashkenazi clusion-body encephalitis. This is a the individual and that environment, members of Israeli society. This is an relatively rare illness which survives the physical environment, and the ultra-orthodox group which only al- for many years after a measles at- economy. lows marriages between its own tack. It brings about changes in per- members and for this reason it is es- sonality, an intellectual deficit, paral- Action at the Level of Prevention pecially affected by genetic illnesses. ysis and finally death. An association The identification of couples who with the measles virus began to be We need to emphasize with great wish to marry who are both het- noticed in the middle 1960s. Over force that true prevention takes place erozygous at the level of their genet- the following ten years a vaccine with reference to genetic illnesses ic make-up—and may thus have against measles began to be intro- through the diffusion of counselling children affected by Tay-Sach’s dis- duced. At the beginning of this pro- in relation to genetic inheritance both ease—wisely leads to the breaking of gram of vaccination there was the before marriage and before concep- the engagement. This is something fear that the weakened virus which tion. For all forms of illness, on the which occurs without great difficulty was employed in the vaccine could other hand, such prevention needs to because on the whole the marriages itself be the cause of this illness. But take place through an expansion in within this ethnic group are arranged some twenty years hence it now ap- prenatal medicine (help during preg- by the parents of the future marriage pears clear that this policy of vacci- nancy and perhaps in the future the partners. The program of screening nation has led to a progressive surgical correction of malforma- has led to the identification of tens of diminution of new cases of Daw- tions), perinatal medicine (improve- couples at risk and in this way the son’s disease which indeed now ap- ment in forms of assistance during birth of many children suffering pears to be an illness whose days are actual childbirth), and postnatal from a form of mental retardation numbered. medicine (correction of metabolic which gets progressively worse has More recently we have learnt deficits, vaccinations, early forms of been avoided (Brodie et al., 1993). about the prevention of damage rehabilitation, and the prevention of An example of metabolic correc- caused by Gonda toxoplasma. The the postnatal causes of mental retar- tion which will perhaps be possible maternal infection caused by toxo- dation and their consequences). in the near future involves treatment plasma can cause a visual deficit in Certain examples serve to give us of the Smith-Lemli-Opitz syndrome, the child and more rarely certain an idea of the great potential to be a genetic condition which was identi- forms of intellectual disability. To- found in a policy of prevention in re- fied some thirty years ago. This is an day we can use methods of screening lation to mental retardation. They al- illness which is characterized by in the fight against this condition and so enable us to dwell on what the fu- mental retardation, growth deficit, it has been demonstrated that the ture will bring for us in this area. microcephaly, cranial-facial dimor- identification of newly-born children I think it would be a good idea to phisms, and other malformations. who are infected but do not show begin with the by now historic exam- This syndrome is present in about clinical symptoms can be achieved ple of phenylketonuria. This in- one in every twenty thousand births through the use of the same blood volves a congenital error in the me- in the United States of America and sample employed for the screening tabolism which is transmitted by re- is considered the second most com- of forms of metabolic disturbance cessive autosomic channels caused mon disturbance caused by recessive (Guerina et al., 1994). Although the by a deficit in the hydroxylase autosomatic transmission, second diagnosis achieved by this method phenylanin enzyme. This illness af- only to cystic fibrosis. The incidence has to be corroborated by other tests, fects about one birth in every thou- of this illness is understated, at least and despite the fact that false nega- sand. If this condition is not treated it in Italy, because hitherto diagnosis tives are possible, early identifica- inevitably leads to moderate or seri- has been based upon clinical data. tion can allow the application of ous mental retardation. Knowledge The recent discovery of low levels of treatment during the first year of life. about the enzyme deficit has led to cholesterol accompanied by high In this way the deficit and the dis- the introduction of methods of levels of a precursor of cholesterol ability can both be significantly re- screening which are now carried out has enabled us to classify this illness duced. at birth on a broad scale. Children as arising from one of the congenital The prevention of mental retarda- who are seen to suffer from this con- errors of the metabolism (Tint et al., tion is also possible through the use dition have to undergo a diet involv- 1994). It is more than obvious that in of suitable dietary treatment. Re- ing phenylanin which is an the future this discovery will lead to search of the last few years presents a aminoacid which constitutes a nor- an early identification of new-born number of powerful arguments in fa- mal part of our food intake. This children affected by this illness and vor of the idea that folic acid can play treatment has led to a dramatic re- to their treatment with supplemen- an important part in the prevention of duction in the number of cases of tary cholesterol. binding defects within the neural mental retardation caused by But prevention is not solely a tube. We are dealing here with such phenylketonuria. question of the congenital errors of important illnesses as spina bifida, A more recent example of screen- the metabolism. Infectious diseases meningocele and anencephalia (this ing for a congenital alteration of the can also cause mental retardation and last condition leads inevitably to the metabolism involves Tay-Sach’s dis- this is something which can be pre- death of the new-born child within ease which can now be identified in vented as well. An example which the space of a few days). It seems healthy carriers. A mass application by now is of historical renown in this that the introduction of 0.4g of folic of this method of screening was used field is that of Dawson’s subacute in- acid every day can lead to a reduc- 70 DOLENTIUM HOMINUM tion of at least 60% in the binding Intervention at the Level new forms of treatment which ap- deficit of the neural tube (Werler et of Treatment pear to be promising. al., 1993; Czeizel, 1993). As a result, We are gaining ever greater infor- women in child-bearing age should It is not possible in this paper to mation and knowledge on the use of increase their consumption of folates dwell in detail upon all the methods atypical antipsychotic drugs such as both through the consumption of ad- and forms of treatment and rehabili- clozapine and risperidon. This is a ditional vitamins and by means of a tation which are now available to us category of drugs which, unlike tra- special diet, and in particular when in relation to the condition of mental ditional neuroleptics, have the ad- they decide to become pregnant. retardation. I will not therefore dis- vantage of fewer extrapyramidal To conclude this section, it should cuss the field of physiotherapy, lan- symptoms and a lower likelihood of be observed that there is also a sec- guage rehabilitation, psychomotrici- inducing tardive dyskinesia. ondary form of prevention. For ex- ty, the various forms of psychothera- Despite certain contrary results, ample, it is well known that children py, and so forth. I will instead limit the antagonists of the meconics— suffering from the condition of men- myself to outlining the advances and in particular naltrexon—seem to tal retardation have very many more which have been achieved in the play an important part on controlling accidents than normal children of the field of psychopharmacology and self-wounding forms of behavior. same age. Although this difference will refer to the prospects that are Furthermore, drugs such as buspiron tends to diminish as these children now being opened up in the whole and the inhibitors of serotonin re-up- grow older, it is nonetheless true that field of gene therapy. take have displayed a promising ef- we need to place greater emphasis fectiveness in the treatment of the upon the prevention of secondary Pharmacological Treatment problem forms of behavior connect- cerebral damage caused by trauma in Although the prestige of pharma- ed to mental retardation. This sug- children who suffer from the handi- cological treatment has undergone a gests that the behavioral disorders cap of intellectual disability. decline over recent years as is the associated with the condition of in- case with all forms of medical ac- tellectual disability may be caused Intervention at the Level tion—something which corresponds by alterations in the serotoninergic of Diagnosis to the crisis of the institutional mod- metabolism as is the case with obses- el—the myth of drugs as a miracu- sive/compulsive forms of distur- When faced with a patient suffer- lous solution to the problems of men- bance and panic attacks even though ing from mental retardation the med- tal disability continues to hold sway the sets of symptoms which are dis- ical doctor and health care institu- in the collective imagination. This is played may well be different. tions should improve the diagnosis underpinned by the greater prestige The use of certain anti-epileptic through an identification of the caus- enjoyed by the medical profession drugs to control mood swings or as es and the pathogenesis of mental re- than that bestowed upon psycholo- instruments in the control of behav- tardation. A mentality directed to- gists and educators. The indiscrimi- ioral disorder is a practice which is wards such an improvement will en- nate use of drugs is very widely prac- by now well consolidated. The ef- courage an indirect advance in re- ticed because it is seen as the most fects of psychostimulants such as search, guarantee the prevention of convenient solution available to methylphenidate in the control of at- further forms of deficit (as in the case solve behavioral problems in pa- tention deficits or hyperactivity also for example of metabolic or deficien- tients where staff are not trained in seem to offer hopes for the future. cy illnesses), and help in the identifi- methods of behavioral treatment or Mentally disabled patients have a cation of those areas of behavior where the system is unwilling to in- biological and psychological vulner- which are most affected and influ- vest time and human and economic ability and this means that the nega- enced by the condition of mental re- resources in changing the attitudes tive side-effects of neuroleptic drugs tardation. In this way greater preci- and conduct of the staff and their pa- are of especial importance and sig- sion will be achieved in deciding up- tients. In reality many behavioral nificance. In addition to the negative on individualized policies of inter- problems are messages which can be effects on the patient’s cognitive vention and greater success will be understood in rational terms. functions, and in order to act in har- obtained with regard to treatment The pharmacological treatment of mony with the principles of risks and and rehabilitation. The ability to pro- mentally retarded people remains an benefits, attention should always be duce precise forms of diagnosis has extremely difficult course of action. paid to the high frequency of side-ef- undergone major leaps forward in re- This is the result in particular of a fects of a Parkinsonian nature, dysk- cent years. We need only think here lack of precise diagnostic criteria in inesian or dystonic elements, and tar- of advances which have been made the assessment of the psychopatho- dive dyskinesia. The malign neu- in molecular biology or in the tech- logical expressions and symptoms of roleptic syndrome, which can lead to niques of neuroimaging. Health care mental retardation. In addition there death, fortunately enough is rare but institutions should match this need to is a conspicuous absence of con- in these patients it is more frequent improve the character of diagnoses trolled clinical studies of this whole and more serious than in other cate- by guaranteeing access to services field, not least in relation to the most gories (Boyd, 1993). In recent years and especially to hospital services, commonly used drugs such as the the toxic effects of drugs which alter and without committing those acts of neurolytes. Although there are obvi- the serotonin have been noticed and discrimination which at the present ous limitations in their application, it this also is something which is prob- time make the mentally retarded per- is nevertheless true that recent re- ably more common and serious in son an unwelcome guest. search seems to offer a number of patients who suffer from mental re- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 71 tardation (Sternbach, 1991). affect a sole gene and which cause person, that is, towards his malad- Given all these elements and the serious forms of mental retardation justed behavior, and towards the en- limited effectiveness of psychophar- than in relation to light conditions of vironmental and social supports that macological treatment we should intellectual disability where the envi- he needs in order to be able to live perhaps dwell upon the ethical cor- ronment often plays an important with success in a given environment. rectness of an indiscriminate use of role. However, like the much lament- This tendency is to be found in the psychotropic drugs. More than 50% ed Professor Lejeune, I also believe 1992 version of the definition of- of mentally retarded people are treat- that the prospects for gene therapy in fered by the American Association ed with psychopharmaceuticals, of- relation to mental retardation rooted on Mental Deficiency. In approach- ten receiving more than one drug and in genetic factors is an answer which ing the question of capacity for adap- in large doses (Deb and Fraser, is far too simple, indeed of a school- tation this definition employs the 1994). In this field we must seek to boy level, which will probably be concept of social intelligence rather avoid possible abuses and we should preceded and rendered useless by than maladjusted behavior, a notion respect the personality of the mental- other more effective methods. In or- which previously held sway. ly retarded person. In particular we der to give an example of his posi- The ability to recognize that the should make sure that the neurolep- tion, Professor Lejeune argued that mentally retarded person is an indi- tics which are employed do not be- in his opinion before juvenile dia- vidual in the full sense of the term come a sort of chemical strait-jacket. betes could be corrected by gene necessarily means that attention The future improvement in this therapy a method would be discov- should also be paid to his opinions. condition will lie in a more frequent ered by which transplants of pan- This is especially so when action is use of action at the level of behavior, creas membrane cells from animals taken in relation to his body. We also in the identification of guidelines in would allow the passage of insulin have to accept the suffering and the relation to tried and tested forms of from the transplant without there be- frustration that we feel when we are treatment, in a constant monitoring ing any attack on the transplanted unable to understand him or when we of the effectiveness and the negative cells by the host body’s anti-body are unable to communicate with him. effects of psychopharmacological system. forms of treatment, and in the ability Schooling to distinguish groups of responders Intervention at the Level Traditional schooling requires a from groups of non-responders. of Education section all of its own. In discussing this subject I will only refer to the Pharmacological Testing At the beginning of this paper it Italian experience which is neverthe- The improvements in standards of was observed that the definition of less seen in other countries as being medical practice cannot be separated mental retardation includes the pres- very advanced. Until the 1970s the from scientific research and thus ence of a deficit in relation to gener- schooling of the mentally retarded from the ability to test new drugs and al intellectual functioning (measured child in Italy took place within the medicines. However, each testing by intelligence quotient) and the health care institutions themselves or raises ethical questions and prob- demonstration of limits to the indi- in the case of children who had not lems, as indeed in borne out by a vidual’s ability to adapt to the needs been institutionalized within special spreading tendency within centers of and requirements of his environ- schools or in special classes. Howev- research and study to examine the ment. Although it is true that the con- er, a movement grew up which was ethical bases of every new initiative. cept of intelligence quotient is right- based upon clauses 34 and 38 of the The questions raised are even more ly seen as something which is rigid Italian constitution which cam- pressing and the necessary examina- and rather unyielding, it is also evi- paigned in favor of the social integra- tions must be even more detailed dent that it is possible to act upon the tion of handicapped people. This met where one is dealing with individuals difficulties that an individual experi- with a response on the part of parlia- who suffer from a condition of men- ences in his adaptation to the envi- ment which passed laws 30.3.1971 n. tal retardation. Without entering too ronment. An improvement in this 118 and 4.8.1977 n. 517. Subsequent deeply into this whole subject, here maladjustment can even lead to an ministerial circulars (n. 199 of reference can be made to the ques- individual no longer being classified 28.7.1979, n. 258 of 22.9.1983, n. tion of what constitutes real consen- as being mentally retarded. 250 of 3.9.1985 and n. 262 of sus and to the need to assess the ben- Specialized forms of education, 22.9.1988) developed and improved efits which the individual participat- programs involving the development upon this legislation and led to the ing in the experiment might be able of how to use various kinds of instru- closure of special schools for handi- to gain. ments and tools, and a behavioral ap- capped children, the abolition of spe- proach are only a few examples of cial classes, and the creation of forms Gene Therapy the large number of opportunities we of support and school integration In this area today one often hears have to act at the level of education which employed a clinical diagnosis talk of the hope that a deficit can be in order to help those who suffer to promote an approach based upon corrected through the introduction of from the condition of mental retarda- the profiles and functional diagnosis normal genetic sequences into the tion. If I wanted to capture the salient of each individual child. genetic code of a patient. It is proba- features of contemporary develop- At the present time, and despite ble that in the future such forms of ments in this sphere, I think I would notable resistance, handicapped chil- therapy will be highly beneficial say that emphasis is now being di- dren are present in nearly every Ital- more in relation to alterations which rected more towards the deficit of the ian school of whatever level or char- 72 DOLENTIUM HOMINUM acter. Many children suffering from when considering cases of mental re- can facilitate social integration and mental retardation are in the class- tardation, to reflect at length upon the acceptance on the part of the room, at least until the school-leav- whether it is a good idea to institu- community of people afflicted by in- ing age. tionalize such people. The decision tellectual disability. Steps towards The scholastic integration of men- will depend upon the seriousness of greater levels of independence can tally retarded children is undoubted- the case, the levels of behavioral dis- also be encouraged. Staying within ly a highly civilized goal even order of the intellectually disabled the family for as long as is possible though from an ethical point of view person, the condition of his family, or residence within self-managing we should ask ourselves whether at- and the nature of the institution. homes (with various levels of exter- tempts to place such children is nor- The best solution, obviously nal professional support) are certain- mal classes is necessarily always a enough, would be to provide all the ly more suited to ensuring the digni- sound policy. necessary forms of assistance and ty and the normalization of these Although a normal class can well care within the family itself. Howev- people than traditional forms of insti- act as a factor of stimulus for the er, we must recognize in a spirit of tutionalization, at least as regards child suffering from a light or moder- true realism that in certain cases (be- those who suffer from light or mod- ate form of mental retardation, it can cause of cultural deficiencies, eco- erate forms of mental retardation. nonetheless prove rather disturbing nomic constraints, or the age or Like all revolutions, the antisegre- for children suffering from serious or health of those who would have to gationist movement has also had its very serious kinds of intellectual dis- provide such help), the family is not innocent victims, and gradual, ability. Indeed, they may be preventable to deal with the very real prob- thought-through and assimilated ed from acquiring that minimum of lem of a member who is afflicted changes would have been more ap- instruction which they would other- with mental retardation. Society for propriate and positive in their effects, wise gain in a protected environ- its part has the moral duty to pursue a not least in order to avoid the risks of ment. Furthermore such integration policy of solidarity towards families reaction and hostility. However, we often takes place in an uncontrolled which have such members, and this should in all honesty recognize that and unregulated way and without the duty should involve the provision of often it was only the extremist cam- suitable training and instruction of economic support and services paign in favor of the closing of these pupils and teachers. In this way fur- which can lighten the burden borne old institutions which led to legisla- ther rejection and stigmatizing can by the family. Society should also tive or judicial initiatives which take place. guarantee those suffering from men- moved in that direction and redirect- It should also be observed, in con- tal retardation who live outside insti- ed financial resources towards the clusion, that a policy of integration at tutions, sufficient standards of med- creation of places with lifestyles sim- all costs in normal classes often acts ical care and forms of rehabilitation ilar—in so much as this was possi- to deprive children suffering from within clinics or where necessary ble—to those of other members of serious mental retardation from re- within the home. the community. ceiving a precise diagnosis and the Even in those cases of mental re- The debate on the merits or demer- benefits of specifically aimed forms tardation where a policy of institu- its of institutionalization is now over. of rehabilitation. In normal schools tionalization is obligatory, society At the present time discussion cen- such diagnosis and rehabilitation are has the duty to ensure that within ters around how to guarantee or im- generally impossible because the long-term institutions health care and prove the social integration of intel- low number of mentally retarded forms of educational rehabilitation lectually disabled people during a children means that there can be no are guaranteed to mentally retarded period of financial stringency. One justification for the costs involved in people and that the internal condi- solution to this problem could lie in providing a service of diagnosis and tions which are offered to them removing emphasis from the provision rehabilitation which is really effec- spect the dignity of man. Only con- of services to the strengthening of the tive. Furthermore, and without tak- stant vigilance can prevent the fre- supports provided by the natural ening the whole question of costs into quent degeneration of such institu- vironment. account, it should be pointed out that tions into places of segregation and in the non-specialized context of the violence. The use of institutions can Intervention at the Level normal school people who are be gradual and flexible in line with of the Family specifically trained for such initia- the original situation of the patient tives and who really want to carry and the local cultural and economic The family is the most important them out are usually far and few be- resources which are available. and fragile link in the chain of help tween. The move from the old closed in- provided to the mentally retarded. stitutions which could hold thou- The birth of a child who is mentally Intervention at the Level sands of individuals to open and retarded gives rise to different kinds of Health Care Institutions stimulating institutions allows the of reaction which range from rebel- overcoming of segregation and the lion to aggression, from isolation to It has already been observed in creation of ways of life which are apathy, and from feeling different to this paper that there is a right to live less artificial. The establishment of feeling marginalized. This disquiet within one’s own family and a right small centers in an urban context and disturbance affects all members to receive the highest possible stan- where community models of life are of the family including the disabled dard of care and assistance. With in operation, in conjunction with the child. He himself feels that he is the these rights in mind it is advisable, support of voluntary organizations, cause of these difficulties, that he is “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 73 to blame, and as a result he does not America is in reality the outcome of time. Although a causal relationship live in a state of tranquility or calm. economic factors and conditions and between the two phenomena cannot The humanization of caring for the connected to the educational level of be demonstrated beyond all doubt it mentally retarded becomes more the mother and the age of the mother seems clear that such a connection possible when the solidity of the at the moment of birth. To put it more really does exist. The lessons to be family itself is greater and when the simply, black children are more like- drawn from all this in terms of assistance that the state offers that ly to be exposed to a variety of harm- changes which are needed in politi- family in the way of legal and eco- ful factors both before and after birth. cal and economic terms to bring nomic help and in the form of ser- These negative factors are cumula- about alterations in attitudes and be- vices is more pronounced. One can- tive in their impact and involve a havior which will be more respectful not in schizophrenic fashion ask condition of disadvantage in relation of the environment are more than ev- families to take care of their mental- to the forms of cognitive stimulus ident. ly retarded members in the home and and early educational experiences An increasing interest in the role then at the same time undermine the which black children have to endure of lead and other metals such as cad- solidity of the family itself. (Yeargin-Allsopp et al., 1995). mium, chromium, cobalt, mercury Action must involve families and nickel in provoking mental retar- above all else when long-term pro- Intervention at the Level dation is also to be observed at the grams of stimulation are being ap- of the Relationship present time. Such metals are used in plied or when very early intervention between the Individual many building materials, in petrol, is required. The involvement of the and his Environment and in such discarded products as parents also ensures that action takes worn-out batteries. We are beginning place within the normal life environ- In dealing with the whole question to receive solid information on the ment of the child and gives the health of the relationship between the men- presence of these substances in the care worker the opportunity to ob- tally retarded person and his life en- amniotic liquid extracted during am- serve the child indirectly for a long vironment we should strive to reduce niocentesis (Lewis et al., 1992). The time and from close at hand, and this the potential conflicts which can subject is still very much open to dis- is something which can be of vital break out and to overcome the forms cussion but it seems that there is in- importance in any assessment of the of experience which are marked by deed an inverse relationship between case. However, efforts should be isolation and anonymity. The condi- the hemal level of some of these tox- made to ensure that the parents are tion of mental retardation would gain ic substances and the intellectual lev- not overburdened with responsibili- much from the creation of an envi- el of the child. This is also the case ties and work, both to avoid a condi- ronment which promotes human re- when other possible causal factors tion of burn-out and to reduce the lationships and the feeling that the have been eliminated. risk of the married couple entering mentally retarded person has of be- In discussing the impact of toxic into a state of crisis. longing to a distinct community. We substances present within food and also need to work towards the accep- drink I will only refer here to the role Intervention at the Level tance of the movement towards so- of alcohol. Exposure of the embryo of Social Environment cial integration without which there and unborn child to alcohol while would be no opportunities for accep- still in the womb is linked to a syn- The environment is the factor tance in the local area, no offers of drome marked by delayed pre-birth which makes all the difference to work, and no pressure upon the legis- and after-birth growth, by craniofa- many people who suffer from light lature to pass suitable measures in- cial dysmorphism, and by alterations intellectual disability. An interaction volving legal and economic support. in the functioning of the central ner- with a welcoming and stimulating vous system which can include men- environment can place such individ- Intervention at the Level tal retardation. Although there are uals within the range of normal per- of the Physical Environment wide geographical variations in the formance and functioning. For this incidence of the alcoholic foetal syn- reason improvements to the environ- Unfortunately, year after year tox- drome which are themselves linked ment in which poor children grow up ic elements in food and in the envi- to different dietary habits, it is esti- can help to reduce the incidence of ronment, and other polluting forces, mated that at a worldwide level the light mental retardation within such are becoming ever more important in incidence of this syndrome is of 1.9 sections of society and thereby di- causing conditions of mental retarda- cases every 1,000 births. The alco- minish the need to engage in institution. As an example of environmen- holic foetal syndrome may thus be tionalization (Zigler, 1995). tal pollution I would like to refer here considered as constituting one of the The importance of social factors is to a recent article which refers to a most important causes of mental re- stressed by the commonly noticed cluster, that is, to an outbreak of new tardation. Alcoholism is in a state of presence of higher levels of intellec- cases, of children suffering from constant diffusion and requires a tual disability in the less privileged Down’s syndrome in the city of careful policy of prevention in order social classes. Even when racial fac- Berlin. This took place nine months to avoid mental retardation in the tors seem to be at work (Murphy et after the tragedy of Chernobyl (Sper- form of the alcoholic foetal syn- al., 1995), it is possible to demon- ling et al., 1994). It is very unlikely drome (Spohr et al., 1993). strate that the higher incidence of that the connection is merely one of A work of education in relation to mental retardation amongst the black chance given the very close tie be- future mothers should also be em- community of the United States of tween the two events in terms of barked upon and developed, espe- 74 DOLENTIUM HOMINUM cially where a moderate consump- spend today in bringing up a “nor- break with the past, such initiatives tion of alcohol is encouraged in so- mal” boy who eats American-style are based upon objective methods of cial terms. Alcohol can in addition be fast food and spends his days in front assessment and appraisal which en- linked to growth retardation and to a of the television?” able us to direct our efforts with reduction in the circumference of the There is a very short step from greater precision,and to control and cranium (Geva et al., 1993). denying the economic basis of the monitor the effectiveness of the ac- To conclude this section on the birth of a mentally retarded child to tion that we take. physical environment, it should be denying that child the necessary care Today action and initiatives in this observed that the environment can and treatment in periods of econom- sphere must become more individu- also cause forms of intellectual dis- ic hardship. There is also a very short alized in character. Forms of stan- ability by natural routes. Somewhat step from this position to that of ster- dardized intervention are no longer later in this paper I will dwell upon ilization—a policy proposed in a feasible because they do not take ac- the question of the impact of a lack very recent resolution of the Euro- count of the special needs of each in- of iodine in drinking water. pean parliament. dividual. What we need to do is to A recent research carried out in develop plans of individual action Intervention at the Level Chicago (Fujiura and others, 1994) which can involve very high levels of the Economy sought to quantify the costs to a fam- of social competence and models of ily of having an adult member afflict- life which are ever more similar to Any action or initiative in relation ed by mental retardation. This inves- those of the daily lives within the to intellectual disability cannot be tigation showed that the costs of community of normal people. In separated from the economy. With- maintenance were no higher than seeking to achieve the adaptation of out the necessary economic re- those involved in the maintenance of the mentally retarded person to soci- sources such work would not be pos- a member not suffering from mental ety, we also achieve the adaptation of sible. Some experts believe that to- retardation. The problems arise when society to the disabled person and wards the end of this century the im- the family receives a low contribu- appreciate and promote his social pulse in certain European countries tion (whether from work or state role. towards allocating resources to sup- welfare) from its mentally retarded The complexity of the problems port projects of integrated assistance member. For this reason the costs of involved means that action in rela- for the mentally retarded will come his maintenance falls largely on the tion to mental retardation should be to an end. These experts believe that shoulders of the family itself. Impor- effected through the mechanism of in Western Europe and in the United tant policy decisions follow from this multidisciplinary teams. But this States of America we are moving to- state of affairs because supplying the very fact also means that there is the wards the end of a policy of support family with the complete costs of risk that information will be distrib- for the mentally retarded. Individuals maintenance constitutes a mere frac- uted wrongly, that the parents will suffering from forms of intellectual tion of what it would cost to put its have to endure excessive stress (de- disability will be crushed by other mentally retarded member in an in- prived as they are of points of refer- competitors for these precious re- stitution. ence and forced to engage in the life sources in a process which will dis- A redistribution of wealth is also of a sort of therapeutic nomad, wan- turb the whole relationship between called for at a planetary level. We dering among a large number of dif- the suppliers and the users of ser- need only think here of how endemic ferent health workers), that there will vices (Boston, 1994). cretinism can be caused by a lack of be an operative and cultural frag- For some years now a debate has iodine. This lack is in absolute terms mentation of the individual, and that been in progress regarding the provi- the most frequent cause of serious there will be conflicts and tensions sion of services to people suffering mental retardation in the world. Its between health professionals and from mental retardation in terms of pathogenesis is still very imperfectly themselves. costs and benefits. Authoritative known but its prevention through the It should be added here that at the British obstetricians reject this kind supply of iodine is simple and very present time action can be taken in of approach and call upon the med- cheap. And yet the developed world relation to all ages and with different ical classes to resist the appeals to forgets about this problem, a prob- approaches and methods from the become “suppliers of technological lem which is of immense importance prenatal stage to the stage of patho- services obsessed by costs” (Elkins in many developing countries. A re- logical aging. On the one hand, the and Brown, 1993). After declaring medial policy would cost very little action taken must indeed be early on that the idea that a person suffering but would give the peoples of devel- in the patient’s life. Any service at all from the Down syndrome costs soci- oping countries many less burdens can only be offered if the problem is ety about $196,000 is absurd and and a much more marked degree of recognized. The role of pediatricians out-of-place, Elkins and Brown go intellectual capital. is of fundamental importance in this on to ask themselves and to ask us in area and, as has already been pointed provocative fashion: “What is the out, the same may be said of the role cost for a family and a society to The Necessary Aspects of Action of parents. Indeed, the earlier the bring up a “normal” person and to condition is diagnosed and the path educate him to the point of his be- Hitherto attention has been paid to of treatment and rehabilitation is becoming a doctor? What is the cost of the different areas where action in fa- gun, the greater are the hopes of re- a person who spends a number of vor of helping the mentally retarded covery. years in prison? How much do we is called for and can take place. In a At the other extreme, the action “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 75 which is now performed must con- of dementia end up by being placed which can be taken to help individu- tinue and take on different forms be- in long-term institutions before they als suffering from intellectual dis- cause of the constant increase in the should be, and in such places the un- ability and to emphasize the ethical number of mentally retarded adults. familiarity of the staff with their spe- implications of the different courses The elderly population is on a con- cific problems leads to inadequate of action. However, certain general stant increase. At the same time the forms of care and assistance and to observations are also possible. The improvement in medical treatment an accelerating decline in functional attitude of society in general and the has led to an increase in the number capacity. medical classes in particular towards of elderly people who are mentally To conclude this section, it should mental retardation has oscillated be- retarded. It is estimated that at the be pointed out that action requires tween behavior which involves a sort present time in the United States of guarantees that the individual will be of resigned approach and an attitude America the number of adults who respected. Such action must not be which we could define as being “lib- are over the age of sixty and suffer interference; it should not take the eral.” As is always the case, the ex- from mental retardation is about form of excessive intervention or un- tremes of these two positions meet. 173,000. Projections for the future controlled experimentation. Excess- For example, the failure to engage in suggest that these will increase and es of zeal and extremist positions more in-depth diagnosis which reach a figure of 333,000 in the year must be avoided. The disabled per- marked the experienced of many 2025. The phenomenon certainly has son’s right to be different should also segregationist institutions was the a number of important conse- be recognized. perhaps unintended cause of the quences. The aging of the population Before going on to the conclusion campaign to place mentally retarded involves an increase in senile demen- of this paper I would like to empha- children in normal schools at any tia. It is thought that at the end of the size that action in favor of the person cost. The same may be said at a prac- second millennium the number of suffering from mental retardation tical level of those who fail to devel- Americans afflicted by Alzheimer’s and the involved and careful study of op the diagnosis and choose instead disease will be on the order of ten intellectual disability is not only an to minimize the problem and to ig- million. act of justice towards mentally re- nore the individual by referring only A large number of studies have tarded persons themselves but also to the label placed on him by social suggested that a sizeable proportion has very great significance for hu- stigma. of adults suffering from Down’s syn- man society. It seems to me that the best way to drome who are over forty years of The study of intellectual disability deal with the problems of mental re- age develop clinical signs of has led to advances in our knowledge tardation is to be found in action Alzheimer’s disease even though in of the mechanisms of mental devel- rooted in the categories of realism levels lower than those who display opment, and this in turn has enabled and hope. Hope deprived of realism the neuropathological alterations us to create better ways of dealing ends up by ignoring what the indi- which are characteristic of with the needs of mentally disabled vidual is capable of and means that Alzheimer’s. Such characteristics are people and at the same time to pro- he will not receive the necessary sup- to be found in the brains of nearly all mote the mental and physiological port. Realism without hope involves elderly Down patients. Something development of normal children and an inability to recognize what the similar, even though this has been lit- the achievement of correct education most recent research into the human tle studied, seems to occur in other within the family. brain tells us in clear terms - that cog- forms of mental retardation. An example of this is to be found nitive potential is never static and At the present time there are strate- in a recent study (Brunner et al., that the brain is endowed with a cer- gies by which to treat Alzheimer’s 1993) which has led to the identifica- tain plasticity whose intensity in- disease, but nothing or little is avail- tion of the gene locus of a distur- creases when stimulus is applied at a able in relation to mentally retarded bance connected with chromosome very early age. Recovery, therefore, people who display symptoms of X. This disturbance involves notable is always possible and its extent de- Alzheimer’s. It is probably necessary levels of aggression and a defect in pends both upon biological facts and to alter the character of the programs the metabolism of type A upon how early the diagnosis is of such treatment and to adapt them monoaminissidases. The results of made and the rehabilitation is at- to the changes in the behavior and the this study can be used for the more tempted. capacities of the patient. However, general study of aggressive behavior. If there is a sincere wish to avoid we lack general guidelines on how to Knowledge about the mechanisms neglect or the concentration camp, achieve an early and effective diag- which lead to mental disability and the policy of placing a mentally re- nosis of Alzheimer’s disease in men- pathological forms of behavior tarded person in an institution is not tally retarded people and on what which are connected with such dis- longer possible. What we need is kind of treatment and care to provide. ability can offer information about constant and competent social con- The public authorities in the field of the biological bases of the cognitive trol and direction. In the same health and social services lack the functions and behavior in people not way,no action is possible in this necessary experience to deal with affected by mental retardation. sphere (not least of an economic this problem and fall into crisis when character) unless it is based upon sol- they have to draw up programs to Conclusion idarity - solidarity within society help this kind of citizen. The result of should thus be inculcated as a value. this is that patients affected by men- In this paper I have sought to de- A sound vision of the whole prob- tal retardation who become victims fine the possible forms of action lem means that we should develop a 76 DOLENTIUM HOMINUM feeling of love towards the mentally wrote to a simple quarterly review of a price too high in the triple screen for Down syndrome. Clin Obstet Gynecol 1993, 36:532- retarded person, and that such an in- the Faith and Light Community as- 540. dividual should be seen as a person sociated with Jean Vanier. In her en- FERNALD C.D., When in London....: differ- and not as a mere member of a cate- counter with the members of this ences in disability language preferences among English-speaking countries. Ment Retard 1995, gory. “A love which opens to the oth- community who work so splendidly 33:99-103. er person in his unique individuality for the disabled, this mother discov- FLETCHER J., HICKS N.R., KAY J.D.S., BOYD and speaks to him with the following ered a new meaning in her suffering P.A., Using decision analysis to compare policies for antenatal screening for Down’s syn- decisive words: ‘I want you to be’. If and in that of her child. drome. BMJ 1995, 311:351-356. there is not this acceptance of the FUJIURA G.T., ROCCOFORTE J.A., BRADDOCK other person from the outset, whoev- A Letter D., Costs of family care for adults with mental retardation and related developmental disabili- er he may be, recognizing in him a ties. Am J Ment Retard 1994, 99:250-261. real albeit obscured vision of Christ, Not all of us receive a contempla- GEVA D., GOLDSCHMIDT L., STOFFER D., then it cannot be said that there is re- tion of the suffering which surrounds DAY N.L., A longitudinal analysis of the effect of prenatal alcohol exposure on growth. Alco- al love... Every authentic love re- us, but all of us will be called to ac- hol Clin Exp Res 1993, 17:1124-1129. states in a certain fashion the initial count for our reply. Last Sunday, the GUERINA N.G., HSU H-W., MEISSNER C., evaluation of God, repeating with the Feast of Christ the King, we listened MAGUIRE J.H., LYNFIELD R., STECHENBERG B., Creator in relation to every real hu- during the liturgy of the Mass to the ABROMS I., PASTERNACK M.S., HOFF R., EATON R.B., GRADY G.F., Neonatal serologic screen- man individual that his existence is a terrible destiny which awaits those ing and early treatment for concenital Toxo- ‘very good thing’ (Genesis I, 31)” who are not able to perceive the face plasma gondii infection. N Engl J Med 1994, (John Paul II to the ‘Cottolengo’ of of Christ in the smallest, in the poor- 330:1858-1863. LEWIS M., WOROBEY J., RAMSEY D.S., MC- Turin, 13.4.1980). est, and in the most suffering. We CORMACK M.K., pre-natal exposure to heavy “A very good thing.” Instead of will also be held to account for how metals: effects on childhood cognitive skills and being a burden the mentally disabled we have treated the mentally dis- health status. Pediatrics 1992, 89: 1010-1015. LUCKASSON R., Mental Retardation: defini- person is a teaching chair. He teaches abled, and it is our hope that our tion, classification, and system supports, edn 9. us that nobody is perfect. He teaches judgment will conclude with the Washington DC: American Association on the right to diversity, the respect for blessed judgment—“Come, O Mental Retardation; 1992. MATSON J.L., SEVIN J.A., Theories on dual differences, the true basis of every blessed of my Father, come to the diagnosis in mental retardation. J Consult Clin possible form of social integration. kingdom that I have prepared for Psycol 1994, 62: 6-16. To employ the words of Elkins and you.” MURPHY C.C., YEARGIN-ALLSOPP M., DE- COUFLÉ P., DREWS C.D., The administrative Brown (1993), he teaches us that prevalence of mental retardation in 10-year old “the value of a civilized community Professor GIAN LUIGI GIGLI children in metropolitan Atlanta, 1985 through founded upon welcome rather com- Professor of Neurology, 1987. Am J Publ Health 1995, 85: 319-323. PUFFER R.R., Family planning issues relat- petition. He teaches us the philo- Hospital of St. Mary of Mercy, ing to maternal and infant mortality in the Unit- sophical ideal of unconditional love, Udine, Italy ed States. Bull Pan Am Health Organ 1993, 27: the theological concept of grace” Secretary General of the 120-134. International Federation of Catholic REID D.H., BALLINGER B.R., Behaviour (the freely given). Medical Associations symptoms among severely and profoundly re- It was with this belief in his heart tarded patients: a 16-18 year follow-up study. that E.Mounier wrote these follow- Br J Psychiatry 1995, 167: 452-455. SPERLING K., PELZ J., WEGNER R-D., DOR- ing words to his wife about their RIES A., GRUTERS A., MIKKELSEN M., Signifi- daughter who was immobilized and cant increase in trisomy 21 in Berlin nine dumb because of the effects of a very months after the Chernobyl reactor accident: temporal correlation or causal relation? BMJ serious attack of encephalitis: “I 1994, 309: 158-162. have undoubtedly never experienced Bibliography SPOHR H.L., WILLMS J., STEINHAUSEN H.C., the state of prayer so intensely as Prenatal alcohol of exposure and long-term de- BOSTON S., Too deep for tears, Harper velopmental consequences. Lancet 1993, 341: when my hand said things to that Collins, London, 1994. 907-910. face which failed to reply, when my BOYD R.D., Neuroleptic malignant syn- STERNBACH H., The serotonin syndrome. Am eyes were directed towards that emp- drome and mental retardation: review and J Psychiatry 1991, 148: 705-713. analysis of 29 cases. Am J Mental Retard 1993, TINT G.S., IRONS M., ELIAS E.R., BATTA ty look which spoke far away.” This 98: 143-155. A.K., FRIEDEN R., CHEN T.S., SALEN G., Defec- dimension of the contemplation of BRODIE E., ZEIGLER M., ECKSTEIN J., BACH tive cholesterol biosynthesis with the Smith- God in the face of a person who has G., Screening for carriers of Tay-Sachs disease Lamli-Optiz syndrome. N Engl J Med 1994, in the ultraorthodox Ashkenazi Jewish Commu- 330: 107-113. been severely compromised in his in- nity in Israel. Am J Med Genet 1993, 47: 213- YEARGIN-ALLSOPP M., DREWS C.D., DECOU- telligence touches the very highest 215. FLÉ P., MURPHY C.C., Mild mental retardation points of mystical exaltation, re- BRUNNER H.G., NELEN M.R., VAN ZAND- in black and white children in metropolitan At- VOORT P., ABELING N.G.G.M., VAN GENNIP lanta: a case-control study. Am J Pub Health quires a total acceptance of the cross, A.H., WOLTERS E.C., KUIPER M.A., ROPERS 1995, 85: 324-328. and cannot be asked of anyone. H.H., VAN OOST B.A., X-linked borderline men- WERLER M.M., SHAPIRO S., MITCHELL A.A., However, it becomes much easier tal retardation with prominent behavioral dis- Periconceptual folic acid exposure and risk of turbance: phenotype, genetic localization and occurrent neural tube defects. JAMA 1993, when the love of God enables us to evidence for disturbed monoamine metabolism. 269: 1257-1261. meet the mentally disabled person Am J Hum Genet 1993, 52:1032-1039. WILLEMSEN R., MOHKAMSING S., DE VRIES and his family through the freely- CZEIZEL A.E., Prevention of congenital B., DEVYS D., VAN DEN OUWELAND A., MANDEL anomalies by periconceptual multivitamin sup- J.L., GALJAARD H., OOSTRA B., Rapid antibody given love of people who can bear plementation. BMJ 1993, 306: 1645-1648. test for fragile X syndrome. Lancet 1995, 345: witness to Him. DEB S., FRASER W., The use of psychotropic 1147-1148. Some years ago I was very struck medication in people with learning disability: ZIGLER E., Can we “cure” mild mental re- towards rational prescribing. Hum Psy- tardation among individuals in the lower so- by a letter which a young mother of a chopharmacol 1994, 9:259-272. cioeconomics stratum? Am J Public Health seriously mentally retarded child ELKINS T.E., BROWN D., The cost of choise: 1995, 85: 302-304. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 77

BRUNO SILVESTRINI

Aberrations in the Natural Order of Things

The term aberration is used here an event that so often reveals erst- ings?” At the time, we stared at to refer to human beings whose while latent mental disturbances, him incredulously, without under- characteristics distinctly differ my only concern was that they standing what he wanted to say— from those of others belonging to might have normal bodies and so absurd did his words sound that the same species or social commu- minds. we thought we were dreaming. We nity. The difference can regard As the years went by these tried reasoning with him. One of various somatic or mental traits, memories gave way to other expe- us spent hours and hours trying to but here we shall mainly discuss riences and reflections. I later en- make him see sense, all to no avail. its psychic reflections. We shall countered severe mental illnesses Only years later did I learn to rec- begin by recalling certain personal that caused a person’s departure ognize in this lucid thought the experiences and then pass on to from the reality we all know. One first signs of schizophrenia. De- more general reflections. day with a group of friends we spite being rationally irrefutable, My first encounter with aberra- found ourselves having to deal these thoughts split off from the in- tions occurred when, as a child, with an emergency, a drowning stincts and emotions that normally my parents took me to visit a home boy. Instinctively, we jumped into imbue us. Later I also came to for disabled persons. Many had the water and brought the boy to know schizophrenics in a fit of severe handicaps that had reduced safety. Only one boy stayed be- psychosis who asked desperately them to a purely vegetative exis- hind watching the scene, motion- for help to protect them from their tence. Most of them were children, less, apparently paralyzed with hallucinations. Despite realizing but some were adults. For the first emotion. But he was actually the inconsistency of these intru- time I found myself face to face blocked not by emotion but by a sions, they seemed unable to free with a stark reality that I had never lucid thought that he later ex- themselves. I also came to know even dreamt possible. It made me pressed in these terms: “What right the endogenous depression that feel upset and frightened. My first have we to intervene in another can transform a person’s life into instinct was to run away, to go out- person’s life? Whatever do we unbearable, burning suffering end- side into the open air and to erase know about their inner suffering in suicide. People suffering those images from my memory as from depression rarely ask for help soon as I could. Then, my mind because they believe that their dif- became gradually taken up with ficulties come not from within comparing the condition of those themselves but from reality. beings to the life of a healthy child Hence, they look askance at those surrounded by family affection, a who propose treatment, wondering child who lacked nothing. Until whoever could be foolish enough then I had never realized how to fail to understand that what lucky I was. Nor would I ever have needs putting right is not them- understood had it not been for my selves, but the rest of the world parents’ wish to teach me in this around. traumatic manner. Those de- Through these experiences I formed bodies and those suffering, have come to appreciate the need half-witted faces often returned to to distinguish between how we my mind in later years, helping me perceive aberrations and how to remain calm even in the face of those who live through these aber- adversity that to others seemed un- rations from within perceive them. surmountable. Compared to those In contrast to the schizophrenic distant images, even death seemed who begs to be freed from his hal- to me a lesser evil. When my chil- lucinations, others take part in dren were born and later when their illness, have made illness they reached the crisis of puberty, their way of being, and know no 78 DOLENTIUM HOMINUM other ways. They ask for nothing eventually became completely ap- accumulating ever more power more than to live in peace in ac- athetic. Once that had happened, and wealth, even when these cord with what they are. she began to feed herself again goods become useless and coun- In this connection, I would like normally and survived for some terproductive. I was greatly im- to cite another personal experi- years in a disabled state, depend- pressed by the members of a small ence. When I was a child and an- ing upon others even for her sim- community who have settled into a tipsychotic drugs had yet to be dis- plest needs. She was a humble per- ruined convent they have restored covered, in the small town where I son, yet endowed with an extraor- and turned into a garden. Their grew up one often encountered dinary sense of dignity. It seemed way of life reminds me of the people who wandered around the to me that refusing food may have cloistered monks of old. Some streets talking nonsense but other- been her way of asking to die in community members have with- wise behaved normally. I had to re- peace, following the natural course drawn from drugs; others still sign myself to accepting the sneer- of events. Probably, when having struggle to do so. Many come from ing they occasionally had to bear. to cope with the same situation rich families from which they re- But those who suffered most were again, I would still opt to prolong ceived everything, from complex their relatives, for they suffered the her survival. But whether this de- toys when they were children to disgrace of having a mentally ill cision is right remains an unan- cars and expensive clothes as they person in the family. swered question. grew up. And they were sent to fa- Depression also appears differ- Yet another aberration that I mous schools reputed to ensure ent according to whether it is have often needed to cope with is qualifications and suitable career viewed from within, or from with- drug abuse (Silvestrini, 1995). It openings. The only gift they never out. Some forms of depression usually originates from a mental received was the one they really arise from an external cause—for discomfort that the affected person needed: the ability to accept their example, a physical illness, a fam- tries to relieve through drugs. This diversity. ily quarrel, trouble at work, or the discomfort may consist of a real I have used these concrete cases loss of a dearly loved person. The disease, of the depressive or schiz- as a way of entering into the prob- sick persons suffer desperately un- ophrenic type. It may also arise in lem, but this has left too many til they plunge into an overwhelm- otherwise normal persons who are questions unanswered. For exam- ing state of despair from which incapable of accepting the rules ple, what are the confines between they cannot escape. Yet these same that chiefly govern living together. normality and aberration? And, in problems cause apparently analo- Whereas these individuals would addition, supposing that an aberra- gous suffering in other persons, like to follow their own natural in- tion is actually a deviance from without precipitating depression. clinations and their own talents, normality, to what extent are we What matters, then, is not so much they find themselves compelled to authorized to consider it a danger- the cause of suffering or the suffer- do boring, repetitive activities, to ous oddity, to combat and to cor- ing itself but how sufferings are keep pre-arranged time schedules rect it. These are concrete ques- perceived in the inner self. The and to obey rules that they simply tions; they demand concrete an- subjective component becomes do not understand. They would be swers. Parents have to answer such even more prominent in endoge- content merely with the funda- questions when their children ask nous depressions, which arise mentals of life—food, health, and to lead a way of life that will to without apparent external causes. liberty—whereas they live in a so- some degree make them social Hence, in facing up to aberra- ciety that believes in success, in outcasts. So does a mother faced tions, we should endeavor to put with the agonizing dilemma of ourselves in the place of the pro- whether to bear a pregnancy to full tagonist. In thinking back over term when the foetus is deformed. those far-off childhood experi- And so does a physician who has ences, I have often wondered, to decide whether to start aggres- then, how much of the problem lay sive therapeutic efforts to sustain with the persons who had deformi- life or rather to let life take its own ties and how much lay rather with course. Finding an answer to these me, the onlooker. It is a difficult and other questions means em- and possibly misleading reflec- barking upon reflections of a more tion, but one we have to make. Let general order. In trying to discuss me restate it in other terms, refer- them I shall exclusively use the bi- ring to a case that involved me di- ological point of view to which I rectly. am accustomed. A dear friend suffered a stroke One normally makes a distinc- that irreversibly damaged her tion between the spontaneous flow physical and mental faculties. For of life that comes about without some months afterwards she utter- human intervention, and the ly lost her appetite, reaching the changes that human beings intro- point of obstinately spitting out the duce into life by exploiting their food put into her mouth. So she special intellectual and manual was parenterally fed until she abilities. The former is also called “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 79 the natural order of things; the lat- applications have become en- route so far followed. It is the ter, progress. Both terms subtend twined, as have the intellectual and pause when human beings group scientific and technological devel- manual abilities in our organism. together into species endowed opments pursued by humanity. Hence, we are faced with two with a fundamentally common The Church, too, accepts that life distinct moments of life: the bio- identity recognizable to all, despite began with relatively undifferenti- logical moment, which belongs to individual dissimilarities. It is an ated primordial organisms that the natural order of things, and identity made up of somatic, func- evolved into multicellular organ- progress, which depends on hu- tional and intellectual characteris- isms comprising specialized and man intervention. Both cause life tics as well as rules of behavior differentiated tissues, organs, and to evolve in a direction opposed to and cohabitation. In contrast, di- apparatuses. Despite their differ- that taken by the rest of the known versity implies resuming an inter- ences, these multicellular organ- world. In other words, life has rupted journey, in an unceasing at- isms belonged to a single system evolved not towards disorganiza- tempt to pursue it thus perfecting into which they integrated, sus- tion and division, but towards in- ever more the identity of life. taining one another. Biological creasingly organized and struc- From a strictly biological view- evolution, therefore, continued un- tured material and abstract config- point, diversity, understood as der the form of social evolution, urations. In this way, life has de- aberration or deviance from the represented by living beings who fended its own identity. It has pro- path thus far followed, consists gathered together into communi- tected its identity from adverse chiefly though not exclusively in ties made up of individuals and natural forces and improved, per- genetic mutations. Whether the subdivided into categories. Each petuated, and transmitted it to oth- change introduced is deemed good category dedicated itself to a spe- er configurations capable in turn of or bad depends not on the mutation cific activity. And as they became pursuing the same pathway. To do itself, but on the advantages the better and better at doing it, it so, living beings had to become mutation offers for the survival, made their lives worth living. With distinctly aware of their own iden- evolution, and progress of life. mankind we passed gradually tity, at first unwittingly, and then, This is the fundamental criterion from the primitive society, made once they had reached the stage of that establishes whether an aberra- up of small family or tribal groups, mankind, through conscious self- tion is good or bad, whether it within which there already existed criticism. should be preserved or rejected. a subdivision of roles and tasks, to Philosophically speaking, it is For this reason, every aberrant ever more ordered societies in hard to distinguish between bio- form of life, whether vegetable, which biological and social evolu- logical evolution, in which man al- animal, or another type, disappears tion drew a further impulse from so participates, and progress. from the face of the earth if it is scientific and technological For progress is linked to the in- useless or harmful; but is pre- progress. The advancement of tellectual faculties inherent in hu- served if it is useful in an absolute knowledge, along with the ability man nature; just as flight is innate sense or only in specific, contin- to translate knowledge into practi- in the bird. Both also share two gent conditions. For example, an cal applications, is one of the pre- distinct yet nonetheless comple- abnormal capacity to retain salt in rogatives of humankind. At this mentary elements: similarity and the organism is essential for sur- point knowledge is no longer en- diversity. Similarity is the inter- vival in arid climates. But in places trusted to traditional skill {dotto}, mediate evolutionary stage, the where water abounds and survival but to a community whose mem- pause necessary to consolidate the is prolonged it transforms into hy- bers all participate in exploiting in- pertensive disease. The constitu- struments and machines that mul- tional traits linked to depression, in tiply out of all proportion the intel- itself a feared disease, seem identi- lectual and manual forces of the cal to those that in different cir- individual. In this way, man has cumstances sustain the creativity gone way beyond the dominion of of the artist and the scientist. his senses, penetrating into the mi- In the so-called natural order of croscopic, ultramicroscopic, mole- things, aberrations are maintained cular, atomic, and subatomic or eliminated according to the ap- world to reach the point where ma- parently ruthless criterion of their terial and energy merge. Humanity utility. On closer inspection, how- has also looked out to the origins ever, this criterion is also a corol- of the universe, using the force of lary of the general law of solidari- thought sustained by ever more ty. What actually sustains life, al- powerful instruments to overcome lowing the individual components the laws of physics of the universe of a living organism or the individ- and the speed of light. Thus we uals that make up the community have succeeded in deciphering the to survive and live together, is the genetic code, which contains the ability to satisfy their needs mutu- past, the present, and the future of ally. The organs of the human life, and can now even manipulate body have the ability to satisfy the it. In this process, cognition and its needs of the organism to which 80 DOLENTIUM HOMINUM they belong; the organism has the envisage a condition that will in their various forms. Apart from ability to satisfy the needs of its sooner or later concern them, too, defining aberrations, we need to constituent organs. Both survive, in illness, aging, or adverse cir- establish rights and duties, not on- grow, and develop as long as they cumstances. Normal persons en- ly on the part of society as a whole, respect this rule, first enunciated dowed with wisdom will therefore which at times asks for protection, by Menenius Agrippa. A tissue assist the less fortunate, because but also on the part of the individ- that breaks this rule transforms it- they realize that this is the way to uals whom society rejects and out- self into a cancer, thus dragging to support and help themselves. casts who claim only their roles ruin itself and its host organism. Respect for aberrations arises, and their rights. It is a difficult Conversely, an organism that can- therefore, not only from religious task, yet one that we can no longer not supply its organs with what or ethical principles, but also de- put off. For we who proclaim nor- they need destroys not only its or- pends on strictly biological rea- mality are accumulating a debt to gans but also itself. soning that foresees both the es- others. Should we fail to honor this In the same way, aberrations re- sential evolution of life towards debt, it will ultimately crush us. In main or disappear according to configurations of growing organi- my opinion, the most suitable whether or not they favor the de- zation and complexity and at the place for planning our action could velopment of life. This is a simple same time expresses the strength be the National Committee for but illuminating concept. It is the of solidarity, without which life Bioethics (Il Comitato Nazionale common good that transforms it- would break up. Yet again, at the per la Bioetica). self into the individual good. And end of his tormented and twisted it is solidarity that coincides with peregrinations, the scientist dis- Professor BRUNO SILVESTRINI looking after oneself. Hence the covers with amazement that he has Professor of Pharmacology commandment “Thou shalt love simply arrived at the point which at La Sapienza University, Rome thy neighbor as thyself” becomes a others following the main road biological as well as an ethical and reached long before. religious rule of life. My paper has remained so far on Compared to their impact on the abstract levels that are hardly suit- natural order of things, aberrations able to the dramatic urgency of the raise more complex problems in daily problems that forms of aber- the civilization of man. Even ration pose. Let me therefore offer though the criterion understood as a concrete proposal, namely a reciprocal utility remains, aberra- Statute on Aberrations. To my tions without an immediate useful- mind, this should spring from reli- ness are not eliminated. In persons gious, secular, ethical, and philo- Bibliography who are weak, deformed, atypical, sophical contributions, as well as suffering, and incapable of surviv- contributions from those who have SILVESTRINI, B. Malati di Droga, Sperling ing on their own, normal persons firsthand experience of aberrations & Kupfer, Milan, 1995. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 81

CARLO LORENZO CAZZULLO

The Acceptance of Mental Illness

First part The Stigmatization multifaceted forms of behavior of Mental Illness which may admit different, often 1. Introduction discordant interpretations. The pri- The following question is posed: mary issue is whether or not we Since ancient times mental ill- Is what happens to the patient just should believe in the patient’s be- ness has prompted intense emotion a result of poor information, a bad havior? among the uneducated, as well as disposition, or is it the effect of the The crux of the matter therefore among the learned. The reasons ancient fears we all have regarding becomes a correlation between the for feelings such as curiosity, fear, the sly demon of mental illness? patient’s past and present behavior, and fascination still exist, even if The individual suffering and the with the consequent risk of criti- more tenuously, and are constantly collective distress related to men- cizing pathological symptoms or, stimulated by the mass media, tal illness are in reality amplified, on the contrary, of not recognizing movies, and books. The primary often substantially, by two ele- them and to linger over misleading motivation for such an interest re- ments constantly found—and per- elements so as to posit a person’s sides most of all in the incompre- haps inherent—in such a condi- “peculiarity” while thus delaying hensibleness of the mentally ill tion: stigma, with the consequent therapeutic action. and their presumed inability to social isolation to which the ill are This is where the stigma comes communicate, together with the subjected during their existential from, the idea that the mentally ill constellation of “strange” events experience. Here the stigma is are dangerous—still so wide- surrounding them. quite different from and much spread in society and hard to erad- Such events are not limited to harsher than what happens with icate. the ill, but in the end concern all other diseases—perhaps compara- This situation is reproduced, in the members of their families, ble to what happened in the past an even more radical fashion, with gradually expanding into the so- with transmissible diseases (or, in drug addiction, although today a cial context. It thus seems evi- some respects, with AIDS at pre- scientific proof exists of the fact dent—and this will be the object of sent). that the drug addict has, in the ma- our specific attention—that those Some psychic disturbances— jority of cases, not made a free suffering most profoundly from such as schizophrenia, mental choice, but manifests a pathology; the changes brought about by handicap, or drug addiction—trig- however, society still disapproves mental illness are, first of all, pa- ger a certain stigmatization, which of the addict and reproaches the tients themselves, but the changes may, in turn, greatly affect the family for not predicting or pre- in their mind and behavior soon quality of life of all involved, the venting the behavior of addiction. “contaminate” their immediate en- sick and often their families as These aspects grow in importance vironment. well. when the drug addict is also “cont- The acceptance of mental illness The most evident case is schizo- aminated,” when such persons and its unpredictable complexity phrenia, the most severe of all self-destructively encounter a arises, therefore, in the family ini- mental illnesses. The symptoms of death-dealing virus, HIV, for tially—often left alone to face this schizophrenia, especially at the which science and medicine have terrible dilemma—and only outset, represent a subtle discrep- no remedy. These subjects then be- through the family can it be broad- ancy between the subject and the come guilty twice over—guilty of ened to society as a whole, with an surrounding world. Such discrep- being unable to accept the pains improvement in the quality of life ancies are connected with the sub- and joys of life in the world and of patients. ject’s inability to follow a goal co- seeking escape in the sedative ef- herently—that is, a lack of finality fects of substance abuse and guilty in behavior. People in contact with of bearing a new pestilence. schizophrenics—the family, first These dynamics of stigma and of all—therefore face an ambigu- isolation are not, however, in- ous, sometimes elusive problem, escapable, as demonstrated by an- 82 DOLENTIUM HOMINUM other illness that is well known to- multifaceted and with broad clini- age), is related in over 80% of the day and that may accompany dif- cal and therapeutic applications— cases to high expressed emotion ferent stages of life: depression, a the analysis of Expressed Emotion responses. severe pathology in itself, even (EE). Its components are, on the The results in drug addicts indi- more common than HIV in the one hand, represented by excessive cate a high frequency of high EE general population. emotional involvement, hostility, profiles, similar to those observed Today depression is socially rec- and criticism, which produce high for schizophrenics, and a direct ognized as an illness which, even EE, and, on the other, by warmth correlation between a lowering of if severe, is curable, and this idea in the relationship with the patient Expressed Emotion and better ad- in turn affects society’s conception and by positive remarks concern- herence to therapeutic programs, of this illness: depressed persons ing his behavior. including the various forms of are no longer stigmatized and may (Fig. 2) High Expressed Emo- treatment beginning with thera- be accepted by any member of so- peutic communities. ciety without being treated as FIG. 2 In contrast, in families with SYMPTOMATOLOGICAL RELAPSES schizophrenics. Their symptoms DURING SCHIZOPHRENIA moderate and severe cases of men- are well-known, and the clinical tal retardation, a situation signify- 90 features are described without fear 82.4 ing heavy family burdens, emo- on the mass media, and, most of 80 tional over-involvement is seldom all, this suffering is understood by 70 accompanied by hostility, and Ex- most people and increasingly ac- 60 pressed Emotion tends to be low. cepted on a family and social level. 50 Relatives of such patients seem to This awareness is a great advan- take advantage of the chance to ex- tage for the ill and fosters early 40 plain disorders—their symptoms treatment of relapses, facilitating 30 and behavioral manifestations— needed therapeutic action. 20 17.4 with an easy interpretation of them 10 as an organic pathology. Such an understanding diminishes the The Family and Mental Illness 0 mystery of the causes of the illness High EE Low EE and eases acceptance of treatment In considering the problem of Chi Square = 4.10 p <0.05 programs. mental pathology and of the men- Where the etiologic mystery re- tally ill, it is convenient not to for- tion conditions usually produce remains, however, as in multiple get the third protagonist, directly lapse rates of up to 80% in cases of sclerosis, EE is high in 46% of the in contact with them on a short- schizophrenia; such rates are cases and requires special atten- and long-term basis—the patient’s halved when warmth or empathy tion to the family and its emotion- family. towards patients are elevated. al response. Within the family a series of dy- (Fig. 3) In depression, high Ex- namic phenomena occur, linked to the suffering of the ill member, FIG. 3 Second part with the alteration of responses of SYMPTOMATOLOGICAL RELAPSES other family members and nega- DURING MOOD DISTURBANCES What has been said until now tive attitudes causing individual 60 may be somewhat pessimistically 53.1% and collective distress and even 50 interpreted as the negative side of triggering pre-existing personality 40 the initial proposition in this brief disturbances. Physicians are fre- paper. Its positive aspect brings us quently the first to encounter such 30 to the basic questions of availabil- situations, and their professional 20 ity and the ability to know. and ethical stance is decisive for 10 10.0% Availability is linked to a basic managing them. 0 acceptance of the dignity and autonomy of any human being. If FIG. 1 % High EE Low EE EXPRESSED EMOTIVITY any one of us accepts an essential Chi Square = 4.15 p <0.05 truth a priori—the limitations, by Negative factors Positive factors virtue of our human nature itself, (rejection) (acceptance) pressed Emotion rates for hostile of the extent of our knowledge and ¥ Excessive ¥ Emotional or overinvolved relatives’ attitudes emotional warmth of its temporality; we must be (in this case, usually spouses) pro- grateful for the half of the vessel of involvment ¥ Positive ¥ Hostility remarks duce a mean relapse rate higher knowledge which is full and not ¥ Criticism than with low EE results. The despair over the other half, which wives of depressed patients appear is empty. (Fig. 1) Family tension—so- to be more critical than their hus- In knowledge today we may called “emotional temperature”— bands towards them and female find precious information enabling is recognized and measured today siblings. us to understand the pathogenesis by using a methodologically con- Attempted suicide, prevalent in of some mental illnesses more and sistent scientific construct which is female subjects (21-22 years of better and, most importantly, the “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 83 means for early treatment. sity, together with a reorganizing A proper communicative rela- It is essential to recognize illness of cognitive processes and modali- tionship involves a) decoding mes- in its initial stages. The sooner an ties, can lead to a real improve- sages; b) helping the concerns of illness, any illness, is recognized, ment of the illness itself. others to emerge (maieutics); and the more chance there is to con- The possibility of developing c) becoming aware of complexity, trol—and sometimes eradicate—it, more rational emotional dynamics, without trivializing any message, while at the same time preventing in the family and outside it, can be even if expressed with special lo- its spread in the family environ- implemented, according to the cutions. ment. The family can, as I suggest- most recent orientations, through 4. To free the ill from loneliness, ed, limit its emotional response, proper psychoeducational inter- isolation, and abandonment. Suf- maintaining it at levels more useful ventions, which I will mention lat- fering induces isolation, a reduc- for itself and for the ill. er on. tion of social contact, a feeling of Family members find them- 3. To facilitate interpersonal being “different”: such feelings selves on a two-way street: they communication. The patient and may generate mechanisms of re- are active subjects of psychologi- his social environment influence volt and aggression, or, on the con- cal support for the ill member. each other, in a circular, diachron- trary, of closing oneself off and de- They are passive subjects needing ic manner, negatively as well as taching oneself from the commu- direct, targeted support, as well as positively. On the one hand, pa- nity. truthful information on their rela- tients may respond to ambiguous The family, thus left alone, can- tive’s illness. They are people suf- or negative relational feedbacks not assimilate the loss, but falls in- fering, then, alongside the ill who with a reduction in self-esteem and to complex mechanisms of guilt suffer, and the more the ill move a feeling of refusal. In a certain induction and intolerance, making towards a chronic state, the more number of cases, patients live the ill person a scapegoat, an atti- they, too, suffer. through isolated experiences of tude that alleviates the underlying All observers agree on one is- guilt induction and overt refusal: distress only temporarily. sue: often we arrive too late at the this is often due to an ill-founded 5. To accept the language of the families of schizophrenics—as attempt by relatives and of other ill and try to understand the deep well as the families of other pa- emotionally significant persons at roots of it through interpretation. tients—and treatment thus re- struggling against self-directed One should, in other words, under- quires a long period of prepara- guilt feelings, the most important stand the ill and their feelings, tion. of which centers on the inability to without losing respect for them, From such considerations there communicate properly and thus helping them to understand them- arise certain principles for the ac- manage to help the patient. Inade- selves better. The influence of the tion of all seeking to contribute to quate communication reduces pa- family group is, once again, essen- a better acceptance of mental ill- tients’ emotional adaptation and, tial. ness and at the same time to a bet- as a result, the acceptance of what If the behavior of the ill is con- ter public image of it. happens to them, too. stantly influenced in a positive way 1. To provide information on this by the family reality, we can see illness—to know it and be defend- real clinical improvement, with a ed against it. An important activity freeing of individual and collective in this regard, related to the core energies which have been lost or problem of schizophrenia, has blocked for some time, along with been—and is still being—carried an unexpected evolution of conva- out by the Association for Re- lescence, and, finally, an increase search on Schizophrenia. This in the strength also needed to en- moral body, with altruistic and sci- dure the deficiencies induced by entific aims, has developed a fam- illness, which sometimes cannot ily intervention program tailored be remedied. to the specific needs of Italian When adequate mechanisms of families and based on information. social support and consensus are Information is essential to work- offered to the family, it can recov- ing on schizophrenia because it is er a strong, positive role in the best the central core of the stigma, the manner. terrible visage of a plague. None 8. To disseminate information can accept this for themselves or on mental illness in society. Al- their families. though mental illness is still not 2. To control emotion, fostering perfectly known in its causal and cognition and intelligence. I have pathogenic mechanisms, it is also already talked about the impor- true that scientific knowledge has tance of emotion in the family, es- progressed to the point where the pecially in the form of Expressed facts relating to mental illness are Emotion, as regards mental illness. now better understood. Proper in- I want to emphasize that a proper formation among citizens of the reduction of such emotional inten- “state of the art” in psychiatric 84 DOLENTIUM HOMINUM knowledge it essential today for all as group leaders. plans, and refocus their energies action intended to create better ac- The best result of psychoeduca- towards them (M. Klein). ceptance of mental illness. tional work is not the disappear- According to Aristotle, a ten- ance of the symptoms of mental dency towards depression is a illness, which may be achieved characteristic of genius. And ge- Psychoeducational Action through proper psychiatric treat- nius and lunacy, as far as schizo- ment, but rather the attainment of phrenia is concerned, often follow Aside from the therapeutic po- certain key goals. a common way: artistic, as in van tential residing in information, * Understanding the psycholog- Gogh, or philosophical, as in Niet- family psychoeducational action ical needs lying behind the symp- zsche. sets in motion other positive fac- toms and disturbed behavior. Finally, the acceptance of men- tors, with enduring positive effects * Realistic acceptance of one tal illness is essentially compro- on families. another’s needs. mised by a ghost of the deep— * Hope is instilled. * Reduction of excessive expec- fear. Fear can be defeated by a * Common problems are shared. tations which may crush the pa- wider knowledge, but also by the Often family members believe tient, with the development—if trust of those working with the ill, they are alone in facing these kinds they are lacking entirely—of real- as well as those close to them. For of problems, but once they partici- istic, balanced expectations. all of them, exposed to the burden pate in groups, they discover they * Reduction of the tendency to of a hard task, the words of Pope are not alone and can share anxi- judge and of contradictory behav- John Paul II will be helpful: “Do eties and fears. ior, often due to a lack of legit- not fear, and cross the threshold of * Catharsis. Intense expression imization of the illness. hope.” of emotion within the group is im- * Improvement of communica- portant since it reduces tensions in tion channels, which need constant Professor CARLO LORENZO the family and helps to develop reinforcement. CAZZULLO group cohesion. Any psychic disturbance can Honorary President of the Italian Society for Psychiatry * Learning. Family members lead to positive results. President of the Association may acquire a knowledge of im- Depression, therefore, is always for Research on Schizophrenia portant aspects of their own behav- a critical experience; in working Emeritus Professor of Psychiatry ior, confronting their opinions with through depression, people may at the University of Milan those of other participants, as well grow, mature, reconsider their Round Table

The Mentally Ill in Different Social Models 86 DOLENTIUM HOMINUM

ELIOT SOREL

Health: an Invaluable Asset for a Robust Economy and Democracy

The health of nations a major employer, representing hancement. Some cost-reduction is the wealth of nations. 10%-15% of the economy in some measures have been valuable inso- —William J. Durant countries. far as they prompted a re-examina- National health plans are tion of health care systems. In Health is an invaluable asset for presently under crippling financial some cases the re-examination has developing robust economies and pressures, resulting in personnel led to giving prevention high pri- democracies. The World Health cutbacks, cost reduction (e.g.: the ority and to creating incentives for Organization defines health as “a least expensive, not most effective, prevention, early detection, and in- state of complete physical, mental medications prescribed; hospital tervention, as well as disincentives and social well-being and not stays arbitrarily limited), and plan- for over-utilization of services and merely the absence of disease or ning largely driven by economic late interventions. Consumers infirmity... ( and advises that)... considerations. But the pursuit of have been stimulated to participate (t)he health of all peoples is funda- short term gains are likely to lead in the health decision-making mental to the attainment of peace to long terms losses that have a processes. Providers are forming and security and is dependent up- negative impact on the health of new networks, have initiated new on the fullest cooperation of indi- the population and increase rather treatment guidelines across spe- viduals and states.” Against a mul- than reduce costs (e.g.: 24-hour cialties, are developing outcome tifaceted backdrop of increasingly hospitalization for labor and deliv- studies of benefit to consumers, globalized national economies, ery increases post-partum risk and providers, and payors by enhanc- frequent reliance on child labor, treatment expense for mothers and ing accountability. worker marginalization by virtue infants). Health promotion, illness pre- of rapid and pervasive technologi- We are living in an era in which vention, and risk-sharing, in the cal advances in production, and cost/benefit analyses are focusing broadest sense, are all the joint re- the recurrence of old diseases (tu- on cost-reduction and profit en- sponsibilities of national health berculosis) and emergence of new care plans, businesses, govern- ones (Ebola virus, AIDS), increas- ments, health care providers, ing percentages of gross national workers, and their families. Sound products are now devoted to health waste disposal practices, responsi- and health-related expenditures, bly managed food processing, and particularly in the first few and last attending to employee well-being remaining years of life. The health benefit not only corporate stock- status of individuals, families, holders but also society’s stake- communities, and nations is deter- holders. Sharing health-related mined by environmental, biologi- risks (environmental, high-risk be- cal, psychosocial, sociocultural, haviors, violence, and illnesses) spiritual, economic, and policy among governments, businesses, variables, in transaction with each other payors, providers, and con- other. sumers of health care services is an Economic factors affect health essential part of a revised social planning and implementation as contract that emphasizes shared well as access to health care, ac- responsibilities, and both moral countability of providers, quality and ethical imperatives. Thus, the and outcomes of treatments, and availability of accessible, quality the depth and breadth of research health care services is an essential and training. In turn, the public stabilizing force in the matrix of health of a country affects its eco- society. Health care models which nomic productivity, effectiveness, emphasize prevention at primary, and efficiency. The health sector is secondary, and tertiary levels, as “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 87 well as ensure access, accountabil- ness, participation, and commit- mindful of changing global condi- ity, and quality outcomes are re- ment to their own healing. Physi- tions, policy makers can harness quired, along with a partnership cians need to approach with hu- multiple environmental, biologi- between public and private sec- mility, caring, and high standard of cal, psychosocial, sociocultural, tors. excellence. They must be at ease spiritual, and economic factors. Business that have become in- not only as clinicians, researchers, They can rely on professional and creasingly global in nature need to and educators, but also as advo- technical assistance based upon recognize that their success de- cates for their patients. This part- the most recent scientific innova- pends, in large measure, as much nership extends beyond the patient tions and discoveries to develop upon their multi-national labor to include the patient’s family, and integrated economic and health force as on strategic planning, cap- beyond the physician to include models in the new millennium. italization, innovation, and ex- the entire health team of profes- Policy makers must panding markets. The health of the sionals, paraprofessionals, and Ð emphasize the importance of labor force is an invaluable asset. health care workers. Together, health across sectors; An unhealthy labor force severely they need to develop a new health Ð promote systemic cross-sector limits productivity, quality, com- language intelligible to people and cooperation; petitiveness, and profitability. Bil- professionals alike.1 The newly Ð encourage risk-sharing among lions of dollars each year are lost emergent language and concepts patients, families, pshysicians, and as a result of environmental condi- will facilitate joint participation payors in the context of medical, tions (toxic waste exposure, “sick and risk sharing in clinical, eco- financial, ethical, and legal deci- building” syndrome, “mad cow” nomic, and ethical decision-mak- sions; disease) or events (natural disas- ing processes pertaining to health Ð balance the allocation of re- ters, massive national and regional care. sources among prevention, treat- development projects, with their Policy makers have an unprece- ment, training, and research; accompanying population disloca- dented leadership opportunity to Ð develop flexible multi-sectoral tion, ethnic conflicts and “cleans- make health a leading component reforms, restructuring, and retrain- ing”); undiagnosed and/or insuffi- of their initiatives. Doing so will ing; ciently treated worker and/or benefit not only health systems, Ð promote public ad private sec- worker family illnesses (AIDS, in- but also education, justice, com- tor cooperation, nationally and infectious disorders, high blood merce, and labor sectors. Their ternationally; pressure, cancer, depression, other failure to consider the importance Ð foster complementarity be- psychiatric disorders); high-risk of health undermines economic tween job creation, social protec- behaviors (including smoking, strength and political stability at tion, and health for all. sexually transmitted diseases, sub- national and international levels as Patients and their families, stance abuse and dependence); illnesses spread across borders, physicians, nurses, and other ethnic, domestic, and workplace create enormous and possibly dis- health care team members have violence. Investing in the health of astrous expenses of an economic, the challenging task of going be- workers and their families will not social, and political nature. yond their traditional roles and as only reduce these losses, but will When they are responsive to partners develop a new language result in significant tangible re- their constituents’ wishes and of health that informs, educates, turns to workers, their families, and advocates health and econom- businesses, and governments. The ic policies that are buttressed by state of health of the labor force is solid scientific evidence and hu- not only important for its intrinsic mane, ethical considerations. value, but also for its value added. Although the patient-physician Professor ELIOT SOREL relationship is the cornerstone of President of the World Association the healing process, in recent years for Social Psychiatry (USA) it has become hostage to professional biological reductionism and political and commercial economic reductionism. The patient is not the illness; cost alone cannot exclusively determine choices for patients and physicians. Patients and physicians need to free their relationship from reductionistic forces and engage in a redefined Note and reinvigorated partnership 1 Prior terminology was professionally de- characterized by mutual respect, rived: the physician/patient (relationship). Re- trust, caring, and guided by scien- cently, market forces have given rise to “new” tific excellence and humanistic terminology: the consumer/provider (relationship). Neither adequately reflects the com- considerations. Patients need to plexity of the relationship and the forces influ- approach this task with assertive- encing it. 88 DOLENTIUM HOMINUM

TONY ANATRELLA

The Depressive Society

In this paper I would like to ex- and tackled. Paradoxically, at the think that not much can be done amine and analyze those elements same time we can perceive that and that events do not depend up- which foster a climate of depres- mental disorders have not in- on what we do at a personal level sion, and I would like to discuss creased in France over the last thir- or upon our own lives. Plans for this subject with special reference ty years but that our patients, when the future are lacking; the experi- to France. Our society is afflicted they consult us, display a growing ences of previous generations no by a sense of sadness whose caus- tendency to complain of an exis- longer seem relevant and are for- es go beyond the simple fact of un- tential void. We have before us gotten; and moral and religious employment and extend beyond an forms of psychic suffering whose traditions no longer appear to be economic crisis which marginal- causes people cannot explain but resources with which it is possible izes an ever-increasing number of which nonetheless clearly damage to construct meaning and establish people. their lives. Although individuals links with the new realities of con- In a recent study the World can always avail themselves of a temporary conditions. Health Organization defined de- psychotherapist in an attempt to al- In this context depression ap- pression as the malady of the rich leviate their suffering and treat pears as a loss of instruments and countries of the world.1 The WHO what is causing their condition, tools. Men find themselves alone estimates that by the year 2020 this malaise, which is characteris- and without resources. They go to mental afflictions and nontrans- tic of civilized societies and which look for them at a pharmacy, in the missible illnesses will have in- can be observed in our patients and gamut of psychopharmaceuticals. creased by 15%. The illnesses in society more generally, cannot It is certainly true that the useful- which are the greatest danger are be approached solely from a med- ness of these drugs in cases of need not those which are commonly be- ical point of view. Very often it in- cannot be denied—however, there lieved to be so—this study calcu- volves questions about the mean- is a great risk that we will abuse lates that deaths linked to the ing of an individual’s existence them. smoking of tobacco will increase which lead to a concentration upon Originally seen as instruments threefold over the next twenty-five the problems of existence itself. by which to treat and deal with years to reach a level of 8.4 million This environmental depression has mental illness, they have become deaths a year in the world. The become a mass phenomenon and much sought-after products be- death rate caused by AIDS should involves a very real social problem cause of the comfort they bestow pass from one to 1.7 million over which economic growth and dy- upon their users. This form of drug the same period. These statistics namism will not be able to solve in addiction expresses the emptiness bear out the ever-more perceptible automatic fashion. In addition, it is and the fragility of the contempo- state of malaise which is present in often masked by the optimism of rary inner man. Today people drug the rich countries of the world and the models engendered by the themselves to be more prominent bear witness to the conditions of mass media. and effective at the workplace, in life which foster the emergence of relationships, and in their personal new kinds of illness or psychic lives, whereas only recently drugs troubles linked to changes in living 1. The Lack were first and foremost a means by conditions. of Internal Resources which to escape from reality. Exis- Indeed, despite the conditions of tential problems and our states of prosperity which prevail in our de- A certain diffidence, marked by mind have now become unbear- veloped societies we often hear in- the idea that solutions do not exist able because we are unable to face dividuals complain about feeling to our existential problems, is be- up to them and to tackle them ef- bad. One of the reasons for these coming ever more widespread. fectively. complaints is asthenia and a feel- This sense of powerlessness cre- At the back of these phenomena ing of depression—that is, tired- ates a damaging environment and is the demand for self-help by indi- ness and the idea that the realities the belief that reality is beyond our viduals who have become vulnera- of existence cannot be dealt with control. We are encouraged to ble because they are alone in life. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 89

Persons increasingly become a social psychiatry measures with ior in order to give themselves the problem for themselves. Medi- reference to the social ties of an in- impression that everything is go- cines and drugs falsely seem to be dividual. This structure is con- ing well. In reality certain ques- means by which to increase per- structed during childhood because tions have been put to one side sonal potential or by which to gov- it is the outcome of narcissism and whose return will be paid for later ern and manage emotions and be- parental identification. It allows an at a very high price. Faced with havior—individuals do not know inner debate between what chil- events, modern men live alone and the governing principles or the dren are and what they want to be- without a historical consciousness points of departure by which to or- come. It becomes a moment of as if the world and the universe ganize their own existence. More- evaluation and programming of had been born with them. In these over, they do not always know the the psychic destiny. It should be conditions it is very difficult for an boundary between changes in stated that human life is not possi- individual’s personality to achieve mood which herald a pathology ble if there is no commitment to a maturity in relation to time and to and existential questions. A large project to which such essential engage in long-lasting commit- number of people find themselves psychological functions as identi- ments, not to mention the achieve- in a black and confused state, and fication, the ego ideal and the su- ment of the perception of objective the problem is whether they are ill per-ego ideal can be bonded. values. or whether they are unable to bear These functions enable the indi- We find ourselves in societies or to give a meaning to their lives. vidual to act if the social environ- which forget their own pasts and At the present time we tend to ment communicates the symbolic the role of their own pasts. The understand and approach most materials which are necessary for narcissism of contemporary mod- problems in psychological terms. such an operation. But nowadays els which convert the individual Genes express their problems with this transmission is defective in a into the reference point and the a psychological or psychopatho- serious fashion and provokes ab- purpose of everything is rather logical code although the answer sences in the field of ideals, interi- tragic because in such conditions in terms of a product is a tie which orization, and sexuality. the social bond can no longer be enables the suffering to be alleviat- Depression has a precise med- lived out and fails to be a source of ed. The product is sought after so ical meaning which must not be projects. Life stops at individuals that the people can insert them- confused with a transient feeling and there can be no life before selves more successfully into soci- of sadness and suffering which in- them or, indeed, after them. This is ety and become more available dividuals experience when they especially true if we become within the community, achieving undergo difficulties. This sad- locked into a mentality of the thereby a state where they are no ness—which is often provisional “strike” in relation to births or the longer affected by sensations or in character—does not cancel the transmission of the cultural inheri- perceptions which they do not capacities of individuals. Indeed, tance. know how to manage and which they remain able to act and to find The asthenia we are dealing cannot become thoughts because solutions by which to manage the with here is not caused by a physi- they lack suitable words. Thus it is adversities they come up against. cal factor, but, on the whole, is the that individuals enclose them- Depression, in contrary fashion, product of an inner paralysis. Men selves within their own subjectivi- is an illness and is a state of pro- gradually encounter difficulties in ty without being able to occupy found and painful sadness which achieving the real as they grow their own inner space and without has repercussions in the daily life old. This undoubtedly arises from wanting to be confronted by objec- of the sufferer to such a point as to the fact that our conditions of life tive laws and realities, which by alter the ability of individuals to do not foster inner development, definition exist independently of live and to function. Disgust, lack but keep it at a superficial level. the individual. of interest—that is, despair—take From a psychological point of Contemporary men tend to live possession of them and they be- view individuals lack—from like sick people and to direct their come blocked and able to live only childhood onwards—those guid- attention towards medicines which in the present. They are oblivious ing images by which they can they believe can deal with the of the past and are unable to pro- learn to live out and to act upon ex- problems of their existence— ject themselves into the future— ternal realities. In wanting to turn problems which are in fact caused individuals are unable to detect the past into a clean slate, and in by a lack of personal resources. ways out of their crisis—unless, withdrawing from the duty to Our society does not trust itself that is, they face up to their rela- bring up their children, individuals and at times one can well ask tionship with reality. engage in activity whereby their whether one knows why one lives, The intensity of this sadness offspring are constantly left to why one works, and why one gives the impression that individu- themselves because adults do not loves. als’ resources are exhausted and know what to say to them or what In my book2 I described society their capacities destroyed. But this to transmit to them. By such a as being “depressive” because I sadness—where love for life and route we have promoted a counter- wanted to underline the crisis and delight in it are no longer active— identification in relation to our his- the suffering of the psychic struc- can also be masked by the individ- tory and our origins. A widespread ture of the ideal in the psychoana- uals’ production of different forms feeling levels our contemporaries lytical sense of the term and which of activity and of euphoric behav- as if there were an attempt to erad- 90 DOLENTIUM HOMINUM icate the shame which we feel over At the present time identity and in- projects which they intend to be- our origins and our past. This pre- stitutional bonds are neglected out stow upon their psychic destiny. In vents us from thinking positively of simple disinterest or because of other words, it is through the inter- about the future. However, it is a fear of being deprived and limit- mediation of this action that indi- now clear that without a past it is ed, not to speak of being castrated. viduals establish a relationship difficult to construct a history! If Nowadays people plant, cultivate, with the outside world; by the modern man encounters difficul- and build for the moment. This is same route reality is able to enter ties in achieving the real, this is not done for future generations, their inner self. without doubt because he lacks but with materials which grow old But in order for this operation to reasons for living. badly and which are without an in- be possible—I would like to ob- It is, therefore, not so much soci- ner dimension—such as glass and serve once again—the environ- ety which is depressive as individ- metal. ment must provide values. Other- uals. In coming into contact with Although the independence and wise individuals risk losing their society they experience an imbal- freedom of the individual are ego for an ideal. This usually cor- ance and are unable to deal with priceless achievements, inherited responds to a phase of develop- reality; they have the impression from Christianity, the risk we run ment in early childhood which is that they are unable to act upon is that of wanting to look after our- reactivated during puberty or ado- events. Individuals find themselves and to believe that we are lescence. Because the ego ideal selves with themselves alone; they the purpose and measure of every- becomes a process of evaluation, lack the support of a society which thing. According to the mood we the difference between what indi- lives without a future. The find ourselves in, our relationships viduals are and what they want to ephemeral becomes king. Individ- with values, for example, can be become creates a gap. It is from uals have to rely upon their own relative. In this way we forget that this point that a subjectivity devel- will, not least because modern they constitute an objective di- ops within which inner debate will conditions of life promote a short- mension which goes beyond what be possible and the work of the in- ening of time. The state of de- we are, as occurs, for instance, in teriorization of elements collected pressed persons is expressed in a the case of the prohibition of in- within them can be carried out. feeling of not being able to exist cest. We are not the founders and It is precisely this operation for others or for an ideal; they re- the judges of the law. which a large number of young main marked by existential bore- Our social expressions and the people are unable to achieve be- dom. dominant models presently in cir- cause of a lack of the materials of culation produce narcissistic men identification and of culture by who worry about themselves in a which to fill their inner selves. 2. The Crisis positive sense. But they can also Their interiority remains flat and of the Inner Man close them up within, and lead superficial. When the inner self is and of the Ego Ideal they to their own subjectivity, and poor, it leaves space available for to that alone. Indeed, external real- the emergence of impulsiveness The contemporary crisis attacks ity is poorly integrated and the and the practical expression of pri- the working of the psychic appara- processes of interiorization be- mary instincts and inner orienta- tus, and in my book I demonstrated come impoverished. tions. Communication also be- how the structure of the ego ideal It is often thought that the de- comes very problematic and diffi- can be made ill by this process. pressed express a lack of interest cult. This reality explains the in- It has been stressed that the ego in reality. It would be more accu- crease in psychopathologies af- ideal which is created, taking nar- rate to assert that they are unable to fecting the inner dimension of cissism as its point of departure, is reach reality. They find themselves young people, such as drug addic- one example of the evaluation of blocked within a structural power- tion, anorexia, bulimia, and forms projects which derives from lessness and thus turn to strategies of behavior involving emotional parental and social identification which involve expedients. The dependence along the lines of the but also from cultural ideals. The lack of the ego ideal leaves indi- “baby-couple” model3—a situa- individual can engage in an interi- viduals in a situation and set of cir- tion where the relationship of con- orization of these latter elements cumstances where they lack re- servation is more important than only in proportion to society’s sources. the feeling of love. evaluation of them. The psychic structure of the ego To conclude this section, it Contemporary mentalities are ideal—which has often been re- should also be observed that the concerned with the individual di- ferred to in this paper—is con- collapse of political ideologies— mension and live out a feeling of structed during childhood when after they had caused the econom- social belonging which is much individuals realize that they them- ic and moral degradation of a large lower than that of previous genera- selves are not enough and that the number of peoples—has given rise tions. This is because the social en- universe is not at their mercy. They to the view that a life cannot be vironment is uncertain and deval- accept the idea of giving up a part constructed without reference to ued. Indeed, when individuals of their narcissism and project it as an ideal. It is no longer illusions have a historical consciousness an ideal which then becomes laden which appear as a deception but they achieve their existence over with personal interests, their the very sense of the ideal as a psy- the long term through institutions. parental identifications, and the chic function which comes to be “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 91 altered. In most depressive states it ing on the principle that children essential to this process. The im- is to be observed that the ego ideal have all that they need for their de- ages of comics and of television suffers from not being able to im- velopment within themselves, cartoons are unable to foster and part dynamism to the personality. adults have abandoned this role in promote this development. The It is unable to include the personal- favor of the autonomous upbring- written and spoken word develop ity within a project; it no longer ing of the children. These latter the memory and mental images knows how to innovate—in short, have to direct themselves and learn because they associate rationality, it lives without a future. If the ego things on their own. These chil- imagination, and feelings. The im- ideal does not experience a conti- dren cannot rely upon adults and ages of the screen are sensorial, nuity in social life supported by thus develop a deficiency in sup- factual, and without memory. shared and universal ideals, then port. They thereby come to look When people watch them too of- the social field, relationships with for dependency forms of behavior ten, they become depressed be- other people, and the conse- and for support during the stages cause of a feeling of not doing any- quences of the actions of individu- of adolescence and post-adoles- thing and of being empty. als for society as a whole lose their cence. Indeed, early pseudo-inde- In addition, the impoverishment value. Persons remain with them- pendence weakens individuals of the inner self gives excessive selves, alone, as though they were who, in turn, look for alienating space to externality. The notable in a desert. dependencies and seek to “lean” importance attributed today to the Although individuals are the on others or on esoteric or magic body—which should thus bear the subject of social life and not mere- activities and products because identity of the individual—is a ly a social effect or product, as has they lack internal resources. good example of this. “I express been proposed by Marxism, they However, the psychic function myself with my body, but my head can only become such at the price is always waiting for identification is unable to think!” When individ- of education and transmission material in order to achieve devel- uals no longer know what to do, which awakens them to them- opment. It has to do its work in the they exhibit their own body and in selves and to reality through a life face of a refusal: “Above all, do some cases take off their clothes. project. This life project is bound not identify with us—we do not Such rapidly revealed nakedness is up with the will—that is, with ra- have anything of value to pro- more the expression of an incapac- tional research and a humanizing pose!” This is what we can hear ity to be ourselves than the mani- conception of existence. certain adults say who do not want festation of a new-found freedom. One of the purposes of the inner to be objects by which children It is a way of canceling and dis- self, it should be remembered, is to build themselves. And if every- tancing the anxiety caused by in- promote association between sub- body withdraws, psychism no ner emptiness and uncertainty. jectivity and truth, between sub- longer has the objective material The bad working of the ego ide- jectivity and objective realities— which it needs to advance. Without al is at the center of the life of men that is, those realities which do not cultural material, personalities are in the “depressive society” and ex- depend upon the individual. This left to the partial explosion of their presses itself in a number of symp- internal process enables the indi- impulses and draw upon objects toms which can be observed vidual to elaborate his impulses which come from the archaic rela- through two principal phenomena. through secondary productions tionships of their childhood. One is drug addiction, which is an such as intellectual reflection, so- Hence the international success of expression of difficulties in occu- cial, cultural and artistic relation- films such as The Great Blue, pying one’s inner space and inte- ships, the meaning of law, reli- which symbolizes flight from oth- grating the law. Because of a lack gious faith, or the upbringing of ers; The Dead Poets’ Society, of resources transmitted by soci- children and the formation of which is immersed in youthful ide- ety, individuals come to lack guid- adults. It encourages the expansion alism to the point of suicide; and ing images and directives and thus and the development of an inner Wild Nights, which asks the pa- become maintained in a condition self, which means that a relation- thetic questions “How can others of a body cut up into little pieces. ship with the outside world is both be found?” and “How can our Suicide as an expression of de- possible and beneficial for the in- emotions be identified in the con- spair (and not a symptom of dividual and for society as a fusion of feelings and psychic bi- anonymity, as described by Emile whole. sexuality?” Once again it is the Durkheim) is constantly on the in- elaboration of the inner self which crease. Between 1975 and 1986 is lacking. The fact that the life of there was a 67% increase in the 3. The Fragmented Society the emotions and the senses pre- number of suicides committed by Neither Educates nor Builds vails over thought is a telling com- people between the ages of fifteen ment on the state of contemporary and thirty-four and a 42% increase The essential problem of the cri- subjectivity. in those over the age of fifty. The sis of interiority is to be found in The formation of intelligence silence which surrounds suicide upbringing. We have observed and awareness are two fields shows that it is difficult to ask over the last twenty years that rela- where we must work if we want to questions about it and that people tionships involving upbringing promote the process of interioriza- do not want to inquire into the mo- have been increasingly neglected tion. Reading, reflection on texts tives which lead individuals to lose in a large number of contexts. Act- and on the thought of authors, is hope in themselves or in society. 92 DOLENTIUM HOMINUM

At the same time young people tain moral masochism. The same sire for truth and a desire to inquire become fragile because they have may be said of the derisive ap- into it in a spirit of love for life. to look to themselves to solve their proach so loved by the mass me- But this hope also springs from an- own personal problems and those dia. It is as if the need to destroy other dimension which is both reli- of society, where previously they were stronger than the need to gious and moral. Here, however, could look to such institutions as live! we have a subject which is not the family, school, and Church for As a science of the unconscious, province of the psychoanalyst. support and a place to grow. psychoanalysis, although it may The problems which we are not have a message of hope in rela- Rev. TONY ANATRELLA faced with today are much more tion to the meaning of human exis- Psychoanalyst, serious than those which constitute tence, has much to offer through Specialist in Social Psychiatry, a crisis because a crisis is always its therapeutic methods—that is, Paris limited in time and the outcome of psychotherapy and psychoanalytic particular difficulties and factors. treatments—and through its theo- Today we can see that all fields are ry. It can promote an understand- affected and afflicted. For this rea- ing of the individual and thereby son, we can safely affirm that we enable him to deal with his own are faced with a state of chaos conflicts and live a better life. Psy- where society is disintegrating and choanalysis is a stance in favor of where there is a refusal to engage life and not a surrender in the face in the construction of symbols of the misfortunes and suffering of Notes which are essential to the develop- existence. 1 Impact Médecin Quotidien, Paris, nº 934, ment and expression of individual The seduction of despair is 16 septembre 1996: Les prévisions de l’Oms and social life. clearly present in the contempo- pour 2020. 2 TONY ANATRELLA, Non à la société dé- The depressive society is not a rary masochistic consciousness pressive, Paris, Flammarion, 1993. destiny, but a set of conditions and constitutes a challenge which 3 TONY ANATRELLA, Interminables Adoles- which generate and maintain a cer- can be met only if we have the de- cences, Paris, Cerf/Cujas, 1988. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 93

MODEST KABANOV

Ideology, Politics, and Psychiatry

Psychiatry has been connected degree for many patients up to the velopment of psychiatry. Though with ideology and politcs since beginning of the fifties of our cen- the emergence of the non-restraint distant times. This circumstance tury, when the first psychotropic concept had begun to complement has found its reflection in the bib- preparations appeared. However, the developing biological model lical parables, in the theological at that time (at the beginning and of mental illness with its environ- treatises of the Middle Ages, and in the middle of the last century), mental “arrangement,” still the in the more advanced periods of reformers appeared among the changing of paradigm, i.e. com- the evolution of society in its phi- psychiatrists in some European prehension of a mixed (biopsy- losophy and morals. Psychiatry countries who effectively began to chosocial) disease model of a was not regarded as a medical sci- apply the so-called non-restraint mentally ill person, did not take ence for a long time; it was more system when treating their pa- place at that time. Only today, in “within the competence” of the tients. These were D.B. Tuke and the light of the systemic approach, church, which interpreted it by D. Connoly in England, V. Chiaru- is this “model” finding more and proceeding from sacred positions. gi in Italy, W. Griesinger in Ger- more acceptance. Care for the mentally ill was pro- many, I.F. Ruehl, A.U. Fraese and, Strengthening the positions of vided mainly by the representa- later on, S.S. Korsakov in Russia. biological psychiatry, in great tives of religious confessions and The influence of the “demonic measure under the influence of the their monastic services. The ap- forces” was replaced by the under- German school of psychiatry, con- proaches to the mentally ill were standing of mental illness as a nected with the progress in the de- dissimilar in different cultures and brain disease. This approach was velopment of natural sciences, countries, and sometimes consid- vulgarized sometimes under the specifically physiology, biology erably varied. On the one hand, influence of philosophical schools and genetics. Political cataclysms patients were revered as saints (J. Moleschott, L. Buchner), but it in the epoch of Napoleon II and (“God’s people”) (for instance, the was, however, a progressive phe- Bismarck, as well as of Russia un- so-called “yurodivies,” hysterical nomenon for that period in the de- der Nicholas I, called “the gen- “prophesiers” in Russia); on the darme of Europe,” led to rein- other hand, they were frequently forcement of state power. The ide- treated as persons subject to de- ological conception of “enlight- monic (Satanic) influences, as oc- ened absolutism” and manifesta- curred in many countries of West- tions of intensified struggle be- ern Europe, especially in the peri- tween the materialistic and idealis- od of the Inquisition. Medicine, tic views in philosophy and the undeveloped at that time, practi- natural sciences have met with cally did not give attention to varying success to our day; all of them. The situation in psychiatry, this could fail to affect, directly or its shaping into a special branch of indirectly, the status of psychiatry medicine and science, began to both as science and the sphere of change at the end of the 18th cen- practical work. The first dissident tury (Pinel); and at the beginning appeared with the stigma of a of the 19th century psychiatry was madam (in Russia this was the recognized to be a sphere of med- philosopher Chaadayev, a friend ical activity, and it was agreed that of Pushkin). The latest achieve- “lunatics” ought to be treated and ments of biological sciences, not morely supported by charity. It chemistry and pharmacology in should be said, though, that in particular have led to development those already distant times, treat- of an immense number of pharma- ment often had a brutal character, cological (especially psychotrop- which it maintained to a certain ic) remedies; their number is 94 DOLENTIUM HOMINUM growing from year to year, nearly protest can also be attributed to the gas in the basements of this estab- in geometric progression, and also reform of the Italian psychiatrists lishment, produced a painful im- represents, besides being a posi- who follow the ideology and poli- pression. These facts are less fa- tive factor, a menace for the health cy of the Basaglia School in Tri- miliar to broad circles of the popu- of the population. At the same este. The Italian reforms in the lation, especially outside Ger- time, psychiatry remains almost area of mental health services have many, much less than the Nazi incapsulated, fenced off from gen- their own pluses and minuses and atrocities, for instance, in Os- eral medicine, society and human are the object of differing judge- wiencim or Buchenwald. Luxen- ecology. Stigmatization of the ments among Western psychia- burger and Rudin were the psychi- mentally ill person, as well as, to a trists, whereas they always met atrists of the Third Reich who de- certain degree, the psychiatrist with a sharp rejection in totalitari- filed the role of the doctor and pro- (whose work is almost always sur- an Russia. In our country, espe- vided a theoretical basis for work- rounded by a haze of mysticism, cially in the Stalin-Brezhnev peri- ing out the racist laws of the Nazi of peculiar “magic”), still takes od, all innovations which dis- ideologists. And it took place in place, even though in different, played, in the opinion of the au- enlightened Germany, where at softened forms, as compared to the thorities, an ideological colouring the beginning of our century G. Si- times of Paracelsus. A mental pa- were ostracised. A purely biologi- mon laid in the Gutersloh Mental tient remains in the opinion of cal approach to psychiatry reigned Hospital the foundations of con- many people a “loony,” a kind of and was supported theoretically by temporary social medicine based monster who ought to be pushed the Pavlovian teaching on the on the principles of humanism and aside from the society of so-called “higher nervous activity,” correct- respect for the diseased man’s per- normal people and only then treated “in the necessary direction” by sonality. However, not long before ed by some medicines without the communist leadership and its Simon and also in Germany, the penetrating into the core of his/her scientific servants. Both in Hitler- well-known philosopher F. Niet- spiritual problems connected with ian Germany and Stalinist Rus- zsche, who was seriously mentally attitudes towards his/her own self, sia—the countries with markedly ill himself at the end of his life, disease, and the surrounding totalitarian regimes—the influ- had made a considerable contribu- world (the family in the first ence exerted by ideology and poli- tion to the Ubermensch (super- place). And from the point of view tics upon psychiatry manifested it- man) ideology: his works, togeth- of an average man (even a contem- self very distinctly, though there er with the works of M. Stirner and porary one), the psychiatrist “de- were also some differences in the other philosophers, were used by tects” “the insane,” allegedly approach to solving this “awk- the national socialists in shaping everywhere, and is himself a queer ward” problem. In Germany, a their ideology and policy. Some man, an eccentric. This viewpoint considerable percentage of the ideas of F.M. Dostoyevsky were has been generally accepted by mentally ill as well as the alleged- also used by them in their politics public opinion (including doctors ly “inferior” Jews were subject to for a certain period. The distortion with other specialities) and in var- physical extermination. My ac- of scientific, philosophical and ious branches of art (in fiction and quaintance with the mental hospi- even religious tenets for political films, for instance). The biological tal in the town of Bernburg, in manoeuvres in general policy, sci- approach to patients, which is still postwar Germany, where mental ence, medicine and especially psy- alive today (especially in the acad- patients were being murdered with chiatry as a branch of the latter to emic clinics), postulates a practi- combat the “inferior” strata of so- cally fatal genetic predisposition ciety was also typical of other dic- to mental disease, and this results tatorial regimes. The mentally ill in therapeutic nihilism and favours in the Soviet Union during Stalin’s labelling (stigmatization) of the time, though not exterminated di- mentally ill. The dynamic psychi- rectly, were kept under inhuman atric conception of Adolf Meyer conditions. Instances can be men- and the psychoanalysis of Sieg- tioned when Russian psychiatrists mund Freud failed to affect signif- in the thirties saved some persons icantly these positions of classical (“the alien class element”), such as psychiatry, especially in German individual representatives of the and in Russian psychiatry, which clergy, nobility and even party followed ideology and politics for functionaries, from imminent a long time. As a reaction to the death by concealing them in men- “dehumanization” of psychiatry, tal hospitals. Later on, in the times which has an extremist character, of N. Khrushchev and L. Brezh- we can see the emergence in West- nev, the psychiatric services were ern Europe and the USA of so- used for repressive purposes in the called antipsychiatry (Cooper, struggle against the differently Szasz and others), completely minded (the so-called dissidents). negating the medical model of But it occurred less frequently mental illness. than is asserted today and not This negation in a spirit of everywhere. It is well known to “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 95 me, since from 1960 to 1964 I abuse, and other forms of self-de- even persecuted in Russia during worked as Chief Psychiatrist of St. structive behaviour were called the Soviet period. So, for instance, Petersburg (still Leningrad at that “birthmarks of capitalism” in psychology was among those rout- time). The label of mentally ill those years or were explained by ed in the mid-thirties and dragged (“madman,” “loony”) often pur- the “deleterious influence” of the out a miserable existence for many sued a person all his life. In the So- “West.” Mental diseases were years mainly in pedagogical insti- viet period, the attitude of the au- mentioned, if at all, in the newspa- tutes (as a kind of supplement to thorities as well as of scientific per columns on “their morals” pedagogy). There were no psycho- and medical ideologists towards which referred to the “rotten” way logical journals (until 1955); so- psychiatrists was very negative. of life of the West based on the cial psychology and sociology Firstly, psychiatry was regarded merciless exploitation of man by were declared to be bourgeois as a minor science (as if not quite man in capitalist society (one for- false science. The traces of this necessary) as distinct from thera- mulation was “mental diseases are ideology remain to our day. peutics, surgery, obstetrics, gynae- ulcers of capitalism”). And since But, following the formal down- cology, etc. It was “consecrated” in the USSR there was not and fall of communism and collapse of by the Pavlovian teaching and there could not be any exploita- the totalitarian system, the situa- nearly tabooed due to the efforts of tion, psychiatry was in our country tion in Russian society represents the ruling circles and their compli- merely a “survival” of that society a unique phenomenon in world ant scientific bureaucracy. It mere- which must soon disappear. As a history. A global crisis of post- ly existed officially and was taught result of such “theories,” a number communist and post-Soviet soci- in an abridged form at medical in- of mental hospitals were even ety ensued due to an absence of stitutes. There existed a network closed in many parts of our coun- traditions and spiritual founda- of mental hospitals (very neglect- try (specifically in Leningrad), and tions in relation to politics, eco- ed though, and quite often situated new ones were not built as a rule. nomics and psychology. Former in former prisons, barracks for All, including medicine, was ten- ideals (false and utopian, though) prisoners of war or convicts, in se- dentiously ideologized in the have been lost as well as the “foot- mi-downfallen monasteries) and structure of Russian society for ings,” whereas at the same time, psychoneurological dispensaries, many decades, and theoretically liberty of speech, of the press, of which existed mainly in large substantiated by the “immortal the will, etc., lost decades ago and cities. At the same time, prior to teaching of Marx-Engels-Lenin- suddenly retrieved, fell on unpre- so-called perestroika (restructur- Stalin” (even though Stalin disap- pared soil and turned into permis- ing), psychiatry and psychiatrists peared from the number of above- siveness accompanied by absen- were seldom mentioned in the mentioned “Fathers of the teism, xenophobia and an even general press. Some publications Church” after denunciation of his greater loss of spirituality. The appeared solely in scientific litera- deeds by N. Khrushchev, yet the number of cases due to stressful ture, specifically in the only psy- spirit of his conceptions and even influences has increased sharply, chiatric journal. It is necessary to nostalgia for his “wise leadership” first so-called borderline states, in- note that in the Tzar’s era and ear- are still alive in certain circles of cluding neuroses, psychosomatic ly post-revolution years, up to the the population). Psychiatry was disorders and self-destructive be- beginning of the thirties, many not an exception; other anthropo- haviour. Interest in religion has specialized journals were pub- logical sciences were ignored and awakened in society, due in partic- lished in psychiatry and other re- ular to various crisis-related lated disciplines. Manuals for stu- changes and accompanying stress dents and young therapists were factors, which we regard as a pos- also published in the Soviet years, itive phenomenon. Unfortunately, but, beginning in the mid-thirties, this interest bears in many people they were studies lacking individ- a superficial and even feigned uality and ignoring almost com- character (the 70-year rule of pletely personal and environmen- state-supported atheism has result- tal influences on the development ed in this miserable situation). of nervous and mental diseases. In Great preoccupation in all strata of our land of “triumphant” or “victo- society, specifically in psychia- rious” socialism it was generally trists, is caused by the emergence accepted for a long time that psy- of an immense number of reli- chiatry and the mentally ill com- gious, semi-religious and overtly promised our ideology and our po- pathological sects, which are litical systems leading towards prophesying fantastic nonsense communism, the latter being char- concerning the “end of the world,” acterized as the “bright future of zealotry of various kinds and other mankind.” The advent of this fu- dubious proposals (for instance, ture seemed imminent, even the so-called “White Fraternity,” though nobody could describe its or Japanese Aum Shinrikyo Sect, real form and content. Many ill- which had many adherents in Rus- nesses, such as alcoholism, drug sia). Many people mistrustful to- 96 DOLENTIUM HOMINUM wards all conventional institu- journalists, and political scientists, And this is perhaps the most dif- tions, official medicine, including must play an important role in ficult problem confronting con- psychiatry, among them, turn for solving a number of state prob- temporary psychiatry, which is advice to psychics (specialists in lems connected with liquidation of changing its status. Psychiatrists, extra-sensory methods), parapsy- consequences of the general crisis: without losing face (i.e., their pro- chologists and sorcerers and char- for instance, training the cadres of fessional peculiarity), at the same latans to not only get deliverance modern-type specialists, participa- time, paradoxical as it may sound, from their diseases, but also from tion in the so-called screening of must undergo depsychiatrization “spoiling” and “bewitchment”; leaders, rehabilitation of patients to a certain degree; as a matter of they believe in the reality of alco- with manifestations of post-trau- fact, this problem has been dis- holism treatment in the absence of matic stresses, wide-scale psy- cussed by many specialists, main- patients by using their photos, and choprophylactic measures, etc. We ly social workers, for a long time in deliverance from alcoholism must not limit our activity only to (however, according to V.M. “after one seance only,” etc. Be- solving traditional problems such Bekhterev, the boundary between sides, these methods of healing as treatment and rehabilitation of clinical and social psychiatry is a cost a great deal of money. already developed mental dis- very relative one). But their voice Communism naturally suffered eases, where considerable reforms remains a voice of one crying in a fiasco; the totalitarian system are also necessary. But politicians the desert for both politicians and collapsed, but survivals of both are and ideologists must understand the public at large. Perhaps until alive, and much time is needed to us, the psychiatrists, first of all. some maniac “organizes” (God get rid of them, especially in the They must not be afraid to get in forbid!) another Chernobyl or spiritual sphere (“two or three un- touch with us, to establish contacts something still worse. whipped generations are needed,” with us in every way for those said A.I. Hertsen on one occa- problems where psychiatrists, psy- Professor MODEST KABANOV sion). And here psychiatrists, in chotherapists, and social psychol- Director of the Bekhterev Institute close unity with psychologists, so- ogists can be of help to them (to all for Psychoneurological Research cial workers, teachers, lawyers, of us, more precisely). in St. Petersburg, Russia “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 97

VINCENZO DI NICOLA

Culture and the Web of Meaning: Creating Family and Social Contexts for Human Predicaments

Introduction: Defining Predicaments texts, and 3) social psychiatrists Social Contexts seeking to add an international di- Predicament is a concept that mension to their concerns. The In order to understand the expe- tries to grasp the human experi- McGill group led by Wittkower rience of mental illness in different ence of illness in a meaningful and later the Transcultural Section societies, we need a vocabulary for context (Di Nicola, 1989): of the World Psychiatric Associa- those experiences and a method predicaments are painful social tion chaired by Murphy chose to for understanding the “situated na- situations or circumstances, com- bring together the first two con- ture” of illness and suffering. This plex, unstable, morally charged cerns. means that illness is situated in a and varying in their import in time Raymond Prince (1983) offered given time and place, that is has a and place (Taylor, 1985, p. 130). a broad and practical definition: history and a geography, that it We can elucidate predicaments transcultural psychiatry is con- takes place in a network of rela- through the patients’ personal his- cerned with the comparison of tionships starting with the family tories and by understanding their mental disorder among different and the social world. Together “idioms of distress” and their “ex- ethnic groups and/or cultures. In these particulars create and define planatory models of illness.” Prince’s view, transcultural psy- culture as a “web of meaning” in Idiom of distress (IDs) is a con- chiatry deals with three areas: the words of anthropologist Clif- cept from medical anthropology to 1. Cultural variation in psychi- ford Geertz (1983). identify the ways people express atric symptomatology and diagno- In this paper, which is based on their dilemmas and their pain in sis (comparative psychiatry), my forthcoming book (Di Nicola, their local language and folkways 2. The study of culture-bound 1997), I define the notion of (Nichter, 1982). syndromes, “predicament” to understand the Explanatory models of illness 3. How culture affects healing human experience of mental ill- (EMs) are what generates a per- practices (such as indigenous heal- ness and its expression in “idioms son’s answer to basic questions ing practices). of distress” and “explanatory mod- about their predicament: Why me? One implication is that all expla- els of illness.” The family and cul- Why now? What is wrong? How nations of mental illness arise from ture create social contexts for this long will it last and low serious is what anthropologist Clifford understanding. As these social it? What problems does it create Geertz (1983) calls “local knowl- contexts are so crucial in shaping for me? How do I get rid of the edge” and all therapies are what I individual and family responses to problem? (Kleinman, 1988, p. call “cultural products,” not just illness experiences, I take stock of 156). indigenous healing practices. An- changes in Western societies and other implication is that all therapy the accompanying trends in the needs to be culturally informed. human sciences, such as anthro- Transcultural Psychiatry Emphasizing epidemiology (the pology, family therapy, and cultur- study of the distribution of illness), al psychiatry. The term “transcultural psychia- Murphy (1982) called his land- Then, I review recent progress try” was coined in the 1950s by a mark text, Comparative Psychia- in two subdisciplines for the study group of psychiatrists at McGill try (the international and intercul- of mental illness—family therapy University in Montreal. At the out- tural distribution of mental ill- and cultural psychiatry—to bring set, according to Murphy (1986, p. ness), which he defined as “the these changes together for a clini- 13), the field catered to three main study of the relations between cal model of cultural family thera- target groups: 1) researchers inter- mental disorder and the psycho- py. ested in the influence of culture on logical characteristics which dif- mental health, 2) clinicians who ferentiate nations, peoples, or cul- found Western psychiatric teach- tures, whose main goals are to ing unsuited to practice in societies identify, verify, and explain the with very different cultural con- links between mental disorder and 98 DOLENTIUM HOMINUM these broad psychosocial charac- in the medium of intersubjective resented by the formation of the teristics” (p. 2). This important as- engagements” (Lewis-Fernandez World Alliance of the Mentally Ill pect of the field emphasizes objec- & Kleinman, 1995, p. 434). This (by representatives of patient, con- tive population research using a leads to the view of illness as em- sumer and self-help groups in comparative approach with little bodied experiences based in biolo- many countries), has grown. direct focus on or applicability to gy and shaped by cultural process- In the humanities: the problems of individuals or es. And cultural psychiatry * Postmodernism, born of the families who come for our help. emerges as the discipline that can perpetual crisis of modernism in- With this objective stance, com- examine the connections between cluding the diverse demands of parative psychiatry leans to the social worlds and embodied ill- multicultural societies, emerged as etic viewpoint which calls for the ness. the dominant social theory (Har- researcher to develop an analytic vey, 1989), undermining the foun- structure from the outside with dation philosophy of the Western concepts and criteria assumed to Changes in Society tradition (Rorty, 1989). be “universal.” and the Human Sciences * With “text” emerging as a From the beginning, though, ubiquitous metaphor in social transcultural psychiatry was also A number of significant devel- thought (Geertz, 1983), the field of interested in emic perspectives— opments in all Western societies semiotics (the study of signs and generated within the specific cul- are shaping the experience of men- symbols) became the hot new so- ture in question. Questions from tal illness ways that demand a social science, from literary and film the “emic” viewpoint in transcul- cio-cultural approach. theory, to narrative approaches in tural psychiatry include: What is In society: therapy (see Josselson, 1995). the experience of mental illness in * Diversity issues have become In cultural studies: a particular culture? How is it ex- much more prominent in most * Transcultural psychiatry depressed by the members of that Western societies; bilingualism bates centered on the key themes culture? How is it explained by and translation are common social of the universal and the particular, them? and, What sorts of healing concerns (Edwards, 1994). similarities across cultures versus practices do they turn to for help? * Racism has become more differences and uniqueness, the clearly identified as a systemic “classic transcultural psychiatry” problem in society and in health- versus the “new cross-cultural “The New Cross-Cultural care professions (Fernando, 1988). psychiatry” (Kleinman, 1977). Psychiatry” * Professional discourses have * Pragmatically, much of the re- become politicized; for example, search in transcultural psychiatry Arthur Kleinman (1977) of Har- there is discussion of the political focused more on clinical issues vard University criticized the “old implications of psychiatric diag- and introduced some valuable transcultural psychiatry” as being noses and of professional prac- clinical ideas for diagnosis (on preoccupied with “universals tices. PTSD, see Marsella et al., 1996; across cultures, notably externally- * There has been a greater em- on cross-cultural diagnosis, see imposed Western psychiatric cate- phasis on understanding patients’ Westermeyer, 1987), and treat- gories. In its place, Kleinman pro- perspectives, issues of advocacy, ment (on self-mutilation, see posed a “new cross-cultural psy- rights, and empowerment by pro- Favazza, 1996; on clinical meth- chiatry,” an interdisciplinary fessionals. ods in transcultural psychiatry, see framework drawing on the rapidly * The self-help movement, rep- Okpaku, 1996). expanding discipline of medical * “Cultural consultation is a col- anthropology along with newer laborative effort” aimed at sup- methods in psychiatric epidemiol- porting rather than undermining ogy. Kleinman emphasized a more local authority and expertise, rely- “emic” approach, arguing that ing on others as equals (Kirmayer, concepts of mental health and ill- 1995, p. 168). ness are culturally based and that * Medical anthropology and concepts and therapies should be cross-cultural psychology have be- drawn from local cultures to be ef- come more mainstream, visible in fective. undergraduate programs and in The view that emerges from cul- medical and other professional tural psychiatry in the 1990s is of a curricula. processual understanding of cul- * Psychology and other social ture situated in and created by the studies have turned even more to social world of families and other questions about the construction of interpretative communities. the self, identity, and family stories With this growing emphasis on (Bruner, 1990; Gergen, 1991; meaning-making and the social Shweder, 1991). construction of reality, culture is a * Sex-role studies have signifi- process “located not in the minds cantly rewritten the postmodern of individuals, but between people, social landscape (Gilligan, 1982; “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 99

McDermott et al., 1983). focus on culture. Shweder rejects chiatry is supposed to deal with. In the family therapy field: cross-cultural psychology, psycho- Socio-cultural psychiatry is a * Attemps to integrate individ- logical anthropology, ethnopsy- means whereby psychiatrists, and ual and family therapy. chology, and other universalist ap- other health workers who use psy- * Increasing client-orientation is proaches to a general psychology, chiatry in a multicultural setting, reflected in more visible tech- arguing for cultural psychology as can examine themselves, their in- niques (open reflecting teams, in- a study of the ways mind and cul- stitutional practices and their dis- stead of strategic messages a from ture jointly make each other up (p. ciplines for social influences that a hidden team) and a more collab- 73). produce and perpetuate bias. (p. orative stance (interviewing as a 3) Developmental Studies: Jaan 104). conversation; therapy as a dia- Valsiner (1989) has conducted a In Fernando’s view, socio-cul- logue). trenchant critique of developmen- tural psychiatry would incorporate * More emphasis has been tal psychology, calling for a “cul- sensitivity to cultural factors and placed on pragmatic issues (how ture-inclusive developmental psy- extend psychiatry from individual to resolve problems, how to em- chology.” With Valsiner’s work concerns to family and cultural power clients) and brief therapy and others as a spring-board, I group, as I have argued. But above approaches. have called for a “transcultural all, socio-cultural psychiatry is: * Constructivism and social child psychiatry” defined as “de- a viewpoint, as well as a way of constructionism have become the velopmental questions about chil- working, that is relevant to the dominant conceptual models of dren’s metal disorders in cultural needs of a multicultural society, family therapy, eclipsing systems context” (Di Nicola, 1992, p. 40). taking in social realities that affect theory (see Hoffman, 1990). cultural groups. (p. 104) * Narrative has emerged as a In his scholarly book on Cul- new perspective in family therapy Socio-Cultural Psychiatry: ture, Health and Illness, Cecil Hel- (echoing cultural anthropology’s “A Relevant Viewpoint man (1994) writes: “The relation reviews of its own work) (see Paré, for Multicultural Societies” of culture to family dynamics is 1995). complex, and to some extent con- In the light of all this, there have In his critical book on race and troversial” (p. 288). Helman been a number of calls for para- culture in psychiatry in Britain, echoes some of the concerns digm changes—throughout the so- Suman Fernando (1988) defines a voiced above about “the danger of cial sciences and among clinicians. new approach to these issues. Fer- stereotyping all Italian families,” We will examine two—one from nando argues that psychiatry needs for example, in the “minietnogra- cultural studies and another from its own definition of its social and phies of the family cultures of dif- family therapy. cultural tasks—not one imported ferent ethnic groups in the USA” from anthropology or family ther- in the volume by McGoldrick and apy. What Fernando thinks we her associates (1982). Helman also “Paradigms Lost”—Changes need is: registers the corollary concern of in Social Theory a “socio-cultural psychiatry” “ignoring major differences be- that is sensitive to culture in a tween families” based on other so- This catalogue of social changes broad sense while maintaining a cial and cultural variables (p. 299). has had its reciprocal impact on practical, perhaps pragmatic, He also articulates something that social theory. Here are three other stance in insisting on being rele- concerns me deeply—and is al- related areas of the human sci- vant and useful to people that psy- ways treated dismissively when I ences where new paradigms are raise it—that “family-oriented eth- being imagined. nic groups are sometimes de- 1) Anthropology: In a brilliant scribed as if their differences from essay that prefigured its impact on the Anglo-Saxon family type (with therapy, cultural anthropologist its emphasis on individual, rather Clifford Geertz (1983) calls the than family goals were pathologi- text analogy “the broadest of re- cal by definition” (p. 288). cent refigurations of social theory” and “the most venturesome” (p. 30). Narrative thus emerges as a A New Story key idea for understanding human for Family Therapy: experience. “The Family-as-Culture” 2) Psychology: Jerome Bruner (1990) and Richard Shweder Bringing many of these threads (1991) call for the establishment of together, David Paré (1995) calls a “cultural psychology”. Bruner, in for a new paradigm in family ther- response to the mechanistic fea- apy, summed up in the following tures of the information-process- question and answer: ing approach to cognitive psychol- What would a family therapy ogy, wants to reinject meaning and look like that made no pretense of narrative into psychology with a being value-free, that included a 100 DOLENTIUM HOMINUM temporal dimension, that included for families, if they are not best pology. New York: Basic Books, pp. 19-35. GERGEN, K.J. (1991). The saturated self: both persons and relations, that seen as systems? In the “family-as- Dilemmas of identity in contemporary life. was contextual, that induced the culture metaphor” (Paré 1995), New York: Basic Books. reduction of power differentials families are interpretative commu- GILLIGAN, C. (1982). In a different voice: Psychological theory and women’s develop- between therapist and family, that nities, or storying cultures. In their ment. Cambridge, MA: Harvard University hoped for, and promoted, the em- book on “narrative therapy in the Press. powerment of families, that valued postmodern world,” Parry and HARVEY, D. (1989). The condition of post- modernity. Oxford: Basil Blackwell. equality over authoritarianism, Doan (1994) invite clients to be- HELMAN, C.G. (1994). Culture, health and and that valued an education come authors, telling the stories of illness. Third Edition. Oxford: Butterworth- method as well as the therapeutic? their own lives and recruiting an Heineman. HOFFMAN, L. (1990). Constructing reali- (Erickson, 1988, p. 233) audience for their stories. ties: An art of lenses. Family Process. 29, 1- Paré’s answer is: “a therapy that All the changes in society and in 12. views families as storying cul- family theory that have coalesced HOWARD, G.S. (1991). Culture talee: A narrative approach to thinking, cross-cultural tures) (Paré, 1995, p. 14). The nar- into the emergence of a new para- psychology, and psychotherapy. American rative metaphor, a textual reading digm for family therapy—based Psychologist 46, 187-197. of life that sees lived experience as on narrative metaphors and social JOSSELSON, R. (1995). Narrative and psy- chlogical understanding. Psychiatry. 58, 330- a text, “places persons in interpre- constructionist approaches— 343. tative communities” (Paré, 1995, “families as storying cultures”— KIRMAYER, L.J. (1995). Versions of inter- p. 14). By offering a model of ther- come together with my proposal cultural therapy. Transcultural Psychiatric Research Review. 32(2), 166-177. apy as “sense-making,” searching for a synthesis of family therapy KLEINMAN, A. M. (1977). Depression, for meaning, Paré argues that sys- and cultural psychiatry as “cultural somatization and the new cross-cultural psy- tems theory is an outdated story. family therapy.” chiatry. Social Science and Medicine, 11, 3- 10. The conceptual model he offers in KLEINMAN, A. (1988). Rethinking psychia- its place is social constructionist Professor VINCENZO DI NICOLA try: From cultural cateqory to personal expe- epistemology. On the other hand, Director of the Department rience. New York: The Free Press. of Child and Adolescent Psychiatry LEWIS-FERNANDEZ, R., & KLEINMAN, A. the postmodern stance moves at Queen’s University, Kingston, Canada (1995). Cultural psychiatry: Theoretical, clin- away from either/or constructions ical, and research issues. Psychiatric Clinics to both/and juxtapositions. In this of North America 18(3), 433-448. spirit, Paré reassures us that there MARSELLA, A.J., FRIEDMAN, M.J., GERRI- TY, E.T., & SCURFIELD, R.M. (Eds.)(1996). is no need to reject useful ideas Ethnocultural aspects of postraumatic stress from the systems era of family disorder: Issues, research and clinical applications. Washington, DC: American Psycho- therapy (see p. 15). But what is the logical Association Press. truth? Where do we find bedrock? MCDERMOTT, J.F., ROBILLARD, A.B., There is no final truth, only “pre- CHAR. W.F., et al. (1983). Reexamining the concept of adolescence: Differences between ferred meanings” (Paré, 1995), adolescent boys and girls in the context of “edifying discourses” (Rorty, their families. American Journal of Psychia- 1989), and the “stories we live by” try 140, 1318-1322. Bibliography MURPHY, H.B.M. (1982). Comparative (Howard, 1991). I think it is time psychiatry: The international and intercultur- to stop calling for new paradigms BRUNER, J. (1990). Acts of meaning. Cam- al distribution of mental illness. New York: and turn to syntagm: bridge, MA: Harvard University Press. Springer-Verlag. Instead of bringing a working DI NICOLA, V.F. (1989). The child’s MURPHY, H.B.M. (1986). The historical predicament in families with a mood disorder: development of transcultural psychiatry. In method with me into the session Research findings and family interventions. J.L. Cox (Ed.), Transcultural psychiatry. Lon- (paradigm), I try to capture a fresh, Psychiatric Clinics of North America 12(4), don: Croom Helm, pp. 7-22. different discourse with every 933-949. NICHTER, M. (1982). Idioms of distress: DI NICOLA, V.F. (1992). De l’enfant Alternatives in the expression of psychosocial family, in every session (syntagm). sauvage à l’enfant fou: A prospectus for tran- distress: A case study from South India. Cul- (Di Nicola, 1993, p. 54). scultural child psychiatry. In N. Grizenko, L. ture,Medicine and Psychiatry 5, 379-408. There is no bedrock, only “final Sayegh & P. Migneault (Eds.), Transcultural PARÉ, D.A. (1995). Of families and other al issues in child Psychiatry. Montréal: Edi- cultures: The shifting paradigm of family vocabularies,” the irreducible lan- tions Douglas, pp. 7-53. therapy. Family Process 34(1), 1-19. guage we use to make sense of the DI NICOLA, V.F. (1993). The postmodern PARRY, A., & DOAN, R.E. (1994). Story re- world, according to Richard Rorty language of therapy: At the nexus of culture visions: Narrative therapy in the postmodern and family. Journal of Svetemic Therapies world. New York: Guilford. (1989). When “stories go awry” 12(1), 27-41. PRINCE, R. (1983). Lectures in social and (psychopathology, relational prob- DI NICOLA, V.F. (1997). A Stranger in the transcultural psychiatry. McGill University, lems, human predicaments), the Family: Culture Families, and Therapy. New Montreal. and London: W.W. Norton & Co. RORTY, R. (1989). Contingency, irony and task of therapy may be best de- EDWARDS, J. (1994). Multilingualism. Lon- solidarity. Cambridge: Cambridge University scribed as “story repair” (Howard, don: Routledge. Press. 1991). The best available tool for ERICKSON, G.D. (1988). Against the grain: SHWEDER, R.A. (1991). Thinking throuch Decentering family therapy. Journal of Mari- cultures: Expeditions in cultural psychology. story repair may be the articulation tal and Family Therapy 14, 225-236. Cambridge, MA: Harvard University Press. of a new story in new words: what FAVAZZA, A.R. (1996). Bodies under TAYLOR, D.C. (1985). The sick child’s Michael White (1986) calls “re- seige: Self-mutilation and body modification predicament. Australian and New Zealand in culture and psychiatry Second edition. Bal- Journal of Psychiatry l9(2), 130-137. description.” As Paré aptly con- timore: Johns Hopkins University Press. VALSINER, J. (Ed)(1989). Child develop- cludes: “by changing our mean- FERNANDO, S. (1988). Race and culture in ment in cultural context. Toronto: Hogrefe ings, we change our worlds” psychiatry. London: Croom Helm. and Huber. GEERTZ, C. (1983). Blurred genres: The re- WESTERMEYER, J. (1987). Clinical consid- (1995, p. 15). figuration of social thought. In Local knowl- erations in cross-cultural diagnosis. Hospital And what is the new metaphor edge: Further essays in interpretive anthro- and Community Psychiatry 38, 160-165. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 101

ANDREA CALVO PRIETO

Family Reality in Regard to Mental Patients in African Countries

1. Introduction which, in turn, is as much entitled type of “family”, any member of to enjoy that success as himself. the group who strays away is There is no healing process in His failures, for example, by quickly excluded, especially if he Africa that can be undertaken falling ill, are considered to be behaves in an anti-social manner, without the involvement of the caused by others with whom mat- which is the case with mental pa- family, which is viewed as a ters have to be settled before any tients. group that gives meaning to the return to prosperity can be ex- individual, and as something that pected. concerns everyone and can only This strongly paternalistic con- 2. Material and methods function well with the participa- ception of the family is at the ori- tion of all, without exception. gin of the legendary African soli- The study concerns 40 patients The notion of health to the Ban- darity which, in theory, consti- of Bantu origin who are chronic tus (peoples of the Central tutes a counterweight to the rejec- psychotics treated as out-patients African Region) is a stage of tion of the members of the family in the “TELEMA” mental health complete well-being based on a system. The individual receives centres in Kinshasa, Zaire, and in way of living, good conduct and from the group material support Yaounde, Cameroun, during the abilities in relation to the other and protection against external year 1995. members of the family group. economic, physical and mystical A personal history analysis In black Africa, the family is aggressions. Hence, traditionally which is as detailed as possible considered to be made up of the speaking, the mental patient is was carried out for each patient in entire clan, which is a collection never disqualified with regard to order to determine the role of his of individuals who share a com- his contribution towards the co- family entourage in providing mon ancestor, as far removed as hesion of the family group; he support to him. possible. It is therefore a vast simply changes his role, and as- We tried to determine not only family system with no clear lim- sumes the one in which he is most the presence or lack of material its, and which reduces the indi- useful. The African “madman” is support to the patient from his vidual member to his most basic a clear symptom of a problem family group (shelter, purchase of state in the interest of the group. within the group, and thus makes psychotropic drugs, food, etc...), The life of a person (his health, it possible to resolve unsettling but also the availability and con- socio-professional fulfillment, conflicts that had so far been hid- cern of the family in the face of etc) can only be conceived in re- den or ignored. behavioural disorders afflicting lation to his family, within which Life in the towns, far away on of theirs. his real value really depends only from the family to which people In the observations, we try to on his position as grandfather, fa- are inextricably linked by blood interpret the type of support ther, son or grandson. and by the land, compels individ- which sometimes goes as far as The obligations towards the uals to group themselves into the rejection of the patient. family lead to an exaggerated in- “neo-families” on the basis of fluence of the powers of the their hailing from a common vil- group or of its members on the in- lage, region of the country, or 3. Data concerning the patients dividual and, on the other hand, to even a given neighbourhood. Un- and their entourage a tactical withdrawal of the indi- der these circumstances, people vidual from personal responsibili- come together as a matter of ne- The study involves 40 patients, ty. cessity; their rights and obliga- including 25 women and 15 men, Thus the happiness or misfor- tions are not rigidly binding, and all unmarried although 7 of them tune of the black African always their ties are not very strong given had had apparently unwanted seems to be the business of oth- that, when all is said and done, children before or during the ers. The individual owes his ma- these ties are based essentially on course of their mental illness. terial success of the community material considerations. In this Their average age is 27.5 years, 102 DOLENTIUM HOMINUM with the extremes being 17 and fies the external cause of the dis- visible forces. These forces can 48 years. order, apportions blame, clears only be fought by those who are None of the patients had at- others of the charges, and reinte- capable of returning what is visi- tained a high level of education, grates the patient in the family ble to its normal state while up- and only 5 of them had been gain- circle. All traditional birth and rooting the underlying evil acces- fully employed before the onset conflict resolution practices are sible only to the initiated. of their mental disorders. used or exploited to explain the The doctor or healer must as- The main family support is a significance of a mental illness sume a double role, that of a close relative in 75% of the cases and to determine the healing “trained” practitioner (from a (30 patients); he is at least a fami- process. Even the charismatic master or in a school), and that of ly member of one of the parents in Christian movements quite often an initiate (which requires the ac- 20% of the cases (8 patients); he go through the family unit within quisition of powers that are in- has a salaried job in 25% of the which evildoers known as witch- comprehensible or at least inac- cases (10 patients); or he never es or evil spirits are hiding. More- cessible to ordinary mortals). showed up at all in 5% of the cas- over, it is not enough to identify The Central African Bantu So- es. the demon or devil in person to ciety may entrust its mental pa- In the case of the guardians reassure everybody, especially tients for peace of mind only to a who presented themselves, con- the patient himself. person or an institution where vis- sultations with soothsayers-tradi- In the final analysis, projection ible physical treatment is sup- tional doctors had been arranged onto others, a favoured defence posed to be accompanied by a in 80% of the cases. And in all mechanism of Africans, helps to more-or-less supernatural know- these consultations, the culprits foster family solidarity Uncon- how of the healers. This may rep- had been pinpointed within the sciously, the African (Bantu) re- resent an advantage for religious family except in one case where linquishes his responsibilities in healers who have obviously been the patient was found to have per- favour of the group or the family initiated, in their various orders, sonally involved himself in magi- which alone is important. The in- to fight against elusive forces cal practices. dividual who is only worth some- through prayer and established thing as a member of the family discipline. After all, the social cannot afford to assume any re- conventions which may have 4. Observations on information sponsibility likely to upset the been trampled underfoot by the concerning the patients harmony and unity of the family. “madman” in question could be On the other hand, the family understood by others as divine The ages of the patients in- feels “obliged” to find the culprit transgressions or sins. Just like volved in the study are consistent responsible for any misfortune traditional taboos which can only with those of psychiatric patients that befalls a member of the be “corrected” through psycho- in black Africa. group. The family considers itself socio-cultural practices, sin can The patients are relatively une- as one and indivisible, with the only be eradicated through a non- ducated and do not have any in- consequence the the suffering of physical process and a psycho-af- come that could have made it pos- one member is automatically fective medium. sible to found a stable and re- shared by all the members of the The notion of “healing” in spectable home in the negro- group. In short, the most pathetic, Black Africa leaves no room for African context. miserable or sick member of the relapse, recidivism or a mere at- In reality, Africans recognize group becomes the concern of tenuation or stabilisation of the children who are valuable mostly everybody. problem. The family member, the for the future; active parents, that As a result, the treatment of an patient who is not what he was is, those who are still capable of individual must be based on a col- before, even with respectable so- producing children; and the elder- lective approach both in form cial behaviour, incites the family ly who are depositaries and guar- (healing takes place within the to look elsewhere. In the end, it is antors of the wisdom to pacify or group, and in public) and in sub- a frantic race towards the hypo- destabilize the group. stance (the entire group feels sick, thetical doctor or healer who has Bachelors remain “children” ir- or at least indisposed). the final solution: healing without respective of their chronological The healer, in order to reas- the least unpleasantness in the fu- age, and are thus trapped in the sured the patient and his family ture. position of irresponsible, vulnera- entourage, must not only relieve The mental patient’s family can ble and eternally protected mem- the visible symptoms plaguing only understand the therapeutic bers of the African family in its the group, but must also, and es- framework of the psychiatric hos- broadest sense. Under these cir- pecially, battle or give the impres- pital as being the visible part of a cumstances, a mentally ill bache- sion of having conquered the in- process that must continue into lor is quickly marginalized where evitable occult or invisible forces the unprecedented, in an experi- there is no support from a large which are responsible for all be- ence that is barely materialized by group, which is the case in towns. havioral disorders. The fact is that the collective memory supported In 80% of the cases, the mental any deviant behaviour is alien to by cultural beliefs (witches, an- illness would have been referred the person concerned and, hence, cestors, spirits, ghosts, living to a soothsayer/healer who identi- can only have been induced by in- dead, evil genies, etc.). “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 103

In fact, the African “muntu” other kinds of misfortune, natu- ing, and their experiences of the has two bodies, a visible one on rally has a cause or at least an as- vicissitudes of life. Unfortunate- which medicine works and an in- pect that does not originate from ly, in urban areas, solidarity is al- visible one on which only a strat- the victim. most exclusively devoted to the egy that examines the invisible This extra-individuality of economic survival of the family. can work. mental illness absolves the patient Very little effort is devoted to the In modern diagnosis (psychi- of all guilt and strengthens the protection of individuals, espe- atric pathology) the African in unity of the family group. Here, cially psychotic ones. general expects that, somehow, the individual is what he is only In urban areas, the family certainly not in western medicine, thanks to, or due to the fault of the group is characterized by its the real malady, the real etiology, other members of the group. many latent or active conflicts of a behavioral disorder will be Whoever touches the individ- due to the lack of unity between identified. For example, a guilty ual touches the family group; thus its members; thus is fosters the person practising witchcraft must the witch-doctor is often seen as development or the manifestation be identified, even named (with being sadomasochistic in the of psychic disorders essentially the title or grade of witch). Thus sense that, in harming another based on the fundamental notion the usual precautions will be tak- person, he is also harming him- of conflict in relationships. en to prevent the witch from self as part of the family body, The future of the mental patient harming the patient and his fami- which is one and indivisible. in Africa is inextricably linked to ly. In rural areas, withdrawal from his family situation. The family The guilty party who is behind the family group (already ren- must be sensitized and included every illness in Africa, is in the dered fragile because it is bigger in all stages of patient care, from end a necessary evil for society. and destabilized by the socio-eco- the traditional understanding of He must exist; he must have nomic crisis) on account of psy- the illness to the modern psychi- “worked” in the dark so that there chosis quickly triggers off self- atric care of patients. should be an “imbalance” within protection and rejection mecha- It seems important to us to em- a family group. It is only after nisms as a matter of necessity. phasize the need to create a social tracking down the guilty person Dependence on a usually small protection system for the mental- and delivering the victim that the salary further limits the power to ly ill in order to restore the former group can once more find peace. intervene, which is already weak- role of the family in this respect. After all, one must know one’s ened beyond the nuclear family enemy to fight him well. (father, mother and children). By Sister ANDREA CALVO PRIETO Habitually, the disease is trans- this very fact, the result is an Psychiatric Nurse mitted by an incantation which abandonment of the traditional Director of the Mental Health Center must be revealed. Hence deliver- role of supporting others. of the Hospital Sisters of the Sacred Heart of Jesus ance from the evil incantation can The mental patient is the first in Yaoundé, Cameroon only be accomplished through a victim of this rejection (or, better beneficent incantation, which still, of this lack of support). This must be public, and pronounced is even more painful when there on a stage where the actors are the is a general lack of support struc- patient and his family. tures at all levels. We are experi- The origin of mental illness in encing a kind of division between Africa is not exclusively linked to the unity of the family and the the group of living family mem- abandoning of the weakest members; ancestors or even invisible ber, who is thus exposed to the Bibliography beings linked to the earth, the for- difficult socio-economic realities est and rivers belonging to the of the moment. In the end, we are DE ROSNY E., (1994), L’Afrique des Guérisons, Paris, Ed. Karthala. family are also permanent dan- confronted with a kind of frag- HEBGA M.P., (1982), Sorcellerie et prière gers. mentation of the African family, de déliverance: réflexion sur une expérience, In the towns, where neighbours resulting in the “marginalisation” Paris, Présence africaine. KASWA K. E MAMPUNZA M.M. (1986), Le in a neighbourhood and col- of the mental patient. vécu de la maladie mentale par les tradiprati- leagues at the workplace are the In rural areas on the contrary, ciens de Kinshasa. Njanja Méd., I, 14, 5-6. “family” of town dwellers, magi- the family ends up accepting the MAHANIAH K., (1982), La maladie et la guérison en milieu Kongo, Kinshasa, EDIC- cal or occult practices are often special status of the mental pa- VA. incriminated as being at the root tient who can calmly move unim- MAMPUNZA M.M., KINSALA Y.B., M’PANIA of mental disease. Paradoxically, peded between his world of hallu- P.M., DECHEF G., BADIBANGA, MBANZULU P.N., e YANGA K., (1984), Profil psychosocial these sources of harm bring peo- cinations and social reality, espe- de la psychose puérpérale à Kinshasa, Afr. ple without natural family links cially as the financial cost of this Méd. 23, 217 (107-110). closer to each other. They are un- support is, in spite of everything, MASAMBA M., (1976), La libération des envoutés, Yaoundé, Ed. Clé. consciously percieved as poten- quite low in the villages. M’PANIA P.M., MAMPUNZA M.M. e tial pathogenic links created by In actual fact, the family can MAWETE K., (1985), Influence des éléments communal living which leads to a only be stable when all the mem- climatiques sur la santé mentale à Kinshasa, Anales Médico-psychologiques 1985. more or less close-knit group. bers remain united in their way of SOW I., (1977), Psychiatrie dynamique To the African, illness, like all thinking, their way of understand- Africaine, Paris, Ed. Payot. 104 DOLENTIUM HOMINUM

AMELIA MUSACCHIO DE ZAN

Society, Family, and Mental Health

The values of urban society interest, receives money without family handed down by Cooper have undergone very marked doing anything to earn it, accepts and Laing, the leaders of the anti- changes. As my generation well bribes because it is the logical psychiatric movement. In his book remembers, in economic matters thing to do, engages in compro- The Death of the Family Cooper one honored one’s word, work was mise because it is the only way to argues that it is “useless to talk a positive value, the achievement win, or behaves like an arrogant about the death of God or the death of success through one’s own ef- pupil who wants to be better, he is of man.... We cannot directly ex- forts was logical, responsibility for thought to be engaging in forms of pect the death of the family—this and in one’s actions was taken for behavior which are held up as val- system assumes in the form of a granted and respect for older peo- ues. The results of all this are a social obligation the role of filter- ple, for one’s father, one’s teacher, lack of personal responsibility— ing in hidden fashion most of our one’s priest, or for authority in and an escape to the external is experiences and emptying our ac- general, was lived and experienced their common theme. tions of every kind of genuine and in a natural way. The vicissitudes which have tak- generous spontaneity.” He also as- Children are still seen by many en place and a series of tiring so- serts that “the upbringing of a parents as a blessing and families ciopolitical struggles have caused child in practice means the sink- take care not only of their own immense damage to the achieve- ing, the submerging of a person. In children but also of the children ment and practice of solidarity. the same way to educate someone belonging to other people—entire- The ordinary person observes all means to lead him outside of and ly as a matter of course. this and deludes himself into far away from himself.” There is still love and funda- thinking that he is faced with posi- These ideas and their propo- mental respect for parents. There tive changes. At the same time a nents can exercise a certain seduc- is real affection between members constant “triumphalism” makes it tive appeal on people who are not of the family and there are also difficult for him to remain loyal to careful and cautious. However, hospitality and a readiness to inte- his ideals. their intrinsic deceit comes out grate the stranger or foreigner, Our society does not always cul- when the author later goes on to forms of behavior which are a tivate its virtues, of which there are say that “while writing the final marked by a special warmth. a great many, but gives great imparts of this book against the fami- Increasingly influential circum- portance to the values of other so- ly I am afflicted by a very deep stances rooted in different factors cieties in an attempt to give itself spiritual and physical crisis.... have had a negative influence on an identity of new youth. Those individuals who have ac- this kind of lifestyle. The practice Many people act and feel that companied me and looked after of depending on a benefactor state they are the representatives of a me with great care during the has had a profound impact even clean, healthy, and dearly-loved worst part of this crisis are my though many people both in the country, and they do this at a very brother, my sister-in-law, and their past and at the present time have heartfelt level. At times it seems to young daughters.” (5) tried to eliminate the error of con- be difficult to confess this love in This deep psychology has been fusing the rights of the individual public in the same way as it is dif- rendered superficial and has with an obligation which involves ficult to admit love for God. Cer- spread far and wide, and for this everything being obtained without tain phenomena have the effect of reason its ideas and concepts have personal effort. Furthermore, the inducing changes which obstruct had a major impact. As a result of culture of work has faded in al- the development of the best part of this diffusion, we often hear the most unnoticed and imperceptible people and impede the belief that employment of such much-dis- fashion. the family is something which cussed terms as “liberation,” “trau- This change in outlook has been must be defended and maintained. ma,” “complex,” “assuming,” and so great that we are now faced with For example, not so long ago “accepting responsibility,” used in a situation where when a person psychiatrists like ourselves had to ways which are completely di- does only what is in his own self- put up with the ideas about the vorced from their original con- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 105 texts. These words, which are very disturb, or discourage, so material for stability but in many cases detached from their roots, often well-being weakens, softens, and there are children looked after by bear latent or manifest criticisms prevents making serious decisions only one parent. The absence, against the stability of marriage, which involve the exercise of pa- change or alternation of one of the against the free and mature choice ternal or maternal authority and parents is a common phenomenon. of the marriage partner, against the the acceptance of the natural phas- This is as true of poor families as right to postpone gratification for es of life which occur within the of rich families. This reality pro- the sake of a sound ideal, and family. vokes pathology. against the decision to resist the On the other hand, given on the At various international confer- dictates of an infantile impulse. whole that it does not matter ences and places of debate our By way of example, we have whether what advertising says is country has defended the integrity heard it said over and over again to true or false, love for truth be- of the family and promoted the de- the point of boredom that repres- comes alienated in favor of the defense of life from the moment of sion is a source of various kinds of sire to be able to buy—in this way conception. However, those in fa- physical and psychic disturbance. the critical faculties of the individ- vor of abortion now seem at times But we do not hear it said with ual become weakened. In this con- to be in the majority. The choice in equal insistence that it gives rise to text, because the value of a man favor of life is undermined in a such negative effects as envy, ha- lies in what he has and not what he whole variety of ways and forms. tred, and resentment, which emis, the individual ego yields and We can detect attempts at decul- ploy the sexual impulse as a means becomes submerged in an inhu- turalization. The road signs in the of expression. The fact is that psy- man collective ego. At the same cities and the billboards are written chology in today’s world is unable time, the achievement of this par- in English. The language of many to deal with the subject of instinct adise on earth requires a hard and people is debased and full of bad in the same way as our society terrible effort. words—something which is usually does in a variety of ways— The men and women who sur- taught them by the television. that is, through the hypothesis that vive have a clinical profile which Good manners and good upbring- forces are at work which seek re- at first sight is contradictory—they ing, elements which reflect charity lease. Instead, it relates instinct to are always very busy and at the and love towards one’s neighbor, the workings of the ego. same time passive; they strive to have been replaced by a certain The ego distributes and connects earn money and gain prestige but dullness and anger in ways of be- in keeping with its structure, the cannot enjoy them; they have an having. nature of its relationship with the acute critical spirit towards priva- Our urban society is emptied of interior world, and the intimate tions but are themselves without a religion and the sacred. Cribs are and unrepeatable emotional situa- human and social sensibility; they hardly ever seen at Christmas. Fa- tions of each and every person. seem to have strong characters, but ther Christmas gives out presents (15) they are weak in spirit. (15) and the Three Kings are forgotten. Various writers refer to an area As we can see, society is perma- Holy Week for many people is a of the ego which is “free from con- nently convinced by the mass me- period of extended holiday which flict” and Kohut outlines to us the dia of the inevitability of divorce, amounts to a good opportunity for vicissitudes of the maturation of marital betrayal, abortion, addic- rest and tourism. the “self” and its very delicate bio- tion, and the legalization of drug- Religious sects have proliferat- psycho-social balance. He goes on taking. The superficiality and the ed among people without real val- to provide lessons on how that so- corruption of the world complete ues who have need of a spiritual phisticated being in a state of for- this demoralization. On the other life. Like healers and seers, they mation which is the human indi- hand, it should be observed that increasingly confuse people and vidual should be treated with care corruption is the logical conse- distance them from more rigorous and tenderness. (13) quence of the elevation of money devotion and belief. Other factors act together to up- into an absolute value. The mass media have an impor- set mental health. The constant supply of informa- tant role in all this because they of- Advertising and the appeal of tion in favor of the right to modify fer as models adults who are not television are unrelenting. It is dif- sexuality and the promotion of the suitable. They are people with ficult to escape the charm exer- naturalness of accepting alleged whom children cannot identify in cised by the changes provoked by matrimonial unions between peo- the formation of a sound sexuality, advertising. When the consumer ple of the same sex is followed by who are not up to forming their mentality becomes established, the logical conclusion that these characters, who do not inculcate not only can things be changed, unions should be allowed to adopt joy in professional development, but also one’s marriage partner, children. who do not inspire a sense of hu- friends, and even ideals. They all Furthermore, we have wit- manity and social responsibility become mere consumer goods and nessed a fall in the total number of within them, or direct them to- are dependent upon the desires, the marriages accompanied by an inwards a transcendent projection of needs, and the whims of the mo- crease in de facto marriages, and their personalities. Furthermore, ment. this is especially true of the large this abandonment of duty has In the same way as privations cities. (1) meant a retreat from initiative, and engender despair, irritate, oppress, Families demonstrate a desire the schools have to perform a 106 DOLENTIUM HOMINUM number of roles with little or no specific time into the specific indi- derdevelopment is dramatic in its help from the families of their vidual who receives it. The be- expression, and especially during pupils. lief that the soul is created specifi- childhood—deficiency illnesses, In some families things are giv- cally for each individual compels infections, diarrhoea, malnutrition, en to children so that they will not the medical practitioner to adopt a and the unemployment of both of disturb their parents, and when a very special attitude towards his the marriage partners—the pathol- great deal is given, in actual fact patient—each form of treatment ogy of development displays indi- they disturb even more. So it is must be directed towards the hu- cators of physical health which are that they are left to search for lead- man being even when that being is undergoing rapid improvement, ers who appear to be more suitable seriously weakened. but which are paralleled by a wors- than their parents, whoever these Visits to psychiatric hospitals ening of psycho-social health leaders may be, or they are pushed have increased over recent years. which is expressed in sterility, sui- into an early independence or mar- If we consider the pediatric hospi- cide, divorce, and psychosomatic riages at an early age with equally tal of Tabar Garcia, we can see that illness. (9) uncertain outcomes. the first visits numbered 2,783 in At times one of the most brutal Henry Ey dwells upon other as- 1993 and rose to 14,641 in 1995. and unjust attacks which takes pects of forms of mental patholo- In the José T. Borda psychiatric place and which people have to gy. (6) This great French psychia- hospital for men the number of undergo is that of the spread of trist, who recently left this world, visits in 1993 was 5,539 and 7,932 drugs. Many people adopt the im- demonstrates that mental illness is in 1995. In the Moyano psychiatric practical proposal that they should the pathology of freedom. Mental hospital for women the number of be made freely available. Among illnesses in various ways and de- visits was 1,009 in 1993 and 1,768 the many socioeconomic argu- grees suffocate freedom and the in 1995. (2) Furthermore, 11.64% ments which are waved about it is ability to decide between different of patients admitted from January never made clear that this escape courses of action. 1993 to March 1996 were psycho- into a world of noncreative dreams It should also be observed, how- pathic—that is, people who suf- and fantasies does not allow peo- ever, that although patients can fered from anti-social disturbances ple to face up to, and to deal with, suffer the most serious forms of al- of their personalities. (3) a life which however difficult at teration, there nonetheless sur- The OPS has demonstrated that times is the only tie which allows vives within them a hidden and the causes of death in Argentina the mental apparatus to function lively personal life. This was well between 1980 and 1990 were as normally. demonstrated by an episode I wit- follows: first, heart disease; sec- Cardinal López Trujillo has giv- nessed when I was a medical stu- ond, malign tumors; third, cardio- en very clear expression to one of dent and which I have never for- vascular illnesses; fourth, acci- the factors which is directly con- gotten. A teacher who no longer dents; and fifth, arteriosclerosis. nected with the forms of social loved his sick patients showed us a (17) In these statistics we can per- pathology which have been de- catatonic schizophrenic patient so ceive the presence of conditions of scribed in this paper. He argues that we could study the condition a clear bio-psychosocial character that the phenomenon of drug-ad- of “automatic obedience.” The and the consequences of the im- diction is directly related in its in- various positions which the patient pact of illnesses involving social cidence to levels of interior empti- adopted were a direct outcome of and psychosomatic adaptation. ness, lack of ideals, inner desola- his condition. Although the pathology of un- tion, and a youth which has re- In an unusual example of lack of ceived nothing from the family or respect, the teacher then grasped from society in the way of values the patient by the hair and began to by which to live in truth. Drugs are shake his head in order to bring out an escape, an unreal world by the point he was teaching. The sick which an attempt is made to fill a man then gave him a sharp gap. We have before us an existen- punch—without, however, dis- tial void which leads to escape, to playing anger—and then proceed- “journeys” of compensation, to a ed to return to his autistic and cata- search for an elusive happiness. tonic stance and posture. (14) There can be no doubt that an in- Nacht (16) reminds us that a ner life which is invisible to our strong ego has overcome fear and eyes exists within people who suf- that it is only in this way that it will fer from very serious forms of become free. A times this drug- mental illness. This is also the case taking of the young members of a when the intellect, the will, and the family is an act of submission be- feelings are assaulted and kept cause they are afraid of both inner down by the illness. and outer reality. In this way fear As the Fifth Lateran Council makes them inferior, it standard- teaches us, (4) the soul is not only izes the individual and leads the the form of the body—it is also human being to delegate his pow- immortal and is infused at its own ers of independent thought to other “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 107 people and thereby abandon his leasing sexual charges through natural communication with those own self-determination. conflicts which are not sexual in who are older—tales, anecdotes, In one way or another society origin. ways of saying things, songs, creates conflict between the gener- Although these people have friendship, and trust between the ations. The rootlessness and abyss been described as individuals who young and the old, certain warm between generations helps to gen- display a permanent style of intimacies between people of very erate—as, indeed, all psychiatrists grandeur, it must be emphasized different ages. All these elements, have observed—schizoid and psy- that they also suffer from a feeling and many others, are priceless fac- chopathic symptoms, emotional of futility and emptiness when tors in building a sense of one’s coldness which hides a desperate their defenses of grandeur begin to own value or identity. need for love, and the search for crack. How often we have seen in pa- substitute identifications in order These forms of pathology are tients with problems of identity the to remedy by one way or another termed “deficit” pathologies be- phenomenon of the treatment be- the torments of the super-ego. cause they involve personalities ginning to work when they begin Contradiction itself becomes the which in appearance are very solid to stop rejecting what they have resign of this damaging absence of but which from the outset lack a ceived from their parents and start care. structured formation of the person- engaging in a progressive under- Contemporary forms of psy- ality. Their egos remain very vul- standing of those parents and in a chopathology include drug-addic- nerable for this reason. There are process of reconciliation with tion, alcoholism, dependence upon many causes behind these deficit many of the traditions which have psychopharmaceuticals, work, and pathologies, and one of the most been transmitted to them. This en- upon the attraction of television important is to be found in the fact ables the patients to recover their and computers. The alimentation that such individuals, when they own inner freedom and to start on pathologies such as anorexia and were young, were not suitably fol- other roads which are very differ- bulimia correspond to a bio-psy- lowed or appreciated to allow ent from those of their parents cho-social correlate whose interi- them to achieve a successful iden- without, however, provoking a ority is alienated because of the tification with the good aspects of sharp break. On the contrary, this cult of beauty, being thin, and ex- their parents. can constitute a step forward be- treme values which involve both The lack of parents or tutors ginning with a fusion with the the family and society. with clear ideas about what is valuable elements of inherited These pathologies of our time good, bad, right, wrong, true, or ideals. This involves a recovery of are connected with other very seri- false can give rise to a personality the inner good of the individual; it ous distortions of the personality. which has no moral criteria but means integrating the past with the The “borderline” personalities which acts according to personal present and constructing a harmo- (10), (11), (8) have been described advantage, convenience, and need nious base for the future. as “stable in their instability.” The and without any moral contradic- This paper has involved a rather people suffering from this condition between opposites. incomplete attempt to identify cer- tion are impulsive, have profound It is more than evident that in a tain features of contemporary soci- difficulties with their personality society the continuity of the tradi- ety—the reference to the demol- identity, display irritability or un- tional inheritance of ancestors is ishing theses of anti-psychiatry, suitable anger, and threaten suicide transmitted in a natural way only the proud incomprehension of a or actually carry it out. These are through the family, by means of widespread psychologism, the al- people who have intense relation- most inescapable paternalism of ships with others, but who swing propaganda which acts as a patho- between affection and idealization genic element for vulnerable and hatred and devaluation. This minds, the attack on children and provokes and involves emotional young people caused by the weak- problems and difficulties in their ness of adults and certain forms of human environment. Such people aggression launched against their suffer from a feeling of chronic psychic structures which can be emptiness. excused only with difficulty, and People who suffer from narcis- the convenience of seeing genera- sistic disturbances of their person- tional isolation as inevitable. alities (19) are afflicted very early All this is often analyzed ac- on by a lack of order in their affec- cording to the cold criteria of so- tive tensions. Turned inwards in ciopolitical bureaucracy and—I their desire to be admired and ap- repeat the point—may have the preciated, they lack personal em- character of an alarmist process of pathy, use other people for their listing which, although it is true to own ends, have fantasies of life—as I indeed believe—is also grandeur, become easily offended, only part of the picture. Here one and usually engage in a kind of might make reference to the re- sexualization of their problems search conducted in London into where they look for a way of re- the emotional reactions of children 108 DOLENTIUM HOMINUM

to the terrible bombing of the last tacks of the external enemy. When 5. D. COOPER, La Muerte de la Familia (Paidos: Buenos Aires, 1972). war. It was discovered that the the internal moral cohesion is in- 6. H. EY, En Defensa de la Psiquiatría peace of mind and serenity with tact, no form of destruction com- (Crear: Buenos Aires, 1977). which the adults bore these bombing from the outside can cause se- 7. A. FREUD and D. BURLINGHAM, War and Children (International Universities Press, ings was the cause of the low num- rious injury to the children. (15) New York, 1943), 8. J.Gunderson, Borderline ber of children afflicted by trau- Personality Disorders (Washington, Ameri- matic shock. Furthermore, the lev- Dr. AMELIA MUSACCHIO DE ZAN can Psychiatric Press, 1984). el of infantile anxiety was propor- Director of the Department of Mental 9. J. HALLIDAY, Medicina Psicosomatica Health at the Medical School of the (Eudeba, Buenos Aires, 1961). tionate not so much to a clear no- 10. P. HARTOCOLLIS, Borderline Personal- tion of danger as to the attitude and University of Buenos Aires, Argentina ity Disorders (International Universities approach of the parents towards Press, Inc., 1986). 11. O. KERNBERG, Trastornos Graves de la this danger. Moreover, when there Personalidad (México, Manual Moderno, was conflict within the family, the 1987). consequences were far more seri- 12. H. KOHUT, Come Cura el Analisis? (Buenos Aires, 1986). ous than those provoked by the Bibliography 13. H. KOHUT, “Introspection, Empathy, bombings. (7) and the Semi-Circle of Mental Health,” Inter- This means that, notwithstand- 1. B. BALIAN DE TAGTACHIAN, J.L. DE national Journal of Psychological Analysis, IMAZ, R. BOUTELL MERCENARO, and M.I. PAS- 1982, 63, pp. 395-407. ing the external violence, the real SANANTE, El Divorcio en Cifras (Educa. 14. A. TRUJILLO LOPEZ, “Por una Ecología authors of harmony were the par- Buenos Aires, 1985). Humana,” Actas de la VI Conferencia Inter- ents. Their children suffered the 2. L. BERTOCCHI, E.CERULLO, and L.GAR- nacional Droga y Alchoholismo contra La Vi- CIA Comportamiento Institucional ante la De- da, Dolentium Hominum, 19.8.1992, (Ti- effects of the bombing only when manda de Atenciòn en Salud Mental (Trabajo pografia Vaticana). the conflicts within the family ren- Monografico, Carrera de Especialista en 15. A. MUSACCHIO DE ZAN, “Sociedad Ac- dered their parents the effective al- Psiquiatrìa, Faculdad de Medicina, Universi- tual y Familia,” Psicologia Médica, vol. V, 3, dad de Buenos Aires, Unidad “Borda,” 1996). 1980, pp. 399-404. lies of the aggressors. 3. Boletin Borda no. 52, of the José T. Bor- 16. S.NACHR, “Role du moi dans la Thera- There is a great deal of hope, da Psychiatric Hospital, VI, May 1996, p. 92. peutique Psychanalytique,” in De la Prtaique therefore, in the humble recogni- 4. The Papal Bull “Apostolici Regiminis de a la Théorie Psychanalytique (Preses Univer- Leon X” promulgated the eighth session (De- sitaires de France, 1950). tion of the fact that one’s own erro- cember 19, 1513) of the V Council of Letran. 17. OPS, Las Condiciones de Salud el las neous behavior is what renders the See E. Denzinger, El Magisterio de la Iglesia Américas (Washington DC, Vol. II, 1994, pp. family more vulnerable to the at- (Barcelona, Herder, 1995), p. 217. 26-39). “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 109

friday 29 november GISELA CRESPO

Anxiety: The Illness of All

Anxiety is a universal human ern times as “The Anxiety Age.” confronting a new discouraging experience, a vital force, with This anxiety has a sense of uni- reality, sometimes even hostile. adaptive capacities, able to in- versality and it matters to all of (3, 9) duce in the subject behaviour that us. It is related to a worldwide Anxiety disturbances have will satisfy physical and psychic context of quick changes that been exhaustively studied recent- conditions necessary to the estab- force fast adaptive attitudes and ly; we now know that it is a very lishment of a biological, psycho- impose new lifestyles that don’t frequent pathology. Clinically, it logical or social equilibrium in a respect the traditional or familiar can presents in three different certain moment and context. values. Before the Industrial Rev- categories of symptoms. Anxiety described in this way is olution, changes were slow, be- normal anxiety. coming swift after it. The scien- Subjective Manifestations Ð We speak about pathological tific and technological advances The intensity of the anxiety states anxiety when the adaptative ca- exceeded man, without answers ranges from some internal agita- pacity is lost, exceeds the opti- to the newly generated problems, tion to true panic: it can be ac- mum limit for the harmonic func- and coming up sometimes with companied by nonperception of tioning of the individual and perverted solutions in the name phenomena. reaches an intensity and persis- of dignity and human rights. tence that is pathological. Cities are growing in an anar- Behavioural Manifestations Ð Sobrad Cid (1959) has defined chic way, erasing the memory of Very heterogeneous ranging from pathological anxiety as an “emo- the old family spaces. Villages great agitation with self-aggres- tional state of painful affective turn into a desert with the aban- sion raptus to a deep inhibition. tonality, accompanied by sui donment of the fields. The short- Appearance of avoiding conduct generis feelings of internal ten- ening distances supported radical crucial to the life of the individ- sion constantly regenerated and transformations in rural life and ual, usually with very invalidat- from which the patient cannot re- impeded adaptation to new social ing personal and social conse- lease himself.” (8) standards. Unemployment rises quences. Anxiety disorders are the most in Europe and in the rest of the common disease in psychiatry, world and with it, insecurity and Somatic Manifestations Ð They and their disfunctional character, illegal activities. The big geopo- are the neurovegetative correla- inducting great suffering, inca- litical spaces, the breakdown of tus of the anxiety disorders: di- pacity, and costs, makes them one the frontiers, brings new threats gestive symptoms (diarrhoea, of the most severe pathologies. and reinforces the competition nausea or discomfort, abdominal Among the more than a thou- for survival. pain), as well as respiratory (dys- sand million people in the world We see the rush, the absence of pnoea, suffocation, alkalosis that that suffer any kind of psychiatric time to have a good time; talking can put life in danger), cardiovas- disease, four hundred million between people is lost, the ability cular (tachycardia, palpitations, have anxiety disturbances (Hi- to listen and be heard... even to chest pain, pre-cordial discom- roshi Nakagima 1996). look. War increases; people run fort, hypertension), suduresis, Anxiety and depression, true away from fear, hunger and hu- trembling or shaking, hot-cold, “plagues of society,” affect 30% miliation. The absence of integra- urinary disorders. of the general population in a cer- tion programs aggravates the ex- These symptoms also have a tain moment of their lives, with isting problems and exacerbates cognitive component, which af- evidence of an increase in this xenophobic behaviour. The adap- fects thoughts, perceptions and disease marking the Twentieth tation problems patent in these learning. Century as the “Century of Anxi- populations can be severe, main- Independently of the intensity, ety and Depression” Stuart A. ly in the weakest, in the presence the symptoms are felt as threaten- Montgomery 1993.(19) of stress factors related to leaving ing (fear of dying, going mad or W. H. Auden designated mod- their countries and families and getting crippled). “Cognitive dis- 110 DOLENTIUM HOMINUM tortion” reinforces anxiety, Risk Factors in substances and their privation. Al- adding more somatic symptoms Anxiety Disorders (12) cohol (the most important), illicit and shaping true ciclus-viciosus. drugs, coffee, benzodiazepins. Anxiety acquires in this way Social Demographic Factors Life Episodes: Separation and characteristics of a true autono- Sex: Preponderance in the fe- loss are responsible for a great my behaving as an “organising male population; 66 to 90% ac- number of anxiety disturbances in psychopathological nucleus” of cording to Thorp and Burns, con- the year, or most frequently the the anxiety disorders. (14) firmed by others. In panic disor- month, preceding their appear- According to the international der the sex ratio varies between ance. disease classification ICD-10, 1.5 and 6. In the single panic at- anxiety disorders are classified tacks and severe recurrent crises, Personality Factors into: (7) the female preponderance is from There are some individuals Ð Disorders of phobic anxiety: 2 to 3 and 2.5 to 5, respectively. In with a premorbid anxious person- Ð Agoraphobia panic disorders the female pre- ality than can be carriers of a Ð Agoraphobia with panic dis- ponderance is questionable. stress adaptation mechanism turbances Age: Anxiety disorders have deficit (Lepine et al). But in a Ð Agoraphobia without panic their beginning between twenty general way the personality is disturbances and thirty years old. The largest perfectly normal. (15) Ð Social phobia incidence is between 25 and 44 Ð Specific phobias years old, dropping radically after Familial Factors Ð Other anxiety disorders 65. In social phobia the beginning We must consider genetic and is much earlier, between 11 and environmental factors. Studies Ð Panic disorders 15 years. with twins revealed in 15 pairs a Ð Generalised anxiety disor- Marital Status: Panic crises concordance for anxiety disorders ders are much more frequent in di- in 41% of monozygotic and 4% in Ð Mixed disorder of Anxiety vorced and separated people than heterozygotes. Togersen (1983) and Depression in married ones. This difference found a very elevated concordance Ð Obcessive-Compulsive dis- does not affect agoraphobia. for panic disorders in monozygotic orders twins but not for generalised anxi- Ð Posttraumatic Stress disorder Social Cultural Factors ety. (29) These studies confirm the Ð Somatoform disorders. In panic disorder, especially in strong genetic bond for panic dis- phobias (mainly the social pho- orders but not for generalised anx- bia), there is a low social educa- iety (Pauls D.L. et al.). (26) Epidemiology tional profile related to isolation, of Anxiety Disorders bad social-economic conditions and bad social functioning Phobic Anxiety Disorders Results vary very much among (avoiding behaviour). scientists, depending on the refer- Evolution and Prognosis: One Social Phobia (19,20) ence population and the way the of every two patients has an un- One in every ten persons suf- data were collected. Nowadays favourable evolution; a bad prog- fers from social phobia in a cer- we have more precise data as a nosis is connected with the un- tain moment of his life. result of more accurate methods, favourable economic and social- There is a high risk of co-mor- the use of standard equipment cultural factors as well as a long bidity with different pathologies and multivariate statistic analy- period of disease (more than six such as the major depression, sis. years). Accentuated co-morbidity agoraphobia and panic disorders, In an American study (Mental with somatic as well as psychic alcohol abuse and consumption Health Institute) and a Swiss one diseases. High mortality from of other substances. from Angst and Doble (Mikola cardiovascular diseases as well as Suicide is two times higher 1985), the following prevalences suicides and consequences of al- than in the general suicide popu- were found (Table 1): cohol abuse. lation, independent from sex and social condition. It starts between 10 and 15 years with serious TABLE 1: EPIDEMIOLOGY OF ANXIETY DISORDERS problems in the development of Masculine Feminine the child, education, professional preparation and also in the rela- Panic Disorders 0.3 to 0.8 % 0.7 to 1.8 % tionship with others. Social phobia, culturally, is more frequent in Agoraphobia 0.9 to 3.4 % 2 to 17.8 % the West that in the East maybe Anxiety Disorders 1 to 4 % 2 to 12.3 % because in these countries it is seen as a personality disturbances and therefore not curable. Never- The results show a marked pre- Precipitating and theless the clinical signs are iden- ponderance in the female popula- Predisposing Factors tical. tion. Of organic nature: abusive of It is usually sub-diagnosed or not “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 111 diagnosed at all, which makes the Panic Disorder Panic responds well to a relax- prognosis even worse. The social ation therapy and medicines like phobia has a malignant evolution, It is characterised by a sudden benzodiazepinesm RIMAs and when not treated adequately. appearing and progresses very SSRIs. There is need for a sys- The phobic person is charac- fast. It can be preceded by an Au- tematic diagnosis because treat- terised by “being afraid of being ra and duration is brief, disap- ment is possible and effective. evaluated,” which leads to behav- pearing after a maximum intensi- ior of dissimulation, rationalisa- ty period. The panic can appear in Biological Bases tion, avoiding. In this context he a spontaneous way or be un- Noradrenergic system, GABA- avoids medical help because he is leashed by an ansiogenic situa- Benzodiazepinic receptor system, afraid to face strange people, action that patients sometimes do serotoninergic system, adenosine cepts his disease as normal, is not perceive. system, peptide systems. afraid of the mental disease stig- It can result in two clinical pat- ma, uses adaptive strategies terns: psychological (discomfort Main Factors (above described); disbelieve in with the feeling of imminent cata- in the Panic Disorders the cure and in the doctor, and strophe, loss of control, fear of ¥ Sudden and dramatic beginning feels discouragement about the dying or going mad), and somatic of the attack; attitudes of the doctor. (tachycardia, palpitations, sweat- ¥ Anticipatory anxiety; When social phobia is not ac- ing, dizziness with a great neu- ¥ Strong genetic bonds. companied by co-morbidity re- rovegetative participation; dysp- cource to medical services is low, noea, suffocation which can lead but with comorbidity, it is very to alchalosis with dramatic med- important and superior to the non- ical consequences). Objectively Obsessive-Compulsive phobic: 59% in ambulatory and the pulse is more or less Disorders 37% in psychiatry. Comorbidity 130b/min. with sistodiastolic hy- varies between 75 and 90% of the pertension (due to catecholamins) The main points in this distur- cases (Table 2). and hyperpirexia. bance are obsessive thoughts Associated with the anxious (emerging against the will of the TABLE 2: CO-MORBIDITY paraxistic manifestations some patient), or recurrent compulsive IN SOCIAL PHOBIA behavioural-cognitive responses acts. The obsessive thoughts, arise, leading to the final clinical ideas, images or impulses “intro- Simple Phobia 59% signs (uncontrollable agitation duce” themselves into the mind of Agoraphobia 45% and/or escape to a “safe zone.” the individual, repeatedly and dis- Alcohol abuse 19% The disease progresses with re- tressingly because of their violent Drug abuse 17% peated crises, between which or obscene content and lack of Major Depression 17% there is an “anticipatory anxiety” any meaning to the individual, because of fear of new crises. The that tries at all costs to oppose drama in panic disorder is that the them until he gives up. The com- In social phobia there is no an- patient perpetuates and renovates pulsive acts are attitudes that re- ticipatory anxiety, as in panic his suffering (the frightening peat themselves and are not use- with or without agoraphobia. crises and the anticipation of the ful or pleasant to the patient. Usu- The isolation in the social pho- fear of new crises), and organizes ally they come along with auto- bias is the pretext for depression, his life around that fear. Avoiding nomic symptoms of anxiety and so common in the social phobics, behaviour regarding the supposed anguish, internal or psychic ten- and the idea of dying comes out as psychogenic situations appears, sion. a solution: there is no desire to die which leads to the isolation of the but it is necessary! In this point it patient. There is a strong associa- Comorbidity in the is different from agoraphobia. tion with phobias, namely agora- Obsessive-Compulsive Disorders phobia, depression, alcohol addic- With Depression it is very Main Characteristics tion. But the intensity of the antic- common. The depression symp- in Social Phobia ipatory anxiety can be such that it toms can precede, accompany or dominates the clinical signs and is follow the beginning of the obses- ¥ Fear of being watched by others in social events; also a reinforcement to alcohol sive compulsive disorders ¥ Constant fear of being exposed abuse. The neurobiological and (OCD). The differential diagnosis to embarassing and humiliating behavioural changes linked to the bases itself on the early beginning situations; alcohol metabolism aggravate the and chronicity of the OCD, and ¥ Avoiding of phobogenic situations panic disorders, making the prog- the resistance to SSRIs and to the nosis more severe (George et sismotherapy. The social phobia responds coll., Chignon et coll.). With other Anxiety Disor- well to treatment with RIMAs The mortality is high: toxic ef- ders... It is also very frequent: and SSRIs. Psychotherapy by it- fects of ethanol, association with 47% with phobia, 18% with gen- self is limited in results but it is of somatic diseases such as mitral eralised anxiety, 14% with panic some value when associated with prolapse, spasmophilia and the disorders. Alcohol abuse can be psychopharmaceuticals. hyperventilation syndrome. found in 24% of patients with 112 DOLENTIUM HOMINUM

OCD. The panic disorders are there is need for hospitalization is (1993). 8) CORTESÃO E.L., Diagnostico das neu- present in 20%, agoraphobia with the diagnosis of OCD made. In a roses e Eastados Afins na Praxis policlinica, 11% and simple phobia with group of students that were hospi- Act. Med. Port, 2:4/3 (1980). 10%. talized during the school year, in 9) CROCQ L., DOULHEAU C., SAIHAN M., Réactions emotionnelles dans les catastro- With Panic Disorders... The 17% OCD has been diagnosed, phes, Encycl. Med.Chir. (Paris-France), Psy- clinical signs emerge sooner and against 1.5% of nonhospitalized chiatrie-37-113-D-10. alcohol consumption rises to 37% students. These studies confirm 10) EY H., BERNARD P., BRISSET C.H., Manuel de Psychiatrie (1978). and depression to 89%. In these the frequency of the disease, the 11) GILLIÉRON E., KAUFMANN L., La di- cases there is a heavy family his- incapacity it causes and the need mension familiaire dans les troubles psychi- tory and the prognosis reserved to go through medical units. For atriques et psychosomatiques, Praxis 60, with a bad response of the panic 332-337 (1971). this reason doctors must be alert- UELFI J.D., CRIQUILLION - DOUBLET © 12) G attacks to Aprazolan . ed to OCD. The treatment con- S., Depressions et... Syndromes anxio-dé- With the Social Phobia... We sists of SSRIs, with very good re- pressifs, Hors Série Audix Medical, 15-18; see a drop in sensitivity to sero- 65-69 (1992). sults. The biological basis of 13) HANTOUCHE F.G., Troubles obses- toninergic agents, and RIMAs are OCD is related to a specific dis- sionnels compulsifs, Encycl. Med. Chir. then indicated. turbance of serotonin. (Paris-France) Psychiatrie, 37-370-A-10 With Schizophrenia... In re- (1995). 14) KAPLAN H.I., SADOK B.J., GREBB J.A., cent investigations it was found in Professor GISELA CRESPO Kaplan and Sadok’s Synopsis of psychiatry, 161 schizophrenics. Many au- Director of the Unit for the Williams & Wilkins 7th Ed (1994). Study, Prevention, Treatment, 15) LÉPINE J.P., CHIGNON J.M., Semiolo- thors corroborate the severity of gie des troubles anxieux et phobiques, Ency- the symptoms and reserved evo- and Recovery of Alcoholics at Miguel Bombarda Hospital cl. Med. Chir. (Paris-France) Psychiatrie 37- lution in cases of double diagno- 112-A-10 (1994). in Lisbon, Portugal 16) LUBAM-PLOZZA B., POLDINGER W., Le sis (OCD+Schizophrenia). This Malade psychosomatique et le médecin fact has therapeutic implications, praticien, Basileia: Edit. Roche (1974). with the use of clomipramin, 17) MARTINOT J.L., Apport de la Tomo- graphie par emission de positrons en psychi- which improves the OCD... atrie, Encycl. Med. Chir. (Paris-France) Psy- With Motor Tics... The co- chiatrie- (Fr) 37-160-A-10. morbidity is significant with the 18) MAUDEL G., La crise des génerations, Gylles de la Tourette syndrome: Paris: Payot, (1969). 19) MONTGOMERY S.A., Ansiedade e De- 63% of the obsessive patients pressão, Climepsi Editores, Sociedade have tics and 50% of these have Medico Psicológica Lda Lisboa (1993). 20) MONTGOMERY S.A., Pocket Reference family backgrounds. Also in 25% to Social Phobia, By the WPA Social Phobia of the tic carriers, there were fa- task force - SP, Science Press. milial antecedents of OCD. In an- 21) MUSACCHIO A., Stress environment and Immunology”, F.M.P., III Serie (XVII) other study, 22% of obsessive pa- 1-2 Jan-Jun (1995). tients had a family background of 22) NORMAN T.R., BURROWS G.D., JUDD tic carriers, against 2 to 3% in the F.K., MCINTYRE I.M., Serotonin and panic disorders: a review of clinical studies, Int. J. general population. In the Gylles Clin. Res., IX (2) 152-157, (1989). de la Tourette syndrome obses- 23) NORMAN T.R., JUDD F.K., STAIKOS sions are frequently of great sexu- V., BURROWS G., MCINTYRE I.M., High affinity platelet [3H] LSD binding is deal violence. There is also a fre- creased in panic disorders, J. Affects. Dis., quent association with bulimia 19, 119-123 (1990). and nervous anorexia with aggra- 24) PAICHELER G., Psychologie Sociale, vation of the clinical signs and Ed. Techniques - Encycl. Med. Chir. (Paris- France), Psyciatrie, 37-876-A-50 (1994). prognosis. The presence of dis- Bibliography 25) PAUL A., LANDSBERGIS et coll., Job turbed personalities is also very Stress and Hearth disease, evidence and strategies for prevention, Internet Ex Mi. 1- frequent but OCD itself can be re- 1) AZORIM J.K., VALLIM, PRINGUEY D, 15 (1993). sponsible for perturbations of the TISSOT R., Bases biochimiques de la psychiatrie, Encycl. Med. Chir., (Paris-France) 26) PAULS D.C., BUCHER K.D., CROWE, personality difficult to distinguish Psychiatrie 37-040-A-10. NOYES, A genetic study of panic disorder pedigrees, Am. J. Herm. Genet. 1980. from primary, secondary or coex- 2) BALINT, M., Thrills and Regression, London (1959). 27) SATORIUS N., USTUN T.B., COSTA E istent personality perturbations. ILVA 3) BERNER P., Psychiatrie Ecologique- S , J.A. et al., An international study of (13) psychopathologie des Migrations, Encycl. psychological problems in primary care, Considered a rare disease, we Med. Chir. (Paris-France) Psychiatrie, Arch Gen-Psychiatr (1993). know today that OCD is a high 37889 A20,5 - 1989. 28) STEIN M.B., UHDE T.W., Panic disor- 4) BOULENGER J.P. et coll., Anxiogenie ef- der and major depression Psych. Clin. N. prevalence disease twice as fre- fects of caffeine in normal controls and pa- Am., 11, 446-460; 1988. quent as schizophrenia or person- tients with panic disorders, in: Sevier, New 29) TOGERSENS, Genetic factors in anxiety York, 1986. disorders, Amch.Gen.Psychiatry. 1983. ality disturbances. Of high preva- INAR LRIKSEN INAR 5) BOULENGER J.P., ZARIFIAN E., L’ap- 30) V M.N., U -V M., lence in teenagers and young proche Biologique de la pathologie anx- BLEGEM L., Troubles psychologiques et psy- chiatriques induits par la Torture, Encycl. adults it is frequently sub-diag- ieuse, in: BOULENGER J.P., L’attaque de panique: un nouveau concept? pp 119-151 Med. Chir. (Paris-France), Psychiatrie nosed or not diagnosed at all, be- 20 Gouveau, Château du Loir, 1987. 37889 A , 5-1989. EISSMAN cause of the lack of cooperation 6) BOULENGER J.P., BISSERBE J.CL., ZARI- 31) W M.M., The epidemiology of panic disorder and agorafobia, in: HALES by patients. 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FERRUCCIO ANTONELLI

When Disquiet Invades the Body

1. The Reasons Behind tions—without giving us time to process where a feeling becomes the “Leap from the Psychic reflect); 2) or because they are so an action (acting) and comes out to the Somatic” complicated and intricate in nature (out) from its true natural location as to prevent us from understand- (the psyche) and invades the soma. When disquiet invades the ing their limits, identifying them Typical examples of this are body: this phrase captures the clearly, or translating them into “breaking into tears” in order to in- whole concept of psychosomatic thoughts (in order to reflect upon terrupt a discussion which is push- medicine, a current of thought them) or to express them orally (in ing one to the very limit or a situa- which recognizes the strict inter- order to talk about them and un- tion which we are not able to con- dependence between the mind and burden ourselves); 3) or, to control. Or even an act of vomiting the body (the psyche and the so- clude, because they are evident which symbolizes the “rejection” ma) at all levels—from the physio- and clear in character but we are not of a gastric intake but of a situ- logical to the pathological, and aware that we do not have any ation which has become unbear- from the preventive to the thera- practical means by which to deal able and intolerable to us. Or an at- peutic. with them and manage them. tack of ejecting diarrhoea which “Disquiet” is the precursor to In such cases emotions cannot symbolizes the passing of the dan- “disturbance”—disquiet precedes be expressed through normal psy- ger—given that I cannot escape, I disturbance, it is an alarm bell chological channels—that is, let a part of me run away. which calls for immediate adap- through thoughts, words, behav- tive action. But if it persists it pro- ioral adaptations (perhaps even duces disturbance—that is, a state through shouting or banging one’s 2. Why Somatizations of illness. fist upon the table)—but take the Are on the Increase Disquiet is an “emotion,” a state route of the body and “speak” with of being characterized by ill-hu- the guts or the muscles. In techni- Disquiet somatizations—that is, mor, dissatisfaction, the wish (or cal terms one speaks here of “act- psychosomatic manifestations— the need) to change something in ing out,” by which is meant a have always existed and taken order to return to a state of well- place. Even Plato and Aristotle being. A banal example of disquiet perceived their presence. But at may be found in the example of the present time they are constant- the tiredness of an arm after carry- ly on the increase, and are present ing a suitcase. Here the remedy is in a good 80% of human beings, of an elementary nature—the suit- whether they are ill or not. case is put down and picked up One of the first reasons for this again with the other arm—that is, state of affairs lies in the fact that that the emotion of disquiet is the daily lifestyle of civil society “managed” in cognitive fashion, (which is industrialized, culturally which means with rational meth- diversified, mechanized, electri- ods, and thereby eliminated. fied, computerized, and accelerat- But this process is not always ed in its rhythms) is an endless easy because some (indeed, many) source of disquiet. Progress seems emotions of disquiet are of such a to make everything much simpler character that they cannot be but in reality it imposes frenetic “managed,” and this is for three rhythms upon us; it requires us to reasons: 1) either because they are have a state of alertness which is sudden and fleeting (for example, so constant and intense that at an a feeling of fright hits us like a slap internal level it reaches unbearable in the face; indeed, it strikes the and intolerable heights. It deprives heart and makes it beat—palpita- us of those pauses to which 114 DOLENTIUM HOMINUM mankind was used and to which it bances known by the term of panic It is impossible to list the infinite was attached for centuries, such as attacks (the famous DAP) the or- number of aspects of the prism of going for a walk, a family meal, gans even seem to explode in a disquiet. I will cite only one the pleasure of playing with chil- great scream. In technical terms amongst the most common—lone- dren and grandchildren (as used to we speak about a “vegetative liness. This does not mean the iso- occur before the emergence of the storm”—the storm is made up of a lated life of hermits. It means feel- baby sitter), or playing as an end in set of wind, thunder, lightning, in- ing alone. Quasimodo wrote: itself (before sport became unnat- undations. In the DAP we en- “Everybody is alone in the heart of ural and changed into a veritable counter palpitations, sweating, the earth.” Various categories are form of commercial activity). tremors, pains everywhere, a feel- as alone as hermits, alone in the It is certainly true that stress ing that one is about to faint, anxi- spirit. The elderly, for example, (stressor and stressed) only afflicts ety about death, the need for air, despite the physical presence of those who allow themselves to be and disturbances of physical bal- children and grandchildren; old stressed: it is said that rain falls on ance. age pensioners who have invested everybody but only wets those too much in their working lives who do not open their umbrellas. and not enough in their emotional But, to continue with the 3. What Disquiet? lives or in pastimes or hobbies; the metaphor, whereas once it rained handicapped; the maladjusted; every now and then, now we are In this conference the term “dis- those who have fallen from wealth faced with a deluge, and as a result quiet” is employed with a very or from positions of prestige or everyone gets wet. Progress wide meaning. In the case of psy- power; and the wretched, those should certainly be welcomed, but chosomatosis, on the other hand, who have failed even in the sup- it remains a fact that those who disquiet has a very specific conno- posed remedy of drugs or alcohol. have not experienced it somatize tation—the psyche of the sick psy- So-called hypochondriacs are also much less, such as animals and the chosomatic person is healthy in its alone, those people who go to the peoples of the third world, where structure and functions (indeed the doctor because they feel that he is the rate of psychosomatosis corre- schizophrenic person or the indi- the only person still ready to offer sponds to the level of develop- vidual suffering from the Down them help. ment. syndrome never somatize) but is Loneliness is a pathogenic fac- A second reason for the increase fragile in the control of emotions. tor which is as serious in its impli- in the presence of the somatization The disquiet which involves cations as any virus. It can double of disquiet is to be found in a new somatization is existential—that the probability of disease and of approach to the body promoted by is, there is something “which is death. As can be seen in so many contemporary culture. In Homer’s wrong” in the existence of the in- cases of widows and widowers Greece the “soma” was the dividual. By this we mean in the who finish their statement with body—the strong arm or swift foot way of existing, in the lifestyle, in that horrible phrase “by now,” a of heroes were separated from the relationships with the family phrase which mental hygiene their corpses. Until a century ago members, or at work, or with food, wants to cancel from every dictio- the body was a value only during in bad habits, and in the anti-eco- nary on the face of the planet. Nev- youth. This was when one died too nomic administration of such emo- er say, “by now”—this is a phrase young, when at the age of forty tional potentialities as love, ambi- which connotes suicide. And nev- one was in decline, at fifty obese, tions, values or morality. er say “I suffer from loneliness”— and at sixty on the way out. Today it is as unhealthy as going for a a large number of those aged sev- walk in the snow dressed in a enty or over play tennis, and at all swimming costume. The care of ages men and women take care of loneliness is very simple: one need their looks through cosmetics, aes- only adhere to the so-called “safe- thetics, fitness, dieting, and so ty agencies” such as the family, forth. It may be the outcome of a clubs, old people’s centers, volun- myth or of fashion, but such, in- tary work, and so forth. deed, is the situation. In the collec- I referred above to hypochondri- tive mind the body has become a acs. It should not be thought that constant and inflated value. To these are the prototype of the psy- speak with the body at one time chosomatic patient. There are psy- was the sole prerogative of young chosomatic disturbances—that is, and beautiful women, and of Hol- illnesses caused by disquiet which lywood film stars. Today nearly at times are fatal in their impact, everybody speaks with their bod- such as heart attacks or cancer. We ies. We should not forget that psy- are all well aware of famous peo- chosomatic disturbance is itself a ple who have been destroyed by matter of “speaking with the cancer after being destroyed psy- body.”Alexander defines it as the chologically by highly distressing “symbolic language of the bodily events such as loss of dear ones, organs.”In the frequent distur- arrests, or failures. This should not “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 115 surprise us. Serious occurrences in trying to find a solution with a cer- haps at root there are only two: life (so-called “life events”) cause tain calm, perhaps a solution 1. Adaptation. There should be a lowering of the body’s defenses, which is only partial and tempo- no rigid taking of positions, no “al- exactly that special malfunction of rary, but which nonetheless is reas- ways” or “never.” We must learn the immune system which is the suring or at least relaxing. The to be “walls made out of rubber.” primum movens of the process of technical term employed here is Adaptation does not mean passive cancerogenesis. the English word “coping.” The acceptance, surrender, or humilia- English say “hope and cope.” The tion—on the contrary, it means technique of coping is a form of positive, productive and winning 4. How to Defend Oneself psychotherapy, on a par with coun- behavior. Under the weight of selling and problem solving, terms snow the branch of an oak tree Some degree of somatization is which do not correspond to the may well break; the rush which inevitable, somewhat on the same Italian phrases “to advise” and “to bends, however, manages to sur- scale as a head cold and, therefore, solve problems,” but which are vive. not difficult to bear. However, it is nevertheless very near. Not all 2. Good humor. Putting things absolutely essential to keep the problems can find a solution but in their proper perspective and jus- state of somatization from becom- they can, after a certain fashion, be tifying are much more healthy ing chronic. In order to ensure this tackled. The Chinese declare with than hatred and anger. Lorenz an attempt must be made to tackle wisdom, and have done so for cen- used to say: “The man who laughs the disquiet-emotion at its source. turies, that “if there is a remedy to does not shoot” at himself or at Tackle, not confront. A confronta- a problem, why worry, and if there other people. This is a truth which tion implies commitment, an ef- isn’t a solution, why worry, any- we would do very well to reflect fort, heroism—approaches which way?” upon. are not very useful and which are The rules of mental hygiene to also very expensive in terms of the ensure a warding off of the risk of Professor FERRUCIO ANTONELLI economy of the psyche. In con- the somatization of disquiet are President of the Italian Society trary fashion, “tackling” means few in number, but essential. Per- for Psychosomatic Medicine 116 DOLENTIUM HOMINUM

JULIO LICINIO

The Biology and Psychology of Depression

Introduction pressed than the population at large. similarities across countries in pat- Social studies on stress are now terns of major depression; however, Depression is a state that can be testing the hypothesis that stress the differences in rates for major de- experienced by all human beings as may be caused by administrative pression across countries suggest a reaction to loss or deprivation. De- work involving decisions that affect that cultural differences or different pression is also a severe disease that job security. It is still unknown risk factors affect the expression of affects the mind and the body. How whether social factors cause clini- the disorder.3 does one differentiate feelings of cally-relevant stress that contributes depression experienced by all of us to depression. from the disease of major depres- Major depression is a universal The Psychology of Depression sion that affects only certain indi- experience that transcends cultural viduals? Feelings of depression that boundaries. It is among the most Psychologically, melancholic are part of the general human expe- common forms of mental illness in major depression presents as a state rience are not long lasting; they are the world. A recent population- of organized negativistic outlook, not associated with severe symp- based epidemiologic study assessed especially attached to one’s sense of toms, and they tend not to affect the rates of depression in 38,000 self: typically, the profoundly de- function. For a diagnosis of major community subjects in 10 countries: pressed individual feels either like a depression to be made it is required the United States, Canada, Puerto burden to others or the object of that an individual feels depressed or Rico, France, Germany, Italy, their disgust, and is hopeless about has a general lack of interest for at Lebanon, Taiwan, Korea, and New the prospects that this worthless self least 15 consecutive days. More- Zealand. The results showed that may have for future gratification in over, there should be associated lifetime rates for major depression either love or work. Because these symptoms affecting appetite, sleep, vary widely across countries, rang- feelings rarely yield to the individ- sexual activity, memory, concentra- ing from 1.5 cases per 100 adults in ual’s most carefully constructed ar- tion, hopelessness, and despair, the sample in Taiwan to 19.0 cases guments, the sense of helplessness most likely resulting in detrimental per 100 adults in Beirut. The annual is exacerbated. Consequently, effects on performance of profes- rates ranged from 0.8 cases per 100 shame deepens and a vicious cycle sional and personal duties.1,2 adults in Taiwan to 5.8 cases per is initiated that can lead to suicide. Can depression be caused by the 100 adults in New Zealand. The Major depression is also classi- modern world? That is an important mean age at onset shows less varia- cally associated with inhibition of and complex question. Depression tion (range, 24.8-34.8 years). In physiological events that are associ- has been reported since antiquity; every country, the rates of major de- ated with restorative functions, in- therefore, it is not a “modern” dis- pression were higher for women cluding sleep, eating, growth, and ease. Nevertheless, many believe than men. Insomnia and loss of en- reproduction. The response rate of that the stress of life in the 20th cen- ergy occurred in most persons with melancholic depression to antide- tury contributes to precipitate de- major depression at each site. Indi- pressant treatment is in the 60-80% pression. That hypothesis is hard to viduals suffering from major derange.4 test experimentally. Sociologists pression were also at increased risk Cognitive elements and vision of earlier in the century postulated that for comorbidity with substance life contribute to personality struc- the industrial production process abuse and anxiety disorders at all ture and to life experience. Al- that alienated the worker from the sites. Persons who were separated though there are no standard cate- product of his/her work might cause or divorced had significantly higher gories under which specific intel- stress, hopelessness, and depres- rates of major depression than mar- lectual orientations towards life can sion. Social research no longer fo- ried persons in most of the coun- be grouped, there is some conven- cuses on stress as the result of the tries, and the risk was somewhat tion for assessing whether a particu- industrial production process, as it greater for divorced or separated lar view corresponds more closely has not been demonstrated that as- men than women in most countries. to a comic, romantic, tragic, or iron- sembly line workers are more de- These large datasets show striking ic vision of reality. These visions “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 117 differentially shape expectations in mind but that it affects the function- age 70. Because 35% of post- life and the sense of the place that ing and the structure of the human menopausal women at this age have disappointment, ambiguity, sad- body. Thus, our group and others one or more osteoporotic fractures, ness, risk, and triumph play in hu- have looked at anatomical and this finding is of clinical signifi- man affairs. As such, they interact functional alterations that can occur cance. Approximately 40% of the with other aspects of life experi- in depression as a result of in- premenopausal women in our study ence, learning, temperament, and creased activity of HPA function, showed bone mineral density deter- biological predisposition and are caused by increased CRH produc- minations two or more standard de- postulated to modulate the response tion. viations below peak bone density, a to external reality and inner experi- level which represents a loss in ence, and hence towards or away bone strength sufficient to render from the contingency of depressive The somatic consequences them at present risk for pathologic despair. of stress-system activation fracture. We now believe that the burden in depression Patients with depression have of internal conflict and external been shown to manifest several al- stressors interacts with genetic sus- Decreased bone mineral density terations in neuroendocrine regula- ceptibility and other biological fac- in women with depression. tion that could contribute to loss of tors to influence the likelihood of Our group has recently found that bone mineral density. Approxi- the development of clinically rele- pre-menopausal women with cur- mately 50% of patients with depres- vant major depressive disorder.1,2 rent or past major depression have sion manifest hypercortisolism,1, 2 clinically significant decrements in and moderate hypercortisolism of bone mineral density,13 as assessed the magnitude seen in depressed Depression and Stress by dual X-ray absorptiometry women manifesting decreased bone (DEXA). Women with past or cur- mineral density can accelerate bone As the genetic basis of depres- rent depression were individually loss.15 However, the mean loss in sion is still unknown, we have fo- matched for age, height, weight, trabecular bone we observed (e.g. cused our research on the biological menstrual status, reproductive his- 15% in Ward’s triangle) far exceeds mechanisms of the stress response tory, ethnicity, and for a variety of what could be expected on the basis and their role in the biology of ma- factors known to influence bone of hypercortisolism alone, so that jor depression. Moreover, by defin- mineral density, such as smoking, other factors must be implicated. ing the biological basis of the stress alcohol consumption, etc. As com- Decreases in growth hormone (GH) response we can address the inter- pared with healthy women the mean secretion can also contribute to loss section of biology and psychology (±SD) bone density in 25 women of bone mineral density;16 however, in major depressive disorder. with past or current depression was the subjects with past or current de- Specific circuits in the brain 6.5% lower at the spine (depressed pression showed no evidence of hy- modulate the response to stress. women 1.00±0.15 g/cm2, normal posomatotropism, as evidenced by Those include the autonomic ner- women 1.07±0.09 g/cm2, p=0.02), normal insulin-like growth factor 1 vous system, and neuroendocrine 15.7% lower at the femoral neck (IGF-1) and IGF-binding protein 3 networks.5 We have studied the hy- (0.76±0.11 vs. 0.88±0.11 g/cm2, p< levels. Decreased sex steroid levels pothalamic-pituitary-adrenal 0.001), 13.5% lower at Ward’s tri- also contribute to loss of bone min- (HPA) axis, and its role in the biol- angle (0.70± 0.14 vs. 0.81±0.13 eral density,16 but our depressed ogy of depression, for several rea- g/cm2, p<0.001), and 10.8% lower subjects with bone mineral abnor- sons. 1) Corticotropin-releasing at the trochanter (0.66±0.11 vs. malities did not have amenorrhea hormone (CRH), a 41 amino acid 0.74±0.08 g/cm2, p< 0.001). In addi- during depressive episodes. Thus, neuropeptide that is synthesized in tion, women with past or current de- the causes of this dramatic decrease the hypothalamus, and extra-hypo- pression had higher urinary cortisol in bone mineral density in women thalamic sites and that regulates excretion (71±29 vs. 51±19 µg/d, with depression are not yet fully the HPA axis, can cause a syn- p=0.006), lower serum osteocalcin elucidated. drome of behavioral and biologi- levels (p=0.04), and lower urinary cal stress.6, 7 2) Classical, melan- deoxypyridinoline excretion Hippocampal atrophy cholic major depression is associ- (p=0.02).13 We have also shown that in depression ated with increased activity of the there are no differences in vitamin- Interestingly, Sheline et al., HPA axis, caused by high levels of D-receptor alleles (Aa, Bb, and Tt) studying women with a mean age of CRH, and adrenal hyper-respon- in depressed women and control 68 years, found hippocampal atro- siveness to adrenocorticotropic subjects that might explain these phy in patients with depression, hormone (ACTH).8,9,10 3) Drugs findings.13, 14 Thus, it is likely that when compared to sex- and age- that treat depression lower CRH humoral factors cause loss of bone matched controls.17, 18 The causes for gene expression in the hypothala- mineral density in depressed pre- this neuroanatomical finding are mus.11, 12 menopausal women. still undetermined. Cortisol causes Having ascertained that there is Our group of 25 women, average neuronal loss and hippocampal at- dysregulation of the HPA axis in age, 41 years, showed a mean bone rophy in experimental animals. depression, we have now expanded mineral density at Ward’s triangle Hippocampal atrophy in depressed our concepts and propose that de- of the hip that was similar to that women was correlated with dura- pression is not only a disease of the seen in post-menopausal women at tion of illness, suggesting that expo- 118 DOLENTIUM HOMINUM sure to high levels of cortisol during to another POMC transcription fac- ly removed in one block, stored at - episodes of depression contributes tor, PO-GA, which binds to a differ- 70 deg C, and sectioned coronally to this finding.17, 18 ent thirteen nucleotide sequence lo- every 1 mm. Species-specific ri- cated further downstream in the bonucleotide probes were generat- Molecular mechanisms POMC promoter and known as the ed from interleukin 1§ (IL-1§) cD- for stress-related susceptibility PO-B site.26, 27 The PO-B site NA, IL-1ra cDNA, IL-10 cDNA to disease [AGAAGAGTGACAG], corre- and IL-13 cDNA. We sequenced We have also examined molecu- sponding to nucleotides -15/-3, is and characterized all probes. Sec- lar mechanisms by which depres- located between the TATA box and tioning, fixing, in situ hybridiza- sion, through elevated CRH pro- the cap site. This sequence is re- tion, autoradiography with 2 weeks duction, might contribute to physi- sponsible for at least 70% of the of exposure, and anatomical local- cal illness. Living organisms are basal POMC. We conducted Gen- ization of the probes were per- constantly exposed to stresses that bank searches for the nucleotide se- formed as described by Licinio et threaten homeostasis. Several as- quences of those two sites con- al.29 To test the specificity of anti- pects of the response to stress po- tained within the CRH-responsive sense probes and hybridization tentially influence susceptibility to element of the POMC promoter, method, we generated controls us- disease. CRH is one of several namely the PCRH-RE and the PO- ing labeled sense and excess cold stress-responsive substances that B site. We hypothesized that those probes. mRNA levels were quanti- influence the response to pathogens two specific sequences of nu- fied by densitometry.30 Total RNA and susceptibility to disease. CRH cleotides might be contained in oth- obtained from pituitaries of rats participates simultaneously in the er genes whose transcriptional acti- treated with LPS 6h after intraperi- organism’s response to stress and to vation or inhibition by the CRH-re- toneal injection was isolated and re- inflammatory mediators;6, 19, 20, 21 it is lated factors PCRH-REB-1 or PO- verse transcription was performed. present in the hypothalamus, and it GA could increase susceptibility to Polymerase chain reactions (PCR) also acts directly as an im- human disease. We found homolo- were set up to amplify the secretory munomodulator.22 Because of these gy between the PCRH-RE and the isoform of IL-1ra, sIL-1ra, and the actions, CRH is an important medi- non-coding region of pathogenic intracellular isoform, icIL-1ra.31, 32 ator of the interactions between the viruses, such as HIV-1, cy- PCR products were cloned and se- nervous system and the immune tomegalovirus, and malignant fi- quenced. We show that the CNS re- system. broma virus, and inflammatory me- sponds to systemic inflammation The cellular response to CRH oc- diators, such as interleukin 1§ con- with pronounced IL-1§ gene ex- curs after the ligand binds to specif- verting enzyme, and homology be- pression and limited expression of ic G-protein coupled receptors,23 tween the PO-B site and the non- genes encoding the counter regula- initiating events leading to changes coding regions of two important hu- tory cytokines IL-1ra, IL-10, and in gene transcription. CRH receptor man oncogenes, c-fes and MAT-1.28 IL-13. This pattern occurs through- binding leads to accumulation of Based on those findings, we hy- out the CNS, including areas such cAMP and intracellular free Ca2+, pothesize a novel mechanism of as the subfornical organ, pineal both of which stimulate proopiome- hormone action by which CRH-re- gland, neurohypophysis, and hypo- lanocortin (POMC) gene transcrip- lated transcription factors, reflect- thalamus.33 In contrast in the anteri- tion. The nuclear mechanisms in- ing the molecular responsiveness to or pituitary, we found limited IL-1§ volved in POMC transcription are CRH, might affect disease suscepti- gene expression but marked induc- not fully understood. Usually, bility by binding to unexpected in- tion of IL-1ra mRNA.33 Using cAMP and Ca2+ activate transcrip- tracellular targets, such as viruses, cloning and sequencing we verified tion by inducing transcription fac- oncogenes, or the genes encoding that during inflammation the splice tors that bind to the promoter region for inflammatory mediators. Infec- variant of the IL-1ra gene expressed of many genes at the DNA respon- tion, inflammation, and possibly in the pituitary and detected by in sive elements CRE (cAMP respon- neoplastic susceptibility would thus situ hybridization is the secreted sive element) and CaRE (calcium be facilitated. isoform, sIL1-ra.33 In conclusion we responsive element), both of which found that IL-1§ is counter regulat- are variants of the basic palin- ed differentially in the CNS and in dromic motif, TGACGTCA.24 Peripheral illness affects peripheral tissues. We propose that However, because the POMC pro- key functions of the brain the central manifestations of pe- moter lacks those motifs,25 research ripheral inflammation are mediated has been directed at finding other We have examined the pattern of by endogenous brain IL-1§ synthe- cAMP responsive elements in that cytokines gene expression in the sized during systemic inflammation promoter. central nervous system (CNS), and in the context of limited central cy- New factors have been isolated pituitary in response to inflamma- tokine counter regulation of IL-1 from CRH-treated pituitary cells, tion. We studied male Sprague- bioactivity. These data show that such as PCRH-REB-1, which binds Dawley rats 0, 2, 6, and 24 h after peripheral illness alters the levels of to a region of the POMC promoter, the intraperitoneal injection of 5 mg expression of specific genes in the known as PCRH-RE [CTGT- of LPS or saline (n=6/group). Injec- brain. Interestingly, it has been pro- GCGCGCAG], increasing tran- tions were timed so that all tissue posed that IL-1§ may have a role in scription of that gene sevenfold.25 collection occurred at 10:00-11:00 the biology of depression.34 The PCRH-REB-1 is 90% homologous h. Brains and pituitaries were rapid- CNS transcription of the HIV-1 “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 119

replication factor IL-1§35 in the con- medicine and imaging open new 10 GOLD P.W., CHROUSOS G., KELLNER C., et al., Psychiatric implications of basic and clini- text of limited transcription of the horizons for research in depression. cal studies with corticotropin-releasing factor. IL-1 replication inhibitors IL-1ra, We can now transcend reduction- Am J Psychiatry 1984; 141:619-627. IL-10, IL-1335, 36, 37, 38, 39 might help ism and use the latest advances in 11 BRADY L.S., WHITFIELD H.J., FOX R.J., GOLD P.W., HERKENHAM M., Long-term antide- explain the negative impact of sys- technology to integrate body and pressant administration alters corticotropin-re- temic inflammation on the clinical mind at the most fundamental level. leasing hormone, tyrosine hydroxylase, and course of AIDS. Additionally, we At some point in the future we will mineralocorticoid receptor gene expression in rat brain. Therapeutic implications. J Clin In- have suggested that IL-1ra may be no longer need to discuss the biolo- vest 1991; 87:831-837. secreted by the anterior pituitary as gy and the psychology of depres- 12 BRADY L.S., GOLD P.W., HERKENHAM M., a systemic anti-inflammatory hor- sion. As research advances, psy- LYNN A.B., WHITFIELD H.J., The antidepressants fluoxetine, idazoxan and phenelzine alter mone that is released in response to chology will be understood in bio- corticotropin-releasing hormone and tyrosine IL-1§ originated from hypothalam- logical terms, and the psychological hydroxylase mRNA levels in rat brain: thera- ic, pituitary, and systemic sources. implications of biological events peutic implications. Brain Res 1992; 572:117- 125. High levels of IL-1§ gene expres- will be elucidated. This work is of 13 MICHELSON D., STRATAKIS S., HILL L., et sion in the brain can explain our moral, ethical, and religious rele- al., Bone mineral density in women with depres- finding of high levels of expression vance. We hope that, by using the sion. N Engl J Med 1996; 335:1176-1181. 14 MORRISON N.A., QI J.C., TOKITA A., et al., of the gene encoding inducible ni- latest tools in biomedical research Prediction of bone density from vitamin D re- tric oxide synthase in vascular, to integrate biology and psycholo- ceptor alleles. Nature 1994; 367:284-287. glial, and neuronal structures of the gy, we will facilitate a more bal- 15 ZELISSEN P.M., CROUGHS R.J., VAN RIJK P.P., RAYMAKERS J.A., Effect of glucocorticoid brain, accompanied by the spillover anced understanding of the human replacement therapy on bone mineral density in of nitric oxide metabolites such as condition. patients with Addison disease. Ann Intern Med 1994; 120:207-210. nitrite into cebrospinal fluid (CSF); 16 HOLMES S.J., SHALET S.M., Role of growth CSF nitrite levels might represent a Professor JULIO LICINIO hormone and sex steroids in achieving and potential clinical marker for sep- Director of the Unit maintaining normal bone mass. Horm Res 40 for Clinical Research 1996; 45:86-93. sis. Animals with a null mutation 17 at the National Institute for Mental Health SHELINE Y.I., WANG P.W., GADO M.H., for the neuronal isoform of nitric CSERNANSKY J.G., VANNIER M.W., Hippocam- oxide synthase have behavioral al- in Bethesda, Maryland (USA) pal atrophy in recurrent major depression. Proc Natl Acad Sci USA 1996; 93:3908-3913. terations; it has therefore been pro- 18 SHELINE Y.I., Hippocampal atrophy in ma- posed that nitric oxide can modu- jor depression: a result of depression-induced late behavior.41 neurotoxicity. Mol Psychiatry 1996; 1:298-299. 19 RIVIER C., RIVIER J., VALE W., Stress-induced inhibition of reproductive functions: role References of endogenous corticotropin-releasing factor. Conclusions Science 1986; 231:607-609. 1 GOLD P.W., GOODWIN F.K., CHROUSOS 20 STERNBERG E.M., YOUNG WD., BERNARDINI G.P., Clinical and biochemical manifestations R., et al., A central nervous system defect in Studies documenting decreased of depression: relation to the neurobiology of biosynthesis of corticotropin-releasing hor- bone mineral density13 and hip- stress (Part 1 of 2 parts). N. Engl. J. Med 1988; mone is associated with susceptibility to strep- 17 319:348-353 tococcal cell wall-induced arthritis in Lewis pocampal atrophy in women with 2 GOLD P.W., GOODWIN F.K., CHROUSOS rats. Proc Natl Acad Sci USA 1989; 86:4771- depression show that a disorder that G.P., Clinical and biochemical manifestations 4775. has been classified as a mental dis- of depression: relation to the neurobiology of 21 STERNBERG E.M., WILDER R.L., GOLD stress (Part 2 of 2 parts). N. Engl. J. Med 1988; P.W., CHROUSOS G.P., A defect in the central ease affects the functioning and the 319:413-420. component of the immune system—hypothalam- structure of the brain and of periph- 3 WEISSMAN M.M., BLAND R.C., CANINO ic-pituitary-adrenal axis feedback loop is asso- eral tissues. Moreover, recent mole- G.J., et al., Cross-national epidemiology of ma- ciated with susceptibility to experimental jor depression and bipolar disorder. Jama arthritis and other inflammatory diseases. Ann cular data might clarify novel 1996; 276(4):293-9. N Y Acad Sci 1990; 594:289-292. mechanisms by which CRH hyper 4 CHARNEY D.S., MILLER H., LICINIO J., SA- 22 KARALIS K., SANO H., REDWINE J., LISTWAK secretion in depression can con- LOMON R.M., Treatment of depression. The S., WILDER R.L., CHROUSOS G.P., Autocrine or 28 American Psychiatric Press Textbook of Psy- paracrine inflammatory actions of corti- tribute to physical illness. A sepa- chopharmacology. Washington, D.C.: Ameri- cotropin-releasing hormone in vivo. Science rate line of investigation in our lab- can Psychiatric Press, 1995; 575-601. 1991; 254:421-423. oratory has shown that peripheral 5 CHROUSOS G.P., GOLD P.W., The Concepts 23 WONG M.L., LICINIO J., PASTERNAK K.I., of Stress and Stress System Disorders. 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J.L., Characterization of a corticotropin-releas- addressing specific mechanisms by Nature 1982; 297:331-333. ing hormone-responsive element in the rat 8 GOLD P.W, LORIAUX D.L., ROY A., et al., proopiomelanocortin gene promoter and mole- which diseases of the mind affect Responses to corticotropin-releasing hormone cular cloning of its binding protein. Mol En- the body and diseases of the body in the hypercortisolism of depression and Cush- docrinology 1994; 8:1377-1388. affect the brain. It is our hope that, ing’s disease. Pathophysiologic and diagnostic 26 LU Y., ZEFT A.S., RIEGEL A.T., Cloning implications. N Engl J Med 1986; 314:1329- and expression of a novel human DNA binding as our research strategies become 1335. protein, PO-GA. Biochem Biophys Res Com- increasingly more mechanistic, we 9 NEMEROFF C.B., WILDERLOV E., BISETTE mun 1993; 193:779-786. can unravel the connections be- G., et al., Elevated concentrations of CSF corti- 27 LU Y., RIEGEL A.T., The human DNA-bind- cotropin-releasing-factor-like immunoreactivi- ing protein, PO-GA, is homologous to the large tween brain function and body ty in depressed patients. Science 1984; subunit of mouse replication factor C: regula- function. The tools of molecular 226:1342-1344. tion by alternate 3’ processing of mRNA. Gene 120 DOLENTIUM HOMINUM

1994; 145:261-265. ated with epithelium. Proc Natl Acad Sci USA Exp Med 1993; 178:743-747. 28 LICINIO J., GOLD P.W., WONG M.L., A Mol- 1991; 88:3681-3685. 37 MONTANER L.J., GRIFFIN P., GORDON S., In- ecular Mechanism for stress-induced alter- 33 WONG M.L., BONGIORNO P.B., RETTORI V., terleukin-10 inhibits initial reverse transcrip- ations in susceptibility to disease. Lancet 1995; MCCANN S.M., LICINIO J., Interleukin 1§, inter- tion of human immunodeficiency virus type 1 346:104-106. leukin 1 receptor antagonist, interleukin 10, and mediates a virostatic latent state in primary 29 LICINIO J., BONGIORNO P.B., GOLD P.W., and interleukin 13 gene expression in the cen- blood-derived human macrophages in vitro. J WONG M.L., The gene encoding for the novel tral nervous system and anterior pituitary dur- Gen Virol 1994; 75:3393-3400. transacting factor proopiomelanocortin corti- ing systemic inflammation: Pathophysiological 38 AKRIDGE R.E., OYAFUSO L.K., REED S.G., cotropin-releasing hormone responsive element implications. Proc Natl Acad Sci USA 1996; in IL-10 is induced during HIV-1 infection and is binding protein 1 (PCRH-REB-1) is constitu- press. capable of decreasing viral replication in hu- tively expressed in rat pituitary and in discrete 34 MAES M., BOSMANS E., MELTZER H.Y., man macrophages. J Immunol 1994; 153:5782- brain regions containing CRH or CRH recep- SCHARPE S., SUY E., Interleukin-1 beta: a puta- 5789. tors: pathophysiological implications. En- tive mediator of HPA axis hyperactivity in ma- 39 SAVILLE M.W., TAGA K., FOLI A., BRODER docrinology 1995; 136:4709-4712. jor depression? Am J Psychiatry 1993; S., TOSATO G., YARCHOAN R., Interleukin-10 30 LANDAU D., CHIN E., BONDY C., et al., Ex- 150:1189-1193. suppresses human immunodeficiency virus-1 pression of insulin-like growth factor binding 35 POLI G., KINTER A.L., FAUCI A.S., Inter- replication in vitro in cells of the proteins in the rat kidney: effects of long-term leukin 1 induces expression of the human im- monocyte/macrophage lineage. Blood 1994; diabetes. Endocrinology 1995; 136:1835-1842. munodeficiency virus alone and in synergy with 83:3591-3599. 31 EISENBERG S.P., EVANS R.J., AREND W.P., interleukin 6 in chronically infected U1 cells: 40 WONG M.L., RETTORI V., AL-SHEKHLEE A., et al., Primary structure and functional expres- inhibition of inductive effects by the interleukin et al., Inducible nitric oxide synthase gene ex- sion from complementary DNA of a human in- 1 receptor antagonist. Proc Natl Acad Sci USA pression in the brain during systemic inflamma- terleukin-1 receptor antagonist. Nature 1990; 1994; 91:108-112. tion. Nature Med 1996; 2:581-584. 343:341-346. 36 MONTANER L.J., DOYLE A.G., COLLIN M., 41 NELSON R.J., DEMAS G.E., HUANG P.L., et 32 HASKILL S., MARTIN G., VAN L.L., et al., et al., Interleukin 13 inhibits human immunode- al., Behavioural abnormalities in male mice cDNA cloning of an intracellular form of the ficiency virus type 1 production in primary lacking neuronal nitric oxide synthase [see human interleukin 1 receptor antagonist associ- blood-derived human macrophages in vitro. J comments]. Nature 1995; 378:383-386. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 121

MALCOM LADER

Abnormalities of the Mind in Schizophrenia

Introduction in a close-knit family. One mater- years of unimaginable disintegra- nal great-aunt had died in an asy- tion of thought processes, of There are more misconceptions lum many years ago but otherwise bizarre ideas, of self-neglect, of about schizophrenia than about the family was devoid of history of isolation from the rest of any other mental illness. These mental illness. He had had a diffi- mankind. But also an example to misunderstandings and downright cult birth with prolonged labour us of a different mode of like, of ignorance are entertained by most but appeared to be a normal persistence in the face of ap- laymen and many doctors, and child. By about the age of 8 he palling adversity, to remind us greatly colour our attitudes to- was regarded as socially inept but perhaps of our limited under- wards these unfortunate people. otherwise appeared quite intelli- standings of the most complex bi- Mixed with the ignorance is fear, gent. He actually did well at ological entity on this planet—the revulsion and a pervading lack of school although remaining aloof, human brain. compassion which condemns and he went to a prestigious uni- many schizophrenic patients to a versity to read Classics. Such a twilight existence. Too often, developmental history is typical Characteristic symptoms schizophrenia is translated literal- (Weinberger, 1995). The first year ly as “split-mind” or “Jekyll-and- passed uneventfully but half way Schizophrenic patients can har- Hyde” as in the novella by the through the second, he became in- bour a vast variety of abnormali- 19th Century Scottish writer, creasingly isolated and began to ties of the mind. The common fea- Robert Louis Stephenson. Schizo- fail to attend his tutorials. The ture is a disintegration of coordi- phrenic patients are dumped into walls of his room at College were nation of mind processes. For ex- the community without adequate found to be criss-crossed with a ample, feelings do not enmesh support and resources, they re- metallic-finish tape. He explained with intellect so that a patient may lapse, commit an antisocial act, that this was to stop the evil spir- laugh incongruously while de- and the headlines in our tabloid its on Mars from beaming mes- scribing the death of a parent. The newspapers scream for better con- sages to him telling him to kill following are the symptoms of the trols to protect the public from himself. His speech was incoher- first order of Kurt Schneider: these itinerant madmen and ent and he appeared to be hearing thought insertion, thought broad- women. Have we returned to the voices. He was neglectful of his cast, and thought withdrawal, au- Dark Ages, or at best the Middle personal hygiene and would gig- ditory hallucinations of a particu- Ages? And should we, as then, in- gle uncontrollably at times. He lar type, and delusions of control. volve religious organisations was taken to the local mental hos- These symptoms are highly dis- more intensively in the care of the pital. criminatory for a diagnosis of severely mentally ill? He never returned to College, schizophrenia—in other words, a never held down a regular job, high concordance (over 90 per never had a regular girlfriend, cent) will be found among profes- A vignette never had any friends, would sionals, such as psychiatrists and refuse to see his family for years clinical psychologists, in attach- But what is schizophrenia; what on end, and lived in a barricaded ing that label to a mentally-disor- is a sufferer like? It is a most var- room in cheap lodgings. He took dered individual. ied condition and a debate has medication only sporadically and been raging for all of this century refused depot injections of an- as to the boundaries of this disor- tipsychotic drugs. He harmed no Abnormal thoughts der or possibly groups of disor- one but people shunned him. I still ders. The following vignette is see him occasionally in the local The symptom of thought inser- fairly typical. Post Office where he draws his tion comprises a belief that alien I first encountered Duncan Social Security payment. thoughts are being forced into the when he was 21. He had grown up Is this a waste of life? So far 33 patient’s stream of thought, into 122 DOLENTIUM HOMINUM his or her consciousness. These in the absence of any external spring fully formed into the indi- thoughts appear foreign and are stimulus to the sense organs, and vidual’s mind, other develop re- often disturbing, threatening or with a similar quality of morselessly. Delusions may crys- obscene. It is not that the patient verisimilitude to a true percept. tallise against a background of believes he is caused to have un- An hallucination is experienced primary delusional mood (Wahn- usual thoughts but that the as originating in the real outside stimming). The delusion may not thoughts themselves are not his— world or the assumed internal alter the patient’s orientation—he he is thinking other people’s world. Normal people experience may believe he is a millionaire but thoughts, or the Devil’s or animals hallucinations especially when live contentedly in penury and or even those of inanimate objects fatigued or when falling asleep or squalor. Many of the other fea- such as a computer, a waterfall or waking up. Hallucinations can tures of schizophrenia stem from a weathered rock. The mode of in- occur in any modality—auditory, or are explained by delusions. For sertion is believed to be by some visual, olfactory, tactile, gustatory example, a patient experiencing external means such as telepathy or proprioceptive. In schizo- abnormalities of thought may no- or microwaves. The patient is phrenic patients auditory halluci- tice a microwave transmitter on quite adamant that the thoughts nations are among the most fre- top of a building whereupon the are not his own. quent symptoms. They may take delusion develops that this is the Thought withdrawal is when a the form of noises, times, single headquarters of the invaders from patient believes that thoughts are words, phrases or entire conver- Saturn. being taken out of his or her mind. sations. Some voices are com- Paranoid delusions, that is, This usually accompanies thought mands to the patients, other pro- fixed beliefs of persecution, are blocking when the patient experi- vide a running commentary and particularly common in schizo- ences a break in the continuity of refer to the patient in the third phrenic patients. Delusions relat- thought-flow through his mind person—“She is washing her- ing to the appearance or function and believes that his own legiti- self—she needs to—she is dis- of parts of the body, or of special mate thoughts have been filched gustingly dirty.” Some patients religious, pseudophilosophical or by an outside agency, often his hear their thoughts spoken out pseudoscientific import may oc- supposed persecutors. These aloud as they think them cur. Grandiose delusions are less thoughts may become common (“gedankenlautwerden”), or im- common but may imbue the pa- knowledge, so-called thought mediately afterwards (“echo de la tient with an unassailable sense of broadcasting, in which the patient pensées”). Other modalities of special mission in life and of be- believes that his unspoken, inner- hallucinations may also occur, for ing endowed with supernatural most thoughts are known to other example, a feeling of inner putre- powers to carry it out. But there is people by radio, telepathy or su- faction. One of my patients typically a bizarre dimension to pernatural agency. claimed to receive messages the belief which distinguishes it As well as abnormalities of which he could read tattooed on from evangelicism. Delusions of control of thought, the pace of the inside of the back of his skull. reference may be noted in which thought may change becoming Usually, however, visual halluci- the individual believes that slowed down with poverty of nations are uncommon. events, objects or other people’s thought, or quickened up with behaviour refer to himself. Delu- pressure of thought. Associations sions of control are beliefs that between thoughts become loos- Delusions external forces govern ones ac- ened or incomprehensible. This tions usually via some weird may manifest itself in illogical A delusions is a belief that is mechanism. Delusional systems thinking—so-called “knight’s firmly held despite evidence to may accrue but become increas- move” or talking past the point (in the contrary and is not a conven- ingly encapsulated as the patient German “vorbeireden”). In its tional belief in keeping with the learns to stop bringing them to severest form, thought and speech educational and cultural back- general notice. become disjointed and incoher- ground of the individual. A delu- ent—“word salad” or verbigera- sion is usually a false belief but tion. Idiosyncratic words or not always—it is the relationship Abnormalities of Affect phrases are coined (neologisms) between content of delusion, in- or ordinary words are used in un- formation available to the individ- Abnormalities of mood are usual ways (paraphrasias or ual and his expected beliefs that is common in schizophrenia and are metonyms). One of my patients important. For example, a person of three main types. Sustained ab- referred constantly to his “sub- suffering from morbid jealousy normalities may occur with anxi- marragism” meaning his hidden may have the delusion that his ety, irritability, euphoria or de- longings to have a normal marital wife is constantly unfaithful to pression. The last may be severe relationship. him even if it is true providing he and all too often a schizophrenic has no grounds for that assump- illness ends up in suicide (Alle- tion. Delusions are held with beck, 1989). Secondly, affect may Hallucinations rock-life intensity and no amount be blunted or flattened with a sus- of argument and reasoning will tained reduction in intensity and These are percepts experienced shift it an iota. Some delusions range of emotional expression. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 123

Thirdly, affect may be grossly in- flexibility, stereotypy and cata- and become dissident may be la- congruous where the emotional tonic excitement and stupor. belled “schizophrenic” and incar- response is incompatible with cerated as mental patients, most current speech or events. notoriously in the Soviet Russian A major feature of schizophre- Other clinical features scandals 20-30 years ago (Lader, nia is anhedonia—a reduced abil- 1977). ity to enjoy life (Norman and The above account is essential- However, there is good evi- Malla, 1991). This may be made ly a cross-sectional examination dence that schizophrenia can be worse by the depressant side ef- of the abnormalities of the schizo- regarded as a disease, illness or fects of medication and eventual- phrenic mind. Many other fea- disorder (Wing, 1978). Evidence ly lead to compliance problems. tures of schizophrenia are impor- from genetic (McGuffin et al., At the outset of acute phases of tant such as the clustering of 1995), epidemiological, bio- the illness intense emotions of symptoms into two or three syn- chemical and brain imaging (Hall terror or exhilaration may super- dromes and the different natural et al., 1994) studies all show a vene in tune with the content of histories of the main types of the major and common biological delusions and hallucinations. Pas- disorder (Andreasen, 1995). New component (Sedvall and Farde sivity feelings may interact so drugs have been introduced with 1995). Thus, very recently, it was that the patient believes he or she some improvement in prognosis found that one of the brain recep- is being made to feel ecstatic or (Kerwin and Taylor, 1996). tors governing the action of the angry. Roughly speaking, a quarter of neurotransmitter, serotonin, was Schizophrenic patients are usu- patients do quite well, making an abnormal in many schizophrenic ally aware of the time, place and almost complete recovery, a half patients (Williams et al., 1996). their own identity (more or less). have a recurrent or chronic illness Nevertheless, many features of Some may persist in the belief but maintain some useful level of the illness are best understood as that their age is that at the outset functioning and a quarter pursue a complex interactions between bi- of the illness. Thus, conscious- severe relapsing or inexorably ological and psychosocial factors. ness in not clouded as in a deliri- downhill course. Their prognosis um nor is memory formally im- is abysmal, especially now that paired as in a dementia. However, “asylum” beds are so scarce. It is Madness and possession attention and concentration may a sobering thought despite all our be poor, and patients may be eas- “advances” in treatment and man- I have emphasised the “first- ily distracted or preoccupied with agement, the overall outlook for rank” symptoms of schizophre- their abnormal inner thought schizophrenic patients has hardly nia, prominently among which are processes. Memory is usually changed over the past century the feeling of thought control, of normal but poor motivation to re- (Hegarty et al., 1994). dissolution of thought processes call information and events may and hence a terrifying disintegra- suggest impaired memory tion of personal integrity. This (Tomkins et al., 1995). Recently, The boundaries bears a superficial resemblance to sophisticated neuropsychological of schizophrenia the concepts of possession and testing coupled with advanced witchcraft so prevalent in Europe brain imaging techniques have I have described the character- in the Middle Ages, and still to be shown that there are fairly wide- istic symptoms of schizophrenia, found in unsophisticated societies spread but rather subtle deficits in at the core of which lie symptoms today (Lipsedge, 1996). However, cognitive functioning which may of thought and emotional distur- there is a fundamental distinction well long antedate the onset of the bance. Lesser forms of the disor- between the two conditions. In illness and be present in other- der abound and merge into abnor- schizophrenia, the control is exer- wise normal close relatives. mal (“schizoid”) personality and cised at a distance and the thought Insight is usually impaired. eccentricity. The boundaries of context is illogical or incoherent. Many patients refuse to acknowl- the disorder are thus ill-defined In people possessed, the control is edge that they are mentally ill but and depend on the type and sever- exercised by an external agency instead develop elaborate and ity of the symptoms and the psy- such as the Devil taking over the bizarre explanations for their chosocial nexus in which they body and mind of the possessed predicament. Poor insight is asso- arise. Mental health professionals individual whose thought content ciated with frequent relapse, se- have different views on the rela- remains comprehensible, albeit vere symptoms and poor compli- tionship of schizophrenia to nor- distorted to the purposes of the ance with medication, thereby mality. This can lead to a total in- usurping agency. In most in- perpetuating a vicious circle. version of epistemology as in stances possessed people are suf- Patients also show lack of voli- Szasz and Laing’s views that indi- fering from a psychological reaction and drive and may become viduals labelled schizophrenic are tion to stress or social circum- increasingly inert. A wide range reacting to the mad society in stances. In others, particularly of movement disorders may be which they live and are not them- with visions or states of ecstasy, seen although less frequently in selves inherently flawed. At the an abnormality of brain function Western countries than hitherto. other extreme, people who criti- such as temporal lobe epilepsy These include posturing, waxy cise the society in which they live may underlie the condition. 124 DOLENTIUM HOMINUM

Of course, the content of delu- severely mentally ill, as exempli- are and how catastrophic the re- sions and hallucination will re- fied by our discharge of schizo- sults of disturbance of these flect the upbringing, education, phrenic patients into an inade- processes. beliefs and psychosocial position quately prepared community. of the sufferer from schizophre- Professor MALCOLM LADER nia. For example, a religious indi- Professor of Clinical vidual will have a religious con- The madness of schizophrenia Psychopharmacology, tent to his delusions believing that De Crispigni Institute of Psychiatry, he has messianic functions or that Schizophrenia is a complex London Park he receives special mentions from mental illness. We assume that a God. The irreligious person will subtle perturbation of brain func- tend not to have such ideas or his tion, most likely biochemical in delusions may be blasphemous in nature, leads to the strange symp- nature. But the form of thought toms and behaviours. The disorder, delusions, hallucina- changes can be gross, with disin- tions etc. are similar across indi- tegration of the personality, or vidual patients despite widely more subtle. In the latter case, varying differences in content. some brain functions such as creativity may be enhanced, although others, such as self-criti- Attitudes to mental illness cism, may be attenuated. Most such as schizophrenia bodily function remains normal, as does most of the routine brain Bibliography Both possession and madness functions such as perception and caused the destruction of personal speech. The abnormality in the ALLEBECK, P. (1989) Schizofrenia: a life- and social order, the devil wreak- schizophrenic brain is subtle but shortening disease. Schizophrenia Bulletin, 15, 81-89. ing havoc, the person becoming widespread. Study of schizophre- ANDREASEN, N.C. (1995) Symptoms, chaotic in thought and deed, and nia underlines for us the complex- signs, and diagnosis of schizophrenia. the soul being endangered or ity of the human brain. Evalua- Lancet, 346, 477-481. HALL, L.D., HERROD, J.J., CARPENTER, eroded. Those attitudes from the tion of the abnormalities in schiz- T.A. et al (1994) Magnetic resonance imag- Middle Ages have persisted in ophrenia raises issues concerning ing in schizophrenia: a review of clinical many societies often covertly. In- interactions between parts of the and methodological issues. In: Schizophre- nia: Exploring the Spectrum of Psycosis. sanity is regarded as a corruption brain, particularly the highest (eds. R.J. Ancill, S. Holliday, & J. Higenbot- of reason, and of order, stability functions, unique to man, such as tam). Wiley, Chichester, England. pp. 115- and equanimity of mind. It is sur- organised speech. Other functions 137. HEGARTY, J.D., BALDESSARINI, R.J. TO- prising that insanity, as with most such as emotions are also better HEN, M. et al (1994) One hundred years of illness, was regarded as a punish- understood when the nature of ab- schizophrenia: a meta-analysis of the out- ment for sinning. Symptoms were normalities is studied. come literature. American Journal of Psy- chiatry, 151, 1409-1416. a warning to search one’s con- The most fundamental ques- KERWIN, R. & TAYLOR, D. (1996) New science and to repent. God tions involve the nature of antipsychotics: a review of their current sta- warned that he would strike with thought and of consciousness. tus and clinical potential. CSN Drugs, 6, 71- 82. madness those who failed to obey The integration and control of LADER, M. (1977) Psychiatry on Trial. his Commandments (Deut. these noumena is taken for grant- Penguin, Harmondsworth. 28:15-28). Conversely, one of the ed by almost all of us. We expect LIPSEDGE, M. (1996) Religion and madness in history. In: Psychiatry and Religion. causes of sinning could be mad- to be separate, integrated individ- Context, Consensus and Controversies. (ed. ness. Both are deviations from the uals with control over our D Bhugra). Routledge, London. pp. 23-47. perceptions of God’s pattern and thoughts, if not all of our mind MCGUFFIN, P., OWEN, M.J. & FARMER, A.E. (1995) Genetic basis of schizophrenia, order for man in his existence on functions. We take it for granted Lancet, 346, 678-682. Earth. Insanity could carry a stig- that our thoughts are our own—it NORMAN, R.M.G. & MALLA, A.K. (1991) ma both in this world and the is an essential part of our being, of Dysphoric mood and symptomatology in schizophrenia. Psychological Medicine, 21, next, with damnation as a further our knowledge of ourselves as in- 897-903. punishment for sin. tegral human beings. We take it SEDVALL, G. & FARDE, L. (1995) Chemi- More enlightened attitudes for granted that our thoughts are cal brain anatomy in schizophrenia. Lancet 346, 743-749. have generally prevailed with private experiences which can be TOMPKINS, L.M., GOLDMAN, R.S. & AX- most illnesses, physical and men- communicated to others by ELROD, B.N. (1995) Modifiability of neu- tal. However, the extreme and speech, facial expression, gesture ropsychological dysfunction in schizophrenia. Biological Psychiatry, 38, 105-111. bizarre nature of schizophrenic or action, not only if we wish to WEINBERGER, D.R. (1995) From neu- symptoms has led to a reluctance do so. This fragmentation of per- ropathology to neurodevelopment. Lancet, to view this condition as a mental sonal wholeness, of the fraying of 346, 552-557. WILLIAMS, J. SPURLOCK, G. MCGUFFIN, P. illness rather than a punishment personality and of the vulnerabil- et al (1996) Association between schizophre- or a sign of weakness. This under- ity of the citadel of the mind lies nia and T102C polymorphism of the 5-hy- current of suspicion and incom- at the core of schizophrenia. This droxytryptamine type 2a-receptor gene. Lancet, 347, 1294-1296. prehensibility has led to our cur- disorder reminds us how finely- WING, J.K. (1978) Reasoning about Mad- rent ambivalent attitudes to the balanced our mental processes ness. Oxford University Press. Oxford. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 125

IGNACIO CARRASCO DE PAULA

The Dignity of Madness

The title of this Eleventh Inter- wounded in that gift which enables observation is also necessary. Al- national Conference—“In the Im- him to feel proud of being a man; most five centuries ago Erasmus of age and Likeness of God: Al- in the man who is no longer able to Rotterdam gave his great friend ways?”—would suggest that the read what is written within him- Thomas More a copy of a small choice of its principal subject self; in that man deprived of the work he had written—Moirae En- arose from the posing of the fol- light of the mind—in such a man comium, or “In Praise of Folly.” In lowing question: Is the most im- human reason contemplates the the pages of this work words are a portant anthropological statement mystery of a new and unexpected lethal weapon wielded in the of the Bible in relation to the great- dignity. hands of irony. Honesty takes on ness and value of man not perhaps Obviously enough, before en- the form of dementia in order to contradicted by the widespread ex- gaging in my reflections upon this satirize the ill-conduct of his con- perience of illness, especially subject, it has to be recognized that temporaries and more particularly where it involves an attack on the this proposition cannot but come of certain men and women of the most precious faculty of man, his up against a common experience Church. But in this small master- intelligence and his freedom, that shared by everyone—madness is piece madness remains a phantom, is, his mind? an evil, a tribulation; it attacks the a mirage which fails to find space And if, as the cultural traditions very source itself of that dignity amongst the elegant grammatical of a Christian character tend to as- which is specific to intelligent be- constructions of the great human- sert with unanimity, the dignity of ings who because they are intelli- ist. This paper has much more man has a meaning in itself and of gent are free and because they are modest aspirations. Its aim, in con- itself which is not conditioned by free are capable of good and evil. trary fashion, is to deal with the contingent circumstances, then Morality as a discipline which is subject of real madness, without, what are the consequences of this both philosophical and theological however, becoming involved in state of affairs in health care, social excludes the behavior of the indi- literary constructions and elegant and pastoral terms, and especially vidual who is mentally ill from its wordplay. in relation to those who in various field of competence. His actions ways are involved in the safe- are those of a man but they are not guarding of health? actions which are really human.1 1. The Concept of Dignity It is in this sense that I have cho- On the one hand, moral science sen the title “The Dignity of Mad- recognizes that one is always deal- The dignity of madness! All ness” for my paper. I do not wish ing with a man who is the operator right and good. But what do we re- to explore the idea—which is ob- of actions, but on the other it con- ally mean when we state that a be- vious, at least within a personalis- cludes that such actions, quite ing, any kind of reality, is worthy? tic framework of analysis—that apart from their objective ethical A man is worthy if he by nature each man because he is man is character, can be attributed—as- has worth, nobility, or excellence. worthy of, and deserves, the great- cribed—to the individual who car- To be worthy means to be deserv- est respect, not least when he is af- ries them out only when that per- ing of regard and respect. Not be- flicted by illness of the mind of the son is fully in possession of his cause of a benevolent or positive body. I wish, rather, to dwell upon mental faculties. I would say that judgement on the part of others, the proposition that illness itself, for moralists, and here I include but because that person really pos- even though it is a source of suffer- myself, the mentally ill person sesses the qualities which coming and of limitation, confers a should not be seen as a protagonist mand such respect and because special and specific form of digni- of history but should be considered other people could not fail to rec- ty upon man. only as a witness. I will bear all of ognize them without becoming If this perception and judgement this closely in mind during the dis- distant from truth and subsequent- is correct,it places us before an im- cussion of the subject of this paper ly from justice. portant and involving paradox: in which now follows. Dignity is foreign to the world the man who is wounded, and However, another preliminary of compassion, clemency, or pity. 126 DOLENTIUM HOMINUM

Indeed, dignity is a fitting object of that which nobody can help desir- bility of man without reference to that human faculty which reaches ing.2 the concept of dignity. Indeed, the and touches the existent—both in If such is the case, we have to human person is such a valuable the form of things and of people— conclude that the question of the good that he cannot be compared in its specific ontological value— dignity of madness is not of an ex- to any other created or known that is, in its quality of good. As a clusively epistemological charac- good. At an axiological level, the result, dignity is not so much a rev- ter. Indeed, in order to understand human person in our universe is elation of intelligence as a discov- the full meaning of the question unrivalled. He is priceless. He ery of will. It is a quality which is before us we must take into ac- greatly exceeds the values that are understood not through the force count the faculty which enables us available to us. He cannot be mea- of logical reasoning, but as a term to love. By this assertion I wish to sured in economic terms, with ref- to describe that unlimited wish for establish a strictly methodological erence to levels of prosperity, in good which we call love. criterion. terms of progress, through the em- One cannot recognize the digni- ployment of parameters of social ty of something or somebody rank, or in similar ways. On the without loving that something or 2. Human Dignity contrary, the status of man pro- that somebody. And it is for this vides a yardstick by which to value reason that at the root of cultural When we preach the term digni- all those things which are available tendencies which do not pay suffi- ty in relation to man what do we to him. cient regard to the dignity of man mean? Is the expression an alterna- One thus comes to understand we always find an alienation, the tive way of saying that man is how erroneous it is to place the exiling of love, and at an even man, and thus a mere tautological mentally ill person within the deeper level the growing danger of declaration, or are we adding a framework of the following an irrational hatred for man him- new element to its meaning? sophism, which, however, is not self. Hobbes is very effective when It seems to me that in terms of its without a certain logic: man is a ra- he repeats the phrase “homo ho- cultural genesis the use of the con- tional animal; as a result, when he minis lupus”—it is not possible to cept of dignity solely and exclu- is deprived of his rationality we love a beast because it lacks the es- sively in relation to homo sapiens can only perceive in him a human- sential pre-condition for the be- is to be explained with reference to ity which has been tampered with, stowal of love—dignity. an acquired knowledge of the insu- a humanity almost of the second This is a lesson which humanity perable boundaries of language. class, perhaps even inferior. Such a is gradually learning at its own ex- We have neither words nor sym- line of argument necessarily im- pense and against a background of bols by which to give an adequate plies that the person who suffers a series of apparently interminable expression to our concepts con- from mental illness is less a man threats and actions against human cerning the value of man. Here we than the person who is mentally life. These are actions which fill encounter all the limits of symbol- healthy. It is at this point that the pages of newspapers all over ism as an instrument by which to mankind must turn to its con- the world every single day. We are gain access to knowledge. Perhaps science and reflect upon certain dealing here with threats which in what I am asserting here can be il- sad episodes belonging to a by no deliberate fashion menace the luminated by placing oneself in the means remote past and upon cer- most defenseless of our brethren, shoes of the author of Psalm 8. The tain present-day fears which are especially when they are at the be- psalmist writes: “When I look at shared by many and which do not ginning or the end of their earthly thy heavens, the work of thy fin- bode a happy future. lives. gers, the moon and the stars which Perhaps we have exaggerated in To return to the subject of this thou hast established, [I ask my- the identification of dignity with paper in more specific fashion, I self] what is man....” (Psalm 8:3- the being who is intelligent and would like to place great emphasis 4). Even the splendid and glorious equipped with free will. However, upon a simple tenet: a good which vision of a starry night is not suffi- both the use of reason and the con- is not loved is not recognized as cient to speak of your created be- trol of an individual’s behavior are being worthy. The will and the ing. What can I say? Only this: a sign, but not a source of humani- freedom of existent man is not to “Thou hast made him little less ty. Notwithstanding the arguments be found in a state of neutral indif- than God” (Psalm 8:5). In more of the animalists—with whom I ference when faced with bonum— modern language, and if the bibli- share many points of view—even as if, that is, he had need of who cal scholars will allow me, perhaps in the hypothetical case (which is, knows what kind of push from the the sentence could be translated in however, very improbable) that an outside to take a position. Freedom the following way: “You have animal might learn to reason, this is necessarily attracted and se- made man worthy of you.” Man is would not mean that that animal duced by the attraction of the good that work of yours which is espe- had acquired the definitive title of of the being. This is one of the cen- cially valuable to you. Or to put it dignity. In the same way, this tral theses in the anthropology of another way: I recognize in man would not mean that we would be St. Thomas. Aristotle himself, in the dignity that you have bestowed any less bound to treat him with seeking to define what good is, did upon him. extreme care and consideration— not go beyond saying that bonum At a rational level, there can be precisely because all living beings, is that which all things search for, no affirmation of the specific no- in a certain sense, form part of the “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 127 dignity of man, the lord and ser- terms we are asking what God definition of illness which satisfies vant of the creation. thinks about this very question. all opinions. The same problem The concept of dignity thus What value does the mentally ill arises in relation to mental illness.3 translates, at an axiological level, person have in the eyes of God? Certainly all kinds of formulas can the Christian vision which places We ask ourselves whether the be drawn up and listed, beginning the human person at the center and Lord—and we with him—also with that of the World Health Or- at the summit of the universe, the perceives his image in those who ganization. One of the greatest only creature which God wanted are not able to grasp that they are contemporary experts in the field in itself. It also expresses a funda- the mirror of the divine gaze. of medical anthropology, V. von mental ethical principle which re- The Bible refers to the tender- Weisacker, tired of the endless quires that the human person ness of God towards the poor, the polemic on the subject, was moved should always be treated as an end disinherited, the sick—all those to declare: “I define as being sick and never as a means, and which who can be seen as being innocent that person who calls me as a doc- forbids him to be treated as a in- victims without a guide and with- tor and whose need I as a doctor strument, as a tool. And God him- out protection. Those who suffer recognize.”4 Obviously enough, self was the first—and I hope you from mental illness without doubt this declaration is too simplistic will here allow me the employ- form a part to the full of this cate- and bears the marks of a polemical ment of rather approximate lan- gory. Furthermore, history teaches challenge. However, it brings out guage—to adhere strictly to this us that the mentally ill person has the tension which exists within the rule in his approach to men. all too often been exposed to the sick person: a lack of satisfaction insensitivity and the discrimina- about what he is and the hope— tion practiced by the so-called supported by the state of need— 3. The Dignity of Madness healthy. that he will recover or achieve im- The Bible even speaks about the proved health. The discussion which has hith- madness of God. Madness was the In the mentally ill person the im- erto been conducted on the charac- Cross. “Mad!” declared the lawyer age and likeness of God emerge in ter of dignity leads us to the Gene- Festus to Paul when the latter was a specific light: that of a state of in- sis statement which is the emblem explaining his faith to him (Acts completeness, that of the need for of this eleventh international con- 26:24). The Apostle describes help. Is this not perhaps the condi- ference: “in the image and likeness himself as a fool when writing to tion and the fundamental destiny of God”. the Corinthians (2 Cor 12:11). Fur- of the man who searches for salva- Indeed, when I ask myself about thermore, the Book of Wisdom tion? In this sense the individual the nature of the dignity of man I (5:4) warns us about how wrong- who suffers from mental illness is certainly pose a question of an ax- doers declare the just to be mad in for all of us a witness both of our iological nature. But at the same far too easy a fashion. Indeed, it is origins and of our destiny. In him time I raise an ontological prob- no easy task to distinguish great is to be found a dignity which is lem—the question of causes, the men before they have obtained a both a gift of God and a task for question of the ultimate reason for specific place in history: is this man. why the human person is so valu- man a madman or a saint or a ge- able. nius? Monsignor IGNACIO CARRASCO If we refer again to the example It is certainly true that in this DE PAULA of Psalm 8 which has been cited in context madness is not referred to Member of the Pontifical Academy for Life this paper as an expression of the in a pathological sense but as a Professor of Moral Theology at the Roman Athenaeum of the Holy Cross, amazement which is felt when form of behavior which does not Consultor to the Pontifical Council man considers man, we can ask belong to the usual or as a phe- for Pastoral Assistance ourselves the following question: nomenon which goes beyond the to Health Care Workers in the eyes of God how is the hu- parameters of daily experience. man person seen? What does the Thus it is that living in coherent Creator perceive when his gaze fashion with one’s own human falls upon his creature made of dignity can seem to be an example flesh and spirit? The Bible proof authentic madness to some. vides the following answer: God However, the evident linguistic sees himself, God contemplates difficulties which we encounter in his own countenance, his own im- distinguishing between the nor- age. It is for this reason that God mal—in the sense of what is loves man in a way which we healthy and thus not pathologi- Notes would never be able to express or cal—and the normal in the sense evoke adequately were it not for of mediocre, of the condition op- 1 S.THOMAS, I-IIae, q.1 a.1. the fact that He himself revealed posite to that of the hero (the ge- 2 Cf, Etica a Nicomaco, 1,1 (1094 a 3). 3 See Diagnostic and Statistical Manual of the nature of this love through his nius or saint)—are not without Mental Disorders (DSM-IV), 4th ed., pub- Son, the Word made man—Christ, their significance. lished by the American Psychiatric Associa- the perfect image of the Father. This difficulty is at the root of tion, Washington, 1994, pp. xxi-xxii. 4 V. VON WEISACKER, Filosofia della Medi- When we deliberate upon the the marked embarrassment which cina, edited by T. Henkelmann, (Milan, dignity of madness in essential medicine experiences in finding a 1990), p. 84. 128 DOLENTIUM HOMINUM

ANTONIO FERNANDES DA FONSECA

Creativity and Mental Disturbance

Introduction accurate idea about his destiny. type of communication. We consider that the main abil- The first controversial point of It is not very easy to give an ac- ities and psychological motiva- Rogers’ interpretation is to accept curate definition of creativity as tions that integrate the process of or not to accept that only in a this is a broad concept with a cer- creation are thought, memory, in- “harmonious” and “authentic” tain complexity which, because tuitive perception, an extraordi- environment an individual will be of this, can be understood in sev- nary memorization, and a strong able to create and reach high lev- eral different senses. connective fluency, together with els of personal and social mean- In what concerns us, we have a persistent will and an intense ing. There have been many cases always understood creativity as awareness of the environmental of skilled people who have creat- the expression of a totality of events and circumstances which ed valuable works, although they manifestations which character- encircle the individual. have lived in a “not harmonious” ize the originality of an individual So, let us take the opportunity and “not authentic” environment. or of a group of individuals. to wonder whether every human Rogers’ interpretation and That was, in truth, the concept being and every individual, with “comprehension” is, naturally, a we tried to state in our book Psy- no discrimination at all, has a cre- way of regarding creativity from chology of Creativity, seen ative ability. a general and anthropologic-hu- through the biography of four For a long time many famous manistic point of view, i.e., a psy- “talented people,” published in intellectuals have tried to give an chotherapeutic perspective which 1990.1 answer to that question. Many au- is the result of the experience of a Those manifestations concern thors, from Kant to Butler, from man who devoted all his life to the various capacities (feelings, Piéron to Trousseau and Valéry, the practice of psychopedagogic motivations, reflections and behave dealt with this problem, in therapy. haviour) that an individual or a relation to which Carl Rogers, an But there are other interpreta- group of individuals may show as American psychologist with an tions of the context and meaning a consequence of the different in- anthropological-humanistic ori- of the creative impulses. cidents experienced during their entation, developed a psychoped- To a certain extent, Rogers’ in- evolution and maturation. Some- agogic therapy that was given the terpretation is an anticipated and times such incidents are related to designation of non-directive cre- optimistic answer to the desire we the psychophysiological and sen- ative attitude. all have of knowing whether sual experiences that follow evo- According to that author’s cri- every individual has a creative lution and maturation; on other terion and experience, every indi- skill. occasions, they are related to the vidual has enough forces for this It is clear that the answers to projects and ambitions each indi- creative development, for the ac- such a doubt are far from being vidual or group of individuals quisition of culture and adapta- unanimous. gradually builds up. tion to the environment. As there are optimistic authors, We usually say that in this However, these forces can only like Carl Rogers and the Spanish sense creativity seems to be, for fully develop if the individual’s philosopher Ortega y Gasset, who the human being, the route of relations with the environment thinks that “every man carries hope by means of which he anx- are authentic and empathetic. with himself, in a lower or higher iously aims at finding the paths of By “authenticity” Carl Rogers degree, the possibility of increas- his return to Eden. In other words, means that the relations of an in- ing the metaphysical weight of we could say that creativity is the dividual with other people need to the earth,” the truth is that many skill which the human being can be supported by equilibrium and other authors agree that the power get of dialoguing, abstracting, un- harmony, and by “empathy” he of creating is a gift of some privi- derstanding his role in the family means the way through which leged human beings. and in society and of elaborating, those relations should mainly be Obviously, all of us are able to by means of his intuition, a quite directed to an “understanding” create something, in a certain mo- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 129 ment. Sometimes it is the creation ly and in a global sense have tried operations, formulating asser- of a work which will become fa- to interpret the creative genesis tions and solving problems. mous; other times it is a mere atti- are “the structuralist way,” the In truth, it is only from this age tude or initiative, which can con- “anthropologico-existencialist on that the human being begins to tain a certain originality. way” and the “psychoanalytical be capable of creating, penetrat- Many other times, our creativi- way.” ing his inner world, and of defin- ty shows itself through our inter- The structuralist’s perspective, ing his own identity. There have est in imitating, admiring or con- in which different theories are in- been many artists who, in autobi- suming other people’s creativity. tegrated, like the “psychological ographic descriptions or in In this sense, we can say that development” of Jean Piaget “memoirs” have reported that it every man has a certain instinct of (1896-1980), the “linguistic” the- had been at that age that they had creativity or imaginative adven- ory of Noam Chomsky (1977),2 felt their inspiration gain force or ture intrinsically in the desire of and the “structuralist theory,” of their creativity emerge. going beyond himself. Claude Lévi-Strauss (1958),3 is This aspect of self-identity can But it is obvious there are some supported by the concept that cre- have a very expressive influence human beings who are more ca- ativity corresponds to a complex in the genesis of creativity, as pable of creating than others, and psychological process of “forms,” seems to be the case with Fernan- it is in that first group that we can “images,” “structures” and origi- do Pessoa, the Portuguese poet of include the talented and genial nal “configurations” that show this century who said that “the in- personalities. The word “creativi- specific symbolic characteristics, telectualized sensation was the ty” derives from the verb “cre- not superposed on elementary basis of every form of art, and ate,” the ability of causing some- parts that constitute them. that it was the consciousness of thing to exist, taking something Therefore, the creative mind that sensation that acquired an from nothingness (“the non exis- would have a gift for orientating, aesthetic character and value.” tent”), or else, establishing rela- correcting or transforming struc- Nevertheless, the structuralist tions that had not been conceived tures or configurations of a con- interpretation by itself doesn’t up to then, i.e., the ability of institutional, physiological, imagi- seem likely to explain clearly the venting, showing something new, native or ideative nature and tak- foundations of many literary, “innovating.” ing them as a starting point, orga- plastic and musical creations in Man has always attributed this nizing new systems or even uni- which, besides the logic of num- ability to the “Supreme Creator,” verses with a completely new sys- ber space, time and cause, the ex- the divinity who is supposed to tem, which would become explic- perienced configurations and the have created the world from the it and comprehensible by means emotional structures that enrich “nothing.” It is for this reason that of the symbols of communication their contents must be valued, the current French philosopher and of language. sometimes even emphasized. Jean-François Lyotard, states that In this sense, language appears On the other hand, there are the work of creation leads to the- as a pre-eminent verbal system, many cases of gifted people ology. Generalising, we could like a pattern for all forms of whose creative productions are therefore draw the conclusion thought and, through creativity, multidimensional; those individ- that man, when he creates some- able to become colours, shape, uals certainly have cognitive sys- thing new, comes closer to God volume, or vice versa. tems with a multivalent interac- and, overcoming all his frustra- According to this structuralist tion, as must have been the case tions, becomes immortal by his perspective, with cognitive foun- with Leonardo Da Vinci, to cite return to Eden. dations and supported by the ba- an example. Goethe said that “art” in its dif- sic categories of human thought In this respect, we must re- ferent forms, poetry included, (Roman Jackobson, Malinovsky, member that for the explanation was the way of going beyond life. Radcliffe-Brown), the creator of the creative phenomenon the Let us try to go to the very soul would be able to use certain sys- existence of certain volitive struc- of some of those personalities we tems of ideative-imaginative-lin- tural components of persistence can call the “builders of the guistic interaction, in one of and decision is very important, world” and the “creators of cul- which the organization and the that is to say, the structure of the ture” (musicians, writers, poets, formulation of thought would be will mentioned by Nietzsche that philosophers and scientists) and centered. enables the gifted person to “se- who, thanks to their exceptional It is mainly to the work of Jean lect” the configurations he thinks gifts, start aiming at perfection, at Piaget that we owe quite com- the most productive, and “elimi- the high moments of their cre- plete information about the way nate” those he considers sec- ation. the process of knowledge acquisi- ondary and not useful. tion is developed during adoles- Michelangelo was one of the cence. most typical examples of that Interpretative theories The author’s studies on the psy- power of decision. of creativity chology of development proved Therefore, we think that it is ac- that it is only during adolescence ceptable that the structuralist per- The great psychological per- that an individual begins to be spective might help us to under- spectives that more systematical- able performing symbolic mental stand the way the structures of 130 DOLENTIUM HOMINUM logical thought, which are the tigo that takes possession of us sible for the whole psychic func- foundations of a certain scientific and it is by means of it that we be- tioning of the individual, both in creativity, can organize them- come conscious of our condition.” his normal and psychopathologi- selves in the way Descartes de- For Kierkegaard, anguish puts cal expressions, including artistic fended. It is also on the basis of us face to face with the choice of and outstanding ones. this structuralist perspective that our existence, because anguish, In this respect, the role of the some authors have recenty been as Heidegger says, is a cosmic subconcious in the genesis of the establishing a certain relation be- feeling that becomes characteris- work of art has been explored by tween genius and mathematics, tic of the human condition, com- a great number of psychoanalists, and also between this latter and promised with the world. since psychoanalisis was created. some mental disturbances. Choice will thus be the privi- For many of them the creative im- The anthropologico-existen- leged movement of the existence pulse, which would be no more tialist perspective is based on the of each individual, and the elabo- than a brilliant facet of a posses- concepts of the existential analy- ration of an original project which sion feeling or an oneiric symbol sis of Soren Kierkegaard (1813- will permit him to escape from that has its expression in shapes 1855) and of the intentional alienation (the loss of the human and colours, would essentially be movement of conscience of Ed- essence). The author of a creative supported by conflicts, like the mund Hüsserl (1859-1938) for work would be the one who, Aedipus complex and other in- the explanation and understand- through a kind of eidetic intuition, fantile fantasies, deeply incrusted ing of the different states of exis- might have a great ability or a in the subsconscious. tence and consciousness of the special form of perceiving the Shakespeare’s Hamlet, would human being in relation to the world. be a significant example of that world he lives in. For the anthropologico-exis- psychoanalytical theme, accord- This perspective was improved tentialist perspective, neither the ing to which the scandinavian by the “ratiovitalist” concept of logical systems nor reason (in the prince strongly wishes to get rid Ortega y Gasset that a man does rational sense) will therefore be of the man who occupied his fa- not truly exist unless integrated the fundamental structure of cre- ther’s place, as his stepfather. into his circumstances. ativity. In the “Mona Lisa” by Leonar- For Kierkegaard there can be For Ortega y Gasset, “reason” do da Vinci, in Edgar Allan Poe’s many fundamental ontological is nothing but an integrative func- tales, in Pygamalion by Bernard structures, corresponding to the tion of life. Shaw, as well as in almost every individual way of “being in the Existentialists prefer a theory artistic expression, orthodox psy- world” including moral and spiri- of consciousness, in its perceptive choanalysts have no doubt in tual values and relational experi- and imaginative aspects. And Or- finding the impulses of an infan- ences. tega y Gasset thinks that the real tile conflict with incestuous char- According to Hüsserl’s point of energy nucleous incrusted in hu- acteristics. view, human consciousness ap- man consciousness is the function The psychonalytical concep- pears as an experience of that ex- of life he calls vital reason, whose tion admits that affective fan- istencial essence, that is to say, as stimulating action of sociocultur- tasies of children do not always an intentional movement towards al structures decisively con- reflect love. In certain cases, they the comprehension of the object. tribute. may involve anguish and even Among the different states of Essence would only exist from “hatred.” existence experienced by the in- a personal perspective of exis- Jean Paul Sartre and Charlie dividual, the aesthetic state (of tence. And that perspective, Chaplin seem to be good exam- impetuous desire) would be the which is primordially acquired in ples of people who suffered from one that could best define the per- an intuitive way, will be the more deep anxiety in childhood. sonality of a creator. But the reg- significant, the more intuition and And as an example of refer- ligious state (of anguish and of a individual consciousness are en- ences to experiences of hatred feeling of abandonment) would dowed with an artistic or creative during childhood, there has been be the one in which, through suf- feeling. frequent mention of the French fering, the individual’s subjectivi- For the psychoanalitical per- writer Marquis de Sade (1740- ty enables him to find the mean- spective, namely for Sigmund 1814), who is supposed to have ing of his existence. Freud (1856-1939), its creator, deeply hated his mother, a feeling Therefore, for the existentialist artistic production would corre- that led him to charge his work philosophers, authenticity in the spond to an effort of sublimation with “blasphemies,” as is the case human being expresses itself in and to a way of trying to over- with the “Dialogue Between a anguish, in the way of living in come certain unconscious pulses, Priest and a Dying Man.” preoccupation. often reinforced by certain infan- In literature, architecture, paint- Man “lives in an irrational dis- tile impulses of an erotic nature. ing, in every work of art, Freudi- pair and consequently becomes Such impulses would be the an psychoanalysis has tried to an alienated, empty being, with main energy source of human ac- find an expression of conflict in no hope and no faith.” tivity, organized into a conscious which the artist’s unconscious Blaise Pascal (1623-1662) had structure which, apart from any fantasies are symbolically pro- already said that “anguish is a ver- scale of values, would be respon- jected onto his love object. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 131

But the libidinous conception so, Newton, Holderlin, Nietzche, and ambiguous, and in every cre- of human nature had to face Maupassant, Poe, Baudelaire, Ver- ation, especially in the one which strong opposition from some so- laine, Van Gogh and Dostoievski. expresses itself with the most re- cial and scientific groups, includ- In fact, it was the study of some fined sensibility, we can notice ing psychoanalysis itself, as hap- of these intellectual phenomena that there is a mixture of masculin- pened with Alfred Adler (1870- that permitted some notable au- ity and femininity. 1937) and Gustav Yung (1875- thors of the 19th century to regard Probably it is because of this 1961). the work of certain of those talent- that many critics have suggested ed personalities as a kind of “bio- the existence of a homosexual ten- psychopathological degeneracy.” dency in people of talent and many Creativity and For example, for Moreau de artists. mental disturbance Tours (1804-1884), Francis Gal- In our view, these two kinds of ton (1822-1911), Lange Eichbaum behavioural expression are not Besides these three theoretical (1928) and Cesar Lombroso necessarily interdependent. conceptions of genius, many au- (1836-1909), there would always As Kretschmer mantained “the thors have supported the possibili- be something common to an artist intrinsic value of genius is not a ty of a close relation between cre- and to a mental patient. number of arbitrary rules, or the ativity and mental disturbance, or According to those authors’ simple determinant of a moral and even, in a more radical way, be- ideas, it would be common to find aesthetic ideal.” tween genius and madness. the presence of an excerbation of A genius is rather an individual In the first case, those authors excitability in most talented per- who possesses a “specific psychic admit that certain individuals, vic- sonalities. system capable of creating, in a tims of an “inferiority complex,” Ernest Kretschmer (1888- higher degree than others, perfect- may, under certain circumstances, 1964), who particularly devoted ly defined positive aesthetic or vi- overcome their difficulties and himself to this problem, also stated tal values that soon receive the la- frustrations and change that “com- that an artistic work may also con- bel of an exceptional and peculiar plex” into creative motivations. tain a somewhat strange element individuality.” There are two examples of ge- of abnormal predisposition which We willingly agree that certain nius frequently referred to in this may become indispensable for expressions of anxiety, certain situation—Toulous Lautrec and outstanding creations. feelings of deep “nostalgia,” and a Lord Byron. And a typical example would be certain emotional instability may Toulous Lautrec, who had an the case of Vincent Van Gogh be a source of inspiration for some enormous sports ambition at the (1853-1890). artistic productions, even excep- age of 14, became the victim of a Manuel d’Assunçao (1926- tional and outstanding ones. Nev- serious deficiency involving con- 1969), a very gifted Portuguese ertheless, to be a genius is neither genital anthrosis, aggravated by painter, used to say that it was at a privilege of every person nor can two falls with two legs broken. the climax of his depressive ac- it be at the mercy of this or that From then onwards, Toulouse cesses that he reached his greatest frustration or complex. Lautrec suffered from a complex, capacity of abstraction. It was as if because of his awkward and rejected reality emerged into con- Professor ANTONIO FERNANDES grotesque figure, no taller than sciousness in a magnetic way and DA FONSECA 1,50 m. as if sorrow and pain changed into Emeritus Professor of Psychiatry That deficiency and the ensuing creation. at the University of Porto, Portugal crisis of alcoholism (he was admit- We could refer to other cases in ted to a hospital for “delirium which certain components of ge- tremens”) did not prevent him nius are interwoven with some from expressing himself in re- psychopathological manifesta- markable paintings. tions. The same must have happened In fact, there have been many with Lord Byron, who suffered situations with psychopathic from paralysis of the right leg, precedents in the families of cre- with a deformity of the foot, be- ators, as happened with Byron, sides his psychopathological her- mentioned before. And there have itage. also been many personalities of In spite of these negative as- genius who have collapsed into pects, though, Byron showed great unruly behaviour, into alcoholism, talent, so great that it influenced, for instance. in an evident way, English and After the advent of psychoana- German romanticism. lytical conceptions, the coexis- Notes Summarizing our considera- tence of artistic creativity and ho- 1 FONSECA, A.F., from Psicologia da cria- tions, we could say that much has mosexuality has often been re- tividade, Escher, Lisboa, 1990. been written about some phenom- ferred to. 2 CHOOMSKY, N., Le langage et la pensée, Payot, Paris, 1977. ena of talent, like Goethe, Goya, The contents of imaginative ac- 3 LEVI-STRAUSS, C., Structural Anthropol- Kant, Copernicus, Stendhal, Tas- tivity are frequently ambivalent ogy, Basic Books, New York, 1958. 132 DOLENTIUM HOMINUM

DINA NEROZZI FRAJESE

A Measureless Mind: Manic-Depressive Illness

There is a particular kind of noyances—medicine to take, re- presses itself mainly through psy- pain, elation, loneliness, and terror sent, forget, take, resent, and for- chological manifestations, yet it is involved in this kind of madness. get, but always to take. Credit biological in origin, although some When you are high, it’s tremen- cards revoked, bounced checks to precipitating environmental fac- dous. The ideas and feelings are cover, explanations due at work, tors are needed to start the process, fast and frequent like shooting apologies to make, intermittent at least in the early phases of the stars, and you follow them until memories of vague men (what did disease. Manic-depressive Illness you find better and brighter ones. I do?), friendships gone or drained, is one of the most easily identifi- Shyness goes, the right words and a ruined marriage. And, always, able disorders; it has been known gestures are suddenly there, the when will it happen again? Which for many centuries. Descriptions of power to seduce and captivate oth- of my feelings are real? Which of the disease are found even in the ers is a felt certainty. There are in- the me’s is me? The wild, impul- Old Testament. Areteus of Cap- terests found in uninteresting peo- sive, chaotic, energetic, and crazy padocia, in the second century ple. Sensuality is pervasive, and one? Or the shy, withdrawn, des- A.D., was the first to suggest that the desire to seduce and to be se- perate, suicidal, doomed, and tired mania and melancholia were part duced, irresistible. Feelings of one? Probably a bit of both, hope- of the same process: “Melancholia ease, intensity, power, well-being, fully much that is neither.” is without any doubt the beginning financial omnipotence, and eupho- This description done by a man- and even part of the disease called ria now pervade one’s marrow. ic-depressive patient, is able to mania.” Over the centuries the But, somehow, this changes. The draw, with few words, a complete clear concepts set forth by the an- fast ideas are too fast, and there are picture of the illness (F.K. Good- cient scientists were obscured by far too many; overwhelming con- win and K.R. Jamison, 1990). The multiple philosophical and fusion replaces clarity. Memory description also clarifies why pseudoreligious beliefs. At the end goes. Humor and absorption on these patients bear “a measureless of the 19th century, Kraepelin reaf- friends’ faces are replaced by fear mind—that is, a mind where feel- firmed the concept that mania and and concern. Everything previous- ings can expand from elation to depression are part of the same ly moving with the grain is now despair, a much wider excursion process, and, for the first time, he against—you are irritable, angry, than the usual mood fluctuations used the term manic-depressive frightened, uncontrollable, and en- that are part of human behavior. psychosis—a disease which, he meshed totally in the blackest Besides mood swings, cognitive stated, was totally different from caves of the mind. You never knew and behavioral alterations are also what he still called dementia prae- those caves were there. It will nev- an essential part of the syndrome. cox (schizophrenia). Schizophrenia er end. Madness carves its own re- Manic-depressive Illness is a in fact tends to be chronic and to ality. It goes on and on. and finally disease which affects mood: it is a follow a deteriorating course, while there are only others’ recollections medical condition which has to be manic-depressive illness is episod- of your behavior—your bizarre, diagnosed, studied, and treated in a ic and exacts a less devastating toll frenetic, aimless forms of con- medical context. The illness ex- from the affected individuals. duct—for mania has at least some grace in partially obliterating memories. What then—after the DIFFERENT FEATURES OF SCHIZOPHRENIA medications, psychiatrist, despair, AND MANIC-DEPRESSIVE ILLNESS depression, and overdose? All Schizophrenia Manic-depressive illness those incredible feelings to sort through. Who is being too polite to ¥ Sporadic disorder ¥ It runs in families say what? Who knows what? ¥ Cronic disorders ¥ Episodic What did I do? Why? And, most ¥ Progressively invalidating ¥ Less invalidating hauntingly, when will it happen process again? Then, too, there are the an- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 133

In spite of all the evidence scien- or others. Besides mood alter- manic episodes do not recur cycli- tifically gathered, even today it ations, cognitive and behavioral cally in all patients, since the ill- easy to find that the illness is fre- symptoms are also present which ness involves periods of full remis- quently misdiagnosed: either as include: inflated self-esteem or sion of symptomatology and peri- schizophrenia or as unimportant. grandiosity, decreased need for ods of well-being, which make the Luckily manic-depressive illness sleep, pressure in speech, a flight recognition of the disorder diffi- has a more favorable prognosis of ideas, distractibility, psychomo- cult on some occasions. The vari- than schizophrenia; it is less inval- tor agitation, and increased inability of behavioral manifesta- idating and, if properly treated, can volvement in goal-oriented and tions and the onset and duration of allow those affected to have a sexual activities. Sometimes irri- manic and depressive episodes are “normal life.” If left untreated, pa- tability and hostility may be the difficult to forecast and represent a tients will suffer from devastating main features; therefore, the pa- totally individual characteristic. mood swings and uncontrolled im- tient may become extremely de- The switch process is the most dif- pulsiveness with painful conse- structive for himself and others. ficult and dangerous period of the quences which will affect their en- The unifying character of the illness. This is the time when man- tire life. It is fundamental to point whole symptomatology is repre- ic and depressive symptoms coex- out that a significant proportion of sented by an overwhelming degree ist, the so-called “mixed states,” these patients—at least 15%—if of energy in every activity, togeth- which cause unbearable suffering untreated, will commit suicide er with an impulsiveness which is to patients. During the switch (Guze and Robins, 1970). Need- totally out of control. process aggressive and impulsive less to say, negative consequences behavior may take place which will also affect family members The depressive episode may be dangerous to patients and and, occasionally, society as a to the people around them. whole, whenever the patient be- The essential feature of a de- comes violently aggressive. On the pressive episode is depressed or ir- other hand, the high levels of ener- ritable mood or loss of interest in Epidemiology gy and creativity typical of the all, or almost all, activities. The manic or hypomanic condition, full symptomatology must last at What is the size of the problem? can lead, in some individuals, to least two weeks. The associated The risk of suffering from a man- important achievements in many symptoms include loss of energy ic-depressive illness, in the general artistic and productive fields (Red- and fatigue, feelings of worthless- population, varies, according to field Jamison, 1993). ness or inappropriate guilt, dimin- different studies, from 0.5% to ished ability to think or concen- 7.5%. In a recent study, performed trate, indecisiveness, psychomotor in the USA, the estimated risk of Symptomatology agitation or retardation, significant suffering from the disease has weight loss or gain, insomnia or been calculated to be around 1.6% Manic-depressive Illness occurs hypersomnia, and recurrent (Kessler et al., 1994 ) of the popu- in multiple forms and degrees of thoughts of death or suicidal lation. If we consider a less severe severity. Behavioral manifesta- ideation. The disturbance must not symptomatology, then the percent- tions—during either the manic or be caused by any other medical age of the population likely to be depressive phase, are distributed condition and must be sufficiently affected noticeably increases. along a spectrum—the so-called severe to cause a marked impair- Manic-depressive illness affects “manic-depressive spectrum,” ment in everyday activity. Depres- men and women at the same rate, where the most severe forms of sive symptomatology varies ac- while in major clinical depression pathology gradually decline to a cording to the age of onset. In in- women represent at least two- sort of personal predisposition, fancy and in senescence physical thirds of the affected individuals. without any sharp boundary. symptoms are more prominent, The higher incidence of the dis- while psychological features are order found in the upper social The manic episode mainly found in adolescent and classes apparently reflects only adult patients. better access to treatment and a The manic episode is the one better education; the disease thus that characterizes the illness. It appears to be equally distributed may start gradually, but, most of- The Switch Process among all social classes. In gener- ten, the onset is rather abrupt. The al, there are not higher rates for the essential feature of a manic The switch process represents illness in the urban population as episode is mood alterations— all biological and behavioral compared to rural areas, although, which may be elevated, expansive, events associated with the often according to some researchers, the or irritable—for at least a week. dramatic change from mania to de- intensity of stressful life-events The disturbance is severe enough pression. The change from depres- could act as a precipitating factor to cause a marked impairment in sion to mania is rather abrupt, oc- in the population living in big occupational functioning or in so- curring sometimes over the course cities, therefore contributing to an cial and personal relationships, or of a few hours or a few days, while earlier onset of manic or depres- to require hospitalization to pre- depression is a more slow and sive symptomatology in people vent harmful consequences to self gradual process. Depressive and living in large urban areas. 134 DOLENTIUM HOMINUM

EPIDEMIOLOGY: THE RISK OF SUFFERING FROM THE DISEASE very sharply on the topic: “...My

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We need to focus our attention and modern researchers suggest on the homeless population. This that the phenomenon could be re- is a growing phenomenon, in lated to the abnormal response to many western countries, partly as light stimulation found in manic- a result of immigration, and partly depressive patients (Mayers and alcohol 45% other or none 40% as a result of the closing of psychi- Davies, 1978; Carney et al., 1988). atric institutions. We can say that a The increased sensitivity to light is Alcohol and drug abuse, espe- proportion of 30% of the homeless also present in subjects defined as cially involving cocaine, is partic- are to be considered as people suf- “at risk” because they have a ularly elevated among manic-de- fering from a manic-depressive ill- marked family history of manic- pressive patients. Patients with ei- ness, considering that alcohol and depressive illness, and this pecu- ther manic or depressive sympto- drug abuse frequently may mask liar response to light stimulation matology also constitute a signifi- this mental disorder (Arce and exists even before the onset of any cant proportion of the total alcohol Vergare, 1984). clinical symptomatology. Accord- and drug-abusing population Looking at the marital status, ing to some researchers, this fea- (Regier et al., 1990). Increased al- manic-depressive patients show a ture seems to represent a biologi- cohol and drug abuse in these pa- higher incidence of divorce, or cal trait which is genetically deter- tients has been interpreted as an at- broken relationships, which would mined, not only an epiphenome- tempt to relieve the painful feel- seem to be the result of the disor- non linked to the disease’s state ings linked to mood swings: the der rather than the cause. (Nurnberger et al., 1988). so-called “self-medication” hypothesis (Khantzian, 1985).

Seasonality Drugs, Alcoholism, and Manic-Depressive Illness Legal Aspects Almost two thousand years ago, Areteus realized that the disease The coexistence of substance The altered behavior arising had a special seasonal pattern: ma- abuse and mental disorders has mainly from the manic upheaval nia exploding during the spring been frequently reported in the lit- may cause significant legal prob- and summer months and depres- erature (for a review, see Regier et lems. There are two ways of look- sion occurring mainly during win- al., 1990). In some instances, men- ing at the issue: one standpoint re- ter time. tal disorders may be the result of lates to the precautions needed to protect the patient from the nega- SEASONALITY tive consequences that might arise from his behavior; the other deals Behavioral manifestations in a manic depressive patient (seasonal type) with all the protective measures that necessarily have to be applied to avoid heavy burdens on the community. It is important to understand that mania violence within domestic walls, frequently brought to court, might Eutimia arise not from a mean person but Mood from a misdiagnosed pathological - condition, particularly when alco-

sion hol and drugs are part of the pic- depres ture. In this case, the right answer winter spring summer autumn win. to the problem may not be found in jail, as sometimes requested, but in proper medical evaluation and treatment. This cannot be considered an substance abuse; most of the time Homicidal outbursts may also absolute rule; nevertheless, a sea- mental illness itself appears to be find an explanation in manic-de- sonal pattern in symptomatology the cause of drug abuse. The pressive illness. Of course, social- has been observed for centuries, American writer E. A. Poe focused ly dangerous individuals may not “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 135 be set free, and society has to be 25, with the vast majority of cases mental disorders have been ig- protected from them; nevertheless, starting before the age of 30; spo- nored because problems linked to in a civilized country, a jail sen- radically, the illness may appear mental illness were not tackled in a tence should go together with ap- during infancy or after age 50. positivistic and rational way. The propriate medical and psychological treatment. THE ONSET OF SYMPTOMATOLOGY In some instances, the reason for 500 referring these kinds of patients to the judge is “excessive involvement in pleasurable activities 400 which have a high potential for painful consequences—e.g., buy- 300 ing sprees, sexual indiscretions, or foolish investments” (according to 200 DSM IV diagnostic criteria). Most of the time the intervention of the no. of patients judge is requested to prevent the 100 destruction of family property. Manic-depressive illness has to 0 be taken into consideration even in 5-10 10-15 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65-70 a work setting, to preserve the job Age of Onset of the affected person, whenever possible. Precipitating events play an im- fear that the discovery of a genetic portant role in the onset of the first diathesis might cast a stigma on The Origin of the Illness episodes of either mania or depres- patients led clinical observers of sion. According to some re- the past to ignore something that in In ancient times melancholia searchers, early precipitating the end turned out to be in- and mania were regarded, respec- events may actually activate the escapable. Ignoring the existence tively, as the result of an excess of preexisting biological vulnerabili- of problems does not mean that black or yellow bile and, therefore, ty, thereby making the individual they are magically annulled; it on- as a medical condition. It is sur- more vulnerable to the next ly means that their solution is prising to see how, after more then episodes (R.M. Post, 1986a). This made more difficult. The con- two thousand years, the concept is a crucial point, inasmuch as it sciousness that manic-depressive has remained practically intact— lends support to the fundamental illness can be genetically transmit- the bile having been replaced by role of early therapeutic interven- ted may foster a correct evaluation noradrenaline. tion to reduce the severity of be- of initial symptoms whenever they Substantially, the illness may be havioral manifestations. appear, thus permitting the initia- considered, in an ultrasimplified tion of proper treatment leaving way, as the result of an excess or a less room for devastating mood deficiency of noradrenaline, re- Genetic Aspects swings. spectively, in mania and depression, at the level of the Limbic Sys- Over the years genetic evidence tem. Noradrenaline is considered has become too massive to be ig- Preventive and to be the most important excitatory nored, and the inescapable fact Therapeutic Aspects neurotransmitter acting at the cere- that manic-depressive illness runs bral level; the Limbic System is in families has to be taken into ac- The only preventive interven- that part of the brain where emo- count. If the illness is the conse- tion is linked to early recognition tions are elaborated and lies under quence of altered cerebral neuro- of the disease and early treatment cortical regions—therefore, be- transmitters, as it appears to be, it to minimize lifelong psychologi- yond the control of higher centers. is no wonder that, as people inher- cal, social, and possibly biological This ultrasimplified conceptual it the eye color or the shape of the consequences. This is possible on- framework has been set forth and face, they can also inherit some ably if there is consciousness of the confirmed at highly qualified re- normalities linked to the neuro- existence of the illness within the search centers throughout the transmitter systems. It is a fact that family. In fact, if some other mem- world in the last 50 years. The core 2\3 of the patients have a positive ber of the family has already been of the illness is, therefore, a bio- family history for the illness. diagnosed as suffering from the chemical imbalance which in- Moreover, the risk of suffering disorder, it is easier to recognize duces, together with an extensive from the illness in the offspring is the early symptoms of the disease variation in noradrenaline cerebral 30%, if one parent is affected, a and get oriented. Otherwise the content, an extensive varaition in percentage which increases to whole family will keep on won- mood. 70% if both parents are affected dering and asking about the rea- The onset of symptomatology (Gershon et al., 1982a). sons for incomprehensible behav- peaks between the ages of 15 and The genetic aspects of some ior which is attributed to bad will, 136 DOLENTIUM HOMINUM if not to a mean personality. the role of the family is crucial in lence of mania. Br.J.Psychiatry 1988; 152: 82o-23. Therapeutic intervention is this phase. It is up to the family to GERSHON E.S., HAMOVIT J., GUROFF J., et based upon neuroleptic drugs, ben- convince the patient to seek help al., A family history of schizoaffective, bipolar zodiazepines, lithium salts, anti- and to see a physician—a tough I, bipolar II, unipolar, and normal control probands. Arch. Gen. Psychiatry 1982a; 39: epileptic drugs, antidepressant assignment. Moreover, it is always 1157-1167. drugs, and psychotherapy. the family’s role to perform the GOODWIN F.K., REDFIELD JAMISON K., Fully developed mania usually hard task of making sure the pa- Manic-Depressive Illness. 1990 Oxford Uni- requires hospitalization. The pos- tient is taking the prescribed drugs, versity Press, New York. GUZE S.B., ROBINS E., Suicide and primary sible stigma that may result should at least to the point when he will be affective disorders. Br.J. Psychiatry. 1970; be weighed against the sometimes able to regain his full autonomy. 117: 437-483. rapid progression of mania into a KESSLER R.C., MCGONAGLE K.A., ZHAO S. et al., Lifetime and 12 month prevalence of condition that could be dangerous Professor DINA NEROZZI DSM III-R psychiatric disorders in the United for the patient and the rest of the Psychiatrist and Researcher at the States. Results from the National Comorbidity community. Department of Experimental Medicine, Survey. Arch. Gen. Psychiatry, 1994; 51: 8-19. La Sapienza University, Rome KHANTZIAN E.J., The self medication hy- Neuroleptic drugs are extremely pothesis of addictive disorders: focus on hero- useful whenever severe symp- in and cocaine dependence. Am. J. Psychiatry, toms, such as delusions and hallu- 1985; 142: 1259-64. MYERS D.H., DAVIES P., The seasonal inci- cinations, are present. Neuroleptic dence of mania and its relationship to climatic drugs are used briefly to avoid side variables. Psychol. Med., 1978; 8: 433-440. effects which also include a possi- NURNBERGER J., BERRETTINI W., TAMATKIN L. et al., Super sensitivity to melatonin sup- ble switch to depression. Because pression by light in Jung people at high risk sleep deprivation can contribute to for affective disorders: a preliminary report. the progression of the manic Neuropsychopharmachology, 1988; 1: 217- 222. episodes into more severe stages, POE E.A., The Fall of the House of Husher benzodiazepines are used as seda- and Other Writings. 1980, Galloway D ed. tive and hypnoinducing agents. Middlesex, Penguin. POST R.M., RUBINOW D.R., BALLENGER Lithium salts were considered to J.C., Conditioning and sensitization in the lon- be the most effective mood stabi- Bibliography gitudinal course of affective illness. Br, J. Psy- lizing agents, and this is probably chiatry, 1986a; 149: 191-201. ARCE A.A., VERGARE M.J., Identifying and REDFIELD JAMISON K., Touched with fire: still the case, although some other characterizing the mentally ill among the manic-depressive illness and the artistic tem- anticonvulsant drugs, such as De- homeless. In HR Lamb ed. The Homeless perament. 1993, New York: Free Press. pakin and Tegretol, may represent Mentally Ill: A Task Force Report of the REGIER D.A., FARMER M.E., RAE D.S. et the preferred treatment for patients American Psychiatric Association Washing- al., Comorbidity of Mental Disorders with Al- ton D.C. 1984, pp 75-89. cohol and Drug Abuse. Results from the Epi- not responding to lithium therapy. CARNEY P.A., FITZGERALD C.T., MON- demiological Catchment Area (ECA) Study. In the depressive phase of the HAGAN C.E., Influence of climate on the preva- JAMA, 1990; 264: 2511-2520. illness antidepressants are, of course, the standard treatment, with some caution regarding tri- cyclic compounds, which might precipitate manic episodes. The new compounds, known as serotonin re-uptake inhibitors, appear to be safer in this regard. Cognitive and behavioral psychotherapy is an essential part of the therapeutic process and focus- es on the negative or distorted thinking pattern of the patient. The therapist and the patient use current happenings in the person’s life as material for their discussion. Trying to rationalize emotional aspects is not an easy task in these patients and cannot be tackled without the support of pharma- cotherapy.

The Essential Role of Family Members

Whenever the manic episode is full-blown, it is impossible for the patient to look for help; therefore, “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 137

WANDA POLTAWSKA

Nonhuman Man

Introduction 1. The Personalist however, every human being in Concept of Man fieri est and he always advances to- Although the concept of “hu- wards greater completeness, and manity” at first sight appears un- Christian anthropology lays thus the whole of his life must be equivocal and unambiguous, the down in unambiguous fashion dedicated solely to a development real truth is that during the epoch what man actually is—a being cre- seen in these terms. we live in there is a clear and evi- ated by God the Creator in his im- Christian anthropology attribut- dent need for its definition—as, in- age and likeness as man or woman. es human rights to every man re- deed, is the case with very many This being not only is brought into gardless of his state of develop- other concepts which at one time being by the creative idea of God, ment because it is based upon the were clear-cut in their meaning— but is considered as being his child, fundamental criterion that man is because this term is repeatedly mis- indeed his favorite child. This is re- the created being of God and is his understood. flected in the fact that being the ob- child. In the same way it cannot ac- At the present time, it may be object of his special love, He sent his cept that any reality whatsoever— served, various distorted criteria own Son into the world for the dictated by man or by other factors lead to the individual not being in- good of this creature, a Son who which can impinge on his des- cluded within the genus humanum through his own passion and death tiny—conditions and thereby lim- of homo sapiens. What has hap- redeemed this beloved creature. its his personal dignity. pened is this: what man is and what But this striking origin of man re- For this reason our neighbor is a he is not, or who he is not, has been quires an act of faith to be accept- person who not only must be total- subject during our times to fluctua- ed, an act of which twentieth-cen- ly accepted but must also be loved. tions and variations determined by tury man seems incapable. Con- It is with this knowledge that a variety of factors which are not temporary man is not able to ac- Christianity approaches all men, only social and political in nature cept or does not want to accept without exception, and it is for hu- but also of an ethical character, to such origins and ends up by nar- man rights understood in these such an extent that at the end of the rowing and limiting the dimension terms that the Church has fought twentieth century man seems un- willed by God, satisfying himself for centuries and still continues to able to discover his true identity. with truths which are much easier fight, even though in our times her What is man? to accept, given the state of his lim- efforts come up against, and have It appears that it is to this funda- ited rational powers. to deal with, obstacles which are mental question that the modern John Paul II has often sought in very great and imposing. world is unable to give an unequiv- his speeches and addresses to em- ocal answer; and the history of the phasize the great dignity of the hu- century which is now drawing to a man person who has—as has been 2. Disturbances in the close involves numerous episodes observed above—a divine descent, Development of the Person and examples of men denying to while at the same time contempo- each other their true identity as rary man, indifferent to his Creator, Research carried out on the de- “men.” Man feels threatened and in strives to invent new conceptual velopment of children has enabled losing his feeling of security he systems designed to define him- us to establish an average statistical seeks to defend himself and thus self. In this way numerous social norm by which to monitor such de- becomes aggressive. The declara- and philosophical ideas have come velopment. These criteria produce tions of the rights of man, of the into being, a phenomenon which a means by which to classify the rights of the child, and of the family can be explained or at least under- person who has developed normal- which every now and then are pro- stood by observing individuals—in ly, even though it often happens claimed by various institutions lack their way of living one can only that theory does not always coin- executive power and remain mere with infinite difficulty detect an el- cide with what actually happens in words—such terms are unable to ement of likeness to God. In the practice. It is clear that develop- defend those who are threatened. personalist conception of man, ment depends on, and is condi- 138 DOLENTIUM HOMINUM tioned by, various kinds of factors But every believer is more than becomes removed not only from which can check or accelerate the well aware that man, independent- his own home, but even from the rhythm of development and ly of his stage of development, is world itself. The modern tendency growth. However although it is always a man, and is so from his of approving euthanasia—an atti- possible to establish the rules conception. And conception, more tude which is gaining ever great which govern the growth of the than being an object of scientific support—is a more than an evident body and intellectual capacities in debate, often becomes the object of testimony to this reality. a form which is relatively objec- political manipulation and chi- tive, it is far more difficult to estab- canery. The moment of conception lish the rules which govern social of human life is the moment of the 4. The Criterion of Utility and mental development. Employ- union of the cells of the mother and ing an index which seems suitably the father. This belief is mandatory There has thus been an increased reliable, certain people are seen as and allows of no uncertainty for all tendency to attribute the dignity of having developed normally whilst men of reason. man only to those people who are others are deemed to be “underde- able to produce goods which work veloped” or effective in a limited B) Disturbances of Personality to the benefit of the development sense. This last takes place when and Other Psychic Alterations of material values. In reality, be- the development has been dis- It would seem obvious that the hind this attitude we can detect the turbed and these people are thereby presence of illness does not have a presence of the right of the prevented from carrying out nor- bearing on a proper conception of strongest. A society constructed mal social functions and proce- what man is, and yet the history of along these lines does not defend dures. mankind shows that people affect- the weakest of its members but, on ed by psychic disturbances are of- the contrary, marginalizes them or A) The Fate of People Who Are ten forced to undergo the rejection eliminates them in pitiless fashion. Not Completely Effective of the whole world. They are fre- We can here observe systems of For a Christian, the evaluation of quently treated worse than ani- classification employed to discrim- the human person involves no mals, and all this despite the fact inate against different groups with- doubt at all. Jesus Christ affirms that mental illness should not be a in mankind. They operate at differ- that He himself is to be found with- reason for the abandonment of the ent levels, each of which corre- in each of these “poor people,” rights of man. In opposite fashion, sponds to a differing stage of hu- both in those who are not yet born one of the first actions of Hitler in manity: there are the weak and and are thus completely defense- Poland was the mass extermination there are the strong. There are dif- less and in those who are afflicted of the mentally ill (and the staff of ferent reasons for weakness and its by any kind of handicap or imped- their clinics). expression also takes varying iment. For centuries the Church It is a well known fact that cer- forms, but on the world stage there has sought to offer her help to tain forms of mental disturbance is an unceasing struggle for the those people marked by such a fate deny the individual the possibility dominance of the world—both of and destiny, and she has done this of communicating, and that others the world of objects and of people. in all the difficult situations which are not able to communicate with In this struggle the weak perish. have been met with. the person subject to such illness. The history of the saints of the But this has no effect whatsoever Church presents an account of hun- on the fact that the man is always a 5. Humanism dreds of holy men who have conse- man, a being who bears rights. crated their lives to such an under- In the history of this struggle of taking. Outside Christian ethics, on might against weakness, we can the other hand, in differing epochs 3. Regressions find every now and then those co- and countries, people afflicted by ordinates which make up the quin- this kind of handicap have been Among those whom we often tessential human factor of man. In treated in a very different way, be- refuse to deem “human persons” such an instance there is a defini- ginning with Sparta and finishing are to be included the elderly, tion of what really distinguishes with present-day legal systems where the processes of cerebral de- man from the animal kingdom— which throughout nearly the whole cline have created a deterioration that is, the capacity for judgment of the world deny the right to life to which is so serious that the individ- and for love. Man finds something sick people, and not only to people ual not only loses the capacities within himself which leads him to who are sick but also to those who which previously constituted his a “metamaterial” and “metacom- suffer from forms of handicap. intellectual and even his moral mercial” attitude, and only this ap- Furthermore, to justify this pre-or- powers, but also his own aware- proach can be assigned the defini- dained attitude of rejection of the ness of who he is. For this reason, tion of being fully human—hu- unborn child there is an attempt to senile illness, rather than provok- manitarian. But such behavior to- substitute the appellation “man” by ing a sense of human pity, often en- wards others can be seen as right inventing definitions which are genders a selfish attitude which and normal only if it includes all ever more perfidiously subtle, such leads those who are near to the el- men, without the operation of disas embryo, pre-embryo or even derly person towards a rejection of tinctions of any kind. fertilized “oocyte.” that old and sick person. He often This is because the appeal— “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 139 which is in appearance fully justi- and yet these conditions are creat- becomes his witnesses. fied—to behave in human fashion ed by other men. Mass experi- During my seminars on pastoral towards others—that is, to treat ments on people, hunger, cold, medicine for the students of my them with comprehension and forcing people to undergo pseudo- medical faculty I often take advan- compassion—can also degenerate. medical tests, the torture and tage of the following example. In It does this when it becomes an in- killing of totally innocent men and the Jagellonica Library of Krakow strument for the satisfaction of the women carried out in the name of a two important documents are to be interests of a social group or of slogan bearing an ambiguous found, both of which go back to selfishness in any form and thereby meaning which is often interpreted 1947. One of these is a sentence becomes totally negative, even in a distorted fashion—is this hu- from the Nuremberg trials which leading to the justification of acts manity? condemned the Hitlerite doctors to which are not human. Is this way In reality, what criteria really de- the death sentence; the other is a the slogan “mercy killing” in actu- fine a man? A thousand times over monograph on the illnesses caused al practical terms becomes the the mite of an innocent child as by hunger, the scientific produc- slaying of the elderly and of chil- large as a pinhead is worthy of the tion of a number of Jewish doctors. dren. The slogan “the good of the name “human” when compared to While dying from hunger in the mother” means the killing of a an SS man in a concentration camp Warsaw Ghetto they engaged in newly-conceived child and in sim- or a gynecologist who destroys scientific observation and study, ilar fashion the good of a nation be- thousands of innocent creatures each applying and contributing his comes the elimination of an oppos- every day without batting an eye- own particular specialization. Af- ing nation. lid. Today there is a great deal of ter monitoring the consequences of Indeed, the twentieth century has talk about inhuman medicine and starvation on the human body, they witnessed a series of manipula- inhuman governments, but in truth proceeded to outline seven stages tions, at times through the employ- the whole of mankind is threatened in the acquisition of illness because ment of various slogans, which fal- in relation to its identity. There is of hunger. When the Ghetto was sify reality and create merely the now an urgent and pressing neces- destroyed, the doctors were able to appearance of what is good. For sity for man to return to his roots. consign the results of their research example, faced with the example What, therefore, we may ask, is to a Warsaw clinic, where some of the satisfied smile of a woman man? years later they were published un- on television who has conceived a der the title Non Omnis Moriar. child through artificial insemina- What I do is to suggest to my tion, nobody thinks any longer that 6. The Samaritan medical students that those doc- this smiling woman has been treat- tors, whether Jewish or German, ed not as a human person but as We need to return to the model might actually have been col- just another farm animal subject to presented by Christ, a model which leagues, given that they were more experimentation. In this way, we is clear and unambiguous and or less of the same age; they might can see how the appearance of which not only gives rise to no have studied medicine together at good conceals the real essence of doubt but also suggests the only Heidelberg, but, in fact, they met the question. criterion for acceptable methods of with very different fates. They be- evaluation: a “human” is that man gan from the same point, but the who not only knows how to wel- first died as heroes (the doctors 6. The “Anus” of Humanity come the needs of others but also went to their deaths together with brings them relief and does every- the patients entrusted to their care), The extermination camp of thing to bestow practical and effec- whereas the second met with an in- Auschwitz has been called by this tive help. These are not mere fine famous end. The acts of man de- name, and, unfortunately, it is not sounding rhetorical declarations— pend upon his free will because hu- the only place of its kind in the they are acts, acts tailored to man. manity, being, and life itself have world. The twentieth century has It is in basing ourselves on such not only been given to man by God known thousands of such places of acts, indeed, that we can discern but also entrusted to him as a moral torture—places where some men who a man is. This is because they undertaking. have decreed and effected for oth- condition and define those who And thus we see that the divine ers a form of destiny which is so carry them out. Thanks to his acts, economy is distinct from the hu- cruel that its very existence beg- a man can become a man of a suman economy. In the eyes of God gars belief. Paradoxically enough, perior moral level; he can grow in the oppressed becomes the victor, we may ask, what really defines his humanity to the point of the full and the tyrant is defeated! the human being in such cases? achievement of this faculty—and For man, who is man? The answer is simple—the ability this is something which lays bare to be inhuman in relation to others. the holiness of man. In contrary Professor WANDA POLTAWSKA No animal would be capable of fashion, through his acts a man can Member of the Pontifical Academy for Life such brutal and sinister acts as lose his humanity, the human fac- Director of the Institute for the Theology of those perpetrated by man upon his tor—he can deny himself. In this the Family at the Pontifical Theological Academy in Krakow, Poland, own kind. Thousands of men are way human acts become witnesses Consultor to the Pontifical Council forced to endure conditions which to man. And his acts will accom- for Pastoral Assistance are usually considered “inhuman,” pany him to eternity—they will to Health Care Workers 140 DOLENTIUM HOMINUM

GEORGE B. PALERMO

Psychiatry and Criminality

Introduction: that are unquestionably part of the titude of indifference, apathy, and The Social Panorama human archetypes have been shat- extreme dependency. From this tered. Social criticism and inces- state, unbridled, immature, and of- To properly appreciate the rela- sant social activism have under- ten antisocial—or for that matter, tionship between psychiatry and mined authority at all levels of so- anti-anything—attitudes have tak- criminality, it is important to first cial behavior. en hold. look at the present situation in our We have reached the point that Destructive rebellion at an indi- society and the events that have moral values are seen as part of a vidual/personal level, is reaching taken place over the past several theory of relativism, together with high peaks among the world’s citi- decades. the breakdown of other valuable zens. Children kill parents, parents The Biblical reported stories of forms of institutional life. The pre- kill children, men abuse women Cain killing Abel, and other reports sent-day family, even though ac- and children psychologically and of violence found throughout his- cepting a dynamic existential adap- physically, rape is rampant. Chil- tory and literature support the fact tation to new technological discov- dren kill police officers, people kill that violence and victimization eries and cultural changes, often or attempt to kill authority figures. have been part of the collective life does not pass on to its members People assault, maim, and brutally and daily relationships since time those traditional values of honesty murder one another at random. A immemorial. Today, social vio- and responsibility so important for singer writes a book full of de- lence is rampant in many of our good citizenship and self-esteem. I meaning pornography with no lit- streets and homes, and at times in do not underestimate that vast so- erary value and full of distorted places of employment. however, it cio-economic events such as lack sexual messages which is ac- should be recognized that social vi- of jobs, poor educational opportu- claimed a best-seller the first week olence is related to social historical nities, the search for a quick solu- of publication. periods and that its highs and lows tion of problems in the fleeting, un- Religion and faith, and the belief seem to follow the cyclical returns natural nirvana of illicit drugs have in God have also come under of the past hypothesized by Giovan contributed greatly to the above in scrutiny and attack. Their positive Battista Vico. further shaking at its roots the and beneficial influence on society Violence, we know, is often the western hemisphere families that at large and on individuals and expression of frustration and hos- have been stable and united for families has been undermined. At tility, at times generated by pro- many years, fully supporting of times, religious representatives found dissatisfaction with the busi- and supported by the Judeo-Crist- have been led to address not pri- ness of life. Today, a good percent- ian tradition. marily the matters of the soul but age of our citizens, especially in In the past several decades, to be also social and human policies that the Western world, direct them- more precise, pseudo psychologiz- have led to misinterpretation of selves inappropriately and unsuc- ing—half-explanatory and at times what Christian community life is, cessfully towards ever changing filled with confusing interpreta- or should be. goals that culture and society in- tions—has often undermined the This is the negative side of the cessantly manufacture for them. relationship among individuals in social panorama that must be dealt Social systems seem to create an our society and especially among with. This is the confused situation undercurrent of manipulation of family members. Progressively, we of a large stratum of humankind in the members of society. Bureau- have witnessed the loss of authori- contemporary society. It is support- cracy, extreme rationalism and ty of the father, the increasing loss ed by extreme individualism that utilitarianism have also changed of the basic role of the mother as a reaches the point of substituting man to an organism whose behav- dispenser of love, and even the oneself for the Creator, aided by iors can often be predicted, manip- children in our society have lost the power given by technological ulated, and controlled. their joy as budding members of a discoveries in all fields of knowl- Moral-ethical taboos that have part of a community and of the edge. On the other hand, it reveals withstood the passage of time and world. People have assumed an at- itself in its failings and weaknesses “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 141 and in that aggression that good came technicians, and their atti- ple as human beings in a world that moral, ethical values and a support- tude, reflecting the attitude of soci- slowly opens up to them but of ing family minimized in the past ety, was often too permissive to- which they are not the creator. A through understanding and aid in wards the expression of angry, hos- psychiatrist should be able to help the achievement of self-control. tile, disruptive feelings, believing any individual, if necessary, to In this panoramic view, one must that it benefited their patients. In so walk through this life, to accompa- not forget the flooding of the doing, however, they often disre- ny him or her through it, even for a streets with drugs and alcohol, and garded a more objective approach brief period of time, without break- the effect of the deinstitutionaliza- to interpersonal relationships, ing or taking away from him or her tion of the mentally ill which took homeostasis of the individual him- those beliefs and hopes that are place in the sixties and seventies, self, life in a family, and security certainly necessary. Unfortunately, basically humane and well-inten- for the progeny when present. this type of assistance often has not tioned, but with often unexpected New psychiatric and sociologi- been delivered. Psychiatrists, how- and harmful consequences to the cal themes in the sixties and the ever, are social beings and their chronically mentally ill. We have seventies led to unbridled eruptions thinking often reflects the way in all had the opportunity to witness of civic hostilities in an attempt to which society is going about life. severely disabled and disenfran- redress at times justifiable claims chised mentally ill people parked through disruptive behavior. on city sidewalks, living under However, when humankind for- The Crime Scene bridges, sleeping in the waiting gets that natura non facit saltum, rooms of city bus or train stations, turmoil often ensues. One cannot Let us look at criminality in con- deprived of care and malnourished, and should not redress disturbing temporary society before dis- at times angry and disorderly, un- situations with disruptive types of cussing a possible remedy for the holding their right to be sick and to behavior. That only brings about situation in which we find our- refuse treatment, disrupting the confusion. The chaotic situation selves, I speak in particular of the normal modus vivendi and fre- that we have witnessed during the United States, which is often the quently arrested because of social past decades certainly testifies to forerunner of things both good and disturbance. Presently, indeed, the that. bad. It is perhaps one of life’s great jail is often the repository of the During the past decades, psychi- truths that crime makes its greatest mentally ill. atry, with its cathartic permissive- impact upon those people who feel ness, has inadvertently quasi justi- the constraints and the indignities fied disorderly behavior by em- of having to live with poverty on a Should psychiatry share bracing an attitude of laissez- daily basis. in a “mea culpa, fairism and relativism, and viewing Crime, however, is not alien to mea maxima culpa?” society as the primary cause of the middle-class and the wealthy. people’s ills, indeed criminogenic. Nevertheless, in the United States, Since the task I was given is to Who is not aware of the progres- murder rates escalate primarily in try to enlighten you about the rela- sive undermining of authority— inner cities with their large minori- tionship between psychiatry and beginning with that of the father— ty populations and heavy drug use. criminality in contemporary soci- who has been portrayed as padre Most of the crime victims are ety, I will have to take you back a padrone. These various means of young and black, as are the victim- while to question whether psychia- indicting society and authority izers. Many of the victims of crime try has in any way contributed to have brought about unbridled im- happen to be in the wrong place at this present state of affairs. As we pulsivity, resentment, hostility, and the wrong time. all know, during the past decades, hatred, and not only social protest, Violent crime, without doubt, is with the advent of psychoanalysis, but protest within families, disrupt- a major problem throughout the the Western world, particularly the ing the harmonious living of many world, even though the highest rate so-called New World, acclaimed a of them. is the prerogative of the United schematic approach to man, mak- A psychiatric approach to hu- States. People are not only harmed ing it a part of the understanding of man problems, in order to be suc- by strangers but are often victim- human nature. Unfortunately, it cessful, must be holistic. Man ized by those they love in their own moved it into a therapeutic ap- should be seen as a composite of homes. Forty-five percent of homi- proach to human ills that supported physical, spiritual, psychological, cides result from domestic vio- pragmatism in interpersonal rela- and environmental factors. It is my lence, and within those domestic tionships, at times leading to hedo- belief that psychiatry should base walls children are being raised and nism, rebellion against norms, ex- its technical expertise on well- usually learn and incorporate into treme individualism, and disregard rounded humanistic knowledge, their behavior the violence of their for traditionally important values which should include not only psy- parents or the adults around them. and relationships. Accepting the chology but philosophy, sociology, They live in a climate of ambiva- Freudian scheme, many psychia- religion, and—why not?—com- lence, fear, and sado-masochistic trists lost that part of humanism es- mon sense. That background aggressive-defensive behavior. sential to the understanding of hu- would minimize the prejudicial so- And they usually adapt to it. This mankind and to their professional lutions of any sectarian psychiatric learned behavior keeps them, to- healing armamentarium. They be- theory and cause them to see peo- gether with the adults around them, 142 DOLENTIUM HOMINUM in a state of insecurity, producing a children and battered women are Most probably, both homicides lack of proficient achievement in frequently reported. I have seen au- and suicides reflect the outer- and school, an inability to relate to one topsies of children as young as one inner-directed aggressivity which another properly, an inability to year of age who, crying for atten- follows despair and the inability to eventually hold gainful employ- tion, have been viciously killed by cope with a way of life which for ment, form a family and care for persons under the effect of cocaine many people is becoming more themselves and their children. This abuse. and more difficult. Marginaliza- usually leads to their marginaliza- Crimes of violence are ubiqui- tion, alienation, dissolution of tion into that large cauldron of de- tous, no doubt. There is no social bonds, lack of jobs, use of illicit pendent persons who daily become stratum that has the prerogative for drugs, and the devasting cocaine increasingly demotivated to be a them, and obviously no culture is and alcohol addictions are all fac- productive member of society. immune. However, it is the high tors that enhance the existential or Their dehumanization, their de- rate of crime that is appalling to- psychological disturbances of personalization, their inner aggres- day, and one wonders what is hap- many of the American people. sivity and their manipulative pas- pening in our society. A survey of However, one should be cognizant sivity at times explodes in the 100 inmates in one house of cor- that even other countries through- worst types of crimes. One wit- rection in the United States re- out the world are devasted by the nesses not only the most uncon- vealed that the inmates attributed same criminal victimization.4 scionable crimes committed by the their fall into criminal behavior to a Juvenile crime has become a dra- most recent serial killers, but also breakup of their families and a lack ma for society and creates a moral the dreadful mass killing commit- of male leadership in their lives. It dilemma for the judicial system. ted by borderline minds which un- seems that our society is growing The crimes are frequently sense- leash their hostility against society into a fatherless society. However, less, utterly destructive and motive- onto groups of people. One wit- not only the father is lacking, but less and the sentences of these nesses numerous cases of explo- also the mother, who because of young people are an indictment of sive violence which make one social and economic factors, is of- society. Many of these young of- question whether people are un- ten absent from the home, and the fenders live in underprivileged able to accept this dehumanized children are left to themselves or to conditions, but that does not justify society of ours—the continuous the supervision of strangers. Often, their antisocial dyscontrolled ac- struggle for survival in a rapidly criminal offenders themselves are tions. It may, however, support the changing socioeconomic world aware that the lack of love and nur- implication that there is something where fluctuations of markets do turing from families prevented wrong with the way society deals their share of killing without using them from developing any sense of with them. There is no justification weapons. value in their life and the inability for killing when not in self-defense. Frequently, one witnesses ran- to establish a loving relationship. It is morally wrong, and we must dom violence and killing of people The most recent statistics re- not psychologize any longer in say- by users and abusers of drugs and garding correctional institution ing that the acts of violence in our alcohol. Many harbor deep hostili- population in the United States re- streets are an identification with the ty against authority possibly due to port that as of June 30, 1994, local aggressor and a destructive way to long resentment over the absence jails held an estimated 484,000 halt the further victimization of the of a father figure and their subcon- adults, or about one in every 398 victimizer. Strangely enough, these scious perception of violence done adult United States residents.2 The are people who at times, when un- unto them by the social system. jails held an estimated 992,000 der the influence of drugs or alco- These are young people who are people in state and federal prisons hol, hallucinate both the voice of virtually conditioned to kill by the at the end of 1994. The number of God and that of the devil in their crimes they see in the streets or in criminal offenses accounted for in confused mental states, almost the mass media. The raping or the United States in any given year putting into a nutshell the eternal beating or killing of unsuspecting is in the range of many millions problem of all societies: the strug- women is frequently reported, but and every year throughout the gle between good and evil. Only the number of cases may be even country 2,000,000 people enter the rarely, however, in my contacts higher than that reported because correctional system, even though with them do they voice an interest many persons, shameful or fearful, temporarily. The total number of in God. Certainly, religious dictates do not report rape, especially if it adults under some form of correc- are missing in their lives and most happens within domestic walls.1 tional supervision in 1994 amount- of them have no inner spirituality We often witness lust-pedophilic ed to 5.1 million.3 Although the and no religious connection. There type of behavior in which children number of homicides in the United is social confusion in their lives and are not only sexually abused but States is reported as declining dur- no goal or purpose. But many of often used as pornographic materi- ing the past several years, the num- these persons can be rehabilitated, al. Often, these children disappear. ber reaches approximately 30,000 especially the very young, before In the United States there are about annually. their criminal behavior becomes re- 5-6,000 people who disappear dur- It is interesting to note that the cidivistic. ing any given year. Many of them number of suicides is actually In observing this type of society, are probably preyed upon by crim- higher by several thousand more the words of the Divine Poet, Dante inal offenders. Cases of battered than the homicides. Alighieri, are certainly helpful. The “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 143 poet, indeed, stated: “When I had port and treatment, without con- growing individual, gli esami non journeyed halfway through my life, sciously or unconsciously under- finiscono mai. There are, indeed, I found myself within a shadowed mining the importance of values— crucial stages in which hostility, forest, for I had lost the path that ethical, moral and religious. Above aggression, and violence may take does not stray.”5 How can the anal- all, they must uphold the personal over and explode. Since antisocial ogy between the mid-life crisis of responsibility of the individual. It behavior is most frequent during Dante and the present-day social is an arduous job, but, if motivated that period of life that goes from crisis be supported? How can the by caritas and a sense of humane 16/17 years of age to about 34 problem of an individual compare and communal duty, can certainly years of age, and is often preceded with an entire society? Both society be successful. Psychiatry should by escalating rebellion during and individual development pass deal with people in their totality, childhood and adolescence, psy- through cycles. In society, there are giving a greater importance to their chiatrists should pay close atten- periods of prosperity and enlight- spirituality. That is why psychiatry tion to the defiant child, the antag- enment, alternating with periods of has partially failed in its promotion onistic adolescent, the antisocial depression and obscurantism just of the welfare of the world. It, too, young person, but also to the per- as there may be alternating mood often forgot the spiritual side of hu- son who is apathetic, withdrawn states and behaviors in the life of an mankind. and isolated. They must speak out individual. The despair of the ma- What about psychiatry and the against the conditioning of film vi- ture Dante may well remind us of criminal offender? Violence is one olence in children and adolescents. the regressive despair of one part of of the most important societal is- At times, the famous ounce of pre- contemporary society, so mature in sues today because of its effect on vention is worth a pound of cure. other ways. As Dante found him- victims, because of the fear created In the legal field, psychiatrists self in the dark forest of depression in the community at large, because must maintain their objectivity and and lost “the path that does not of its enormous cost to society. not become partisan in judicial as- stray,” many in our society have Much can and should be done to sessments of competency or legal lost the right path. Many people prevent it. But there is now a wide responsibility of persons brought seem to be in a forest of social, cul- consensus that law enforcement to trial for criminal offenses. In tural and ethical darkness, where alone cannot provide an answer to fact, at times psychiatrists are ma- the instinctual, impulsive, disrup- the problem.6 Preventing violence nipulated by the legal system, often tive drives at the basis of antisocial demands not only a long-term with dire consequences for society. behavior are increasingly invading commitment but also a compre- Psychiatrists should willingly interpersonal relationships. Dante hensive approach that is not fo- reach out to the inmates in correc- believed that one should look up cused solely on aggressive re- tional institutions, hold group ther- and be directed by wisdom and ex- sponses and that calls upon various apy sessions for anger control, edu- perience when searching for the professionals. Psychiatry must be a cational courses on the manifesta- Ultimate Truth and be motivated by part of that approach. It should actions of anxiety, depression, and love. tively participate in detecting those other manifestations of emotional people who may be prone to possi- illness, and teach people about life ble violent behavior. The purpose problem-solving choices useful in Psychiatry’s Task should be not only preventive but avoiding aggressivity. In their con- therapeutic. While it is difficult to tacts with these offenders, particu- How can psychiatry help reverse anticipate violence, especially in larly in the United States, they must this upsurge of criminal behavior? individuals such as serial killers, take the opportunity to discuss the Psychiatrists have at times given who offer the greatest difficulty in unfortunate consequences that gun up their primary role to ancillary detection and rarely come to the at- ownership often brings about. professionals, many of whom do tention of mental health profes- Indeed, “firearms...rank second not possess their diagnostic and sionals prior to their apprehension, as the cause of accidental death in therapeutic skills, and they should for the majority of criminal offend- children 10 to 14 years of age, ac- attempt to regain that role. They ers who are disturbed adolescents, counting for 72 percent of homi- should abandon the therapeutic ap- frustrated young people, and homicides in this age range.”7 By partic- proach of laissez-fairism, the ac- cidal/suicidal borderline or de- ipating in the re-education of of- cepted theory of absolute rela- pressed individuals, much can be fenders, the psychiatrist will be- tivism, which tended to nullify val- done to alleviate their despair and come aware of a new and different ues and contributed to the birth of a control their aggressivity. This is world—a parasocial world of secularized religion. Their ap- especially important at a scholastic crime and punishment where con- proach to a culture of human om- level and in the workplace, and im- victed people, in spite of every- nipotence which has thus far only plies the cooperation of competent thing, may help to redress the ills augmented feelings of inadequacy professionals. Appropriate treat- of society through their forced re- and despair should be relinquished. ment of these individuals will help flection. Obviously, the correction- Psychiatrists can help people guarantee the safety of society. al institutions must reach out for through their technical knowledge, Psychological problems begin psychiatrists in the hope of creat- their empathic listening, their un- early in life—it has even been the- ing a more humane environment derstanding, and their reflections orized that they begin in utero— for the inmates and better rehabili- with their patients who need sup- but most often in childhood. For a tative programs. 144 DOLENTIUM HOMINUM

Most importantly, psychiatrists Proverbs (22:6) states: “Train up a jail inmates. While, non-Hispanic inmates accounted for 39% of the jail population; black should be persons dedicated to car- child in the way he should go; and non-Hispanics for 44%; and Hispanics for 15 ing for the deviant, even though when he is old he will not depart percent. The annual average increase was 7.2 not overtly mentally disordered. from it,” and it certainly reflects the percent between 1980 and 1994. (Bureau of Justice Statistics, Executive Summary, July Greater help, however, will have wisdom of humankind through 1996, NCJ-161559, U.S. Dept. of Justice, Cor- to come from a moral rebirth, a re- centuries past. Heeding it would be rectional Populations, 1994, Washington DC, newed spirituality, a re-evangeliza- wise in view of the chaotic situa- pp. 1-4.) 3 Ibid. tion of people. In this, the clergy tion in many of our families at pre- 4 Deaths from homicide in some countries will have a unique opportunity to sent, and in so doing perhaps re- per 100,000 population in selected years: USA become involved, not only from duce the criminality in society. (1991) 26,254; Northerm Ireland (1992) 1,627; Italy (199) 1,627; Finland (1993) 166; the pulpit, but with direct spiritual Portugal (1993) 149; Greece (1993) 133; counseling of aggressive criminals. GEORGE B. PALERMO, M.D. Switzerland (1993) 111; Sweden (1992) 117; People need direction. Clinical Professor of Psychiatry Norway (1992) 47; Denmark (1993) 63; Ger- They need support to find their and Neurology many (1993) 966; France (1992) 581; Spain Medical College of Wisconsin (1991) 346; England and Wales (1992) 288. spiritual self and to be told they are (World Health Statistics Annual, 1994, Gene- wrong when they are wrong, rather va, Switzerland: WHO.) 5 The Inferno, Canto I than having their feelings of being 6 See GOLDING in Bibliography No. 10 a victim but not a victimizer un- 7 See CAMOSY in Bibliography No. 11 questionably supported. This le- nient, permissive attitude so far Notes demonstrated toward criminals has 1 Together with collaborators, I conducted a created almost a justification for statistical study in the city of Milwaukee on Bibliography their conduct and has robbed them, homicide, rape, robbery and assault which through a demotivating under- covered a period of 25 years. The four cate- ALIGHIERI, DANTE, The Divine Comedy: In- gories of violent crime that we considered sta- ferno. Allen Mandelbaum (trans.) Bantam standing, of their capacity to tistically demonstrated that in a city like Mil- Books, New York 1982 bounce back, become remorseful waukee, stable in its population, showed that BACHRACH., I.I, Deinstitutionalization: An and accept responsibility for their murder increased 511% between 1965-1990, Analytical Review and Sociological Perspec- rape jumped 1,712%, the frequency of robbery tive. U.S. Government Printing Office, DHEW actions. To say, “They work with rose 1,990% and the number of assaults rose Publication No. (ADM), 76 - 351, 1976. the hand life dealt them” should by 217 percent. CAMOSY, P.A., Incorporating Gun Safety not be the basis on which to build a 2 About 94% of all prisoners were men; into Clinical Practice. American Family 47% were white; 51% were black. Probation, Physician. 54:971-975, 1996. therapeutic relationship with peo- there were nearly 3,000,000 adults on proba- GOLDING, A., Violence and Public Health. ple who commit crimes. tion as of December 1994. Probationers made Journal of the Royal Society of Medicine. up 58% of all adults under correctional super- 89:501-505, 1996. vision in 1994. Approximately, 20% of the PALERMO, G.B., Adolescent Criminal Be- probationers were women, a larger proportion havior. Is TV Violence One of the Culprits?, Conclusion for any other correctional population. About International Journal of Offender Therapy 66% of the adults on probation were white and and Comparative Criminology. Vol. 39(1), 32% black. Six out of ten persons released 11-22, 1995. To summarize, while psychia- from probation had successfully completed PALERMO, G.B., Restoring the Family as the trists can do much to help in the their sentences. Primary Human Community. Journal of Inter- early detection of possible offend- From 1980 to 1994, the probation popula- disciplinary Studies: An International Journal tion grew by more than 1.8 million, an average of Interdisciplinary and Interfaith Dialogue ers, there are many factors which of 7.2% annually. The number of prisoners Vo. V11, No. 1/2, 51-70, 1995.PALERMO, are facilitators of violence. A basic rose by 9% during 1994, the equivalent of G.B., The Faces of Violence. C.C. Thomas, cause of the violence is to be found 82,200 inmates. An estimated 690,000 adults Springfield. 1994. were on parole at the end of 1994, an increase PALERMO, G.B., The Plight of the Deinstitu- in the progressive disintegration of of 2.1 from 1993. Nine of every ten parolees tionalized Chronic Schizophrenic. Ethical the family. A disproportionate were men, estimated of 53% of persons on pa- Considerations, in: Health Care Ethics: Criti- number of young offenders come role were white, 46% black, and 1% of other cal Issues of Health Professionals. Thomasma races. The number of adults on parole tripled D.C. & Monagle, J.F., Editors. 1994. Chap. from broken homes and their poor during the 14 year period (from 220,438). 14, pp. 133-145. upbringing does not lead to the for- On December 31, 1994, the United States PALERMO, G.B. & SIMPSON, D., At the Toots mation of that good character so Army, Navy and Marine Corp held a total of of Violence: The Progressive Decline and Dis- 2,782 prisoners in 33 facilities. Approximately solution of the Family. International Journal important in any society. They lack 98% of military detainees were men and 2% of Offender Therapy and Comparative Crimi- pride and do not feel shame. Pride were women. Half were non-Hispanic whites; nology, 68(2). 105-106, 1994. and shame usually facilitate the 39% non Hispanic blacks; 7% Hispanics; 4% PALERMO, G.B., SMITH, M.B. & LISKA, other races. Of the offenders, 17% percent F.S., Jails Versus Mental Hospitals: The Mil- character formation of children and were convicted for rape and 15% for sexual as- waukee Approach to a Social Dilemma. Inter- adolescents: pride in scholastic sault. Prisoners convicted of murder or non- national Journal of Offender Therapy and work and civic achievements, dedi- negligent manslaughter accounted for 11%, as Comparative Criminology, 35 (3) 205-216, did those convicted of larceny and theft. 1991. cation to one’s community or a hu- During 1994, 306 immates were received PAPESCHI. R., The Denial of the Institution. manitarian cause, or to one’s family under sentence of death by state and federal A Critical Review of Basaglia’s Writings. welfare. Shame is the feeling that prisons, and 112 had their death sentences re- British Journal of ...... , 145.247-254, 1985. moved by means other than execution. State VICO, G.B. The New Science of Giambat- people experience when they rec- and Federal prisons held a total of 2,890 pris- tista Vico. Bergin, T.G. & Fisch. M.H. (trans.). ognize that their actions not only do oners under sentence of death of December 31, Cornell University Press. Ithaca, NY. not conform to their personal val- 1994. An estimate 57% of those under sentence of death at year end were white and 41% ues and expectations but not even were black. Half of the inmates, and here we to the expectations of others. These are talking about non-military inmates, had feelings are universal and do not been under sentence of death for at least six years. Thirteen states executed 31 male prison- know racial or religious barriers. ers during 1994. Men made up 90% of adult “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 145

ADOLFO PETIZIOL

The Sickness and Death of Listening: The Drama of Loneliness

In Italian the term solitudine new solitude which is different reject the fact that the loss has tak- means both a condition without from that which existed at the out- en place. He feels incredulous at emotional significance which in- set. This is the solitude of the loss the fact and full of anger. Certain volves an absence of interaction of a relationship, of detachment, attitudes which are aggressive and with other people, on the one of melancholy and nostalgia. This destructive can arise which in- hand, and a condition which is is the solitude of mourning, of the volve paranoid distrust and feel- emotionally involving and impos- loss of the maternal breast; the ings of persecution—all because ing characterized by the lack of a solitude of someone who loses an of the loss of an ability to enjoy relationship, isolation, and aban- object of love, an object towards the experience of a relationship donment, on the other. In English, which there was rightfully a vital infused with love and affection. however, we have both ‘alone- flow. This is a form of solitude The second stage involves res- ness’ and ‘loneliness’. which is experienced and ex- ignation and surrender. The reality In the first case the absence of pressed as a feeling which leads to of the loss becomes accepted and an interaction with other people the resolution and the integration pain becomes established. The nonetheless presupposes the exis- of relationships with the lost ob- feeling of solitude blends with tence of a resonance of self-con- ject and to an adaptation to the fact melancholy and a sense of nostal- sciousness, an internal perception of that person’s disappearance. gia, both of which are provoked which is ready to direct itself to- We can detect the presence of by the loss which has taken place. wards the perception of others and three stages in the process of the According to Klein, the feeling the environment, an opportunity experience and expression of the of solitude in the individual expe- to participate in one’s own life and feelings provoked by the loss of rience of the process of integra- to live it out in integrated fashion such an object. tion marks the move to the state of in the environment. I am referring In the first stage denial and depression. The process of inte- here to what German phenome- protest are the sentiments which gration represents the positive nology defines as an “appresenta- prevail. The individual seeks to moment of adaptation to the fact tion,” a psychic act which works of the disappearance of the lost in the constitution of the alter ego object, of adaptation to a reality by analogy with the ego. From deprived of illusory perfections. this mechanism there is born that The integration contains elements perceptive experience of the ex- of suffering which are expressed ternality of the other person, of the by the feeling of solitude—that objectivity of time, of one’s own suffering which is necessary for a world, of the shared world and of reduction of the idealization of the one’s neighbor. lost object and to an accompany- The relationship with the world ing achievement of personal inde- of the other is born in solitude pendence. from a special propensity involv- The third stage—that is, detach- ing a “direction of the act” where ment—is characterized by the the vital flow of the person man- abandonment of the object, by ages to move in harmony with the adaptation to a life without that vital flow of the other person. object. If the individual manages From the two solitudes is born a to overcome the loss, he becomes sharing of emotional and affective able to attach himself to a new ob- forms of space. ject and to tolerate the solitude he The opposite path—that is, the has to endure by a process of pro- one which moves in the direction jecting the positive aspects of the of the act towards a divergence of previous relationship onto another the two vital flows—leads to a object. 146 DOLENTIUM HOMINUM

From this examination of these guilt. In such situations we find conditioned by the crisis in family three stages we can perceive the that the anxiety provoked by sepa- values, in major ideologies, and in differences that exist in the way ration—the tragic fear of being the various groups of social sup- the feeling of solitude caused by alone and abandoned, of being port. The interpersonal relation- the loss of a person cared for is ex- drained of the vital lifeblood of ship itself is often replaced by a perienced and expressed. authentic affection—comes to superficial listening to messages The solitude of a person who is dominate the individual. which are completely drained of unable to experience and express If we now move from a consid- their emotional coloring. And the the loss of the presence of a dear eration of the problem of solitude reality which is thus experienced one leads to the living out of a from the point of view of personal becomes crowded with elements sense of persecution. The loss of experience to the rather different of vicarious reality in a sort of the object in this case leads to a realm of interpersonal dynamics, paradoxical process of “acting state of isolation and self-margin- we immediately perceive the fun- out” where collective hyper-reali- alization. The proper and healthy damental importance of the crisis ty becomes banality and meaning- unfolding and evolution of the in- of the process of listening. lessness. dividual’s feelings is disrupted; he We live in a society character- The presentation of an integral feels deprived of something, and ized by the imposing presence of reality causes the suppression of he wants to remedy this loss. As a systems of mass communication the illusion, and with this the result, the individual ends up by and the world of the mass media. death of individual and subjective depending on an illusory and un- Such a society is strongly marked reality. All the qualities of reali- realistic ideal object which acts as by the sending of messages which ty—such as emotions, percep- a substitute. In the best of cases are directed at groups of people. tions, representations, and will— there is an interruption of the The epoch of giant means of become virtual in character. process of self-identity and inde- worldwide communication gives Virtual emotion thereby comes pendence and an accompanying man the opportunity to greatly ex- to create a content for personal inability on the part of the individ- pand the quantity of information consciousness which is not real. ual to be alone. which he receives, but this also in- The subjective emotional experi- But in the worst of cases this volves a diminution of the very ence—which is the intrapsychic solitude becomes an experience of quality of such information. The by-product of a complex process unhappy isolation which is content of the messages also bears of activation directed in physio- crowded with ideal and illusory witness in a direct way to the cri- logical terms at achieving the sur- symbols which disrupt and frag- sis in values which now afflicts vival of the individual—does not ment the individual’s normal rela- our society. refer to messages which come tionship with reality. Such, in- The mass message is imperson- from the real environment of hu- deed, is the condition of autism, al and seeks to impose a collective man relationships, but which in- where the persecutory anxiety of identity on the person who re- stead derive from the world of the the loss of the object multiplies ceives that message. It ignores any already prepared. the fragments of an identity which form of emotional involvement Just as the virtual suffering of is no longer comprehensible. This and runs along lines which are de- the ghost limb follows from the very fact of incomprehensibility tached and dissociated from an af- amputation of the real limb, so goes on in consequential fashion fective point of view. each virtual element follows from to determine a feeling of extreme The emotional repertoire of a the amputation of reality, and the solitude which becomes a form of person is usually made up of emo- predominance of virtual commu- existential isolation. This form of tional experiences which arise nication follows from the amputa- solitude is marked by the sympto- through relationships with other tion of the reality of listening. matic phenomenology of different people. In the world of mass com- The individual will becomes an kinds of psychoses. munication, however, there is a artificially weakened artificial This is the most obscure, sur- more or less illusory activation of limb which is itself virtual. The prising, and at times bizarre form experiences involving human re- will to possess the object of desire of solitude, which is characterized lationships which often lack sig- in real terms becomes the virtual by a disturbance of the flow of nificance. Until the illusion is realization of a desire which is it- oral communication. The adjec- seen and understood as an error, self a virtual representation, a pro- tive and term “autistic” refers to its value is exactly the same as jection into the internal mental the precursors of communicative that of actual reality. But once the space of needs which are not al- forms of behavior, to that stage of illusion is recognized, it is no ways necessary. The loss of the development where a word does longer an illusion. Indeed, the virtual desired object is followed not yet have any kind of meaning. very concept of illusion, and that by the loss of will and a blocking When, on the other hand, the concept alone, becomes an illu- of the real experience of affection. negative connotations of the loss sion. This survey of the influence of of the object completely immerse Mass communication often rep- the virtual on the world of human the feeling of solitude, the anxiety resents an illusory substitute for relationships brings out the impor- connected to the perception of this interpersonal communication. Re- tance of the aspect of the solitude absence becomes translated into a lationships between people seem which springs from the death of feeling of death and depressive to be negatively influenced and listening. Listening gives way to “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 147 judgment, and understanding of a nosological diagnosis em- tudes and stances. On the con- gives way to the need to know. ploying only objectifying criteria trary, the psychiatrist must main- Individual differences come to comes to be a strictly anti-clinical tain his own vitality, the integrity be emphasized in human relation- act. of his own personality, his own ships and the relationship between From what has been said hither- humanity, and his own style. His the medical doctor and his patient to, it becomes clear that the clini- neutrality must not be coldness is a part of this process. In the dis- cal dimension of psychiatry and his sensitivity must lead him cipline of psychiatry in particular, should be based upon understand- constantly to that therapeutic the therapeutic relationship has in ing and that there should be an point which exists between dis- historical terms been based upon overcoming of the limits of classi- tance and closeness to the patient. the moral judgment of the sick fication and labelling. It needs to The nosographic dimension, al- person. Deviant forms of behavior employ an authentically existen- though kept at a level appropriate and madness were identified, stig- tial approach and as such should to scientific communication, must matized, and responded to with a be based in part upon the value of be placed at the margins of the re- process of marginalization. Psy- subjectivity. Such subjectivity lationship with the suffering indi- chological and psychodynamic should be understood not as that vidual, who does not want labels advances and understanding which is arbitrary, but as an exis- but real answers to his questions. should then have modified the tential movement of a subject di- The diagnostic element appears clinical approach to the mentally rected towards understanding an- rudimentary when placed beside disturbed through the introduction other subject. Only in the dynam- the problem of listening to the re- of the concept of transfer and with ics of the encounter between two quests of the patient, which are of- the opening up of fruitful paths of subjectivities can there emerge the ten couched and expressed in research in relation to the meaning global understanding of the patho- codes which are bizarre, but of symptoms and syndromes of logical psychic element which is a which are always related to the madness. The anti-psychiatric point of departure for any kind of great and abiding needs of human revolution then promoted a great treatment, whether biological or existence. Yet modern psychiatry change in the way the mentally ill psychological in nature. over recent years has preferred to were treated and sought to place The act of understanding must concentrate upon objectifying them outside lunatic asylums, be directed towards the creation methods and approaches involv- those places of marginalization. and establishment of a therapeutic ing ever more detailed syndrome This step should have augmented alliance where the suffering sub- models which become ever more and developed the culture of lis- ject remains in a state of implicit drained of real meaning. Diagnos- tening and of the acceptance of waiting for the beneficial action tic action involving interpretation psychic deviation and difference. achieved through the psychia- at a psychological level which is Biological psychiatry itself should trist’s listening to his experiences. all-embracing and full of commu- have bestowed a new clinical dig- In relation to the illness of not nicative functions in relation to nity on the mentally ill person, a listening to which my analysis the sick person seems now to be in dignity which the psychosocial pays such great attention, I am crisis. approach had severely under- necessarily drawn towards laying I believe that we need an effec- mined. stress upon the therapeutic pur- tive integration of the experiences From all these new steps and in- pose of the clinical encounter offered by psychoanalysis, tradi- novations, which all too often within the discipline of psychiatry. tional psychiatry, the neuro- proved unrewarding, there arose This is because at times not the sciences, social psychiatry, and that state of contradiction which slightest attention is paid to the crosscultural psychiatry, if we present-day psychiatry is now benefits that the patient can gain want to overcome the very deep having to deal with and experi- from such a process. This is a cultural crisis which has afflicted ence. form of listening which in actual psychiatry. In a world afflicted by The objectifying knowledge of fact is emptied of its fundamental the neurosis of nonlistening, the illness takes the place of diagnos- curative purpose and often enters discipline of psychiatry must re- tic evaluation and assessment; the into a realm of intellectualistic or gain the credibility of a science at theory of psychotherapeutic meth- pseudoscientific voyeurism. In the the service of suffering man, of a ods and techniques prevails over therapeutic relationship there science which is able to decodify the therapeutic relationship; the must be an atmosphere which en- the most cryptic calls for help, of a opening of the lunatic asylums be- courages the hopes of the patient science which is able to provide comes a process where the phe- that he will overcome his difficul- valid and effective answers with- nomena of marginalization and ties rather than relapse into or re- out the construction of alibis by isolation increase. main in a state of defensive isola- which to become isolated in a Callieri argues that objectifying tion. world of mere speculation. knowledge precludes an openness It is too often the case that the towards authentic difference in need to study the technical possi- Professor ADOLFO PETIZIOL Professor of Psychiatry others. Given, therefore, that a re- bilities of establishing an interhu- and Criminal Anthropology lationship with another person is man relationship in a psychologi- at La Sapienza University, Rome necessary in the clinical act, it be- cally correct way has led to the President of the Italian Society comes clear that the establishment creation of rigid and formal atti- for Social Psychiatry 148 DOLENTIUM HOMINUM

DIEGO DE LEO, PAOLA MARIETTA

Suicide: Determinism or Freedom?

Cultural and Historical Changes Interest in the whole question has (Humphry, 1991) has given rise to given rise to the creation of a num- similar such criticism and attacks The freedom of an act of sui- ber of associations which defend the from 1990 onwards. We know cide—the fact of “performing” that right of man to die “with dignity”— about many Kevorkian “cases” in act rather than “committing” it— the Hemlock Society, which was addition to the first and by now fa- and the whole question of rational founded in Los Angeles in 1980, mous and infamous instance of suicide are matters which have be- and the Deutsche Gesellschaft fur Janet Adkins—the cases, that is, of come the subject of marked atten- Humanes Sterben which was estab- Quinlan, Saikewiczs, Spring, Eich- tion over recent years. This is true lished in the same year in Berlin ner, Bouvia, Cruzan (West, 1993; not only in relation to experts of the (Battin, 1994). Furthermore, since Bettin, 1994) and many others. At scientific community but as regards 1993 forty-seven states of the Unit- the present time of writing we know public opinion as well. ed States of America have passed of at least forty cases of individuals It has been observed that public legislation which defends the right who have been helped to commit opinion has changed its overall ap- of people who find themselves in suicide by this “Dr. Death.” proach to this whole area and that at situations of incurable illness to die We should not, however, fall into a general level it has begun to per- through the employment of a docu- the trap of believing that the whole ceive suicide as a choice carried out ment which is termed a “living will” subject of the right to death is of rein certain life contexts. In a study by (Battin, 1994) or through the agency cent date although it is certainly true Cutler and Danigelis which was of a representative upon whom the that the subject is nowadays dis- published in 1993 it was demon- individual confers the power to de- cussed in different terms. Indeed, a strated that in 1991 70% of individ- cide whether he should go on living papyrus of 2,280/2,000 BC demon- uals belonging to their sample were if he should no longer be in the con- strates the antiquity of the debate. in favor of a law which authorized dition to exercise this choice him- This document deals with the ques- medical doctors to end the life of self (Humphry, 1991). tion of suicide because a man tired patients suffering from incurable ill- The theoretical justification em- of living expresses his intention to nesses. In 1950 the respective figure ployed to support the idea that the kill himself and asks his soul to ac- was only 31%. 66% of the popula- act of suicide in certain circum- company him (Evans and Farberow, tion interviewed in 1994 in Michi- stances can be the outcome of free 1988). Many of the questions raised gan seemed to be in favor of assist- choice is based on the belief that in by this papyrus echo those of con- ed suicide (Bachman et al., 1996). situations of suffering a week of liv- temporary debate: does a man have However, different results emerged ing only involves useless anguish the right to end his life, not least from a study conducted by Seidlitz and a prolonging of pain. In his when he finds himself in very diffi- et al. in 1995 which was carried out book Final Exit: The Practicalities cult and trying circumstances? How on a representative cohort of elderly of Self-Deliverance and Assisted can the conflict between individual people—only 42% of those inter- Suicide for the Dying, Derek freedom and social responsibility be viewed expressed themselves in fa- Humphry (a journalist who founded resolved? vor of the legalization of assisted the Hemlock Society) has outlined In the ancient Israelite world the suicide. the principles of that association. act of suicide was rather uncommon In the world of health care the However, this work may also be and in general it was not accepted. concept of health has changed considered as being a kind of manu- This was because of the strong at- markedly because the tendency has al by which to take your own life. tachment to life and the optimism been to move away from giving im- The work has been roundly criti- which so characterized this people. portance to the illness itself towards cized, not least by Kass (1991) who Although there are examples of sui- laying stress on individual well-be- declared that: “Thanks to Derek cide (from Saul, Razis and Zimri to ing (De Leo, 1993). Attention has Humphry’s book, our youth (in at- Judas Iscariot), neither the Old Tes- thus become focused upon the con- tempting suicide) need no longer tament nor the New Testament cept of quality of life and upon the fail.” The case of Dr. Jack openly condemn or prohibit suicide. notion of a good death. Kevorkian and his death machine The conception of suicide to be “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 149 found in the ancient Roman or man is the property of God and of people who have attempted sui- Greek worlds was not always the therefore only God can decide upon cide and through post-mortem in- same. Aristotle condemned suicide the moment of a person’s death. vestigations into suicide victims. It as a cowardly action and as an in- This position was later criticized has undoubtedly increased our abil- jury to the state but Plato held that by Hume (1882). Over the centuries ity to understand this most complex in general it was acceptable only in suicide has been seen as a blasphe- and intricate subject. The most rele- certain specific situations. On the mous act (that is, a religious sin) but vant information provided by bio- whole, because honor was a domi- also as something which is shame- chemical research relates to the ab- nant value of these peoples suicide ful. Indeed,until the nineteenth cen- normal working of the serotonin was generally seen as a suitable so- tury the person who attempted or system of the human body. Sero- lution to a status of dishonor. committed suicide was considered tonin has been discovered to be an Between the seventh and the fifth the author of a crime worse than extremely influential neuromodula- centuries BC Greek culture was murder. Thereafter there was an im- tor which acts on the central ner- marked by a certain pessimism and portant change—a move from see- vous system. Low levels of its a disenchantment towards life. ing suicide as something shameful metabolite (5-hydroxy-indoleacetic Sophocles, Euripides, Heroditus to considering the man who man- acid) have been discovered in sui- and Democritus, for example, be- aged to commit suicide as not re- cide victims or in people who have lieved that suicide was the best way sponsible for his death because he attempted suicide—especially (if not the quickest) by which to was not compos mentis. The famous where violent methods have been leave this life. The poison by which English legal expert William Black- employed—and this quite indepen- Socrates killed himself—hem- stone (1962) described this shift in dently of whether these people be- lock—was introduced specifically opinion in the following terms: longed to a specific diagnostic cate- during that period. “But this excuse (of lunacy) gory or not (De Leo, 1994). In his work De Ira Seneca de- ought not to be strained to the Most post-mortem studies using fended suicide and observed that length to which our coroner’s juries tritiated imipramine have revealed a eternal law provided only one way are apt to carry it, viz., that every decrease in the number of connect- of entering this life but many ways act of suicide is an evidence of ined presynaptic sites and other stud- of leaving it. The historian Zenon sanity; as every man who acts con- ies have shown an increased num- argued in favor of suicide in cir- trary to reason had no reasons at all; ber of postsynaptic receptors in the cumstances which involved unbear- for the same argument would prove pre-frontal cortex. Research into able pain, mutilation, or incurable every other criminal non compos, as levels of prolactin reactions of illness. well as the self-murder.” phlenfluramin—an overall indica- At the outset in the Christian In this way suicide ceased to be tor of serotonin processes—have re- world there was a strong attraction seen as merely an existential prob- vealed abnormal reactions in people towards suicide because it could in- lem and begun to be seen in medical who have attempted suicide and are volve martyrdom. But with St. Au- terms as well. This in turn gave rise at the same time victims both of gustine, the Father of the Latin to investigation into the causes of greater depression and personality Church, the attitude towards suicide suicide and into the risk factors disorders. A large amount of evi- changed radically. In De Civitate which might induce a person to take dence has shown, therefore, that a Dei St. Augustine argued against his own life. decrease in the serotonin processes suicide on the grounds that it went constitutes a biological indicator of against the Fifth Commandment of “predisposition” although it is still “thou shalt not kill.” The first au- Determinism and Suicide not yet clear if this is the direct out- thentic and explicit prohibition of come of a specific “suicide factor” suicide within the Christian church When suicide is approached in or rather the indirect product of is, however, to be found in the deterministic terms it means that the such psychiatric illnesses as depres- Council of Arles of 452 and the phenomenon becomes subject to sion, schizophrenia or alcoholism Council of Orleans of 533—on the principle of causality. The term (De Leo, 1994). these occasions suicide was defined causality suggests the “connection Other works of research have as being the worst of all crimes. which establishes a relationship be- shown that genetic factors may Subsequently people who had com- tween two entities according to bring about a disposition to suicide. mitted suicide were denied burial in which the second is to be predicted Harberlandt (1965, 1967) and Roy holy ground (967). with certainty from the first” (Gal- (1991), for example, have discov- In the thirteenth century St. imberti, 1992). From such a line of ered high levels of correspondence Thomas Aquinas elaborated a more reasoning suicide becomes the nec- in relation to suicide attempts in precise position for the Church as essary consequence of previous identical twins. But such levels are regards this whole area. In his Sum- physiological or psychological fac- even higher in relation to such psy- ma Theologica this theologian pre- tors, an awareness of which permits chiatric illnesses and disturbances sented three fundamental argu- the identification of certain risk fac- as schizophrenia and depression. ments against suicide: self-destruc- tors. The presence of a psychiatric illness tion is not in harmony with man’s Although biological research is is thus thought to be a marked natural inclinations; man does not an area of inquiry which is relative- shared element. The research car- have the right to deprive society of ly recent,it has managed to achieve ried out by Schulsinger et al. his presence and his activity; and much through biochemical studies (1979), on the other hand, has pro- 150 DOLENTIUM HOMINUM vided good evidence to suggest that substituted by the anti-logic of death (Amery, 1990). To put it in es- there exists a hereditary vulnerabili- death. sential terms, the message which ty to suicide which is independent The logic of life is present in the person who commits suicide from—or at most superimposed up- every situation, at a daily level, at communicates to the world is that of on—the genetic transmission of an the moment—that is—when we re- being able to belong to himself. In affective disturbance (De Leo, mind ourselves that “we nonethe- so doing he demonstrates that he 1994). less have to live.” The person who has an equal right both to life and to Psychic disturbance has for some chooses death places himself out- death. time been identified as a contributo- side this way of thinking—for him It is more than obvious that the ry factor to suicide and has thus life has lost the value of being a employment of this approach as a joined hypotheses of a genetic or supreme good. It can happen that way of understanding suicide in- biochemical nature. The World life imposes limitations and limits volves a denial of the need to estab- Health Organization (1993) argues upon us—that is, insuperable barri- lish whether a determining cause of that a form of psychiatric distur- ers which make life unbearable. the act of suicide exists or not. We bance is the strongest risk factor Forms of incurable illness are ex- can thus more easily understand working for suicide and that there is actly such barriers and constitute el- why such figures as Stig Dagerman sufficient evidence to maintain that ements which deprive an individual (1991)—a Swedish writer who died individuals who suffer from psychi- of his independence and freedom. It at the height of his success and atric pathologies are more likely to is precisely at this point that the al- fame—chose an early death while attempt an act of suicide or to actu- ternative of death rears it head, an engaged in a struggle between the ally kill themselves than normal alternative which is deemed to be desire to be happy and the impossi- people. Mood disturbances, alco- “free” because it is chosen by the bility of being so, and between the holism and schizophrenia are thus individual as the only possible need to be free and the limits and seen as the pathologies which bear means by which to detach himself limitations of life. The same may be the greatest risk of suicide and with- from something which constitutes said of Sylvia Plath (1992), an in these categories the most likely to an unbearable burden—his own American writer who killed herself cause suicide are the sub-groups of body. at the age of thirty-one. In letters to recurrent major depression and type It is thus argued that it is through her mother she frequently made II bipolar disturbance (Scoco and death that all limits and limitations clear that she was unable to bear the De Leo, 1995). imposed by life are overcome and idea of being mediocre and these Various approaches to the subject that it is always through this policy letters also indicate that perhaps she have enabled us to analyze suicide that a project is implemented which took her own life at a moment when from different angles of interpreta- involves the achievement of true she no longer felt able to rise to the tion but the cause of a suicidal act is and final freedom. Jean Amery has occasion of the experiences of her not to be identified in one variable laid especial and overriding stress life. because suicide must be seen as a upon the right which every man has For Margaret Pabst-Battin, the phenomenon which is brought in relation to his own death—such a idea that the suicidal act is an ex- about by many elements. Whatever right, it is argued, should never be pression of free choice amounts to a one’s point of view, a greater aware- called into question. Man can obey correct definition of suicide or ness of the biological variables anybody and also himself and it is rather of that act of suicide carried which are involved, in conjunction by this route, it is said, that he can out by a person who does not dis- with their use within wider psy- choose in favor of death and thereby play elements of psychic distur- chosocial studies, can but increase reject the logic of life. The person bance of any kind and who at the our knowledge about suicidal forms who strives to save a person bent on same time is able to perceive— of behavior (De Leo, 1994). suicide from his fate, it is observed, through a sound evaluation of reali- could well turn that individual into a ty—that death is preferable to life different person but that person (Battin, 1991). Free Choice and Rational Suicide would not necessarily be better. In 70-80% of cases people die of In this approach the concept of degenerative illnesses after a long In opposition to, and in disagree- natural death has to be redefined in period of suffering (Battin, 1993; ment with, determinism there is an radical fashion. Death can be de- 1994). Modern medicine enables alternative approach which sees the fined as being “natural” only in re- man to survive in states where every suicidal act as an action motivated lation to the person who wants it. form of independence has been lost by a deliberate choice to which the Even in the case of an elderly per- even though cerebral functions re- individual attributes a particular son who is aware that his time on main unimpaired or in a condition meaning. From this point of view, in earth is coming to an end there where the individual is in a vegeta- seeking to interpret an act of suicide could be a strong desire for life. The tive state of cerebral death. The ter- it should be seen that not all people person who commits suicide is thus minally ill could therefore easily are ready to accept the idea that life seen as an individual who has cho- constitute a category at risk when is the supreme good of man. For ex- sen a free death as his natural death. we come to consider the policy of ample, Amery (1990) has employed He has, as it were, brought forward rational suicide; but the same could the phrase “the situation which pre- the moment which would anyway also be said of the elderly. Indeed, cedes the jump” to refer to that mo- have come and in this way he has old-age can involve major changes ment when the logic of life becomes become the architect of his own at a cognitive level and can lead to “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 151 psychological changes and the cre- 3. the logic of the motives behind of life and health but also of the or- ation of a new self within the elder- the choice and the unanimity of ganic well-being and life of the ly person (Pajusco and De Leo, judgement on the part of external body. The position of the analyst, on 1994). As a result, the decision to observers (Mackenie and Popkin, the other hand, because it is not take one’s own life would not really 1990). prejudiced by professional training be a choice between life and death Seen in such terms, only a small but made up of a unique relation- but rather a decision as to whether percentage of suicides—between ship with the patient, is said to be di- the new self should live or die (Pra- 5% and 10%—could be defined as rected towards the principle of “pri- do, 1990). being the outcome of a “rational” mum animae nihil nocere.” The an- Battin (1991) has drawn up a act in the light of present-day scien- alyst is said not to act with preven- list of elements which the health tific knowledge or could be consid- tion in view but in an attempt to un- care worker, the doctor or more ered as the only possible alternative derstand the meanings which that simply the person who looks after a to an unchangeable state of suffer- particular individual attributes to person who wants to end his own ing (Diekstra, 1992). his own experiences, including that life, should consider, appraise and of death. For the psychiatrist failure evaluate. This list, it is argued, would involve the suicide of his pa- should help people to understand if The Role of the Health Care tient but for the analyst failure a rational or irrational choice is in- Workers—Prevention would consist in the betrayal of the volved but first and foremost it Always and in Every Case? intimate alliance formed together should lead people to reflect on the with the patient (Hillmann, 1972). fact that the person who contem- It is very unlikely that a psychia- Szasz (1986) argues that a med- plates suicide is not always a de- trist will not have the experience of ical doctor generally feels fully repressed person or somebody who is having to treat patients afflicted by sponsible for the suicide of an indi- some way is affected by a form of suicidal ideas or individuals who vidual in his care because he had ac- pathology. In this approach suicide have already tried to take their own cepted the duty of preventing that could in certain cases be the out- lives (Heyd and Bloch, 1995). The patient’s suicide in all situations come of an independent and bal- possibility that a patient will kill quite apart from whether that indi- anced choice which is in harmony himself can involve very serious le- vidual was actually capable of tak- with that person’s cultural back- gal consequences for the medical ing his own life. In the view of this ground or personal history. practitioner but it can also provoke author, health care workers in the In the opinion of Conwell and a strong psychological conflict field of mental health should feel re- Ciane (1991), one should avoid within the doctor himself. As Bat- sponsible for a suicide and the re- both therapeutic overkill and pater- tin points out (1991), if an elderly sponsibility which the health care nalistic kinds of care. One should person or a terminally ill patient worker assumes means that he not impose forms of treatment asks a medical doctor to end his suf- should be very far from holding the which prolong the life of the patient fering and his life, that doctor may opinion that death falls within hu- and in so doing ignore the indepen- not be prepared to consider suicide man rights. On the contrary, he dence of choice which every person as a possible course of action and should always see death as some- has as a right. At the same time it is thus may not know how to react. In thing which should be kept off for argued by these authors that it is such a situation, and whatever the as long as possible. The approach equally necessary to engage in a request which is made, the response which Szasz (1986) adopts is that of careful evaluation of the other of the health care operator should treating the individual who is vul- courses of action which are open to always aim at ensuring that suicide nerable to suicide in the same way the individual concerned in addition does not take place. The health care as the doctor treats other patients, or to that of taking his own life. operator may thus come to react to rather that he should help him (and Appelbaum (1988) sees rationali- these requests by adopting safety without coercion) only when the ac- ty as a feature of the free choice of measures which are unsuitable or tion of the doctor is requested and an individual and dwells at length which are not sufficiently therapeu- accepted by the patient. Szasz goes upon how this can be judged and as- tic in their aims or impact. on to argue that suicide should be sessed. In his opinion it is necessary The belief that suicide is the ex- seen in the same light as abortion or not only to inquire into whether the pression of mental disturbance or divorce—that is, its acceptability individual is able to choose in an ef- the outcome of an irrational choice depends upon the circumstances. fective way but also to reflect upon or a means by which to ask for help In general, it is clear that the ethical the consequences of that choice for implies the adoption of different position of the health care worker in the person involved and for the so- forms of intervention on the part of relation to life influences his stance cial network more generally. the health care worker (Heyd and in the debate about the right to From this point of view the pres- Bloch, 1995). death. Indeed, it should be observed ence of rational suicide may there- Hillmann (1972) believes that the here that the point of view which fore be detected through a consider- death of a patient vulnerable to sui- holds as an absolute principle that ation of: cide is the most obvious error which human life is sacred and upheld by 1. the realistic appraisal or other- a doctor whose guiding principle is laws which are independent of hu- wise of the life situation of the indi- “primum nihil nocere” could fall in- man will (“ethics of the sanctity of vidual concerned; 2. the integrity of to. In particular, he argues that the life”) attributes to no man the right his mental processes; psychiatrist is not only the promoter to die. An approach, instead, which 152 DOLENTIUM HOMINUM is based upon the importance of the assisted suicide should be based and caused by the illness or there must quality of life (“ethics of the quality these have also been advanced by have been an evaluation by the pa- of life”)—something which follows Quill and those who work with him tient of how he could have ad- rules established by man—would (1992). They are as follows: dressed and managed his disability; appear to offer people a way of see- 1) The request should be volun- he must have reflected on the infor- ing the right to die as the conclusion tary and made directly by the person mation he received about the diag- of a life which would otherwise not who has chosen to die. nosis of his condition; and he must be worthy of being lived. 2) At the moment of making this have thought about his own future A fundamental point of the first request the individual should be and considered the question of eu- approach is the absolute principle compos mentis. thanasia. Finally, another specialist according to which human life must 3) The wish for death should be must have been consulted and this be respected because it is sacred. Its constant and stable and should have in order to prevent the decision be- sacredness does not derive so much existed for a marked period of time ing swayed by the emotions of the from the concept of life as from the within the individual (at least six patient’s doctor or by his cultural fact that it is human, or rather a life months). background—this latter being the of the person as such. The Instruc- 4) An intolerable form of suffer- more probable. tion Donum Vitae from the Congre- ing (a subjective fact) should be A recent study has shown that in gation for the Doctrine of the Faith present. Holland in 1990 1.8% of all deaths (1987) observes that “the inviolabil- 5) There should be no prospect of in the country were associated with ity of the right to life of the innocent any possibility of improvement at active euthanasia and 0.3% with as- human being from the moment of all in the condition of the individual sisted suicide. Although the majori- conception to death is a sign and a (an objective fact). ty of doctors (54%) had requirement of the inviolability it- 6) Help in committing suicide implemented euthanasia or as- self of the person, to whom the Cre- should be entrusted to someone sisted suicide at least once, two in ator had made the gift of life.” who is a specialist in the field. every three requests for such a prac- In contrary fashion the second 7) The specialist should have tice had met with a negative re- position stresses the importance of consulted other colleagues (from sponse (Diekstra, 1992). The diag- the quality of life and lays empha- one to five in number). nosis of the majority of cases in- sis on respect for the free choices 8) Injury and damage to other volved cancer and the average age which each individual can make. people caused by an act of assisted of patients was about sixty (Battin, Natoli (1992) has, however, laid suicide have to be avoided. 1994). 88% of medical doctors who stress on how difficult it is in the 9) Every decision and moment in worked in nursing homes from modern world to define the concept the process which has brought 1986 to the middle of 1990 had nev- of “quality of life.” Indeed, whilst in about assisted suicide should be er helped a patient to die. The re- the ancient world many values were recorded and written down for the maining 18% had practiced eu- recognized as such by the majority purposes of subsequent legal and thanasia fifty-one times (out of 164 of people, in the modern age it is professional evaluation of what has requests) and assisted suicide twen- more difficult to identify what a val- taken place. ty-three times (out of fifty-three re- ue is or what is meant by the digni- Quill et al. (1992) strive to em- quests) (Van der Wal et al. 1994). ty of life or of death. phasize certain aspects of the Many criticisms are levelled method by which assisted suicide against the Dutch approach to this should be implemented: the patient whole question. The first involves Euthanasia and Assisted Suicide should not be alone at the moment the fear that the practice of suicide of death but should be supported by may spread beyond all control with Active euthanasia involves caus- those who have been nearest to him, the result that the medical doctor ing the death of an individual who and the method chosen to achieve becomes a figure associated with has explicitly requested such a path death should not make the patient the bringing of death. Attention has of action (Eareckson Tada, 1992). suffer further. also been called to how the Hippo- Passive euthanasia refers to a death In Holland euthanasia has been cratic oath is being violated. The obtained by a person who has not prohibited by law but is tolerated original Greek version of this oath been able to give his consent be- where certain practical criteria are forbids doctors to administer lethal cause of a serious illness or defor- present (Battin, 1993; 1994). In cas- drugs or medicines to anybody at all mity but which has been imposed es of euthanasia it must be estab- even when they are requested by the with the approval of the members of lished that the patient was not patient himself. It should not, how- his family or by those who have pushed by somebody in the direc- ever, be forgotten that in the Greek been responsible for the patient tion of this course of action; the version of the Hippocratic oath doc- (Eareckson Tada, 1992). Assisted choice must have been constant tors are also prohibited from carry- suicide takes place when the health over time and not a transitory wish; ing out surgery or teaching medical care worker provides the person the patient must have been in a state techniques for money. Neither of who wishes to die with the actual of acute pain which was defined by these two rules are presently obeyed instruments by which to kill himself the individual himself—and not by in the world of modern medicine (Eareckson Tada, 1992). a medical doctor—as being unbear- (Battin, 1993). Diekstra (1992) has proposed able; the patient must have made at- In the United States of America certain clinical criteria upon which tempts to overcome the alienation the problem of terminally ill pa- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 153 tients in a state of coma is very com- psychiatrists were more in favor jected to further control; that the mon. In recent years medical doc- (Cohen et al., 1994). means chosen to achieve death will tors have had to deal increasingly Another survey revealed that in not be suitable or adequate; and that with cases of passive euthanasia. In the state of New York 61% of med- subsequently these means (in this many states the law governs what ical doctors believed that an act of instance, drugs of some kind) will the doctor must do when requests suicide could be rational but 51% be used by somebody else without are made to turn off the machines argued that the doctor should never any kind of control being exercised. and instruments which keep the pa- be obliged to help his patient to take In this area article 579 of the Ital- tient alive. The question of the right his own life, whatever the circum- ian penal code punishes as a crimi- to die is dealt with in such situations stances of the case. 31% of those in- nal act of murder that person who more indirectly and the role of the terviewed, however, were in favor consents or rather “encourages the doctor appears to be more hidden or of the legalization of assisted sui- death of a man with his consent” even invisible. Obviously enough, cide in certain situations (Duber- (Canepa, 1988)—as long, that is, as the “American approach” is not stien et al., 1995). the person who has encouraged the without its critics. In the state of Michigan 56% of act is an adult and someone who is First of all, the interruption of medical doctors declared that if not mentally ill. This could also be certain forms of medical treatment they had to choose between the le- the case in euthanasia, but there is which are being applied to a patient galization and the prohibition of as- no explicit legislative norm on this can have different results and in this sisted suicide they would support point. way it is not easy to decide how the the first course of action. In re- In article 580 of the Italian penal patient should be allowed to die. It sponse to a broader range of propos- code instigation to, or help in, com- can also happen that the patient who als relating to the question, 40% mitting suicide is deemed a crime. is deprived of this treatment does were in favor of legalization, 37% This article concerns those “who not die immediately. This can in- proposed “no law” at all, 17% sup- cause others to commit suicide or volve the illness coming out into the ported the prohibition of any kind of reinforce in others a will to suicide open in all its manifestations and ending of life, and 6% were uncer- or who in any way aid its practice” thus result in an extremely painful tain in their approach to the subject (Canepa, 1988). The punishability death for the patient. (Bachman et al., 1996). is dependent upon the death of the Furthermore, the difference be- The term “euthanasia” is certain- individual and increases when a mi- tween believing that no means of ly linked to the Nazi period and to nor or a mentally infirm person is life support can save the patient and the treatment meted out at that time involved. This article could cover the belief that it is not worthwhile to to the Jewish population. For Ger- assisted suicide where the individ- invest large amounts of resources in man National Socialism the term ual is supplied by the means by supporting that patient in that par- had a meaning which was com- which to take his own life. ticular situation can at times be very pletely divorced from its Greek ori- subtle indeed. There is no national gins. The corruption of the meaning health service in the United States of the term “euthanasia” began with Conclusion of America, and therefore a patient, the so-called “T4 program,” which even though covered by private was launched by Hitler in 1939 and As is evident from this paper, the medical insurance, may feel that he involved the mentally ill, the handi- question of the determinism or the is never really protected. In certain capped, and the chronically ill of freedom of an act of suicide leads us cases a medical choice could be- “Aryan” stock being selected for to reflect upon how we should act, come in reality a financial choice death without any request for eu- whatever the position we actually (Battin, 1993). Moreover, emphasis thanasia having being made by the come to adopt. on the economic aspects of the case murdered individuals themselves. When the position is embraced could transform the relationship be- The T4 program was then continued which asserts that precise determin- tween the medical doctor and his in the concentration camps, where ing causes are at work in an act or patient from “managed care” into people deemed unsuitable were se- attempted act of suicide, then the “managed death” (Grassi, 1995). lected for death for the most varied health care worker must intervene From a questionnaire carried out of reasons. preventively both in relation to po- in the state of Washington on a sam- In Germany, therefore, euthanasia tential acts of suicide and as regards ple of doctors chosen at random, it has remained associated with that safety measures to be applied to emerged that 48% of those ques- terrible period, and German doctors those people who have already tioned agreed with the proposal that have never been given powers to de- sought to take their own lives. in no circumstances was euthanasia cide and act directly in relation to When the principle of causality is justifiable; 39% had the same view death. However, assisted suicide in adopted, we may be led to forget the about assisted suicide; 54% be- the case of rational and responsible importance of the final effect of an lieved that euthanasia should be individuals is not seen as a violation action and fail to understand the made legal in certain cases and 53% of the law and in part is institution- meaning attributed to that act by the held the same opinion about assist- alized (Battin, 1993; 1994). In this individual himself. If the act of sui- ed suicide. Among these medical context the doctor does not inter- cide, for example, were a phenome- practitioners, oncologists and vene directly but the danger in this non which is always attributable to hematologists were generally op- situation is that the diagnosis of the mental disturbance or disorder, then posed to the ending of life whereas patient’s condition will not be sub- the motivations of the suicidal per- 154 DOLENTIUM HOMINUM

son would become of marginal im- Bibliography D. HEYD and S. BLOCH, “L’Etica del Sui- portance because his illness consti- cidio” in S.Cloch and Chodoff, Etica in J. AMERY, Leva la Mano su di Sè (Turin, Psichiatria (Rome, NIS, 1967). tutes the final answer to all inquiry Bollati Boringhieri, 1990). J. HILLMAN, Il Suicidio e l’Anima (Rome, as to causes. P.S. APPELBAUM, “Responses to the Arti- Astrolabio, 1972). Perhaps the health care worker cle by H.Kerlinsky et al.,” General Hospital D. HUME, On Suicide, in T.H. Green and Psychiatry, 10 (6), 428-430, 1988. T.H. Grose, Essays (London, 1882). should undertake an operation of in- J.G. BACHMAN, K.H. ALCSER, D.J. DOU- D. HUMPHRY, “Final Exit: the Practicali- trospection in order to understand GLAS, R.L. LICHTENSTIEN, A.D. CORNING, and ties of Self-Deliverance and Assisted Suicide what his professional and personal H. BRODY, “Attitudes of Michigan Physi- for the Dying,” in O.R. Eugene, Good Life or cians and the Public Toward Legalizing Good Death (The Hemlock Seociety, 1991). opinions are, in order to adopt a Physician-Assisted Suicide and Voluntary L.R. KASS, “Suicide Made Easy: The Evil stance which does not interfere with Euthanasia,” New England Journal of Medi- of Rational Humaneness,” in Commentary, an acceptance of the individual’s cine, 334 (5), 303-309, 1996. 92, 1991. M.P. BATTIN, “Rational Suicide: How can T.B. MACKENZIE and M.K. POPKIN, “Med- decision to take his own life. In- we Respond to a Request for Help,” Crisis, ical Illness and Suicide,” in S.J. Blumenthal deed, it often happens that the “pro- 12 (2), 73-80, 1991. and D.J. Kupfer, Suicide Over the Life Cycle fessional self” is in conflict with the M.P. BATTIN, “Suicidology and the Right (Washington, DC: American Psychiatric to Die,” in A.A. LEENARS, Suicidology: Es- Press, 1990). “individual self” and is more moved says in Honor of Edwin Shneidman (North- S. NATOLI, “Teorie,” in W. Cucco Festini by personal feelings of compassion vale, New Jersey, Jason Arison Inc., 1993). and L. Cipollone, Suicidio e Complessità: and pity than by considerations of M.P. BATTIN, The Least Worse Death Punti di Vista a Confronto (Milan, Giuffrè professional responsibility and (Oxford, Oxford University Press, 1994). editore, 1992). W. BLACKSTONE, Commentaries of the E. PAJUSCO and D. DE LEO, “Il Suicidio training. The conflict between the Laws of England: of Public Wrongs (Boston, Rationale,” in D. De Leo and A. Stella, Man- rational and irrational parts of the Beacon Press, 1962). uale di Psichiatria dell’Anziano (Padua: Pic- health care worker and the patient G. CANEPA, “Introduzione al Problema cin, 1994). Medico-Legale del Suicidio,” in C.Baconci- S. PLATH, Quanto Lontano Siamo Giunti. could make assisted suicide a “phe- ni, La Rinuncia alla Vita: Suicidio e Tentato Lettere alla Madre, second edition (Parma: nomenon of a most dangerous kind Suicidio Oggi (Esam Futura, proceedings of Ugo Guanda editore, 1992). which most certainly cannot be re- a congress on suicide in Genoa, Feb. 20, E. PELLIGRINO, “Compassion Needs Rea- 1988). son Too,” in Journal of the American Med- duced to a model of behavior gov- Congregation for the Doctrine of the ical Association, 270, 874-875, 1993. erned by merely legalized criteria Faith, Il Rispetto della Vita Umana Nascente C.G. PRADO, The Last Choice. Preemptive (Pellegrino, 1993). e la Dignità della Procreazione (Ed. Paoline, Suicide in Advanced Age (Westport: Green- 1987). wood Press, 1990). Reflection on such questions and Y. CONWELL and E.D. CAINE, “Rational C. PRITCHARD, Suicide—the Ultimate Re- issues does not necessarily mean Suicide and the Right to Die: Reality and jection? A Psycho-Social Study (Philadel- that the health care worker should Myth,” New England Journal of Medicine, phia: Open University Press, 1990). 325 (15), 1100-1103, 1991. T.E. QUILL, C.K. CASSEL and D.E. MEIER, take action. It implies, rather, that he S.J. CUTLER and N.L. DANIGELIS, “Total, “Care of the Hopelessly Ill: Proposed Clini- should in the first place work with Age Specific, and Cohort Trends in Attitude cal Crietria for Physicians-Assisted Suicide,” his own patient towards establishing about Euthanasia 1950-1991,” Paper present- New England Journal of Medicine, 327 (19), ed at the XVth Congress of the International 1380-1384, 1992. the rationality of what is being pro- Association of Gernetology, Budapest, Hun- A. ROY, N. SEGAK, B. CENTERWALL, and jected (Werth, 1996). Secondly, he gary, July 8, 1993. D. ROBINETTE, “Suicide in Twins,” Arch Gen should not adopt absolute opinions S. DAGERMANS, Il Nostro Bisogno di Con- Psychiatry, 48, 29-32, 1991. in relation to actual or potential acts solazione (Milan, Iperborea, 1991). P. SCOCCO and D. DE LEO, “Patologia D. DE LEO, “Dalla Qualità della Vita alla Psichiatrica e Comportamenti Suicidari,” of suicide (Pritchard, 1995), but he Qualità della Morte,” Giornale Italiano di Giornale Italiano di Suicidology, 5 (2), 107- should analyze each individual case Suicidologia, 3 (2), 81-82, 1993. 126, 1995. D. DE LEO, “Fattori Biologici nei Com- F. SCHLUSINGER, S. KETY, D. ROSENTHAL, and condition as if it were unique. portamenti Suicidari: Stato dell’Arte,” Gior- and P. WENDER, “A Family Study of Sui- It should be stressed that al- nale Italiano de Suicidologia, 4(2), 87-100, cide,” in M. Schou and E. Stromgren (eds.), though, on the one hand, the deter- 1994. Origin, Prevention, and Treatment of Affec- ministic approach, which takes R.F.W. DIEKSTRA, “Suicide and Euthana- tive Disorders (Academic Press, London, sia,” Giornale Italiano di Suicidologia, 2:71- 1979). cause and effect into account, may 78, 1992. L. SEIDLITZ, P.R. DUBERSTEIN, Y. CON- in effect diminish the freedom of P.R. DUBERSTEIN, Y. CONWELL, C. COX, WELL, and C. COX, “Attitude of Older People man, on the other, support for the C.A. PODGORSKY, R.S. GLEZRE, E.D. CAINE, Toward Suicide and Assisted Suicide: An “Attitude toward Self-Determined Health: a Analysis of Gallup Poll Findings,” Journal of principle of free choice should in- Survey of Primary Care Physicians,” Journal the American Geriatric Society, 43 (9), 993- volve an awareness of the fact that of the American Geriatric Society, 43(4), 998, 1995. although only a life rich in meaning 395-400, 1995. T. SZASZ, “The Case against Suicide Pre- J. TADA EARECKSON, When it is Right to vention,” American Psychologist, 41 (7), is worthy of being lived, in reality Die: Suicide, Euthanasia, Suffering, Mercy 806-812, 1986. life itself is the only instrument by (Grand Rapids, Michigan, Zondervan Pub- G. VAN DER WAL, M.T. MULLER, L.M. which the richness of this meaning lishing House, 1992). CHRIST, M.W. EIBBE, and J.T. VAN EIJK, G. EVANS AND N.L. FARBEROW, The Ency- “Voluntary Active Euthanasia and Assisted can be achieved (Heyd and Bloch, clopedia of Suicide (New York, Facts on Suicide in Dutch Nursing Homes: Requests 1995). File, 1988). and Administration,” in Journal of the Amer- U. GALIMBERTU, Dizionario di Psicologia ican Geriatric Society, 42 (6), 620.623, 1994. J.L. WERTH, Rational Suicide? Implica- Professor DIEGO DE LEO, (Turin, UTET, 1982). L. GRASSI, “Suicidio Assistito in Fase Ter- tions for Mental Health Professionals President of the International Academy minale di Malattia e Operatore Sanitario,” (Washington: Taylor and Francis, 1996). for Research into Suicide, Giornale Italiano di Suicidologia, 5 (2), 77- L.J. WEST, “Reflections on the Right to President of the Italian Society 83, 1995. Die,” in A.A. Leenars (ed.), Suicidology: Es- for the Study of Suicide W. HABERLANDT, “Der Suizid als Genetis- says in Honor of Edwin Shneidman (North- ches Problem (Zwillings and Familien vale, New Jersey, Jason Arison Inc., 1993). Analyse),” Anthropologiscer Anzeiger, 29, World Health Organization, Division of Dr. PAOLA MARIETTA 69-89, 1965. Mental Health. Guidelines for the Primary Pre- Suicidology Unit, Department of W. HABERLANDT, “Aportacion a la Genet- vention of Mental, Neurological and Psychoso- Neurological and Psychiatric Science, ica del Suicide,” Folia Clinica Internacional, cial Disorders, WHO/MNH/MND/93.25, University of Padua 17, 319-322, 1967. Geneva, 1993. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 155

MARIO FRANCESCO POMPEDDA

Psychic Incapacity and the Sacrament of Marriage

1. Lord Christ—where it involves that nature assumes the task of baptized people—to the dignity of preparing and maturing the male The essential reason and central a sacrament. and female individual for marriage point of connection between the sa- However, the source is the same, and of bringing it into existence. If cred and supernatural entity repre- the act from which the marriage therefore by nature each man is led sented by the sacrament of mar- springs existentially and individu- towards marriage not only can this riage and the psychic (in)capacity ally is the same, the obligations and right not be denied to him without of those betrothed to marry is to be the rights which flow from the pact transgressing the natural order it- found in the fact that the only—but are the same, and the juridical rela- self, but in the same way one could at the same time indispensable—el- tionship which emerges is also the not hypothesize—if not as an ex- ement in the constitution of mar- same. We can safely affirm that on- ception which has to be rigorously riage is consent, and thus that hu- ly in the consent and from the con- justified—a subjective condition man act by which the spouses give sent equally and only is there born which precludes the exercise of themselves to each other, and ac- and contained both natural mar- such a right in practical and indi- cept each other, in mutual fashion. riage and sacramental marriage— vidual form. One must, in contrary This can only be understood if that is, the conjugal bond. fashion, begin with the assumption beforehand attention is paid to the However, consent is in its that precisely because of this natur- relationship between what we can essence and exclusively a human al impulse which involves man be- call a natural institution—that is, act: it is specific, that is, to man. cause of what he is, each individual marriage seen within the frame- But not simply because it is he who person is by nature rendered suit- work of the order and the law of na- carries it out, but because it is able and capable of marriage. ture—and the marriage itself cele- specifically to be ascribed to him There is another anthropological brated and existent between bap- because of what he is by nature—a fact which must be reiterated at the tized people, which is therefore a rational being in whom intellect outset in relation to the subjective sacrament. Without entering here and will interact and operate in uni- elements which are specific to the into profound theological questions fied fashion and in syntony. human psyche. As a consequence and more specifically into the doc- One can therefore say that there of what has just been observed trinal principles relating to Catholic is the sacrament of marriage where about the first anthropological fact, dogma and faith, we can at this between baptized people there is but also in full correspondence to stage simply observe that the insti- consent, that is, a human act. the sufficiently elaborated juridical, tution of natural marriage and of or, rather, cultural requirements, sacrament-marriage is unique, even 2. there must be a reference (and not though this last constitutes, and has in abstract fashion) to the psycho- a very special, physiognomy which Two anthropological facts, how- logical capacities of the betrothed is attributable to the baptism of the ever, should be borne in mind so as persons. It must be effected in prac- spouses—something which be- to avoid the construction and pres- tical terms in relation to unintellec- stows a sacramental character and ence of a theory which goes against tual-volitional development of such thereby has specific supernatural the historical, and in a certain sense a kind as to correspond to the act gifts. existential, reality of man. which is to be carried out—that is, Present-day canon law reminds The first fact is that marriage is specifically conjugal consent. If us in succinct fashion that the mat- not only an institution which be- such were not the case one would rimonial pact by which a man and a longs to the natural order and natur- necessarily be led to affirm (with woman establish a community be- al law which is inherent in human reference to the minimum limit of tween each other for life, and which nature. It is also a state towards the act itself) that marriage could by its nature is directed towards the which man by innate impulse is at- bring within itself individuals who well-being of the marriage partners tracted, a condition towards which were not suitable and indeed inca- and the procreation and upbringing his own psycho-physical develop- pable of a truly human act. This of children, has been raised by the ment directs him. One could say would be contrary to the definition 156 DOLENTIUM HOMINUM itself of marriage as a choice of life. ings are endowed with a volitional no actual possibility of reflecting But at the same time, and where and intellectual faculty which en- and consenting and that there is the maximum term of the act which ables them to be arbiters of their thus no capacity to engage in the is to be carried out is borne in mind, own choices in an aware and re- conjugal pact. one would undeniably end up by sponsible fashion and in particular However, the canonical concept requiring extraordinary intellectual of personal undertakings which in- of psychic capacity in relation to and volitional qualities which are volve them entirely and which are marriage goes beyond this stage be- not to be found amongst most peo- directed towards the creation of the cause it implies the achievement, ple. In this way marriage would good of the other partner in mutual and therefore a situation created by, cease to be that right which is uni- communion, and at the same time maturity—something otherwise versal and present in all men and at of the good of other beings which known as discretion of judgement. base that institution which is funda- may be brought into life through In this state of maturity there is mentally natural. It is therefore a full cooperation. joined to abstract and in a certain human act, but in its rational com- sense theoretical awareness, and in ponent elements correlated and 4. a way which completes it, an effec- thereby proportionate to the reali- tive possibility of evaluation at ty—we should say here to the im- At the base of this set of anthro- least in an essential overall sense of portance which is undoubtedly of pological dogmas there is the pos- the act which is carried out and of essential moment because it in- tulate of an essential but radical its implications. In a specific sense, volves the whole existence of indi- freedom which constitutes a power that is, in relation to the marriage viduals and by indirect routes of the of man. This is not so much a ques- bond, of what it means for the per- whole of society—which is present tion of nonsubjection to external son of the contracting partner, and within marriage. agents—because from this point of thus with an intellectual projection view one would have to speak towards future life, in relation to 3. about the freedom of constriction what must be shared in dual union imposed by other people—but with the spouse—and this where What has been said hitherto more that capacity for autonomous there is no exclusion of the trans- about the inescapable and funda- decision and aware self-determina- mission of life and the upbringing mental anthropological aspects of tion, and thus for conscious plan- which must be given to possible the question in order to delineate ning choice which belongs to the children. the contours of the analysis of this whole existence of the individual We should not consider even this paper necessarily leads us to direct himself. sufficient in the context of integrat- our attention both towards the ac- But the question of freedom ited theological-canonical doctrine tive subject of marriage—which is self is inseparably connected, in- rooted in a modern knowledge of man—and towards the specific and deed logically preceded, by that of man if this doctrine is above all essential object of the choice which the question of the nature and effec- compared with and placed beside he makes within it, that is, the mar- tive operative capacity of the hu- the certain conclusions of recent riage pact or contract. man intellect, that is, of the real fac- psychology expressed by various Indeed, reference to psychic ca- ulty of objective awareness of the schools. This is because maturity pacity (or, conversely, incapacity) true. It is from this point indeed that also implies the ability to choose would make no sense if in talking there begins the whole series of after a conscious evaluation of the about the sacrament of marriage we questions relating to the relation- motives which are involved in that did not make absolutely clear what ship between psychic capacity and choice. Conscious evaluation does we meant by the reality of man and marriage. not exclude that within man there at the same time of the institution of also exist and operate unconscious marriage. 5. motives bound up with impelling All this involves beginning from and almost known impulses which a starting point of philosophical Indeed, what intellectual aware- are present on the threshold of his thought which is therefore also cul- ness in this context are we actually consciousness. Here we are really tural. This is not the place to dwell referring to? touching upon man at his deepest upon the means of demonstrating It is in fact self-evident that part, and at the same time meeting the truth or acceptability of this where the light of reason has been him in his most authentic real and starting point. But it can be said that completely extinguished both for historical existentiality. However, from this point we recognize and persistent causes such as cases of that unconscious can be dominated affirm the presence within the psychosis and more in general all by man and he can place his most world which surrounds us of ratio- those conditions where there is de- essential and vital choices in rela- nal entities or beings. We do so not tachment and alienation from exter- tion to it, that is if we do not want to only theoretically and by doctrinal nal realty, and where there are tran- think—even hypothetically—that definition but also at an existential sitory causes such as complete he does not enjoy that level of intel- level and thus through a reality drunkenness, serious subjection to lectual reason and elective freedom which has demonstrated itself his- drugs or suchlike, because of the which enables him to be seen as the torically in the universality of indi- very fact that an authentic human governor of his own choices and at viduals who take part in human na- act can not exist or take place it fol- an even deeper level of his own ex- ture. These rational entities or be- lows that in the same way there is istence. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 157

If such was not the case in indi- are influenced by psychic distur- ment about the psychic capacity of vidual and particular instances we bance which can not always be de- the betrothed person, and this al- would be dealing with people who fined as “mental illness” (if, that is, ways in relation to that specific would have to be seen as being it is possible to give an exact scien- consent which lies at the base of, mentally incapable. tific sense to such a term) but be- and thus gives effective rise to, the cause of which they do not have marriage itself. 6. complete mastery over their own decisions and are thus unable to de- The action of man, however, is termine and govern them. In such a 8. essentially and definitively pro- case there arises the question— This specific dimension can only duced by his will. And this would which is also to be applied to mar- be truly seen to be present when not be the expression of the human riage and more specifically to the consent, and thus the capacity of person nor would it allow the attri- consent from which the conjugal the subject, is placed in relation to bution of responsibility to the act- pact derives—of their psychic ca- its object, to its own content, and ing subject if he did not bear within pacity. That is if one does not want therefore to marriage. This not only himself the qualification of free- in peremptory and immediate fash- or exclusively in a static sense— dom. We refer here exclusively to ion to argue that in such a case there that is, seeing that human act as it is psychological freedom. is a real and authentic incapacity. formed and constituted (which is This means that man, despite all specifically the act of consent), but the influencing factors which bear 7. also, and above all else, in a dynam- upon him from the upbringing and ic sense. By this is meant that psy- education he has received, from the Considering marriage as an insti- chological moment which gives culture and the social environment tution which is also juridical in rise to the perfecting of a status, of in which he is immersed, from the character and seeing it in this analy- a reality which is the marriage irrational tendencies of his being, sis from this point of view, it is self- bond. Involving a relationship with from his own special emotional evident that such an incapacity another person and in fundamental system, and finally from his own must always be looked for, estab- terms a mutual self-giving-accep- subconscious, is able to arrive at lished and almost circumscribed tance of the human persons of the decisions with conscious delibera- within a sphere which is strictly ju- marriage partners, this would nection and by an act for which he ridical. This must be done with the essarily remain a mere abstraction feels himself really responsible. criteria which belong to this disci- if there were no reference to its sub- This concept which I have just pline, and at a more specific lev- stantial content—that is, to a com- enunciated does not mean the de- el—in relation, that is, to the sacra- mitment to reciprocal behavior—at nial within man of the existence or ment-marriage—with parameters the base of specific obligations to even the directive activeness of in- which belong to canon law. which specific rights correspond ner impulses, of drives which at But this always involves a funda- both relatively and specularly. times are strongly impelling, of mental appraisal of the condition of If therefore in psychological anxieties in relation to the satisfac- the psyche of the subject, and thus terms one or other or both of the be- tion of needs which are connatural of the emotional-volitional-intel- trothed persons were not able to and almost fundamental, or even of lectual mechanism by which an in- meet the requirements of what con- possible psychic deviations which dividual moves within his inner life stitutes the marriage pact, there bring about decisions which are not until he reaches the achievement of would necessarily follow an inca- supported by acceptable motiva- his own decision, of his own pacity to establish that pact, to real- tions and in harmony with his dig- choice, of the formation—in a ize that bond which by its total na- nity. On the contrary, by the em- phrase which is strictly relevant to ture is both temporal and vertical in ployment of this concept there is the subject under discussion—of its dimensional character. the affirmation that notwithstand- the act of consent. Here we ening everything man at the apex of counter a point of contact between his rational and specifically spiritu- canon law and the sciences which 9. al being,in his domination of what study the human psyche, that is, The historical reality in which is placed in his way and what ob- with psychiatry and psychology as we are immersed and in which we structs him, knows how to redis- well—this last being understood as act makes us aware, and at times cover himself in his most intimate experimental research and thus car- with lacerating tragedy, of the enor- and authentic reality. He is thereby ried out with the method of empiri- mous difficulty which man meets able to take rationally motivated cal inquiry (distinct in this way with in being adequately capable of decisions of which he considers from metaphysical or philosophical such an undertaking, of living the himself the author, even though this psychology). conjugal life, that is, in all its impli- is achieved with extreme difficulty. It is the inquiry, with its conse- cations. And at the very deepest This does not mean that we are quent configuration of the individ- level of being capable of a giving of forgetting about individuals who ual in his rationality, which consti- oneself to the other in a voluntary because of a special psychological tutes the basis which cannot be de- and totalizing pact of genuinely hu- personal condition find themselves parted from and which is indeed man love—that which is the very in an anomalous state when com- absolutely necessary in every fur- concept itself of marriage under- pared to that of most other men, or ther juridical argument and judge- stood in its natural sense but even 158 DOLENTIUM HOMINUM more in its sacramental dignity. and insecure man. All this, when This is a message directed to all Here we come up against the in- we consider the sublime commit- men but it is even more valid and fluences and conditioning impact ment of a loving giving of the total- full of meaning for those who cele- of the external world, above all else ity of one’s own self to another per- brate the sacrament of marriage in that sense of the relativity of every- son, could raise serious doubts faith in Christ. thing which seems to pervade con- about the widespread if not gener- To these people Christ once temporary man. That fear, at times alized capacity to take on, and thus again speaks a word of hope that terrible panic, of launching to fulfill, the obligations of mar- through the Church so that there oneself into a project which in- riage. may be installed or re-installed— volves and drags with it one’s own for the good of humanity and for existence into the future. That habit 10. each individual—that natural insti- of living for the fleeting moment tution which the thought of the civ- and directing one’s gaze almost In this stressed context and pic- ilization and philosophy of ancient with repugnance away from that ture of contemporary mankind, the Rome did not hesitate to define as undertaking which embraces to- Church once again is called to re- being “principium urbis et quasi morrow and the day after tomorrow member and indeed to present an seminarium rei publicae” (M.T. Ci- and “always.” That insecurity— image of man where he is certainly cero, De Officiis, I. 54): “the first wrapped at times in external self- weakened in his deepest being, but nucleus of the city and almost the confidence—which makes man is always capable of a life which in seedbed of the state.” cowardly, makes him almost adopt dignified fashion corresponds to an attitude of desperation in rela- one created and formed in the im- His Excellency MARIO tion to his own destiny but primari- age and likeness of God. The living FRANCESCO POMPEDDA ly towards his own moral abilities and illuminating presence of God Dean of the Sacra Rota Romana, Consultor to the Congregation and possibilities. That widespread which is present in the deepest part for the Clergy and to the Pontifical and almost generalized state of of his being contains such force as Council for the Interpretation of neurosis which creates a truly weak to lead man to his highest destinies. Legislative Texts, the Holy See “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 159

FRANCISCO ALONSO FERNANDEZ

Intelligence, Freedom, and Holiness

My first proposal, in an act of the ultimate purpose of this ment, to the realm of spiritual and deliberate discipline, is to respect Eleventh International Conference moral values, transcended by the the order of the title line; therefore when it assigned me, maybe over- sheaf of human freedoms. All of we shall take intelligence as an in- valuing the scope of my experi- which evidences that to the com- troduction and holiness will be ence, a paper with such a compli- plexity of our subject now its discussed in the final section. cate and ambiguous headline. sheer vastness must be added, a In fact, we are dealing with a For, as extremely obvious as the vastness which comprises nothing ladder here, one in which you conclusion just reached is, our less than the metaphysic duality of must ascend the first rung, intelli- subject matter is in itself an ex- essence and existence and the an- gence, in order to access the sec- ceedingly complex one under both thropological duality of nature ond one, freedom, which in turn of the conceptual approaches and spirit. will lead you to the anthropologi- through which it can be addressed: In spite of all these identifica- cal summit occupied by holiness. first, the analytic approach, which tions and coincidences, the For there is a conditioning in this leads us to each of such axes sepa- labyrinth of correlations linking progression: one cannot be free rately and tells us right from the intelligence, freedom and holiness without the intellectual resources beginning about the formal poly- cannot be signposted today with- required to understand the alterna- morphism resulting from their out taking into account their com- tives implied by a free choice, as poly-dimensional structure. mon context, formed by the devel- one cannot be virtuous without a In the other conceptual front, a opment of personality in a post- margin of inner freedom allowing holistic approach allows us to dis- modern environment. In the tran- one to practice morality and good. cover a labrynthine web of hierar- sition from the modern to the post- But the validity of this reasoning chized correlations between these modern society, a society charac- is somewhat relativized when we three axial capacities of the human terized by both a postindustrial remember that, as we shall see lat- being, as well as their complemen- stage of development and the mas- er with greater accuracy, intelli- tary nature—since intelligence is sive invasion of communication gence and freedom in both their ascribed to the psycho-organic media, the three entities here ana- functioning and their structure are plane, freedom to the psycho-spir- lyzed experience severe risks and multiple o plural entities, which itual plane, and goodness or holi- changes, which we shall review therefore require specification of ness to the psycho-ethical plane. here succinctly. the exact variety of intelligence or This complementarity can be Human intelligence now com- of freedom we are referring to at found in the humanistic concep- petes with the artificial intelli- any given time. tion of Max Scheler, which Pinto gence of robots and computers and If there is a person worthy of the Ramos1 summarizes as follows: is exposed to the threat of being utmost idealization in the eyes of while intelligence is biologically contaminated by it. The working all the observers, that is precisely conditioned and is a predictable environment in the Internet, for he who combines the three attrib- structure from the standpoint of example, forces us to think and re- utes contained in the title of this the evolution of life as well as a act as a machine on many occa- paper, and who so does to a degree requisite of the same, freedom and sions, which allows obsessive- that allows him to be proclaimed holiness are fundamental charac- compulsive phenomena to emerge. at the same time a perceptive and teristics of the spiritual being and, The postindustrial society is a con- intelligent, self-controlled and indeed, the spirit is not predictable trolling society which, by defini- free, virtuous and holy, being. In from the standpoint of life and is tion, imposes severe restrictions the combination of this trio of an- not required by it. The fortunate on personal freedom. As a result, thropological axes lies, no doubt, complementarity of these three the human being embarks on a the most sublime paradigm for the positive entities stretches, there- search for escape and easily ends development of a human being fore, from the organic substratum up hooked to that very escape. and human behaviour. To arrive to of life, where intelligence flaps its And so arise the new drugless such a proclamation was, perhaps, wings as the pristine ideal instru- addictions, among which is num- 160 DOLENTIUM HOMINUM bered precisely the Internet-addic- Three human types are consid- while the genius does—or to let tion. In connection with this post- ered as superintelligent, on many his fellow human his beings profit modern decline of values, we occasions on insufficient docu- from his experiences—as the sage should ask the theologians mentation.2 They are the highly- does. whether one could justifiedly gifted person, the sage and the ge- And an act of injustice, because speak of a postmodern holiness, nius. The highly-gifted person, the ways of life of the genius and be it only on a contingent basis. propelled by a vast amount of the sage represent the best human knowledge and information gath- examples to be selected among ered by means of a privileged flu- those possessing a privileged 2. id intelligence, achieves brilliant mentality. results in school examinations and A comparative assessment of In my last book, El talento psychometric tests—an intelli- the highly-gifted person, the ge- creador. Rasgos y perfiles del ge- gence quotient higher than 130 be- nius and the sage by means of the nio, I study the “encyclopedic ing precisely his/her conventional parameters of freedom and holi- face” of intelligence and represent hallmark. ness (or virtue) allows us to con- it in different forms grouped in For their part, the genius and the firm the lower position of the couples: fluid and crystallized in- sage, although they both have a highly-gifted person, who in gen- telligence; verbal and executive highly-developed crystallized in- eral is basically driven by compet- intelligence; natural and artificial telligence, are very different in itive, personal interests or at least intelligence; practical and theoret- other cognitive aspects. The mind encouraged by a tug for competi- ical intelligence. of a genius is distinguished by its tiveness. By contrast, the whole If we perform an anthropologi- original contributions in the form life of the sage is oriented towards cal appraisal of the meaning of of discoveries or creations ob- promotion of social values— each of such modalities of intelli- tained by exercising lateral think- which would allow us to consider gence, the most valuable varieties ing (thinking aside, in Koestler’s3 him, in principle, as the champion of human cognition emerge as the terms), or penser à coté, in which of virtue—while the genius, if he following four modules: creative thinking unfolds itself as is to be recognized as such, must 1st—Crystallized intelligence, an association of logical-rational sustain a demanding struggle with being the operational capacity de- and intuitive thinking with imagi- the environment that puts the so- veloped and maintained by a suffi- native and oneiric insights. Usual- lidity of his autonomous freedom cient thinking and studying activi- ly, the true value of the work of a to a test. ty, allows to cleverly handle per- genius is not adequately assessed sonal experience and to convey it before his death. It is for that rea- to other people and is, in sum, the son that apparent and ignored ge- 3. common heritage of both the ge- niuses are so abundant. nius and the sage; while fluid in- On the other hand, the sage is Beside the existentialist thinkers, telligence becomes most notable worthy of admiration for his bril- Tocqueville4 is one of the modern in the production of information, a liant ability to learn from experi- philosophers who has proclaimed process that reaches its highest de- ence, as well as for his great facil- freedom as the supreme value of velopment in the highly-gifted ity to communicate, which allows human life with strongest empha- person. him to afford his experienced wis- sis. Zubiri, the great Spanish 2nd—Verbal intelligence, dom to his fellow human beings philosopher, attaches freedom to which is defined by working with with particular dexterity. the ultimate essence of man. Al- images of words and is much Academic policies, choosing to though many other quotations on more resistant than its opponent, place themselves at the service of the excellence of freedom could be executive intelligence, to the at- those achieving the best results in produced here, the highest merit tack of age. school tests, many of whom be- corresponds to the ancient Judeo- 3rd—Natural intelligence, long to the highly-gifted stock, Christian notion according to which is characterized by the al- have ignored the members of the which every man is free since he is ways-present task of rational com- two other classes of superior cog- fully responsible for his life. prehension, an activity which is nitive structure: those who learn Let no one, however, believe not to be found in any kind of ma- and reason wisely and those who that all opinions coincide on this chines. These, although recog- take paths untrodden by the com- fundamental issue. Always, al- nized as possible artificial-intelli- mon logic in order to build un- though more in the past than gence entities, may be qualified, known elements. nowadays, there have been nega- on the grounds of such a handicap, This preferential treatment of tors of human freedom, who pos- as stupid artifacts. the highly-gifted to the detriment tulate that everything is deter- 4th—Theoretical intelligence, of the sage and the genius is both mined. that enables us to build symbols, an error and an act of injustice— Kant, the philosopher of reason, to set out problems and to make the former as serious as the latter. postulates that human action is questions; while its opponent, An error, because the highly-gift- free not because it is not deter- practical intelligence, operates as ed person is a triumphant profes- mined o hetero-determined, but a kind of adaptive capability at a sional who is nevertheless unable because it is self-determined in the much lower mental level. to contribute a single new idea— form of a will governed by ratio- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 161 nal motives. We had better speak ger, until it becomes uncontrol- 4. of freedoms, in the plural, in order lable and irrepressible, in the to harmoniously link all the vari- pathological matrix of those mod- Sanctity cannot be attested in a eties of freedom, each of them en- ern illnesses we call drugless ad- subject who does not possess a dowed with a highly-developed dictions. Apart from this partial or conjunction of intellective devel- structural dimension. The two ba- selective loss of freedom attested opment and exercised freedom sic varieties of freedom, around in the field of addiction, inner free- that allows him to be considered, which all the others revolve, are dom is always impaired when a to say it with Max Scheler, a per- the freedom of choice, as an indi- psychic disorder occurs. There are son in the full sense of the word, a vidual freedom (although Saint total or partial impairments (as in capable and free individual re- Agustine called it libertas minor) addiction) and gradual impair- sponsible for his own acts. Such a and the civil liberty, as a social ments (the loss of only degrees of person is the owner of his behav- freedom. In order to establish a hi- freedom). Mental illnesses are iour. And the latter, in turn, de- erarchical order between them freedom illnesses, and psychiatry serves to be described as a per- both, we should listen to Una- is the pathology of freedom. One son’s conduct. In Schelerian termi- muno: “Freedom is in mystery; of the basic aims of practical psy- nology, he who is not a person, freedom is underground, and it chiatry is to restore their inner cannot be a saint, or, more accu- grows inwards, not outwards. freedom to the mentally ill. rately, cannot be taken as a model Freedom is not in the foliage, but Regarding external freedoms, of sacred values. in the roots.” our starting point might be natural Let us not forget that holiness in The freedom to choose among freedom, which is only limited by the result of an appraisal, a posi- several options is a common prac- the individual’s capacities, and tive religious appraisal of a person tice in life, usually carried out which takes shape in the basic va- with a proven exceptional conduct without need of deliberation. riety of civil liberty when the nat- pervaded by some difficult virtue. Therefore, most of the people are ural human rights are limited by Man’s estimating ability first not conscious of the role they play the general interest as result of liv- appeared in the world with the in the process of choosing. “A ing in society. Also in this front, emergence of moral conscience. A choice is only meaningful here and psychiatry has adopted a well-def- book of mine discusses this sub- now, it only exists in the present.” inite position. “Psychiatry finds ject in depth, following the train of (McEvoi5). Freedom of choice is the normal conditions for its prac- thought of the acute ideas con- strongly conditioned at its source tice in a social field where the tributed by the Swiss psychiatrist by moral freedom, without which dominant ideology has taken pos- Manfred Bleuler. The appraising it would become mere arbitrari- session of the natural freedoms” function capable of distinguishing ness. In some choices also partici- (Sztulman8). This quotation firmly good from evil, fair from unfair, pates a careful examination of the establishes the impossibility of ad- filled the first-established concep- available options by means of equately developing the science of tion of conscience. For a long time hope, which induces us to decide mental health in a freedomless the only concept of consciousness on feasible options or alternatives, waste, as well as the psychiatrist was the concept of moral con- and/or foresight, that allows us to refusal to be manipulated, whether science, which is the meaning of weight in advance the possible and as a victim or as an accomplice, by Greek syneidesis and its Latin suc- probable results of each option. a freedom-killing environment cessor cum-scientia. Only after the With these ultimate conse- ruled by regressive laws—false Renaissance the meaning of a con- quences of the freedom of choice laws, in Nieto Blanco’s opinion.9 science capable of moral Knowl- is linked still another, rarely-dis- Jaspers10 presents rational dia- edge extended to cover all kinds of cussed variety of inner freedom, logue and tolerance as two imma- knowledge, giving rise to the no- which might be termed freedom of nent attitudes in the exercise of tion of consciousness in the psy- action. To exercise it, as Kant said, freedom. Both of them stem from chological sense. does not mean to erase the wish the acceptance of a plurality of The German language [also] has chosen by will, but to be able to ways of thinking and living. “The two designations for the Spanish withstand it and control it, prevent- reproach projected on the tolerant word conciencia [meaning both ing it from becoming behaviour. that his acceptance of the other’s “conscience” and “conscious- Hume6 (1711-1776), the great clas- ideals and beliefs is due to the ness”]: Gewissen, which means sical empiricist English philoso- weakness of his own ideals and be- moral conscience, and Bewu§t- pher, postulates that freedom can liefs belongs to the particular logic sein, which means psychological only be understood as “the power of the fanatic conquerors of ab- consciousness. While the origin of to act or not to act in accordance to solute truths” (Alonso-Fernán- Gewissen, the word used to trans- the determinations of will.” The dez11). late Greek syneidesis, is lost in the clinic study of addiction, especial- None of the conceptual varieties mists of time, Bewu§tsein started ly of drugless addiction, the addic- of freedom here discussed (free- to be current only in the beginning tion to non-chemical objects, such dom of choice, freedom of action, of the nineteenth century, and was as food, sex, television, buying, moral freedom, civil liberty and le- used to reflect a new meaning of game and work,7 has shed the gal liberty) is alien to the field of consciousness established by the clearest light on this freedom of virtue, which we shall address Romanic languages. action. A wish that grows ever big- now. With this is proven by historio- 162 DOLENTIUM HOMINUM graphical means that the estimat- as data accessible only to subjects axiological models, offering three ing function of the moral con- capable of perceiving them by exemplary profiles: the saint, in science is immanent to the human virtue of their estimating ability. the sphere of sacred values; the ge- spirit, and that its late extrapola- Max Scheler’s ideas coincide in nius, in that of the spiritual values; tion to all kinds of knowledge the first and third respects, but not and the hero, in the vital sphere. marks the emergence of con- in the second. The objectivity of sciousness in the psychological values, according to Max Scheler, sense as a kind of secularized con- as in general that of ethics—which 6. science.12 is the science that holds the key to axiology—is severely relativized While goodness is a moral by History. judgement that, as we have seen, 5. Regarding the third Orteguian has been valued by human con- postulate, Max Scheler holds a ful- science since its very beginnings, To address now the problem of ly concurring opinion, since mod- the perception of mysticism, which axiology in general. The conceptu- ern resentment is in his opinion the merges with goodness to give rise al development of axiology as the origin of the trend to judge true on- to holiness, is more problematic, science of values represents an ly what everyone holds to be true, since it presents many different amazing achievement of the twen- as though unanimity were a criteri- faces. The longing for the ab- tieth century. It was the Spanish on of truth. Men, he adds, agree solute, the search for the transcen- philosopher Ortega y Gasset13 who only about the lower values. The dent, the experience of the mys- sensed with greatest clarity this higher values will be negated or tery, the direct connection with Di- feeling of amazement: “Thus, the reduced to lower ones by many vinity, the state of special conversion behind which Worth has people. This is how an inversion sciousness of a believer: these are most often preferred to disguise it- of the axiologic hierarchy takes some of the experiences used to self has been the idea of Good. For place, according to which the val- define or describe mysticism.16 centuries, it was through the idea ues ascribed the spheres of useful- As an example of the contrasts of the good that thought came ness, pleasure and economy are or oppositions to be found among closest to the idea of the worthy. raised to absolute values. different mystics, let us remember However, Good is but, whether the A similar error has extended to that, while the genuine mystic ex- substratum of value, or a kind of the field of health as well. Thus, perience is luminous, the supreme values, a species within the genus the phrase “health ethics” has Spanish mystic, Saint John of the Worth.” served as a protecting wall used to Cross (1542-1591) reaches the No less amazing is that precise- equate healthy with good, in trans- summit of mystic spirituality with- ly our century, the setting of so gression of the limits between in a real and experienced environ- many atrocities (the evil of our haleness and morality. The moral ment of darkness and night. The century has been defined by John significance of health depends on encounter between God and Man Paul II as a crisis of values14), has how it is achieved and used. There takes place, in Saint John of the been the womb capable to give are evil ways of using or achieving Cross, nightly. Our Saint conse- birth to the development of the good health. Pascal even referred crates night to God, and day to fundamental values of reason. The to a “good use of illness.” Con- night. facts and circumstances that al- trary to the contentions of the “The dark night of the soul” is lowed this birth to take place at Philistines of the ethics of a vitali- the passage to transcendence, that moment were accumulated ty which invades the supravital which Saint John identifies as a during the eighteenth and nine- values, there are many ill people dark night because in it the follow- teenth centuries. who are extremely valuable for so- ing two key aspects are united: Foremost among the scientists ciety and who represent moral first, the absence of incandescent and philosophers who with ade- models. light—“the darkness of the soul”. quate training write about values The catalogue of axiologic mod- Saint John of the Cross adopts a are the thinkers Max Scheler and els valid for a concrete existence conflicting stance in respect of the Ortega y Gasset, united not only (Dasein) varies with the authors, general mystic experience when, by this common concern but also not only in the types they include, after conceiving this life as truly by a friendly relationship, al- but also in the hierarchical organi- dark night, he feels the rapture of though their opinions may differ in zation of the same. The most fre- the darkness of darknesses em- some respects. quently used supreme concept is anated by God, not letting himself According to the Orteguian con- that of moral goodness. Spranger15 be troubles by the two curses of ception, the values are positive or systemizes the most appreciated night: the dramatization of death negative meanings characteristic human models into the following and the concealment of the real be- of the real things and they conform four types: the Homo theoreticus, hind the unreal. to an objective scale, although on- linked to truth; the Homo aestheti- In his Hymns to the Night, No- ly some people can perceive them. cus, linked to beauty; the homo so- valis proclaimed the nocturnal re- Thus, ortega describes the values, cialis, linked to altruism; and the ligion as the religion of death. In first, as “unreal qualities residing Homo religiosus, linked to good- his poems, some of them still un- in real things or objects”; second, ness. Max Scheler devotes his un- decipherable, Saint John of the as objective elements; and, third, finished posthumous work to the Cross talks with God, Death and “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 163

Freedom. Since John of Avila, Notes Evolution Psychiatrique, 1977; 42, 2:657-666. 9 NIETO BLANCO, C., Figuras de la libertad, apart from being perceived as a 1 PINTO RAMOS, A., El humanismo de Max Revista de Occidente, 1990; n¼ 107:112-140. great saint and an unusual mystic, Scheler, Autores Cristianos, Madrid, 1978. 10 JASPERS, K., Allgemeine Psycopathologie, was a sage infused with the gift of 2 ALONSO-FERNANDEZ, F., El talento Springer, Berlin, 7» edizione, 1959. creador, Ensayos temas de Hoy, Madrid, 11 ALONSO-FERNANDEZ, F., Conducta hu- Spanishness and took the appear- 1966. mana, in: Psicología Médica y Social, Salvat- ance of lonely Quixotic figure, 3 KOESTLER, A., The act of creation, Pan Masson, Barcelona 5» edizione, 1990, pp. 148- who maybe secretly inspired Una- Books, London, 1963. 158 e 437-441. 4 TOCQUEVILLE, A., Voyages en Angleterre, 12 ALONSO-FERNANDEZ, F., Conciencia y muno’s verses: “He aquí un es- Irlande, Suisse et Algerie, Oeuvres Papiers et atención, in: Fundamentos de la Psichiatría pañol, un Don Quijote,/un pobre Correspondance, Gallimard, Paris, 1958, p. actual. Paz Montalvo, Madrid, 4» edizione, 1¼ pasmarote...” [Here we have a 91. tomo, 1969, pp. 305-340. Spaniard, a Don Quixote,/a poor 5 MCEVOY, TH., The existential dynamics of 13 ORTEGA Y GASSET, J., Introducción a una free choice, Journal of Existentialism, 1967; estimativa, in: Obras completas, Revista de simpleton...]. 7, 29:1-17. Occidente, Madrid, Tomo VI (1941-1946), 2» 6 HUME, D., De la libertad y la necesidad, edizione 1952, pp. 315-335. Professor FRANCISCO ALONSO in: Investigación sobre el conocimiento hu- 14 GIOVANNI PAOLO II, La splendeur de la FERNANDEZ mano. Alianza Editorial, Madrid, 1980, pp. verité, Ed. Mame, Paris, 1993. 104-127. 15 SPRANGER, E., Formas de vida, Revista de Emerity Professor of Psychiatry 7 ALONSO-FERNANDEZ, F., Las otras dro- Occidente, Madrid, 1066 at the Complutense University (Madrid) gas. Alimento, sexo, televisión, compra, juego 16 ALONSO-FERNANDEZ, F., Estigmas, levita- Member of the Royal National y trabako. Temas de Hoy, Madrid, 1996. ciones y éxtasis, Temas de Hoy, Madrid, Accademy of Medicine (Spain) 8 SZTULMAN, H., Lyberté et Psychiatrie, 1994. 164 DOLENTIUM HOMINUM

ERMANNO PAVESI

The Intelligence of the Universe

To speak about “intelligence of other interpretations of reality. In The Aggregation the universe” might seem like a extreme cases the very concept of and Organization of Matter provocation to many currents of reality itself is called into question contemporary thought. What has on the grounds that it is itself un- Let us take as an example a sub- characterized and continues to knowable and that the image stance such as calcium carbonate. characterize certain tendencies of which man has of it is in actual This substance is to be found in na- both science and the interpretation fact merely a subjective represen- ture in very different forms and is of the results of scientific research tation if not an erroneous con- the constituent part of anorganic is an attempt to explain reality in struction. forms such as stalactites and sta- unified terms as the product of a The natural sciences such as lagmites, a snail’s shell, or the development of matter which has physics and chemistry can con- shells of other kinds of mollusc. taken place in conformity to natur- tribute to expanding and improv- When one goes into certain grottos al laws. The description of this de- ing our knowledge of reality be- one is often amazed at the richness velopment seeks to exclude com- cause they explain certain aspects in forms of the stalactites and sta- pletely not only a supernatural ac- of it but they are not able to give a lagmites which at times seem to tion but also the existence of a reason for reality in all its aspects, take on the appearance of humans plan, a meaning or a purpose in rein its entirety, especially when it or certain kinds of objects. The ality at all its levels: the universe, comes to consider the whole ques- form of each stalactite, however, is living creatures, and mankind and tion of life forms. It is precisely purely a matter of chance and is the its own special existence. In other the study of life forms, that realm result of a process of sedimentation words it is implied that the teleo- where the organization of matter is involving the calcium carbonate logical question has no meaning. more complex, which reveals that which is contained in those drops The task of the scientist, it might they cannot be explained solely of water which have dripped down be asserted at the outset, is certain- with reference to the laws of for centuries or even millennia. It ly to study reality through the em- physics or chemistry. should be stressed that only obser- ployment of the scientific method vation is able to recognize the sim- and the making of clear distinc- ilarity between external form and a tions between facts, demonstrable form which really exists. laws, theories and working hy- In the case, on the other hand, of potheses. the shell of a snail we encounter a The way of looking at things precise form. The three-dimen- which sees the universe as a cos- sional helicoidal form corresponds mos, as the expression of order to a plan of construction which is and harmony, has been placed in very precise. The growth of the doubt during the past and during shell cannot take place within a recent decades various thinkers process of chance or by means of have asserted that new knowledge automatic advance through the im- in the field of physics has led to its position of new layers of calcium confutation in definitive and in- carbonate because the angle of the contestable fashion. curves and the diameter of the sec- The theory of relativity, quan- tion change constantly. When we tum mechanics, the principle of study a shell, we must recognize indetermination, theories about that at each moment of its forma- the origins of the universe, lines of tion the snail secretes the calcium argument derived from the study carbonate in a way which con- of the infinitely great and the infi- forms to its final form. nitely small, have all sought to A section of the shell of another throw doubt upon the validity of mollusc, the nautilus, brings out “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 165 the precision of its internal archi- This theory has been criticized presence of water in the “pre-biot- tecture. It contains chambers orga- by many scientists. The German ic brew.” The reactions of synthe- nized in a regular way which go to chemist Bruno Vollmert, for exam- sis are reversible and the length of make up a logarithmic spiral. ple, emphasized that in the experi- the chain is inversely proportional From a physical point of view, ment conducted by Miller the to the concentration of the water. the atoms of a stalactite cannot be component elements of DNA the This facilitates the fractioning of different from those of the shell of nucleotides were only produced in the chain to the point of even pre- a snail, and from a chemical point minimal quantities and that there venting its formation if the con- of view we are dealing with exact- were, above all, substances with centration is such as to render the ly the same kind of salt. There ex- only one radical, such as formic reactions of splitting faster than ists, however, a substantial and im- acid and monamine, which are not those of the synthesis. Vollmert be- portant difference between these adapted to the formation of a long lieves that the “pre-biotic brew” is two formations. In the case of the chain. Vollmert used a comparison not suitable for the formation of stalactite, the aggregation of the to support his criticism. Let us chains of the length of DNA and calcium carbonate has taken place imagine the formation of a chain therefore that “one must regard the in conformity to chemicophysical where we take a pearl at random formation of a chain of twenty to laws. Its external form is purely a out of bag. Some of these pearls fifty nucleotides as being impossi- question of chance, and at any giv- have one hook and some have two. ble in itself.”2 en moment it is impossible to pre- When a pearl with only one hook Friedrich Cramer, the director of dict with precision how its shape has been added the chain can go on the Max Planck Institute for Med- and character will develop in the in one direction until another pearl ical Experimentation at Gottinga, future. But in the case of the shell with only one hook is encountered. also believes that “the origins of of a snail the growth certainly in When we know the respective per- life cannot be explained by a mere the same way depends upon the centages of the two kinds of pearls reference to chance without rules: physicochemical properties of the that are present in the bag we can life on earth has developed with calcium carbonate, but it also takes calculate the probability that a much greater ease than would place according to a very precise chain of a given length will be have been possible through simple plan which is based upon the infor- formed. In discussing the “pre-bi- statistical fluctuations. It might ap- mation contained in the genetic otic brew” obtained by means of pear that from the very beginning a patrimony of the snail itself, which Miller’s experiment, Vollmert mechanism was at work which se- is codified within the DNA struc- makes the following declaration: lected the “right” molecules and ture of this living creature. “Every chemist who is an expert in allowed them to survive.”3 the field of polymerization knows As a chemist, Vollmert tries to that in a mixture of this kind where explain the chemical basis for cer- DNA substances with only one radical tain biological transformations— predominate, macromolecules namely, that the appearance of a DNA is a chain made up of a se- such as DNA or proteins cannot be new gene presupposes the appear- quence of four special mole- formed.”1 ance of a new segment of DNA. cules—the nucleotides. This se- Vollmert emphasizes the role of Estimating the average length of a quence amounts to an archive another factor which can block the gene at 1,500 nucleotides, which contains the codified infor- formation of long chains—the Vollmert observes that there are mation necessary to the develop- 101,000 possible combinations and ment and the life of every living that as result a chance appearance organism. Without DNA, there- of the “right” sequence is absolute- fore, there can be no life. ly improbable. Before the defini- After Stanley L. Miller had tive appearance of the complete demonstrated experimentally that gene the formation of this chain by passing an electric current cannot even be guided by the se- through an atmosphere made up of lection factor. Indeed, if one ex- water vapor, methane, and ammo- cludes every kind of finalism, it nia one could create numerous must be recognized that it is only chemical substances synthetical- by chance that a segment of DNA ly—among which are to be found which has formed itself sponta- the basic components of organic neously is able at a certain moment composites—the thesis came to be to demonstrate that it contains the advanced that reactions of this information by which to produce a kind during the primordial period new enzyme. led to the formation of these sub- Indeed, it should not be forgot- stances in such quantities that ten that a chain of molecules is there was a spontaneous synthesis nothing more and nothing less of ever-more complicated chains than a chain of molecules. At the which in the end gave rise to sys- very moment at which we refer to tems which were able to reproduce a sequence of nucleotides, we nec- themselves. essarily introduce new cate- 166 DOLENTIUM HOMINUM gories—that is, we consider that on its own axis like a propeller. tainly permits the transmission of chain as a chemical structure The rotary movement of the flagel- oxygen but its methods are insuffi- which has certain built-in kinds of lum is created by the difference in cient for the needs of the body. information. Moreover, the codi- potential which exists between the Haemoglobin has certain special fied information is only a useful internal and external membranes characteristics. Its affinity with the plan of construction if a “reader” of the cell wall. Here we encounter oxygen changes with temperature system is also present—a system a mechanism which can be com- and acid levels. It reaches a higher which is able to read and decodify pared to that of an electric motor level in the lungs and a lower level the information contained in the but which has exceptional capaci- in the peripheral tissues. This structure of the DNA. In addition, ties because it is able to perform means that there is an increase in another system must also be pre- 15,000 rotations a minute—a no- the efficiency by which oxygen is sent which is able to carry out the table performance which is incon- transmitted. instructions. ceivable for man-built electric mo- The role of haemoglobin be- tors.5 comes even more complicated and Even at the level of monocellu- problematical when one comes to Living Organisms lar micro-organisms we find our- consider a special stage in the life selves face to face with complicat- of man—that of the foetus. If one passes from the individual ed and intricate functions which During life within the womb the gene to the DNA chain of the most are made possible only by factors oxygen-carbon dioxide exchange simple organisms we know which are very different in charac- does not take place at the level of about—those made up of a single ter: the movement of the protozoan the lungs in relation to outside air cell like, for example, the es- depends upon the rotation of the but at the level of the placenta cherichia coli—the probability of flagellum which in turn is deter- through the blood of the mother. If finding the right combination be- mined by the way in which the fla- the foetus had the same haemoglo- comes even more remote. The gellum is connected to the cellular bin of the mother there would be a above-mentioned director of the wall. The difference in potential rather limited exchange of oxygen Max Planck Institute of Medical between the internal and external through the placenta—that is, until Research has calculated that the membranes must be such as to al- the concentration of oxygen in the number of possible combinations low this movement and must be haemoglobin of the foetus had not in genetic writing is 102,400,000. His proportionate to the dimensions of reached the levels present within conclusion is more than forthright: the flagellum. All the information the mother. During the womb “It is therefore impossible to ob- relevant to these characteristics is stage man has a special kind of tain this plan of construction of a contained in an equally large num- haemoglobin which is called foetal living organism by mere chance. A ber of genes present in the DNA of haemoglobin and this displays an hypothetical robot which could try this protozoan. affinity with the greater oxygen of out and assess a new combination the haemoglobin of the mother. would not be able—even to the For this reason it is able to achieve slightest extent—to go through the The Complexity a higher level of saturation through whole range of possibilities even if of Life Processes the maternal placenta. it worked without interruption for These facts and elements bring a period equal to that from the Big As in the case of escherichia out the complexity of the whole Bang to the present day (= 1017 coli, the increase in our scientific question. The foetus has to have a seconds). Indeed the time neces- knowledge about biological haemoglobin which has an affinity sary for such an exercise would be processes demonstrates their ex- with the greater oxygen of the equal to about 102,400,000—17 which is treme complexity with ever adult but such affinity can not be 102,399,983 times the age of the uni- greater force. The different func- such as to create a stable link verse. The entire age of the uni- tions are possible because of ex- which would prevent the transmis- verse therefore takes on almost tremely diversified functions and sion of oxygen at a peripheral lev- negligible proportions when com- the action of innumerable enzymes el. It is rather difficult to believe pared to the time needed for an which must act at the right mo- that these two different kinds of “order produced by chance.”4 ment and in the right place. haemoglobin—which correspond An examination of the structure Let us take haemoglobin as an to such very precise needs and re- of the escherichia coli also in- example and the accompanying quirements—appeared by chance. volves many surprises because it transmission of oxygen from the At the moment of conception, has a notable complexity. The es- lungs to the body tissues. We can within the fertilized ovule, we find cherichia coli belongs to the group take it for granted that here we are that in this miniaturized archive of flagellata, bacteria which have a dealing with a very simple reac- which contains the programs for filiform extension which is called tion: the haemoglobin becomes the production of about 100,000 a flagellum. The flagellum of the saturated with oxygen within the different proteins there are also the escherichia colli is not only the ex- lungs which are in contact with the programs for these two types of tension of the wall of the cell. It is external air which is itself rich in different haemoglobin. They have also fixed to the wall of the bac- oxygen, and proceeds to dispense extremely specific separate char- terium by means of a kind of small that oxygen to the peripheral tis- acteristics and also contain the in- cushion which enables it to rotate sues. This mechanism in itself cer- formation which is needed to halt “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 167 the formation of foetal haemoglo- ing because it recognizes that the Notes bin after birth and ensure its substi- development of life as it has taken 1 BRUNO VOLLMERT, Die Entstehung der tution by adult haemoglobin. place is not conceivable without Lebewesen in Naturwissenschaftlicher Sicht. the existence of an idea, of a pre- Darwins Lehre im Lichte der Makromoleku- cise plan. This certainly represents laren Chemie (The orgins of living organisms from the scientific point of view. The doctrine The Self-Organization an advance on the more radical of Darwin in the light of macromolecular of Matter? forms of mechanistic materialism. chemistry) (Gustav-Siewerth-Akademie, On the other hand, however, it sees Weilheim-Bierbronnen, 1995), p. 37. 2 BRUNO VOLLMERT, Das Molekul und das Modern-day scientists recognize self-organization as a physical Leben. Vom Makromolekularen Ursprung that we have here immensely com- property of matter. nicht und der Arten: Was Darwin nicht Wis- plicated and intricate problems The recognition by scientists sen Konnte und Darwinisten nicht Wissen Wollen (The molecule and life. The macro- and questions and that everything that the observation and study of molecular origins of life and species: what is greater than the sum of the parts. nature leads to the conclusion that Darwin could not know and what the Dar- For this reason it is a mistake to try there must be the existence of a winians do not want to know) (Rowohlt, Rein- beck Bei Hamburg, 1985), p. 63. to explain the whole as an aggre- plan or an idea constitutes an im- 3 FRIEDRICH REINBECK, Caos e Ordine: la gation of individual component portant turning point: within the Complessa Struttura del Vivente (Bollati Bor- parts. For this reason the theory universe the work of intelligence is inghieri, Turin, 1994), p. 131. 4 Ibid., p. 32. that the origins of life and the de- recognizable. The question of the 5 Cf., WOLFGANG KUHN, Alles nur Zufall? velopment of living organisms is nature of this intelligence then Schopferglauben und Naturwissenschaft (All the work of chance also fails to arises, but this is a problem which a question of chance? Faith in the creator and the science of nature) (Johannes-Verlag, stand up. Contemporary scientists, is not the exclusive field of con- Leutesdorf, 1994), pp. 15-19. however, seek to propose other cern of the man of science, but theories to explain the “natural” which necessarily also involves appearance of these complex sys- the representatives of other disci- tems. One of these is that of the plines. self-organization of matter. Ac- cording to this theory, matter from Dr. ERMANNO PAVESI the very outset, that is to say from Professor of Psychology the moment of the Big Bang, con- at the Gustav Siewirth Academy, tained within it the “idea” of its Weilheim Bierbronnen, Germany, and at the Theological Institute own organization, the very plans of Coira, Switzerland, of all future developments. and Secretary of the Catholic Medical This theory is certainly interest- Association of Switzerland 168 DOLENTIUM HOMINUM

PAOLO PANCHERI

Man in the Nakedness of His Madness and the Meaning of His Delirium

Delirium has always been seen and in which that person has lived. ly follow that the medical model as the essence of madness. To be What, however, has changed as of interpretation must be defini- in a state of delirium means to a result of the context has always tive in its understandings or even transform the world from a sub- been the interpretation of the actually correct. We can only say jective point of view and thereby alienated state of the delirious per- that in our culture the medical lose the borders between internal son. At various times the interpre- models enable us, far better than reality and external reality. It tive model has been mystical, others, to intervene in various means an abandonment of the magical, or diabolical in orienta- ways and bring back the delirious community of social thought to tion or has taken some other form. person to the social community which one belongs and entrance During the contemporary period and promote the passage from an into a fantastic universe which is and within Western civilization “alienated state” to a condition of detached from that same commu- the dominant interpretive model “normality.” nity. It means losing every ability has, however, been of a medical Obviously enough, the person and capacity for critical appraisal kind. who is delirious does not believe and evaluation about this subjec- The medical model sees deliri- at all that his thoughts, his beliefs, tive transformation of the world. um as a mental illness or distur- his rooted certainties, and his The person who is delirious los- bance, it places it as a symptom forms of behavior are “alien” or es his ability to adapt his own be- within a wide range of psychiatric the result of some form of “mental havior to that of others, and as a syndromes, and it describes its illness.” As a result, he rejects this result his own actions become phenomenological characteristics, medical interpretation of his psy- bizarre, anomalous, deviant, un- whose possible causes at the level chic life and thus resists every predictable, and unforeseen. The of the biological mechanisms of kind of therapeutic treatment. abandonment of the social com- the working of the brain are then The problem thus becomes a munity and the withdrawal into a studied, or at least an attempt is matter of seeing the medical doc- fantastic world which excludes made to study them. tor as a delegate of the social body critical judgment involves the Of course, it does not necessari- who inquires into whether the be- delirious person’s becoming seen liefs of one of the members of the as an anomalous element and a community have the characteris- disturbing factor within the group, tics of actual delirium or mental whether in a narrow or wide sense, illness. He is also to decide on to which he belongs. He becomes whether, as a result, steps should the object, because he is an be taken to temporarily restrict the “alien,” of stigma and of social ex- freedom of that person and clusion. Moreover, he also falls whether the forms of treatment victim to demonstrations and ex- prescribed by the dominant med- pressions of aggression and vio- ical model should be applied. lence. It is therefore of essential im- During the history of humanity portance to define the contours the person who displays what we and limits of delirium, achieve a today call the symptoms of deliri- description of its formal character- um has always been the object of istics from a psychopathological these reactions on the part of the point of view, and determine its social body to which he belongs. “understandability” in relation to However, these reactions have ex- the context, in addition to carrying pressed themselves in different out an analysis of its component ways and forms according to the parts and essential features. sociocultural and historical con- Everybody is well aware of the text in which they have taken place risk connected with a medical in- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 169 terpretation of a subjective belief psychopathology according to personal certainty which is not as being a phenomenon of deliri- Jaspers: subjective certainty, in- amenable to correction. um when on analysis its character- corrigibility, and falseness (im- The problem is complicated by istics do not bear the features of possibility) of the judgment. the fact that there are “incorrigible “illness.” Whereas all the criteria of subjec- subjective certainties” to which tive certainty (“false personal be- one cannot apply the rigorous but lief”) and incorrigibility are mere- clinically acceptable criterion of The “Formal” Characteristics ly outlined or defined in summa- extreme deviance in relation to the of Delirium rized form, a great deal of empha- dominant certainties of the group sis is placed upon the definition of to which the individual belongs. All the major exponents of Eu- the criterion of the “falseness” of This is particularly the case when ropean psychopathology have ad- the judgment, which is altogether one comes to consider the subjec- dressed themselves to the complex more problematic and difficult. In tive certainties about internal real- and intricate question of achieving this respect as well, the DSM III-R ity and the individual experience a definition of delirium through an is in line with classic psy- which is itself separate from exter- analysis of its formal characteris- chopathology. nal reality. tics. Among these leaders in the It is useful here to refer to the It is more than evident that in field, Jaspers has made the most pages written by Jaspers to define this area the criterion of compari- important contribution by estab- the concept of “reality” (from son with the social certainties of lishing the three fundamental which, however, it is rather diffi- the group is not possible because characteristics which enable us to cult to extrapolate operative con- the statements about internal reali- identify the presence of a distur- cepts) and to the attempt by ty, precisely because they involve bance caused by delirium. These Schneider to make the judgment the singular experience of a spe- have been in large measure adopt- about the “falseness of the con- cific individual, cannot in theoret- ed by the psychiatric schools of tents” less problematic; in this en- ical terms be considered deviant thought of the English-speaking deavor he drew attention to the but must be seen as having their world and have also entered the formal differential characteristics own uniform validity. texts and manuals of contempo- between delirious perception and Those experiences, therefore, rary psychopathology, in addition delirious intuition. which refer to the inner reality of to the glossary of the principal The DSM III-R instead follows an individual—even though they system by which mental illnesses a criterion of a social kind which is have the characteristics of subjec- are classified (DSM). based essentially upon the “ex- tive certainty—should not be seen The three criteria which Jaspers treme deviance” of the belief of as examples of “delirium,” but as employs are “subjective certain- the affected individual in relation “alterations of the person’s experi- ty,” “incorrigibility” in the face of to the context of the opinions of ence.” logic and evidence, and the “im- the people in the group to which It should be stressed that the possibility” (or falsehood) of the that individual belongs. It seems whole question and difficulty of content of what is said. The DSM obvious, therefore, that from the approaching the essence of deliri- III-R defines delirium in the glos- use of the DSM III-R it also diffi- um with reference to external real- sary on the classification of mental cult to establish absolute and valid ity has been well understood by disturbance with the following criteria by which to achieve a con- the authors of the DSM III-R, who sentences: stant appraisal of the falseness of a in their definition of delirium refer “Delirium. A false personal be- to the “incorrect inference about lief based upon an incorrect infer- external reality.” ence about external reality which In fact, this attempt to avoid the is upheld with conviction notwith- crucial question of the “falseness standing the fact that nearly every- or impossibility” of the content of body else believes the opposite what is affirmed through a distinc- and which is in opposition to what tion between beliefs about internal constitutes incontrovertible or ob- reality and external reality raises a vious evidence or proof to the con- series of problems and difficulties trary. The belief does not belong to which have still not been resolved. those commonly accepted by the A broad range of internal experi- members of the same culture or ences or “alterations of experi- subculture (for example, one is not ence” exist which have always referring here to a religious be- been classified as being of a deliri- lief). When a false belief implies ous nature even though their level an extreme judgment of value, it is of inference about external reality only seen as an example of deliri- is minimal or at least secondary. um when it is so extreme as to be One needs only to think here of a beyond all credibility.” delirium of guilt or a delirium of It is important to point out that hypochondria as examples of a in the definition of the DSM III-R delirium which involves somatic there are three criteria from classic transformation. 170 DOLENTIUM HOMINUM

The crucial point is that in the delirium seems to express the emerge and become generalized in delirious experience the concepts working-out of thought at a more an inadequate fashion. The ele- of internal reality and of external elementary and ancient level ments of persecution, reference, reality lose their usual reference which has nothing to do with cul- and external influence—and to a point of meaning. The mecha- turally acquired individual differ- lesser extent of hypochondria— nisms which normally ensure that ences but which seems, rather, to belong to this frequent set of a distinction is maintained be- be connected to impulsive needs delirious elements. In these states tween the sphere of internal events and drives which are present with- of delirium the fundamental drive and experiences, on the one hand, in all members of the human towards the conservation of one’s and that of external relationships, species. own life and the ancient, indeed connections, and meanings, on the The second observation in- ancestral terror, that one’s own other, appears not to work. The volves the fact that the great ma- body and one’s own mind can be universe of subjective experiences jority of the contents of delirium altered, broken in their unity, and extends its range to include the can be traced to relatively simple taken away or lost for ever emerge world of objective experiences. basic elements and concerns and become more than evident. Fears and wishes become external which seem to be connected to The second fundamental ele- reality and there is a loss of the certain pre-existing structures of ment is that of contents which are boundary between what is imag- emotional, cognitive, behavioral, connected to sexuality, copula- ined (where everything is possi- and elementary organization tion, and reproduction. The “ero- ble) and practical real experience. which belong more to the species tomanic” forms of delirium be- than to individual humans. long to this category, in addition The first fundamental element is to certain somatic forms of deliri- The Fundamental Subject Ð that of threat or danger. Many of um centered upon one’s own sex- Matter of Delirium the contents of delirium can be re- ual organs, forms of delirium related to fear about external threats lating to sexual possession, those A preliminary analysis of the to the individual’s life, to his phys- centered around hallucinations contents of delirium enables us to ical well-being, or to his psychic and accusation of homosexuality make two observations: the first integrity. This element seems (above all, in males) or sexual concerns the relatively limited clearly to involve an elementary promiscuity (above all, in fe- number of delirious ideas and con- “psychobiological program” di- males), forms of delirium relating cerns which can be ascertained in rected towards achieving individ- to the false attribution of materni- a clinical framework; the second ual and personal survival. Culture, ty or paternity, and those connect- relates to the presence of certain social organization, and individual ed with pregnancy. These kinds of fundamental themes which belong mechanisms directed towards the subject matter of delirium have to relatively homogenous groups management of external threats the common denominator of re- of specific contents. When we help to make rare or transitory this production and seem to emerge as come to consider the stereotypical experience of threat and menace. a shared expression of an elemen- characteristics of these contents, it In certain psychopathological tary psychobiological program should be observed that they are conditions (delirium) this elemen- rooted in the need to preserve the fundamentally narrow in number tary and profound experience of species. and repetitive and that they are fright and fear about one’s own It should be remembered here therefore in evident contrast to the survival and security seems to that in all living creatures the first immense variety of the features level of genetic programming is and contents of nondelirious directed towards the dual aim of thought. defending the life of the individual At the level of clinical observa- and ensuring the survival of the tion, it is very striking that when species. These two programs have thought undergoes a delirious become ever more complex with transformation, its contents expe- the process of evolution in order to rience a levelling and a reduction maximize the achievement of the of subjects referred to, and that evolutionary goal. In the case of this takes place within a frame- mammals a large part of the cere- work of categories which seem to bral structure is organized in such be already established beforehand. a manner as to ensure the survival It is also striking that this process of the individual and to protect his of reduction in the contents has reproductive capacities. In the nothing to do with intellectual or case of man this reproductive pro- cultural inheritance or capacity, gram retains its original biological imaginative capacity or represen- importance and strongly influ- tation, or experiences which have ences his behavior. been undergone before the onset The reproductive psychobiolog- of the appearance of delirious ical program which works for the symptoms. Indeed, the low level preservation of the species can un- of variability in the contents of dergo a number of major changes “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 171 in the ways it expresses itself in re- ness of the temporal limit to exis- forms of delirium become a “hy- lation to the complicated and intri- tence. The appearance of con- percompensational” manifestation cate educational, interactive, and sciousness when a critical limit of which is equally pathological even contextual processes connected cerebral development has been though it belongs to the other po- with the development of the corti- achieved makes the human being larity. Both groups of forms of cal structures of the human aware of the unstoppable passing delirium can in this way be con- species. In the particular case of of time, of the fragility of his sidered as a manifestation of an- social destructuring represented physical make-up and supports, other fundamental aspect of man by the state of delirium it re- and of the precariousness of his which is generated by conscious- emerges—albeit in an elementary ties and bonds, which are in- ness—a “need for eternity.” and distorted form—as an expres- evitably subject to the events of The fourth fundamental element sion of a profound and biological- separation, loss, and mourning. is represented by delirious con- ly conditioned essence of man as a This means that in the presence of tents of a mystic or religious char- living being. consciousness the fundamental acter. The forms of delirium which The third fundamental element matrix of his life is essentially of a involve the belief that there is a di- is more complicated and intricate “depressive” character. rect and privileged communica- in its character and covers a spec- On the other hand, this basic tion of a total or partial nature with trum of delirious contents which mental orientation must be placed divinity, the bestowal of divine are organized in manifestations of side by side with the fundamental powers, and a belief in the magic seemingly opposed polarities. At psychobiological drive to live for powers of prayer or religious ritu- one pole there are the so-called as long as possible—something als all belong to this category. “depressive” manifestations rep- which is required by the millions What characterizes all these resented by delirious feelings of of years of evolution of the forms of delirium is, obviously guilt, death, negation, and ruin. At species. From this point of view enough, not a belief in the tran- the other opposing pole are to be the acceptance of life can be seen scendent or an adherence to a reli- found forms of delirium which are as a special “physiological deliri- gious faith but a subjective cer- defined as being manic, such as um of eternity” which nonetheless tainty, incorrigibility, a lack of so- those involving grandeur and om- involves a constant oscillation be- cial consensus, and, above all, the nipotence. Their common matrix tween the basic “depressive” con- “self-centered” character of the is represented in clinical terms by dition and the “manic” position contents of the delirious experi- the fact that they make their ap- which compensates it. ence. In this example as well, un- pearance in the same grouping of In the case of actual illness these derneath the essential subject mat- symptoms (bipolar disturbance) in oscillations which spring from the ter is to be found a fundamental el- relation to pathological variations common matrix of human experi- ement which can be defined as a in the nature of mood. ence are accentuated and blown need for an understanding and But leaving aside their common up and the contents of the delirium comprehension of the absurd. psychobiological matrix, two es- become an expression of this ma- As in the case of the need for sential elements of equally op- trix. In this way depressive illness eternity, this also derives from the posed polarity lie underneath and its forms of delirium can be evolutionary process of self-con- these two kinds of contents of op- seen as a “hyper-realistic and sciousness. To be conscious posed polarity. In the case of “de- pathological” expression of this means to look for a logical expla- pressive” forms of delirium, the shared matrix, while mania and its nation, or, at any rate, a coherent common subject matter is repre- interpretation of the facts around sented by turning one’s back on one, of events, and objects of life, by a loss of interest in plan- knowledge. When such an expla- ning for the future, and by a fascination is not possible, anxiety in- nation for death. The “manic” creases and reaches such an intol- forms of delirium, on the other erable level that it can only be re- hand, center upon such cardinal duced through the formulation of themes as the denial of death, the a coherent interpretive model. eternity of existence, the immor- A belief in the transcendental tality of the physical structures, involves a process and state of ex- and the negation of the dimension istence where one finds an expla- of time. nation to the seemingly incompre- Leaving aside questions of a hensible reality that a conscious clinical nature and the biological form of life is destined to become determinants which are involved, extinguished by death. It means, we should ask ourselves what the in the final analysis, an act of re- fundamental element might be sponse to the fundamental drive to which links these two poles of the comprehension of the absurd. manifestations of delirium. This is why delirium often in- The common matrix can be volves the dramatic emergence of identified in the knowledge of this fourth fundamental aspect and those endowed with self-aware- trait of the human being. 172 DOLENTIUM HOMINUM

Man Afflicted by Madness thereby emerge as a window adequate and incomplete. Further- and His Forms of Delirium which has been opened by illness more, he finds himself alone in a onto his deepest and inescapable social community which isolates The analysis of the fundamental inner features and character. him, excludes him, fails to under- features of delirium and the ele- Such deeply-present elements stand him and what he is, and has mentary realities which underlie are immanent in each and every the effect of nullifying him. them brings us to a number of key human being. But under normal The second observation to be observations. We have seen that conditions they are able to express made is that the person who enters delirium is the consequence of the themselves in indirect form; they into delirium loses his freedom. functional mechanisms of the are masked and transformed. Only The principal formal characteristic brain which, whatever their causes in states of delirium, or in special of delirium is its inaccessibility to and origins may be, give rise to a life conditions, do they emerge in a criticism, to evidence and proof, subjective transformation of reali- more direct, evident, and dramatic and to the logic of arguments ty. The abandonment of the real— form. which present a different view of understood in the sense of social In a state of delirium, therefore, things. In addition, as has already consensus—means that delirium man becomes more like other men. been pointed out, within the state becomes filled with contents In this state, differences in instruc- of delirium there is an impoverish- which reflect fears, anxieties, and tion, race, and sociocultural orien- ment of the normal activity of wishes which under normal condi- tation disappear. In a condition of thought. Finally, in this condition tions form part of the imagination, delirium man displays his com- the ability to control and manage but which in the delirious transfor- mon matrix, which has been ac- the complexity of the interrelation- mation of the world become the quired through different historical al network of surrounding social new realm of reality. phases from the first appearance of life is always compromised. In- However, when we come to consciousness until today. deed, the delirious condition influ- consider and examine delirium, One may ask at this point ences and directs behavior in the we are also struck by the fact that whether it might not actually be only direction which is possible its contents have lost their rich- the case that the man “naked in his and which is itself conditioned by ness, their variegated mutability, madness” who has apparently delirious belief. The loss of free- their flexibility, and the extreme reached in his state of delirium the dom means that the delirious man variety of the contents of normal very essence of his life in reality is disadvantaged and undefended imaginative production. With re- lives in a privileged condition in relation to competition with oth- gard to their poverty and the which is very different from that er men who, unlike him, are not in stereotypes of their concerns and experienced by normal people, a delirious state. And almost al- orientations, the contents of deliri- who are suffocated and weighed ways he becomes their undefended um express, on the other hand, and down by sociocultural superstruc- victim. in contrary fashion, a limitation tures. Those who have maintained Madness and its states of deliri- and constraint of the imagination, this thesis in the past for the sake um, therefore, fascinate us but at the loss of imaginative creativity, of literary paradox or philosophi- the same time perturb us. They fas- and, above all, the destructuring of cal argument have forgotten or cinate us because through the “ex- the social. have deliberately denied certain periment of nature” which is con- We thus come to the actual con- fundamental facts and realities stituted by mental illness we can tents of the delirious experience which emerge from clinical expe- open a breach in the social armor and condition and thus encounter rience and observation. of man and thereby peer into the certain essential elements and fea- It should be stressed, first and essence of his being in its “naked- tures of life which reflect and are foremost, that the person who is ness.” But we are perturbed by the connected to the ancient and eter- delirious is someone who is in suffering, by the loss of freedom, nal fears or needs of man. The im- deep suffering. It should not be and by the exclusion from the so- perative need to survive, the need forgotten that education and up- cial community which the tragedy to perpetuate the species through bringing, learning and acquisition, of the illness always brings in its reproduction, and the need for rites and conventions, and rules wake. eternity and to explain that which and laws have in all cultures and There can, in fact, be no doubt cannot be explained, are all an ex- all historical periods had the func- that when man is deprived of his pression of the two essential deter- tion of reducing and managing the coverings he displays the essence minants of the psychic life of man: unbearable anxiety linked to an ab- of his “corporeality,” but it is biological programming and consent answer to the fundamental el- equally true that he becomes the sciousness. ements and needs of the human be- object of censure and derision, and Delirium destructures man re- ing. In the condition of delirium that most certainly he is not des- garding social life, it frees him man comes out into the open and tined to survive for long beside from the conditioning influences finds himself without protection in those of his fellows who have nev- of instruction, of his experiences, the face of these anxiety-causing er thrown off such coverings. of sociocultural influences, and elements and needs. He strives to leads him to his most elementary provide an answer and a response Professor PAOLO PANCHERI and profound essence. The analy- to them through the content of Professor of Psychiatry sis of the contents of delirium delirium, but such a reaction is in- at La Sapienza University, Rome “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 173

MARIANO GALVE

Accursed Circles: The Dantean Vortex of Madness

I have always been struck by the can engender a reaction involving the second, with less space but more suffering which is constantly en- frustration and can include a certain pain, which brings great woe” gendered where madness has estab- sense of resentment towards the (Dante, The Divine Comedy, lished itself. As Dante says in his sick member of the family and a Canto V). first canto on hell: “It is... a wild feeling of injustice towards a soci- forest, harsh and strong... Were it ety which does not assume its prop- The moment when the illness is more bitter, it would be death.” It is er responsibilities. Furthermore, recognized as being a mental ill- a place in the form of a funnel the illness causes constant financial ness depends upon how informed which is made of concentric circles difficulties. Often it is necessary to the family is, upon their limits and which get narrower and narrower. “come to blows” to obtain a pay- levels of tolerance, and upon the To fall into it is dangerous. The cir- ment and to advertise the burdens opportunities they have for coming cle captures you and whirls you one bears to have one’s rights re- into contact with a competent and round to no positive effect. The ac- spected. efficient medical doctor. cursed funnel attracts you and When there is a mentally ill per- Mental illness is not something makes you fall into it and thus you son in the home everything be- which easily identifiable. Indeed, at reach the vortex from which you comes more difficult. The family the outset it is nothing more than a cannot escape. It is for this reason feels, and is seen, “in a different set of rare or unusual forms of be- that in this paper I have employed way” in relation to its social envi- havior which are tolerated in one the phrase—”the accursed circles.” ronment. The fear of “what they way another by the person’s envi- will say” becomes a kind of obses- ronment but which in the end be- sion. If these families manage to come intolerable to those people The First Circle: maintain some kind of relationship who have to live around an individ- The Family Space with the outside world, these links ual afflicted by mental illness. are often troublesome, superficial, At the outset these asocial phe- “And so he placed me and so he and difficult. This isolation is an nomena are seen as meaningless or made me enter into the first circle authentic trial and travail for these banal but in time they come to wor- with which the abyss was girded” families. ry the family. After seeking in vain (Dante, The Divine Comedy, Faced with these difficulties, dif- to attribute these symptoms to one Canto IV). ferent families react differently de- or other form of physical illness or pending on their own particular to certain external causes (stress, For families “everything be- contexts and characteristics. They physical tiredness), and after not comes more complicated” when can react with a sense of guilt— achieving anything in the way of a there is a mentally ill person in the “perhaps I should not have worked cure, the family begins to become home. They feel that they are alone during my son’s childhood” or aware of the nature of the illness. in having to face up to their essen- “perhaps he was too spoilt.” They At times the discovery of mental tial problems and difficulties. can react by adopting the stance of illness can be very dramatic—dur- The economic and financial victims: “This illness has landed on ing a crisis the sick person can ex- problems which arise act to modify us like a curse. Everybody has to plode and then disturb the public the structure of the family and to bear their own cross.” And they can peace, forcing the police to inter- create new kinds of relationship be- also become accusers: “If he want- vene. On many occasions, the fam- tween its members. Some of the ed to, he could make an effort to get ily tries to avoid these kinds of ac- family members, the father or the out of this situation.” tions on the part of the police, but to mother, find themselves forced for no effect—often it has no other reasons of income to leave their choice. jobs or to take up working again in Second Circle: The First Contact When families begin to be aware order to deal with the economic and with the World of Medicine of the seriousness of the situation financial requirements of their they do not know whom to turn to, mentally sick child. This situation “So I descended the first circle, into and abandoned to face new and un- 174 DOLENTIUM HOMINUM familiar problems on their own which does not make home visits. care staff and their patients. You they find themselves having to deal Despite all this, private consulta- could go out of the clinic when you with their sick member all by them- tion is a promising course of action wanted. You didn’t need to ask selves. Moved by a feeling of ur- in that it allows families and the anybody’s permission and if you gency, they feel driven to turn to sick to entrust themselves to the had trust in the clinic you always the only person whom they hope care of a “specialist,” to take ad- came back. Free time was very well can help them (and whose action is vantage of individually-organized organized and there were many socially acceptable)—the “family therapy, and to show society that things to do. doctor.” Yet when they do this they through the use of specialist help But most families sooner or later do not seem to worry very much they are really facing up to their have to turn to public services. about his competence in the field of problem. psychiatry. However, at times the part The chance nature of subsequent played by such forms of consulta- Fourth Circle: meetings will determine the future tion does not suffice and the psy- The Public Psychiatric Circuits itinerary of the sick person. chiatrist suggests to the sick person and his family that he should be ad- “So we descended into the fourth mitted to a private clinic. lake, suffering from the painful Third Circle: bank than all the evil of the uni- The Private Psychiatric 3.2. The Private Clinic verse can encompass” Networks The importance of the sick per- (Dante, The Divine Comedy, son is directly proportionate to the Canto VII). “I am in the third circle of eternal, amount of money he pays. He is accursed, cold and heavy rain” recognized as a person in his entire- We can begin this section by re- (Dante, The Divine Comedy, ty and he maintains his own rights ferring to two principal therapeutic Canto VI) and social status. He is a “con- poles—mental health consultation sumer” of psychiatry who hopes and the psychiatric hospital. The journey which the mentally that he will be well served. The sick ill person makes through the psy- person is offered a very welcoming 4.1. The Mental Health Center chiatric circuits can take place in environment. He is subjected to a The mental health center is a part two kinds of context—the private special course of treatment and of the national health service. It is a and the public. therapy in a situation of material public structure which is open to The choice is not a matter of comfort. The room in the clinic has everybody and it is free. It offers mere chance. It is influenced by a less restrictions and the visiting medical, psychological and psychi- set of factors specific to each fami- times are more liberal. Because the atric consultations. It thus plays a ly—its sociocultural level, its pre- number of patients is less, the pa- very important role in the identifi- vious experience and knowledge, tient’s contacts with those who are cation, management and treatment and its level of trust in its own doc- looking after him and treating him of psychiatric disorders. This con- tor. are much easier and his therapy is sultation service can direct families therefore much more individual- in different kinds of directions. It 3.1. Private Consultation ized. can either direct them towards the When the disturbance of the sick Private hospitalization ensures psychiatric hospital—if it thinks member of the family is at a tolera- that he is not a being deprived of that this is what the mentally ill per- ble level he has the opportunity of his own history and pushed out of son needs—or it can suggest forms consulting a psychotherapist and reality. This contractual position of treatment within the same ser- continuing to participate in his own does not interrupt the continuity of vice through subsequent meetings work environment. his existence for ever,and after the with the center’s doctors or simply This kind of help is not without critical period has been overcome it through the administration of drugs its problems—the psychiatrist has a will be much easier for him to inte- and medicines. special relationship with the sick grate himself once again into soci- person and the families are pushed ety. Some sick people receiving 4.2. The Psychiatric Hospital to one side. They become substitut- this kind of treatment make the fol- ed by a stranger who represents the lowing types of remark: “It was “Some people lay supine upon the positive side of things whereas they like a family (one patient observed) ground, some sat huddled up to- have to shoulder the daily responsi- and we used the informal Italian gether, whilst others came and went bilities of the problem. They often “tu” with everyone. The sick peo- constantly” feel that they have been deprived of ple used therapy to help each other. (Dante, The Divine Comedy, their own sick member and become I helped a schizophrenic woman Canto XIV). curious about what happens inside and she helped me to walk. I en- the consulting room. Indeed, they tered into her world, into her fan- To these hospitals are admitted, often become aggressive towards tasies. Little by little I followed her on the one hand, those mentally ill the psychiatrist. Furthermore, dur- obsessions. She could come into people who come from the middle ing moments of acute crisis, the my room. Everybody spoke to classes or the less privileged sec- families are not able to rely upon everybody else in the clinic. There tions of society, and, on the other, the help of psychiatrists, a category was no barrier between the health the “very” sick who cannot be pro- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 175 vided with the long-term treatment within the walls of the institution to tive light and in negative terms. that they need at home or within a which he has been admitted. This ambiguity is the common ex- clinic. Within the hospital, in a more or perience of the families during the When families enter a psychi- less confined state, there are hun- first stages of hospitalization. atric hospital, they think that they dreds of imprisoned people, of mad The families of the mentally ill will encounter intense forms of people (or they were such at one person feel guilty at having had treatment which will cure their time). They number as many as the him admitted to a hospital. They mentally ill relative; rather as hap- inhabitants of a village. They live think that this amounts to rejecting pens in a general hospital. But little crowded together and they have him and thus involves a continua- by little they soon become disquiet- very little freedom of movement. tion of the exclusion imposed on ed and worried because neither the What strikes one most is how him by society at large. At the same health care workers nor the medical “calm” they are, how passive, how time, however, they are well aware environment correspond exactly to mentally and physically stiff; they that they do not have the means, the what is usually expected of a hospi- are deformed and silent; they are expertise or the resources with tal. sad. They spend their time without which to look after and to treat him For these families hospitalization doing anything at all. They smoke themselves. has its duties and they immediately constantly and can be found all On the other hand these families find themselves faced with the over the hospital, on the ground, are worried by the fact that their rigidity of an institution which has asleep (because of the boredom or mentally ill member now finds its own impersonal laws which are because of the drugs which have himself in the hands of people who often traumatizing. One patient re- been administered to them), or per- are strangers, being taken care of members his own particularly haps walking to and fro in a small by nurses who look after him well painful journey: “One night I had to and confined space constantly un- or perhaps not so well. At the same go by car into the city, I went from der the watchful eye of some nurse. time they do not like the idea that bar to bar with my brother in crisis. Most of these mentally ill people these nurses have established a ma- The psychiatric hospital was seem to be completely indifferent ternal kind of relationship with the closed, and so I had to go back the to everything. They are expression- patients. They experience this fact next morning.” less and nothing seems to matter to as a form of competition. They are When they have dealt with the them. Nothing has any impact on envious of the health care staff in administrative side of things, the them at all. One could be led to be- the psychiatric hospital and they families often feel wrongly de- lieve that they do not even feel very often seek to impose their own prived of their own mentally sick pain. Only rarely do they give evaluation of the situation on that member and of their role as rela- voice to protests at something; and staff in an attempt to demonstrate tives. They feel marginalized by nobody is ever heard to complain. that the mentally ill person still be- the health care staff: “My brother And so it is for year after year, in- longs to them. agreed to enter the hospital, but he deed for years, that the confined Indeed, it is possible to analyze had an attack of panic and did not person turns his back on being a the relationship between these fam- want to leave me so quickly. He person; he loses his own self-es- ilies and the nurses who work with- followed me like a little dog. The teem. He has no needs and ignores in the hospital in terms of a sort of doctor ordered me to leave the his wishes and aspirations. He transfer. At the same time, and in room and this provoked the crisis. merely survives, and this is almost parallel fashion, the nurses can per- My brother would have been able the only thing that he can do. He ceive and evaluate the families in to deal with this meeting if it had has no prospects, no stimuli, and no negative terms—as elements who been organized differently.” disappointments. He loses interest are partly responsible for the illness In such cases families often feel in everything and everybody. and as rivals because the nurses and that their mentally ill member no Everything and everybody be- the families of the patient do not longer belongs to them but to a comes the same. approach the treatment which is ad- team of doctors and health care One mentally ill person has left ministered to the patient from the workers. us this account of his own experi- same point of view. For example, At the outset these families and ences: “I don’t know how it hap- the frequent visits of one member the majority of mentally ill people pened. From morning till night I of the family can be interpreted by look to the hospital as a kind of found myself confined and tied to a the nurses as being a kind of pro- “haven.” But this is not the only bed—I thought I was being placed tection which interferes with the in- face of the psychiatric hospital, and under observation. They said that I dependence of the patient himself. these mentally ill people soon dis- was anxious and nervous, but in re- The position and stance of the cover a hidden face of the coin— ality I was angry at them because families of the patients is very ”the hospital-prison.” Although the they stopped me from leaving the changeable. The families shift be- psychiatric hospital is the only op- hospital.” tween confidence in the doctor on tion available to a family which The relationship of the families the one hand and opposition to the does not have the resources to look of the mentally ill to the psychiatric treatment he prescribes and sug- after its mentally ill member itself, hospital, and their position in rela- gests on the other. They thus can al- it is precisely this mentally ill relation to it, is always ambiguous. An ter this treatment in line with what tive who soon becomes aware of evident dichotomy is involved— they think is good for the patient— the violence which takes place the hospital is seen both in a posi- and this itself is based upon the 176 DOLENTIUM HOMINUM ways in which they themselves un- of their patients. As a result, these However, they often fall foul of derstand the illness. people now live on the streets, in bureaucratic procedures and by no With regard to the whole subject homes or in hotel-homes, for the means a small number of them end and question of the patient being most part with their families or by up without a home—they thus dismissed from the hospital, the themselves. They have to endure come to expand the ranks of the so- families oscillate between wanting the protests of ordinary citizens called “homeless.” As a result we to see their mentally ill member and the complaints of the families often find many of them on the leave the hospital on the one hand, themselves or their neighbors. Psy- streets, in the doors of churches or and worrying and being concerned chiatric hospitals have been re- cinemas, in the entrances to under- about the crises and other difficul- placed by a nonhospital system di- ground stations, asking for money ties which such a dismissal might vided into areas or sectors. There from passers-by. At times they use involve on the other. There is also a are prevention centers or treatment forceful gestures and employ temptation to allow the doctor in clinics—psychiatric wards in gen- strong phrases, seeking thereby to charge of the case to take their eral hospitals, day-hospitals, treat- achieve a certain importance. On place in deciding that in fact their ment homes, occupation centers, other occasions, we often en- mentally ill member is “too de- workshops, schools, and so forth. counter them on park benches, in pressed to be sent back home,” a Many former patients of these rows on pavements or clustered to- decision which if taken by the fam- psychiatric hospitals have been gether in shopping arcades, in ho- ilies might involve an intense feel- sent back to their families, even tels, or in charity homes, “dragging ing of guilt. though these families cannot really their rags behind them, their hallu- These families become very look after them. Many of these cinations, their physical pains, and worried when the patient “does not families are on the verge of desper- their illnesses of the soul.” agree” with the psychiatrist. They ation—they are defenseless and Like Dante, we have gone on a think that in order to be cured of his powerless. Some display their in- brief journey through the accursed illness he should have a good rela- comprehension of the situation, circles of madness. We have seen tionship with the doctor in charge and their impatience and irritation how madness encloses, entraps, of his case. If things do not go as with their mentally ill member. and destroys the mentally ill and they should do (if the patient is ag- Others become tired and fatigued their relatives. This is certainly a gressive, unhelpful, and fails to co- and come to abandon him altogeth- most horrible journey. At times, operate) then they become afraid er. In some cases they turn him out however, it is not like this and the that the doctor will lose interest in of the home and leave him to his version that has been given here is him. In the opinion of these fami- fate. Such mentally ill people end often exaggerated. But, on other lies “being a good patient” means up being victims of hunger, the occasions, such, indeed, is the situ- not putting up opposition to the re- cold, road accidents, suicide, vio- ation. By the grace of God, not all quirements of the course of treat- lence and prostitution. Or they are mentally ill people enter these cir- ment. Some families even tell their picked up by the police and taken cles and fall into them. Let us mentally ill member “not to lose back to a psychiatric center or to therefore learn from the prudent contact with the doctor after leav- their families. Such a stance and Virgil: “It is better not to go in ing the hospital.” Indeed, the doc- such forms of behavior on the part here.” For this reason we must do tor in charge of the case should of these families engender a terri- our very best to develop the policy continue to follow the patient and ble sense of loneliness in the men- of prevention in the realm of men- to advise the family even after he tally ill person. He feels that he is a tal health and health care at all lev- has been dismissed from the hospi- burden for his family and that not els—in relation to the family, to so- tal. even his own family wants him. ciety as a whole, and in regard to Fortunately enough, the majority the ideas, attitudes, and behavior of of families are not actually like our culture. And if the mentally ill Fifth Circle: this. fall into these accursed circles, it is Once Again the Family On the other hand, society is un- very important, indeed, that “they and Society just and cruel with those mentally are not dragged down.” For this ill people who were previously reason we must raise walls of “This swamp which gives off a kept in such institutions. Until very strength against this centrifugal great stench, girds the suffering recently they were seen as “empty force and act to promote and sup- city, and we could not enter it with- and bad,” and today they are be- port forces which work in the op- out feeling anger.” lieved to be “a danger for the safety posite direction—namely medi- (Dante, The Divine Comedy, of society.” Society rejects them, it cines, services, research, and care. Canto IX). closes its doors in their face, it mar- If all these instruments should fail, ginalizes them, and it is afraid of let us learn that compassion which Given the present-day approach them. Until only recently they were welcomes, cares for, and watches to psychiatry, these psychiatric subjected to discrimination on the over—a compassion exemplified hospitals seem to be on the way part of the rest of the population be- by Dante’s Beatrix. out. In response to the general cry cause they were not even covered of “We need to reintegrate the sick by the social security system. To- Rev. MARIANO GALVE into society,” traditional psychi- day, luckily enough, such is no Director of Pastoral Care in Psychiatry, atric hospitals have been emptied longer the case. Spain Round Table

Prevention, Therapies, and Rehabilitation 178 DOLENTIUM HOMINUM

PIERRE F. CHANOëT

Prevention and Mental Health

Introduction The wise man laughs at destiny, one hand, and that of democracy, that force which some people con- based upon the supposed existence Can we speak about prevention sider the master of everything. In of human liberty, creativity, and rein a field where the results of treat- fact, it is better to accept the myth sponsibility, on the other. This de- ment are still so often contingent? of the gods than bow before the des- bate has been reactivated in the con- This paper revolves around three tiny of the physicists. This is be- temporary era by the discussion in principle subjects: cause the myth enables us to hope physics and mathematics on chaos a) the many meanings of the term that we will reach an agreement and instability. “prevention”; with the gods through the honor Prevention should thus be placed b) the evolution of this concept in that we render them, whilst destiny in this context of the uncertainty of relation to the limits of the disci- has a necessarily inexorable charac- modern philosophical thought pline of psychiatry; ter. (1) where individual description (tra- c) the arguments in favor of the From its very beginnings the du- jectory) and the description of policy of prevention and its various ality of being and becoming has states are not equivalent. The inter- forms. marked and shaped Western pretation of data does not involve This paper is based upon the be- thought. For Plato (as we know certainties but possibilities and does lief that psychiatry forms a part of from the Sophist) we need both be- not stop at being but extends to a medicine but no such certainty can ing and becoming because if the consideration of becoming, and be entertained in relation to mental truth is linked to being, to a stable such will be the case in this paper. health. This is more than evident reality, we cannot conceive life or from the information supplied by thought without reference to be- public health authorities that 80% coming. 1. The Many Meanings of the factors which go to make up However, the proposition of the of the Term “Prevention” a state of personal health do not “laws of nature,” exemplified by come within the province of medi- the law of Newton on the connec- The old Hippocratic adage that cine—at least, that is, as regards the tion between force and accelera- “prevention is better than cure” is latter’s therapeutic functions. But tion, is both deterministic and re- still very relevant today even illness, whether of a mental or versible in time. If we know the ini- though advances in the field of pre- physical nature, is one of the risks tial conditions of a system subject vention are more uncertain than of life and our existence and re- to this law—that is, its state at a giv- their counterparts in the realm of mains a challenge to men of science en moment—then we can calculate treatment. - those individuals who must seek all the subsequent states. Karl Pop- The term “prevention” has a to predict or prevent the outbreak of per has the following to say on this number of meanings. illness. subject: The classical distinction made by This paper touches upon a very I believe that Laplacian deter- the World Health Organization is old philosophical discussion which minism—confirmed as it seems to that which usually predominates in was set in motion by the pre-Socrat- be by the determinism of physical contemporary discussion of the ics at the dawn of Western theories and their very great suc- question: thought—the debate concerning the cess—is the greatest and most seri- Primary prevention involves ac- nature of determinism and the role ous obstacle in the way of an expla- tions carried out prior to illness of time. nation and a defence of freedom, which aim at preventing its out- Common sense tends to believe creativity and human responsibility. break. One is dealing here with vac- that every event is caused by a pre- The ancient Greeks provided us cination, the rules of hygiene, ceding event and that for this reason with two ideals which have guided health education, and so forth. every event can be predicted or ex- our history—that of the intelligibil- Secondary prevention seeks to plained. ity of nature through a system of identify illness as soon as possible Ilya Prigogine cites Epicurus general ideas which is necessary, through systematic tests and a re- when reflecting upon whether the logical and coherent—and by sponse to urgency, and thereby to universe is governed by determinis- which all the elements of our expe- engage in timely treatment. tic laws: rience can be interpreted—on the Tertiary prevention is based upon “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 179 the recognition that many forms of tion of readaptation and reintegra- than 5,000 mentally ill people in the illness, whether they are treated or tion (tertiary prevention). Further- whole of France. not, leave long-lasting damage, more, epidemiological research has In 1960 the French Ministry of functional weakness, and the peren- shown that mental disturbance af- Health estimated that there were nial risk of relapse. For this reason flicts the least privileged parts of 140.000 mental patients in the na- efforts must be made in relation to the population (in intellectual, cul- tion’s hospitals and 700 psychia- rehabilitation, placing the individ- tural and economic terms) and this trists. ual within the community, the suit- means that psychiatry is naturally In 1993 65,000 psychiatric beds able organization of his environ- of key importance in policies relat- were occupied and there were over ment, and providing him with help, ing to public health. 750,000 mentally ill people within so as to reduce his handicap and The term “mental disturbance” the non-hospital health system. In promote the achievement of his full which I have used here for the first the same year there were 12,000 remaining potential. time in this paper is not completely psychiatrists, of whom the majority Another approach involves mak- identical in meaning to the phrase exercised their profession in such a ing a distinction between passive “mental illness.” way as to render any quantitative prevention and active prevention: calculation of their activity rather Passive prevention is based on difficult. medical principles and involves 2. The Development The exponential increase in the measures which do not require ac- of the Concept in Relation number of individuals receiving tion on the part of the individual be- to the Limits of Psychiatry specialist treatment has meant that a cause such measures are the direct number of forms of disturbance outcome of scientific knowledge Psychiatry was born in a social- which at one time would never have about the aetiology and pathogene- revolutionary context—which is of- been defined as examples of mental sis of illnesses. They provide an al- ten remembered—some two hun- illness have come to be placed most certain guarantee and one of dred years ago. within the psychiatric sphere. At the the best examples of their effective- During the nineteenth century present time forms of mental distur- ness is to be found in the practice of medical doctors were able to create bance which are defined as such by vaccinations. a body of knowledge and informa- epidemiological surveys and in- Active prevention is based on tion under the heading “mental quiries no longer constitute that psychopedagogic principles and in- alienation” and over a period of 150 small one or two thousandths of the volves achieving the cooperation of years these alienists increased clini- population which at one time inhab- individuals in promoting a change cal observation and analysis with- ited the lunatic asylums. In the unit- in their behavior in order to reduce out taking the “extreme” conditions ed States of America the Epidemio- the risks that they run. We are refer- of the context they were studying logical Catchment Area Survey has ring here to: into account. The result of all this employed a sample survey of the Ð the consumption of alcohol work was the creation of a “nosog- population over recent years to and toxic pathologies; raphy” which found its highest ex- demonstrate that the incidence of Ð tobacco addiction and cancer; pression in a work published by mental disturbance reaches or ex- and Emil Kraepelin in 1911. This work ceeds 25% of the American popula- Ð sexual behavior and sexually is now clearly out of date. tion. transmitted diseases such as AIDS. The increase in clinical analysis More recently Kessler and others During the history of the policy and in innovations in the sphere of (1995) have published the results of and practice of public health, great treatment—and here reference the National Co-Morbidity Survey steps forward have been achieved should be made to the development carried out into a sample section of by epidemiological studies. These of dynamic psychology (and in par- the American population. Mental have demonstrated that there is a ticular to the work of Sigmund disturbance over a lifetime accounts close connection between ill-health Freud), of biology (and more for 48% of those afflicted, and that and illness on the one hand, and the specifically to the understanding of lasting for a year, 30%. The most different socioeconomic levels of psychotropes), and of the human frequent forms of disturbance are different parts of the population on sciences (sociology and anthropol- an intensive period of depression, the other. The work of prevention in ogy)—undermined the certitudes of drug addiction or more often alco- this case is not of a medical charac- the lunatic asylum style of psychia- holism, phobias, and anxiety. ter or to do with public information try. The very concept of mental ill- It is thus more than evident that but concerns policies of a sociopo- ness was called into question and the forms of “mental disturbance” litical nature. the new classifications and termi- such as those revealed in these epi- There can be no doubt that be- nology (D.S.M. III, then IV, C.I.M. demiological surveys cannot be cause of the complexity of their ae- 10) no longer referred to mental ill- confused with traditional forms of tiologies,mental illnesses such as nesses but to “mental distur- mental illness. We must therefore schizophrenia, chronic psychoses bances.” As a result the limits and refer to new approaches and emerge and obsessive neuroses cannot ben- boundaries of the discipline of psy- from the narrow framework of clin- efit from the methods and tech- chiatry became rather more impre- ical psychiatry. Here we are dealing niques of passive prevention or (at cise. with the concept of mental health least in most cases) from primary A number of statistics bring out and its connections with public prevention. On the contrary, they the nature of this overall and long- health. This is more than justified if require early identification (sec- term development: we consider the importance of the ondary prevention) and the applica- In 1818 Esquirol listed not more problems of this whole area and 180 DOLENTIUM HOMINUM their intimate links with the social, tween the doctor and the patient, cover. In such a context govern- economic and intellectual context which at first sight seem to be pri- ments tend to diminish their com- to which they belong. vate matters and events, come to be mitment in the health field. The In general terms the following placed within the context of the so- new directions in the sphere of eco- are the aims and goals of health pol- cial network which to a great extent nomic policy which have tended to icy and of those professionals determines them. abandon a directive approach and to whose task it is to ensure that these This is so for example in the field embrace free enterprise have acted are realized: of suicide, a topic which has been to increase worries about whether Ð the promotion of health; the subject of one of the most fa- complete health care is now eco- Ð the protection of health; mous works of sociology ever writ- nomically possible. In far too many Ð the renewal of health. ten. (3) When a suicide takes place countries this has led to a marked It often happens that only the attempts are made to find explana- fall in the quality of health care fi- forms of treatment are taken into tions in the history of the individual nanced by the state. In some coun- account. Even though they may be concerned, his relationship with his tries such as Germany, the United effected in an excellent way in family, his friends, and his work. States of America, France and terms of cost and accessibility, they Every example of suicide is special. Switzerland quality, levels have only represent a part of the aims and The considering of suicides as a been maintained but at the price of a goals involved. Treatment often ne- whole, which are both individual rapid increase in costs which are glects what comes before and after and unpredictable, enables a new now, however, considered unsus- the illness and the whole dimension reality to emerge which is very dif- tainable. of the environment of the sick per- ferent from the specific events A health service is a complex and son. which go to make up that general intricate whole which seeks to We have traced the move from picture. The statistical relationship match needs with costs in certain mental alienation to mental illness between the number of suicides and given contexts which are of a polit- and then to mental disturbance. Just certain social variables can be em- ical and economic nature. as in public health the term “health” phasized—the number of suicides From a general point of view has taken the place of “illness,” is it increases with age and the agglom- there are two major areas which possible that in psychiatry we will erates vary according to country but command attention: move from the concept of mental the general levels remain very Ð the respective responsibilities disturbance to that of mental much the same over time. In other of those active in the health care health? words, suicide—which is an indi- field; and In historical terms the “biomed- vidual act in the extreme—emerges Ð the location and the instru- ical” model lasted for a long time. as a social fact when it is seen in ments of research and innovation. Until the first decades of the twenti- terms of a city, a region, or a coun- When we reflect upon the future eth century the most important try. of health care we necessarily have causes of death were contagious We can understand the “social to dwell upon the very great trans- diseases. The systems of control field” of health with reference to formations both in relation to men- and response were those modelled two models which themselves lend tality and with reference to methods on the methods and thinking of Pas- legitimacy to the methods of the so- and practices which are now ap- teur. At the present time in industri- cial sciences. These models are as pearing on the horizon as we ap- alized countries more than two follows: proach the twenty-first century. thirds of deaths are caused by Ð illness as a natural and biolog- Given the ever more powerful re- chronic illnesses such as heart dis- ical phenomenon which is studied sources of science and technology ease, cancer and mental distur- in a scientific way by biomedicine, will we be able to cancel the in- bance. In addition it has been ob- epidemiology, biological anthro- equalities which oppress our served that these forms of distur- pology, and population genetics; world? Or will these fascinating bance are often correlated to behav- Ð illness as a social and cultural forms of progress merely increase ioral risk factors such as tobacco phenomenon which is studied by our knowledge without it being addiction, alcoholism, drug-addic- ethnomedicine, medical sociology, shared? A certain number of salient tion and so forth or sociocultural el- and social anthropology. features of modern development ements such as poverty, migration, must be taken into account when decultarization and similar ele- we come to answer these questions ments. It should also be observed 3. The Justifications for, and these are as follows: that the world of health and health and the Methods of, Ð the democratization of society policy has become a field of study a Policy of Prevention is a tendency which becomes ever for such social sciences as sociolo- more rooted, and it is a development gy and anthropology and in a more Two recent reviews of the World which is accompanied by decentral- general sense for the human sci- Health Organization which are ded- ization and the giving of greater re- ences. icated to the future of health ser- sponsibility to individuals; The first contribution of the so- vices in the world (4,5) provide Ð fairness is a value which is in- cial sciences to this field of knowl- very useful information on new creasingly respected. Two ideas edge has been to show that a “so- methods, successes and failures. stand out—the provision of overall cial” dimension exists where on the Most countries are worried about care and the application of treat- whole only the individual aspect is the same phenomenon—the fact ment in line with needs; usually perceived. Illness, suffer- that health care costs now exceed Ð ethical considerations are being, death, and the relationship be- what national income growth can coming ever more important in the “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 181 sphere of health policy and care. The French model of social secu- the first category belong Alco- They represent a bridge between rity which is based on both these holics’ Anonymous, associations politics and values. Questions are models has sought to look after the for diabetes sufferers, associations raised as to the moral value of cer- whole of the population from 1945 for hemophiliacs, associations for tain choices which have to be taken onwards but it also has not escaped people suffering from AIDS, and so involving the rights of man, the the risks of increasing financial dif- forth. To the second category be- training of health care workers, the ficulties. long such associations as the UN- application of research, and what The state can not do everything AFAM—the National Union of limits should be placed in relation but there are some things which on- Friends and Families of the Mental- to the treatment of the sick; ly the state can do. ly Ill—and the EUFAMI - the Euro- Ð science and technology are of The first thing it should do is to pean Union of Family and Mentally great importance. Health care is in- assess the needs of the population. Ill, and many other similar bodies. timately bound up with science and Descriptive epidemiology enables In this way a new kind of dia- the advance in such care owes us to measure the incidence and the logue between citizens and the pub- much to the progress of technology. distribution of illness and to allo- lic authorities can be established What we have to do is to take ad- cate resources accordingly. Analyti- (campaigns of information on the vantage of both science and tech- cal epidemiology forms the starting results of research, on the origins of nology in order to promote the point for a strategy of prevention. ill-health, and on the costs of treat- common good. These methods of research which ment and care). A similar dialogue Most countries raise the same are often expensive should occupy could be created between medical questions about the role and respon- a prominent position of importance doctors and the sick (the duty of in- sibilities of the various groups in annual government budgets. formation) and between people at which are involved in the financing, The second thing the state should large (the hygiene of the environ- production, consumption and regu- do is to produce clear rules and ment). lation of different forms of health guidelines by which to organize and care. direct its health service, the aims 3.2. Research Policy and goals of that service, what it 3.1. The Protagonists must do, and the nature and limits 3.2.1. In the field of mental of Health Services of its range of activities. health, for over half a century, epi- The third thing the state should demiology has constituted a method In order to achieve a more effec- do is to provide assistance whether by which to understand the distribu- tive analysis of the current situation in the form of prevention or actual tion of different forms of mental we should take into account and ex- treatment through a public service disturbance, their nature, and the amine the role and responsibilities which should compensate for the context of their emergence. This of the various protagonists of health failings or the inequalities of the method began in the Anglo-Saxon policy and care with special refer- private sector, and propose new and countries, was particularly devel- ence to governments and users. practical models for the application oped in northern countries, and was of the discoveries of fundamental or then adopted by the World Health 3.1.1 The Role of the State applied research. Organization. At the present time The domination of economic this method enables us to measure considerations in health care sys- 3.1.2 The Role of Consumers the distribution and incidence of the tems has given rise to two different Among the various groups which various forms of mental distur- historical models. are involved in the financing, the bance, and to calculate their eco- On the one hand, there is the Bis- production and the organization of nomic costs (the statistics presented marckian model which was devel- health care and assistance, the in section II give a good idea of oped in Germany by Otto von Bis- users—the sick and their families— what these can be). marck and adopted in that country play a pre-eminent part when they Analytical epidemiology enables in 1881. This model provided for a are aware and responsible citizens. us to identify the conditions which system financed in the main by in- Consumers can play this role in a give rise to mental disturbance both surance which protected workers correct way only if they are in- as regards individuals (those people against injuries at work, illness, informed about the consequences of at risk) and in relation to specific capacity, and old age. Such a model their requests both in terms of the sets of circumstances (situations at can achieve a very high level of costs involved and the suitability of risk). The results of these inquiries quality without, however, guaran- what they are asking for. This constitute a mine of information teeing treatment and care at a price means that campaigns of informa- which is of great help in the work of which is accessible to everyone. tion have arisen which enable citi- prevention. On the other hand, there is the zens to know about, and to insist Epidemiology is thus an impor- Beveridge model, which inspired upon, their rights (right to informa- tant tool of knowledge and as a re- the system introduced by Lord Bev- tion, right to health care) and to per- sult it is also a vital preliminary step eridge in Great Britain in 1948. form their duties (hygiene, adher- in the drawing up of health and This model offers everybody com- ence to treatment). This process has health care policy. Its past successes plete preventive and actual treat- given rise for some time to the cre- have been more than evident in the ment but although it has fulfilled its ation of a large number of associa- fight against contagious diseases purpose at a reasonable cost it has tions of consumers, that is, of sick (smallpox, cholera, yellow fever, not failed to fall foul of the risk of people or people who were previ- polio, etc). In more recent times low quality. ously sick, or of their families. To epidemiological studies have en- 182 DOLENTIUM HOMINUM abled us to tackle less simple health co-operation of the members of so- structural economic problems in the problems connected with lifestyles ciety. To this end governments and management and programming of (heart disease and cancer) and to professional workers should take their national health services, our carry out campaigns of prevention on the new and important responsi- countries in the West are forced to whose effectiveness has been more bility of giving people broad and think hard about a number of their than proved. sufficient information. fundamental principles and goals in In the field of psychiatry recent the field of health and health care. research into the role of life events Although the “right to treatment and social support open up new Conclusion and care” remains an essential for- prospects for policies of prevention. mula and conforms to the duties of Mental illness in the strict sense, or Over the last decades our way of a state which is responsible for relapses, are often preceded by a understanding health and life condi- those of its citizens who are stricken disturbance of mental health and by tions has undergone major changes by illness, it is clear that the “right physical suffering whose genesis is because of developments in the to health” is now an obsolete slo- not well known, and these elements economy and in technology. The in- gan. This is because health (which bring into play external, familial, equality in resources between the is not only absence of illness) is of- social, professional, and cultural industrialized countries and their ten the result of forms of individual factors. developing counterparts does not in behavior at risk (general life hy- Epidemiology thus offers a tool itself explain the inequalities be- giene, food hygiene, use of drugs and a set of methods well designed tween different populations in rela- and alcohol, etc.), of ignorance or to develop knowledge about the tion to their standards of health. neglect in the presence of alarm sig- questions involved, formulate One might also think (in provoca- nals (obesity, arterial hypertension, strategies of prevention, and assess tive fashion) that the importance of relapse symptoms etc.), or of the effects of such prevention. But the intense resources of rich nations lifestyles at risk. The “right to this also requires that psychiatry is an actual fact a handicap for the health” thus becomes a “duty re- moves out of its relative isolation future when one takes economic garding health,” the specific re- and enters the realm of public costs into account. The fact that sponsibility of individuals, which health, adopting its objectives and most of these countries have em- depends upon access to primary methods. barked on a policy of reducing the health treatment and to an aware- number of hospital beds and of ness and appreciation of communi- 3.2.2. Advanced Technology medical doctors (one thinks here of ty health. for Tomorrow’s Health restricted entrance into medical col- We thus have before us a new The contribution and discoveries leges), and have increased the train- prospect in relation to health policy of genetics are about to revolution- ing period for nurses, constitutes a and care which bears the name ize our approach to certain illness- clear change in health and health “prevention” or “health promo- es. Soon every one of us will have a care policy. However, at the same tion.” The financing of this policy, genetic profile drawn up at birth time technological advance and a which at one time occupied a sec- which will enable us to know to greater appreciation of medical re- ondary position, should in the fu- which illnesses and maladies we are search have given us greater and ture (in part) take the place of the fi- predisposed. Over the last forty improved knowledge about serious nancing of medical treatment and years scientists from all over the illnesses and how they should be assistance. world have striven to understand treated. how our genes manage to organize We now seem to have come to Dr. PIERRE F. CHANOIT the complex symphony of bio- the end of a period of unprecedent- Hospital Physician chemical reactions which enables ed economic expansion in the in- Expert of the World Health Organization, our cells to function. But there is dustrialized world. The experience Secretary General of the World Associa- still a great deal to be done. A large of less favored countries has shown tion for Social Psychiatry, Paris number of studies carried out into that the health standards of a popu- schizophrenia suggest that metabol- lation depend in large measure up- ic imbalances are probably present on the conditions of life (infections, which are most certainly not causes parasite presence, general hygiene, of the condition but constitute a fac- environmental conditions and so tor of predisposition. In the same forth). And although it is true that way manic-depressive psychosis the developed societies of the tem- seems to be favored by the presence perate zones have weakened most of certain genetic anomalies. of the contagious diseases and in- At the present time we are using creased life expectancy, they have Bibliography the first drugs and medicines capa- not paid sufficient attention to psy- ble of treating Alzheimer’s disease. cho-social and genetic inequalities. 1 ILYA PRIGOGINE, La Fin des Certitudes (Odile Jacob, Paris, 1996). But within fifteen years we will un- At the present time they are becom- 2 K.POPPER, L’Univers Irrésolu (London, doubtedly know the molecule ing aware of the fact that health is a Hutchinson, 1982). which will attack its cause. good which is not given and that 3 EMILE DURKHEIM, Le Suicide (Félix Al- can, Paris, 1877). However, this general develop- many factors—which are for the 4 Santé du Monde, Soigner Demain no. 5, ment raises a large number of ethi- most part nonmedical in charac- September-October 1994. cal problems and questions which ter—have a decisive influence and 5 Forum Mondial de la Santé, Les Systèmes cannot be solved without the direct effect. Now that they are faced with de Santé no. 4, 1994. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 183

JANOS FÜREDI

Integrated Therapies for Schizophrenic Patients and Their Families

I sincerely hope that my presen- The findings of WHO studies and Despite the committed and tation will not be disappointing to of other studies repeatedly heroic efforts of professionals and those of you who have chosen to showed that in the developing humane individuals we cannot attend this session rather than en- countries a higher proportion of say, even today, that segregation joy the beauties of this Holy City, patients with schizophrenia have and condemnation of the mentally the Vatican. Inspired by the extra- a better prognosis than in the ill are entirely absent in any soci- ordinary idea of the Pontifical countries of the industrialized ety. Council and of Cardinal Angelini, world. We must ask, then, why does together with their sensitivity and “And when the time of their im- society recoil so dramatically openness, I have dared to prepare prisonment has expired, if any of from the mentally ill? Why do a discourse in a manner contrary them be of sound mind, let him be they create so much angst in the to the formula we have been restored to sane company, but if soul? There are interesting refer- taught to use through our educa- not, and if he be condemned a sec- ences in the Bible: the line “The tion in present-day psychiatry. ond time, let him be punished Lord will smite thee with mad- There will be only very few dia- with death.” ness” (Deuteronomy 28:28) grams or tables, no correlations or Aurelius Cornelius Celsus (25 would indicate that although factor analyses. Simply, I would B.C.-A.D. 50), a most important demons were considered the pre- like to share some of my ideas writer and medical citizen in Ro- cipitating agent of insanity, the with you. I will try to think aloud, man times, responded to the issue supreme controlling force was and instead of many figures I will of madness, even more harshly in considered to be Divine. Saul’s show you some slides of patients terms of ongoing therapy. Celsus mental illness was thought to have in our clinic, which I hope will believed that rough treatment been caused by an evil spirit sent serve to reflect my thoughts. would frighten a patient out of from the Lord. (Samuel 1). The My subject might be a little bit mental illness. He chained pa- frightfulness of the phenomenon old-fashioned. To talk about the tients, starved them, isolated them of mental disturbances could be social psychiatric aspect of schiz- in total darkness, and adminis- traced back to the fear of myster- ophrenia seems to be behind the tered cathartics in his efforts to ies. The so-called miracle was in- times when we are in the midst, frighten them into health. explicable in primitive societies. and rightly so, of the flourishing (Alexander-Selesnick, The Histo- On the other hand, it could have and predominance of biological ry of Psychiatry, 1966). been understood that certain phe- psychiatry. Therefore, it might Removal of the mentally ill nomena like thunderbolts or thun- seem more appropriate to address from society was prevalent until derclaps could have come from you about serotonin, neuroimag- the epoch of the Enlightenment, the sky and from the gods, but ing or neural substrata than to an- when the great reformers, Pinel, there was no conceivable expla- alyze social and family systems. Tuke, Rush, and others, con- nation why a human being who However, encouraged by, and due tributed important changes to the was completely similar to oneself to two most important scientific organization and administration could be so different. findings of recent decades, I feel of mental-hospital-reform pro- This degree of perceived differ- compelled for the moment to grams. It has to be mentioned that ence could be one of the key draw our attention away from bio- Chiarugi was one of these persons agents in the rejection of the men- logical psychiatry and to remind who did not believe in maintain- tally ill and especially schizo- ourselves of other factors dealing ing a cold or indifferent attitude phrenics because the manifesta- with schizophrenia. toward their patients. He travelled tion of schizophrenia is so ex- The first point is that the studies all around Europe, exploring the treme when compared to the of schizophrenia confirmed that humanistic approach toward the norms. If we are candid, we have cultural factors play a definitive mentally ill and tried to develop to admit that in one way or anoth- role in the course and outcome of extremely modern mental health er we are all a bit neurotic; at one schizophrenia (Sartorius 1990). care here in Italy. time in our live most of us have 184 DOLENTIUM HOMINUM had problems with sleep or even ed himself in his bedroom for studies add up to a considerable with sex and so on. A Hungarian nearly a year. His parents consid- consensus about the measure in poem says, “If there is one day ered this behaviour as nothing predicting relapse. (Bebbington without depression in the life of a more than a sign of tiredness. 1990) male over 55, that is a miracle.” It They refused to acknowledge any The aforementioned findings is somewhat acceptable that we peculiarity. It was only when the point to the task of social psychia- ourselves may experience disor- young man started to refuse his try as was expressed by John ders like panic, alcoholic intoxi- meals that the parents sought Wing in 1970. cation or even dementia—in the medical help. “A social psychiatrist investi- distant future, of course—but it is The second family visited me gates social causes of psychiatric completely unimaginable that we for the first time about a month disorders..., studies social influ- could suffer from schizophrenia. ago. In this case a son, Tom, ences on the course of these disor- Schizophrenia incarnates all the claimed that he never took his ex- ders... The effect that mental dis- differences or deviant qualities ams and that the certificate he re- orders have on society and more that the average individual finds ceived from the school was a particularly on family and friends painful to confront. The average phoney. He ceased all communi- is also a central concern.” (Wing, person perceives the symptoms of cation with his previous society Brown 1970) schizophrenia—perhaps above and remained at home. His par- Being still poisoned by the all—as a total loss of control: ents did not attach too much im- ideas of social psychiatry, I have man’s greatest fear throughout portance to this behaviour and so shown great concern for many history, again and again, man’s re- left for holiday, leaving Tom’s years about how to bring together action has been to strike out younger brother in his care. Dur- the two findings above. What are against those whose beliefs or being those two weeks Tom com- the common factors in those two haviour diverge from the per- plained that people were spying ideas? Although many aspects of ceived norms of his immediate soon him from outside the house those statements are true for other ciety. Although most of the reli- door and that they were reading illnesses, why were they verified gions preach acceptance, religious his thoughts. These complaints first in schizophrenia? and ethnic wars, past and present, were followed by a suicide at- Despite obsessive preoccupa- are integral to our civilization. For tempt—a cutting of his wrists. It tion as well as exhaustive re- the past let’s remember the Inqui- was this incident that on their research, schizophrenia remains sition, the case of Salem and the turn prompted the parents to seek among the greatest mysteries of Holocaust, and lately Bosnia. advice from a surgeon friend. In our civilization. Thousands of pa- The great psychiatric changes contacting me, they claimed no pers and books have been written of the era of Enlightment coincid- urgency and requested an appoint- about that topic and we find fasci- ed also with the Great French ment for some time in the future. nation with schizophrenia not on- Revolution, whose slogan was To change this process of denial ly within psychiatric literature, “Liberty, Equality, Fraternity.” is a monumental task of psychia- but within literature a whole. Im- But our industrial and technologi- try and one which is not always mediately the works of Aeschy- cal society, which is so proud of successful. The obstacle is the dis- lus, Shakespeare or Dostoevski its logical thinking, has yet to belief on the part of families that spring to mind. Why was schizo- achieve social fraternal equality such a disease could occur in their phrenia so important in the past, among men. Different points of midst. And, too often, tragically, and why is it still the crucial un- view, alone, are enough to threat- the expectation they have of their solved mystery of our time? en and divide individuals, no less child never diminishes, but re- I think we have to go back hun- the behaviour and belief systems. mains as high and as fixed as be- dreds of years for the answer, as Difference is not acceptable so- fore the onset of the illness. usual to classical times, and as al- cially—look to the nationalisms Secondly, the time-worn thesis ways to the ancient Greeks. Mod- of Eastern Europe, and not ac- that stress influences the course of ern psychiatry owes much, for ex- ceptable personally—look to the schizophrenia receives impressive ample, to the Hippocratic empha- cases of schizophrenia in the com- current support from the literature sis on clinical medicine. Hip- munity and in the family. on Expressed Emotion (EE). pocrates must also be given credit In my many years of experi- Through the developed semi- for his recognition that the brain is ences with family therapy, I have structured interview it has be- man’s most important organ: “the found that, on the whole, family come possible to assess the emo- brain is the interpreter of con- members react with complete de- tional atmosphere in the home of sciousness.” He and his followers nial to the onset of schizophrenia the patients. The ratings reflected developed psychological thinking within their midst. I would like to a number of critical comments, and put forth the first description recall two cases when after gradu- overall hostility and emotional of mental illness. Unfortunately, ation from high-school the prob- over-involvement on the part of however, their attitude toward the lems started. The first was a cata- some patients’ family members. mentally ill was generally rejec- tonic young man who was However, the value of EE is not tion. This attitude was echoed by brought to my department accom- confined to schizophrenia, but the Plato, who regarded madness as panied by his father. I learned that findings must now be regarded as nothing more than a lack of re- after his exams our patient closet- secure. All in all, the majority of straint of appetites, the opposite of “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 185 discipline and intellectual comberwell) and by means of a set of centrate better on the special clar- mitment and sanity. In his Law questionnaires. ification of confusion and unreal- Plato proposed the establishment The interviews were rated for istic expectations in the families. of a house of moderation, in three dimensions: 1) the intensity which those who held their mis- of expectations, 2) the confusion JANOS FÜREDI, M.D. Ph. D. taken beliefs out of ignorance (ambiguity) of expectations, 3) Honorary President, were to be held for five years in the unreality of expectations. Hungarian Psychiatric Association: order to be given sound instruc- We found a significant differ- Professor and Chair, Department of Psychiatry, Haynal Imre University tion. ence between schizophrenic and of Health Sciences. Budapest, Hungary This observation is the basis of normal families in the confusion our new research, which we refer and unreality scale, but no consid- as Expressed Expectation, as op- erable difference on the intensity posed to Expressed Emotion. Our scale. This means that the so- hypothesis is that the high expec- called normal families express tations families have towards their their expectations almost as in- References beleaguered member are at least tensely as the schizophrenic fami- as harmful to the future of our lies do. On the other hand, the ALEXANDER F.G., SELESNICK S.T., The History of Psychiatry, Harper & Row, New clients as is high EE. schizophrenic families in their ex- York, 1966. To prove our hypothesis one of pectations are considerably more BEBBINGTON P., Expressed Emotion and my colleagues, Assistance Profes- ambiguous, confused and unreal- Schizofrenia, in: Psychiatry: a World Per- spective. C.N. Stefanis, C.R. Soldatos, A.D. sor Zoltan Danics and I conducted istic than the normal families. Rabavilas (eds) Excepta Medica, Amster- a study on 26 schizophrenic fami- Thy study confirmed our long- dam, 1990, pp. 67-72. lies with 91 members. As a con- standing therapeutic strategy that SARTORIUS N., Cultural Factors in the Eti- ology of Schizofrenia, in: Psychiatry: a trol we used 25 so-called normal only the involvement of fami- World Perspective. C.N. Stefanis, C.R. families with 63 members. The lies—besides widely accepted an- Soldatos, A.D. Rabavilas (eds) Excepta Med- expression of expectancy was tipyschotic medications—can ica, Amsterdam, 1990. pp. 33-44. WING I.K., BROWN G.W., Institutionalism measured by means of a modified lead to a long-lasting result. Aided and Schizofrenia, Cambridge University semistructured interview (Cum- by our own research, we can con- Press, 1970. 186 DOLENTIUM HOMINUM

FRANCO IMODA

Psychotherapy

Introduction attempt will merely be made to gospel (Martini, 1979).4 And a pas- draw attention to a number of chal- toral theologian (Clebsh-Jaekle, The definitions of “psychothera- lenges and to point out a number of 1964) refers to four principal goals: py” which are usually given are for areas which are of importance in healing, support, guidance and rec- the most part general and open- the drawing up of a correct ap- onciliation. ended. We are told that the term proach to the subject of this paper.3 For some experts psychotherapy refers to “every systematic effort to is the more or less indiscriminate alleviate a mental disturbance by 1. Psychotherapy is not primarily application of a technique (perhaps psychological means.”1 In this made up of theory. We have to face of an analytical kind) which has open-endedness and high level of a challenge which is of a “practi- been more or less practically test- generalization we encounter not a cal” character. I will not dwell here ed. This demonstrates a hiatus be- weakness but an opportunity. At a upon the challenges involved in tween theory and practice in the specific level of what does this help terms of professional codes of sense that a technique which is held consist? What does it seek to do— ethics and the recognition of quali- to be suitable and justifiable for a achieve a cure, internal equilibri- fications and spheres of expertise. certain kind of difficulty and need um, social adaptation? Personal From the questions which are comes to be applied more or less identity as a form of self-fulfill- posed above, it is clear that we are universally. For example a psycho- ment? Rehabilitation with a view often faced with a wide range—but dynamic solution is offered to a to achieving and expressing human perhaps also marked confusion— spiritual need (or vice versa) or an potential, including the image of in relation to the goals which “analytical” initiative takes place God? All of these alone or other should be pursued, especially as re- within a set of psychological an- things as well? gards their mutual inter-relation- swers where it would perhaps be It is certainly not possible here to ship. Should one be seeking to better to promote an action of “syn- enter into a general and detailed de- recreate a biological-physical equi- thesis” or vice versa. bate on the effectiveness of psy- librium, a greater level of social Again in relation to practical im- chotherapy.2 The aim of this brief adaptation, restore an interpersonal plementation and action,the chal- paper is narrow in outline. Ap- relationship which had previously lenges which present themselves proaching the subject from an angle been too difficult, or provide a concern the “processes” which which is not of an exclusively func- world of meanings and values should be followed. Does one want tional character, and taking as its which can overcome the futility to “illuminate” and render the un- starting point certain practical and and the absurdity of a person’s own conscious conscious or does one theoretical difficulties, this paper life? want to “experience”—that is, re- seeks to emphasize the importance Some authorities have not only live something in a strong or new of an anthropological approach referred to expressive or support fashion? If the relationship is of which can be applied at a practical psychotherapy but have also held importance in this process, to what (psychological) level. The aim is up as their aims such specific goals extent is emotional involvement or not only to find a way out of a cer- as pacification, unification, optimal neutral detachment to be welcomed tain number of difficulties in which disappointment, and interpretation or promoted? Is the element which therapy may find itself immersed (Gedo and Goldberg, 1975). But interprets the disorder as demonic but also to act in a way which cor- we are reminded of the fact—at possession a declaration, a rite of responds to the full to the richness least, that is, if we are Christians— propitiation, or, in extreme cases, of the reality of the human person. that we are also dealing with re- an exorcism? newing the reality that people are Is it possible to use one kind of by their natures made in the image language only and a sole theoreti- 1. Challenges of the Creator (Col 3:3-4). cal model or should we use differ- The pastor/educator reminds us ent forms of language which are Faced with the host of questions that the disciple is sent on a dual suited to the various stages and sit- which present themselves, here an mission—to heal and to preach the uations of personal development?5 “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 187

2. Given these brief references remains of a destructive character, er. But all this has been brought to challenges which arise in rela- it is nonetheless possible that the out and discussed no longer within tion to the actual practical imple- analysis of the hidden component the context of an inevitable alien- mentation of psychotherapy, it is features of human behavior can ation or opposition between the not difficult to understand that open new horizons of freedom and psychological and the religious but there is also a strictly connected that religion and faith can be “puri- rather in a process of legitimate theoretical challenge which bears fied” of less genuine elements. and mutual enrichment (Rizzuto, directly upon the question of the b. It should also be observed, 1979; Jones, 1991; Meissner, anthropological reality of the indi- however, when discussing the 1984, 1987: Spero, 1995). vidual who is to be treated. epistemological side of psy- These two tendencies are com- First and foremost there is an chotherapy, that there is another plementary and this quality can be- epistemological dimension. Re- more constructive tendency. When come especially helpful in the in- cent decades have witnessed the positive in character this tendency terpretation of psychotherapeutic emergence and the dominion with- provides a new appraisal of the change. Here the “positions” of in the scientific world—if not al- contribution of phenomenology, people are a reality lived out by in- ways in relation to culture—of a and lays emphasis upon the impor- dividuals who, because they are new “ethos” concerning the episte- tance of a recognition of those val- the children of their culture and of mological side of the question. ues which most fittingly corre- the interpretations that it offers of The leaving behind of positivism spond to the anthropological struc- their human and religious experi- and technical rationalism (Peter- ture of the human person—and ences,8 are also called upon to real- son, 1968, 1979, 1995; Macquar- thus upon the importance of an an- ize their vocation to the full.9 rie, 1989; Jeeves, 1976) has meant thropological vision—in order to In addition to this epistemologi- that human action can no longer be define the aims of pedagogic activ- cal dimension there is also an as- explained, and certainly not treat- ity in itself. The importance of an pect which is of a more specifical- ed, with reference to purely ethical dimension, of values, and ly theoretical and anthropological “causal” factors. In the same way of the religious realm as a reality character. it cannot be solely “understood” which is also of psychological rel- The practical challenges that through the study of the subjec- evance not only is not denied but is emerge within the therapeutic con- tive—perhaps idiosyncratic— actually actively and positively text involve and touch upon the meanings of the individual. The sought.7 It is recognized that these anthropological reality of the hu- hermeneutic approach has gained forms of psychology which inter- man person. With Gabriel Marcel ground and this has involved a pret our place in the world con- (1970) and an already existing rich search for dialogue or critical contribute to a wider and more intri- cultural tradition, we do not want versation supported by interdisci- cate understanding of this whole to reduce the mystery of the hu- plinary knowledge (Ricoeur, area. man reality of being in the image 1977, 1977a) which offers new op- They help us to have a detailed of God to a mere question or prob- portunities by which to compre- vision of the “positions” which are lem because in such a way the en- hend the complex choice of psy- experienced and which the educa- counter expressed in therapeutic chotherapeutic goals and process- tor must constantly tackle. These help becomes reduced to a tech- es. At a more specific level, we are forms of psychology “serve” as nique. The necessary perception faced with the emergence of the menus of questions and answers which prepares the way for and ac- need for a dialogue between psy- by which certain horizons are de- companies every form of “thera- chology as a human science on the fined, by which given answers and peutic” initiative can and must be one hand, especially in relation to questions are formulated, and by done without ignoring the anthro- its anthropological aspects, and which a certain kind of transcen- pological dimension.10 theological and philosophical an- dence, of a more or less radical na- thropology on the other. ture, is established. Precisely be- The critical dialogue present cause such interpretations are a 2. Areas of Anthropological within the hermeneutic approach part of our culture, they thereby Relevance takes two forms: end up by imposing horizons a. A more critical tendency which although they involve one It seems that there are certain ar- which in its representation of a kind of transcendence also act to eas of especial relevance both in negative moment shows how exclude other kinds. At a more relation to the general way in every action dealing with human specific level, for example, recent which the human person is thought knowledge, including the psycho- studies on the development of the about and treated and in relation to logical, is connected to its time and relationship have demonstrated psychological knowledge and ac- thus reflects the contingent and that there is a close connection be- tion. Psychological and psy- relative aspects of that time.6 The tween the way of thinking about, chotherapeutic initiatives and ob- critique of human motivations was and addressing oneself, to the oth- servations at the very moment for long a characteristic of a form erness of the divine on the one when they allow practical and ex- of psychology which turned out to hand, and the primitive and infan- perienced access to the individual be in large measure reductive. Al- tile experiences by which one also involve the taking of a posi- though in its most extreme and ex- learns to be and to live as individu- tion in relation to these fundamen- clusive expressions this critique als in relation to others on the oth- tal anthropological dimensions.11 188 DOLENTIUM HOMINUM

1. The cognitive area, text, these schools can legitimate moment what the will desires. Does the question, otherness closures onto equally limited hori- not the human and therapeutic jour- The individual is faced with the zons and may produce forms of ney involve the resigned accep- difficulty, whether of a pathologi- psychotherapy which exclude the tance of the “character” which lim- cal character or otherwise, of the exploration of the transcendental its, constrains, and becomes a justi- uncertainty, the incapacity or the (religious) realm or they may in- fication for non-growth, for not difficulty of finding meaning in his volve a more appropriate achieve- risking and becoming that which single acts or in the general direc- ment of the anthropological reality we are called to be? Has life be- tion and orientation of his life. For of the individual, the search for come mere “result” (past) without this reason it is easy for him to de- truth. being a “project” (future) or is it on- ceive himself, to shut himself up The psychological element ly a “project” which is not able to within himself, to avoid questions, which is phenomenologically ac- take on the historical “given” of its to be content with his more or less cessible is to be found in otherness, own history? Or is it a flight into immediate world, to dispense with in the different practical and real imaginary illusions in a self-created that pursuance of “virtue and forms which are acquired during world which flees from reality? knowledge” which would more the course of the individual’s de- easily express the image of God. velopment. 3. The motivational affective area The recommendation “Know thy- and its various internal self” is very far from being simple 2. The command area of action, structures, which are matched and practiced. The “confused” self the voluntary, and freedom within the psychological sphere which psychologists analyze and As a free individual agent, the by the diversity and the seek to interpret is an individual ca- subject is faced with the struggle or integration of the different pable of knowledge and in search the struggles of a conditioned free- levels or stages of the person of the whole of truth. What is the dom which through the taking of The person, a mental-physical- objective, the goal of my research large or small decisions must spiritual subject, is the object of a which is implicit or explicit in my “make” truth. Here we are dealing series of motivating forces, pas- questions? What is the otherness with the complex relationships be- sions or “loves” which he manages within which I have been called to tween the voluntary and the invol- with greater or lesser success to be present? Are we faced with untary, between different wills, be- unify and to integrate. In the indi- autism, with schizophrenic fantasy, tween nature and person. In tension vidual there are natural drives, so- drugs, or merely new idols, the oth- between the figure of Prometheus cial and human interests, and forms er used symbiotically or another or and that of Sisyphus there is the of affection which are culturally le- Another loved in the giving of one- temptation of the flight from free- gitimated or appreciated, and a self? dom—an aspect and expression love which has divine dimensions. These questions define in more not only of pathology but also of The discipline of psychology or less implicit fashion a horizon, a every form of human fragility. which is at the base of every kind world. From one’s own body, that Should one accept the determinism of psychotherapy cannot but be in- is, to material things, to others, to of blind forces or base oneself upon terested in the different levels economic, cultural or spiritual and a utopian (or Promethean) spon- which interact and overlap and ex- religious values. The horizon or the taneity in order to guide one’s press themselves in different forms horizons define the very purpose of choices? How can we categorize of hierarchical integration. During life. the ethical obligation which derive his development how does the per- The schools of psychology from the horizon and the son emerge and how does he man- which are at the base of every edu- metaphors which express it as out- age to unify and integrate these cational or therapeutic initiative lined in the previous observation? component parts? What motiva- specify certain horizons through Upon the fundamental metaphors tions prevail so that some express their fundamental metaphors.12 Is (of the previous point) depend oth- or “serve” the others—the “inferi- the other an object of instinct even ers which define in more or less im- or” at the service of the “superior” when there is an intention to trans- plicit terms the ethical obligation— or, not unusually, vice versa? Is form this into an instinct of life or hedonism, ethical egotism, altru- love for another person only at the death which is almost metaphysical ism, forbidden by the law, agapé service of sexual and hedonistic (psychoanalysis)? Is it another love, the giving of oneself in chari- goals and are these psychosexual which becomes reduced to what it ty. At a psychological level and thus forces informed by an agapé love? is, another which must offer self- also at a psychotherapeutic level, More or less implicit in the same fulfillment to the ego, with the ab- the human person always finds metaphors or specific visions of the solute supposition of a harmony himself in tension between a re- human sciences can be found those between the various human tenden- ceived “given” and the ability to conceptions of the fundamental cies and with the minimalization of choose, to engage in creative self- motivation of the person, those ba- conflict (humanistic forms of psy- positioning. He always ends up by sic tendencies which can freely or chology)? Is it the principle of nat- being in some way a “result” (with in terms of purpose determine, con- ural selection as we encounter in a glance backwards to the past) but dition or motivate human action. the case of the behavioral schools also a “project” (with a glance for- We are not dealing here with this of psychology? wards to the future). The temporali- or that theory which sees need, im- More or less limited in their con- ty expresses in the concrete present pulse, “libido,” affection, the “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 189 propensity to fulfill oneself and ism (Ricoeur, 1986; Kohut, 1980), pable of reunification through a one’s potentiality, the finality of the and upon a norm/value of mutual process of the integration—based love which may possibly lead to respect and a certain reciprocity on upon a transforming motivation— the unconditional giving of oneself the other which ignores wider val- of the various levels of the human as a fundamental motivation. One ues such as self-giving in love and existence understood in terms of has before one, rather, the practical a form of love which can be “sacri- “body,” “psyche” and “spirit.” On- working of each individual accord- ficial” in character (Browning, ly in this way will it be possible to ing to one or other of these systems 1987). speak about an integration (recon- of motivating forces. The multi- In this sense the process of ciliation) of the various structures plicity of these levels which are growth, of development and of the and component parts of the person connected to the bio-mental or his- rediscovery of full human dignity and thus of an internalization of the torical cultural reality of the human as the image of god (based upon values by which freedom deter- person raises questions as to which wider conceptions and horizons) mines itself beyond those influ- fundamental needs must be justly could only take place through: ences and the conditioning effects and morally satisfied and how they A broadening of the horizon which are merely external. should be integrated. This should which does not work through chan- be done, once again, not only with nels of pure knowledge and thus al- 5. Finally, the importance reference to a theory which defines most individualistically but of being able to adopt the an ideal but also as an expression of through a “participation” where the metaphor of “grace” deciding upon practical action. relationship with the other and with in psychotherapeutic action This third area of anthropological an ever greater otherness (guid- The psychotherapeutic process concern introduces the question ance, support) takes place in the depends upon the “vision” and the and the need for the greatest possi- full awareness of the fact that the metaphors which express it. The ble overcoming of reductionism13 choice of horizon is not merely a psychotherapeutic process which and the explicit admission of the rational question. Psychotherapy seeks to lead on to healing, devel- existence of a complexity of levels thus becomes not only instruction opment and growth, but also on to which is present within the sphere but also a search for truth and in re- openness to the richness of human of human action and its various lation with an ever broadening oth- dignity—precisely because it takes motivations. erness the acquisition of a sound place within the reality of fragili- way of thinking which knows how ty—will always be marked by 4. To these three areas should be to ask and look for answers to the struggle and conflict. It will in added that of psychotherapeutic most radical questions. practical terms never be a journey processes. A series of factors Quite beyond every conception of easy passage and spontaneous and elements arise when one which involves a “hiatus” between openness without adversity. Not comes to consider the processes “nature” characterized by its forms will it be able to reduce itself to a by which psychotherapy seeks to of determinism on the one hand historical observation of the forms achieves its goals. Each form of and “spirit” characterized by ex- of determinism within which the psychotherapy requires a treme unconditioned freedom on individual lives. Even at the time of development, a change, and a the other, each form of psychother- the ancients, development and transformation. By what routes apy moves towards the free taking growth encountered the reality of does this change, this on of reality through the responsi- death connected to life marking transformation, take place? ble acceptance of the individual’s their path. For Plato the child had For a long time criticism has own given and his own vocation to to die for the young person to be been levelled at traditional forms of transcendental values. A purely born and the young person had to psychoanalysis and their view of “causal” model based upon the die for the adult to come into this the world. More recently this criti- conviction that everything can take world (see Schachtel’s discussion cism has found clear expression in place through almost mechanical of this point Schachtel 1959, a form which is at once both an- changes in nature—in the same pp.14ss.). thropological and psychological. It way as a spiritualist model which This is a struggle which would observes three characteristic limi- ignores the biophysiological and not find meaning—and thus in the tations in traditional psychoanaly- mental laws and influences of na- same way would encounter diffi- sis which require three correspond- ture—not only reveals itself to be culty in finding a place—in the hu- ing corrections: a. a tendency to anthropologically inadequate but is manistic universe expressed by atomistic mechanism which sees also positively ineffective. Psy- metaphors of harmony, security the individual as a field of interact- chotherapy should not be a desper- and interdependence which in es- ing forces; b. a tendency to enlight- ate struggle to accept one’s own sential terms render a transforming enment rationalism which gives destiny but in the same way it moral action useless. It is a struggle rise to the idea that the process of should also not be a flight from the which perhaps could find a place in “healing” or the answer is first and reality of one’s own history within the Freudian universe, but only at foremost to be achieved by cogni- a process of consoling illusion. the extremes of a tragic and histor- tive means; and c. a tendency to an Quite beyond a mere restoring of ical realism. ethic based on the one hand upon the balance of the affective forces What meaning and thus what rationalism which is thereby un- (healing), the psychotherapeutic convincing and effective motiva- able to rise beyond moralism/legal- action should render the person cation can a psychotherapeutic 190 DOLENTIUM HOMINUM process find which does not have agapé and of charity, which is indicate that the results of psy- the means by which to accept in thereby sacrificial in nature, can chotherapy, although certainly to radical terms the aspect of limit, of overcome the inevitable injustice be seen, are not so certain or wide- fragility, and of death?14 and imperfection which would oth- spread.17 Following the line of ar- In this sense, and quite beyond a erwise be intolerable. In this way gument of many authorities, it conception of the therapeutic “grace” without in any way being seems useful to recommend—at process as being unmitigated the monopoly of the “religious” or least with regard to the field of psy- progress or the resigned acceptance becoming a mere psychological chology—the promotion of train- of unavoidable regression, we must function, comes to play a part in the ing in relation to disciplined re- find a place for a conception of this psychological game. With the char- search (Holu, 1961; Davison and process which is “transformation,” acteristics which are typical of the Lazarus, 1994; Peterson, 1995) and a process where the negative—re- paradox it makes a deeper realism a systematic evaluation of change maining realistically negative—be- possible through its transcendence. in individuals, groups and organi- comes converted into being posi- The image of God which is ob- zations rather than diagnostic and tive. This is what can be found in scured but constantly restored is therapeutic certainty. In welcom- the law of grace, a law which pre- such precisely because it is truly, ing “educators who reflect” and supposes the presence of a “re- and ever more so, human.16 In the who are trained to operate within demptive” vision where the spirit is light of what has been observed uncertainty rather than therapists able to transform what is absurd in- hitherto, a number of concluding who are absolutely certain of to meaning, weakness into remarks are now required. everything they do, one could also strength, and death into life.15 welcome a renewed attention on Anybody who has worked in the the part of experts in the field of “psychotherapeutic” field knows 3. Concluding Remarks philosophy and theology to the that in the process of growth and questions posed by psychology change an encounter/conflict with 1. Psychotherapy can never be when applied to psychotherapy. irrational events which inevitably merely the outcome of the imple- The mystery of the person requires diminish a meaning and are evi- mentation of a technique. The hu- an epistemology and a methodolo- dently absurd is inevitable. Would man person in his reality of being gy which are both suited to its rich- it not perhaps be a more than rea- mystery and the image of God can ness. sonable hypothesis to interpret never be treated as a mere mechan- many halts in the process of psy- ical combination of forces. 5. The importance of this an- chotherapeutic growth, many fail- thropological dialogue is to be ures and abandonments (the forms 2. Science alone does not suffice found: above all else in considering of impasse referred to at the begin- when we come to consider the and defining goals, whether the ul- ning of this paper) as being caused challenges of psychotherapy. But timate, the intermediate or immedi- by a lack of a “mediation” between in the same way religion alone, or ate (horizons), in relation to each purely “psychological” struggle in conjunction with philosophy, is other. But this importance is also to and “spiritual” struggle? Does not not enough. Science is not suffi- be found in the fact that freedom the person in this situation find cient because in the pedagog- and thus an inevitable ethical norm himself divided and reduced to a ic/psychotherapeutic action there is are present in these processes of tragic psychological conflict which an inevitable meeting of the themes change. To conclude, it is also ex- takes place at one level of his being of death and life but also of the pressed in the fact that in the person and placed in a condition where he themes of the origins (past) and the the horizon (or the horizons) and is unable to enter into a relationship end (future), of flight and commit- the forces which are brought into or a connection with the spiritu- ment, of fantasy and reality, of guilt play by the will or by inner impuls- al/religious conflict, the only such and innocence, of time and eternity, es combine together to define the conflict which can confer meaning of intimacy and loneliness, of pain fundamental motivations and pas- and strength? In such cases the im- and happiness. sions. It is these fundamental moti- age of God does not remain ab- vations or passions which are at the stract or a question of principle but 3. An inter-disciplinary dialogue root of what we call maturity/im- is insufficiently directive and trans- between psychology or the differ- maturity or the personal human forming. ent schools of psychology and the task including that of being in the Only faith and a theological and philosophical and theological sci- image of God, or of what we call Christian faith can really take on ences is more than welcome when immaturity-pathology/failure and such psychological elements which we consider the psychotherapeutic thus what amounts to the deforma- are inevitably tragic, and thereby project, although we must of tion of the image of God. confer a meaning even to realities course abandon mutual suspicion which are characterized by the ab- and excommunications. There are 6. In relation to psychotherapy surd. In the inevitable encoun- signs that this dialogue is underway there is a clear need for the adop- ters/conflicts marked by limits and at both an epistemological and an tion of a “metaphor of grace” forms of determinism, only hope anthropological level. which tackles—and with the right manages to satisfy certain necessi- means—the potentially tragic as- ties in a resolution which never 4. We are also invited to adopt a pect of life; and which also trans- ceases to be realistic. Only a love of stance of humility—many studies lates a transcendental and Christian “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 191 reality onto a psychological level Seligman (1995) observes, these data corre- Christian tradition, it is not the case that the spond well with other major works of research different schools of psychology are without a and thereby ensures a deep and sta- carried out into the effectiveness of psy- metaphor of purpose or goal and without prin- ble transformation which is of this chotherapy (Lipsey and Wilson, 1993; Shapiro ciples regarding ethical obligation and that on character because it is true and free. and Shapiro, 1982; Smith, Glass and Miller, the contrary the different expressions of theol- 1980). ogy are weighed down by such ancient bag- 3 One way of approaching this variety (ref- gage. The differences are more a question of 7. There must be an attempt to erence is commonly made to dozens and per- alternative decisions and of attitudes towards recover the original meaning of haps more than a hundred different systems) is these metaphors and principles of ethical to discuss the “models” which are employed obligation. There is indeed a process by which “therapy” and therapeutic through (medical model, psychodynamic model, cog- psychology is gradually and insistently becom- broadening this term to include the nitive model, psychosocial model, moral mod- ing religion and ethics” (Browning, 1987, p. formation of the person employing el, existential model, and so forth). In this way, 89). however, and especially if one remains at a de- 11 De Waelhens (1972) has pointed out how an “overall” vision. The Greek scriptive level, the question for the most part contemporary doctrines regarding the human word “therapon,” indeed, means in becomes postponed but with the advantage person lay great stress upon the importance of essence “servant.” A variety of rea- that one immediately encounters the variety of defining the human being as a “being in the approaches which are available as forms of re- world” thereby leaving behind—and not only sons linked to the history of science sponse to therapeutic requirements and which at a theoretical level—the opposition between and culture have acted to confer constitute an expression of partial truths. The “for itself” and “in itself.” As “pure conscious- meanings which are too narrow on danger of reductionism emerges when the ness” (for itself) or as a “thing” (in itself) the adoption of a model in an exclusive fashion human being would no longer be in the world. this concept. We have to recover its seeks to be applied to the different forms of the It is, however, difficult to find, observes Wael- deepest meaning such as that disturbance, problem or question with the hens, an authentic recognition and a descrip- which one finds applied to Moses same answer and methodology (spiritualism, tion of human consciousness which pays seri- psychologism, or biologism). ous attention to the practical and historical in the letter to the Hebrews 3-5 4 With reference to the Gospels: Matthew, “how” by which the two poles of his being in where we read that “the loyalty of 10:7-8; Luke 9:2; Mark 3:14-15. the world come to be combined. The being in Moses in the management of God’s 5 In the general debate upon psychotherapy the world of the person is therefore taken for a wish for an integration of the various per- granted at the same time at which he experi- house was the loyalty of a servant,” spectives is more than evident (Bietman, Gold- ences its difficulties and vulnerability. It is my almost a preparation and image of fried, and Norcross, 1989; Pine, 1990; Tyson belief that psychological observations can con- he, Christ, whose loyalty “was the and Tyson, 1990). tribute in a critical dialogue with the anthropo- 6 A number of voices have been raised to logical elements to this definition of the being loyalty of a Son in a household “criticize” the strongly individualistic charac- in the world, not least with a view to rediscov- which is his own” (3-6). We should ter of nearly all current forms of psychology. ering the image of God. also connect it to the mission given Because they were born in an individualistic 12 It is interesting to note that a clearly tech- culture, their horizons not only reflect this nical analysis carried out by Gedo (1995) on a to the disciples and described in “ethos” but are also thereby inadequate when it therapeutic process considered fundamental Matthew 10:7-8: “And preach as comes to supplying an answer to more existen- (“working through”) concludes by asserting you go, telling them, The kingdom tial and more radical questions (Bellah et al., that in essential terms one is dealing with an at- 1985; Bevan and Kessel, 1994; Rieff, 1966; tempt to educate the person to sound thought. of heaven is at hand. Heal the sick, Cushman, 1990; Sampson, 1985, 1988, 1989; 13 Understood as the tendency of a discipline raise the dead, cleanse the lepers, Smith, 1991; Vitz, 1980; Wallach and Wal- to reduce the phenomenon which its studies to cast out devils.” lack, 1983). Other observers have stressed the the metaphorical model it prefers. In this way a lack of attention paid to existential problems psychic process becomes reduced to a biologi- by the various contemporary psychological cal or mechanical phenomenon or a religious Professor FRANCO IMODA, S.J. theories (Vandenberg, 1992; Bevan, 1991; phenomenon becomes reduced to a psycholog- Director of the Institute of Psychology Browning, Jobe, Evision, 1990; Chessick, ical process. Side by side with these tendencies at the Pontifical Gregorian University, 1993), to the frequent reductionism of psychol- which can be seen as reductionism “from be- Rome ogy (Eidelberg, 1992) and to the attempt by low” there are also many forms of reduction- psychology to take the place of religion (Butt, ism “from above,” as happens when an illness 1992; Menninger, 1973; Rohr, 1991). In vari- is interpreted as an immediate effect of a moral ous ways these and other possible voices point disorder, or when a mental problem is per- out the limits which contemporary psychology ceived and treated as a spiritual problem which places on human horizons and thus on psy- should be dealt with if not by an exorcism as chotherapy, involving as they do reductive vi- least with an exclusively spiritual form of ped- sions of the “world” in which the individual is agogy. Notes called upon to live and operate. 14 With reference, for example, to the eight 7 Bergin, 1980, 1991; Jones, 1981, 1991; situations discussed by E. Erikson as being the 1 International Dictionary of Psychiatry Lake, 1966; Jones and Stanton, 1994; O’Dono- eight crucial periods of life, one could observe (1989). Or “A form of treatment concerned hue, 1989; Rulla, 1985; Rulla, Imoda, and that in each of these phases or periods a pole of with problems of an emotional character where Ridick, 1986; McDargh, 1984, 1985; Sims, the binomial or conflict represents the situation a qualified person deliberately creates a profes- 1994 and others. of absence or negativity and another pole the sional relationship with a patient (client) in or- 8 Some adults approach the affective aspect situation of presence or of positivity. The eight der to remove, modify, or retard the symptoms of their lives as Freudians; others, as adoles- periods which are all characterized by their which are present, to moderate disturbed forms cents, embody humanistic psychology in their own form of conflict or tension, as many will of behavior, and to promote the positive almost exclusive search for self-fulfillment. remember, are the following: trust/distrust, au- growth of the person and his development” Others are pragmatic in being more or less util- tonomy/shame and doubt, initiative/blame, ap- (Wolberg, 1954, 1988). itarian behavioralists and are guided by the law plication/ inferiority, identity/diffusion of role, 2 It is taken for granted that psychotherapy of success and by the principle of functionali- intimacy/isolation, fertility/stagnation, person- has positive effects even though not all author- ty. The questions and difficulties are so rooted al integrity/desperation (Erikson, 1959, 1960). ities are agreed on this point. In a large pro- in one or other of these “systems” that they Each person lives the presence of the pole of gram of research carried out by Consumer Re- condition in large measure the position itself of absence in a certain way in the sense that (for ports in 1995—a program which was carried the question and the kind of struggle or obsta- example) distrust is never completely reme- out by people moved first and foremost by eco- cle which must be overcome. died and trust is never so great as to eliminate nomic criteria—one of the chief conclusions 9 Forte (forthcoming, in press) has observed all shadow of distrust, and so on in the same was that the treatment carried out by these pro- in relation to theology and psychology how a way for all the rest. Of especial interest is this fessional practitioners works. Of 426 people three-sided order of epistemological, insistence by a great psychologist on the need who were “very bad” at the beginning of the hermeneutic and experiential factors can con- to re-evaluate the role of the so-called “nega- treatment, 87% were “very well” or at least tribute in their various mutual relationships to tive” moment of each polarity. What kind of “quite well” when the research was carried out. certain basic positions such as resistance, in- maturity could a person display if he did not Of the 786 people who were “quite bad” at the difference, surrender or integration. have a certain distrust towards himself and to- outset, 92% were “very well, well, or quite 10 “Whatever the difference may be between wards the rest of the world, if he did not doubt well” when the research was carried out. As these new kinds of psychology and the Judeo- etc.? (Wynne, 1984). 192 DOLENTIUM HOMINUM

15 See the law of the cross in Lonergan FORTE B., Teologia e psicologia: resistenza vue Philosophique de Louvain, 1977, 75, 125- (1964, 1974) and those which Ricoeur (1966, indifferenza, resa o integrazione? In Psicolo- 147. pp. 505-526) in a more specifically psycholog- gia tra antropologia e formazione (in corso di RICOEUR P., Il conflitto delle interpre- ical context has described as being the trans- stampa). tazioni, Milano: Jaca Book, 1977a. (tit. or. Le forming power of certain figures of the spirit. GEDO J.E., Working through as metaphor conflit des interprétations. Essais d’herméneu- 16 “To know man, the true man, the whole and as a modality of treatment. Journal of the tique, Paris: Seuil, 1969). man, one must know God;...to know God one American Psychoanalytic Association, 1995, RICOEUR P., The self in psychoanalysis and must know man” (Paul VI, Address to the Con- 43, 339-356. in phenomenological philosophy, Psychoana- cluding Session of Vatican Council II, n. 8). GEDO J.E. e GOLDBERG A., Modelli della lytic Inquiry, 1986, 437-458. 17 Seligman, 1993; Strupp and Hadley, 1979; mente, Roma: Astrolabio, 1975. RIEFF P., The Triunph of the Therapeutic, Peterson, 1968, 1995; Dawes, 1994; Arle and HOLT R.R., Clinical judgment as a disci- New York: Harper & Row, 1966. Goldberg, 1984, Liberman, Yalom and Miles, plined inquiry. Journal of Nervous and Mental RIZZUTO A.M., The Birth of the Living God, 1973. Disease, 1961, 369-382. Internal Dictionary of Chicago: The University of Chicago Press, Psychiatry (a cura di S. Sutherland) New 1979. York: Continuum, 1989. ROHR R., Why does psychology always win, JEEVES M., Psychology and Christianity, Sojourners, 1991, Nov., 10-15. Bibliography Downers Grove, IL: Intervarsity Press, 1976. RULLA L.M., Antropologia della vocazione JONES J.W., The Texture of Knowledge: An cristiana. vol. 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SELIGMAN M.E.P., The effectiveness of psy- Fortress Press, 1987. LONERGAN B.J.F., The transition from a chotherapy, American Psychologist, 1995, 50, BROWNING D.S., JOBE T., EVISON I.S., (a cu- classicist world-view to historical mindedness, 965-974. ra di) Religious and Ethical Factors in Psychi- A Second Collection, Edito da W.F.J. Ryan e SHAPIRO D., SHAPIRO D., Meta-analysis of atric Practice, Chicago: Nelson Hall/Chicago B.J. Tyrrell, London: Darton, Longmans & comparative therapy outcome studies: A repli- U. Press, 1990. Todd, 194, 1-9. cation and refinement, Psychological Bulletin, BUTT M. MUNAWAR, Psychology, Sin & So- MACQUARRIE J., In Search of Humanity. A 1982, 92, 581-604. ciety: An Essay on the Triumvirate of Psychol- Theological and Philosophical Approach, SIMS A., ‘Psyche’ - Spirit as well as Mind? ogy, Religion and Democracy, Lanham MD: New York: Crossroads, 1989. British Journal of Psychiatry, 1994, 165, 441- University Press of America, 1992. 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SPERO M.H., Psychotherapy of the religious Consumer Reports, (1995 Novembre) Men- MCDARGH J., Theological uses of psycholo- patient, Springfield IL: Thomas, 1985. tal health: does therapy help? gy: retrospective and prospective, Horizons, SPERO M.H., Countertransference-derived CUSHMAN P., Why the self is empty. Toward 1985, 12, 247-264. elaboration of religious conflicts and repre- a historically situated psychology, American MEISSNER W.W., Psychoanalysis and Reli- sentational states. American Journal of Psy- Psychologist, 1990, 599-611. gious Experience, New Haven: Yale Universi- chotherapy, 1995, 49, 69-94. DAVISON G.C., LAZARUS A.A., Clinical in- ty Press, 1984. STRUPP H.H., HADLEY S.W., Spèecific ver- novation and evaluation: Integrating practice MEISSNER W.W., Life and Faith. Psycho- sus non specific factors in psychotherapy, with inquiry. Clinical Psychology: Science and logical Perspectives on Religious Experience, Archives of General Psychiatry, 1979, 36, Practice, 1994, 1, 157-168. Washington D.C.: Georgetown University 1125-1136. DAWES R.M., House of cards: Psychology Press, 1987. TYSON P., TYSON R.L., Psychoanalytic the- and Psychotherapy built on a myth, New York: MENNINGER K., Whatever Became of Sin? ories of development: an integration. New Free Press, 1994. New York: Hawthorn Books, 1973. Haven CT: Yale University Press, 1990. DE WAELHENS A., Une philosophie de O’DONOHUE W., The (Even) Bolder Model, VANDENBERG B., Is epistemology enough? l’ambiguité. Prefazione a Merleau Ponty M. American Psychologist, 1989, 44, 1460-1468. An existential consideration of development, La structure de comportement, Paris: Presses PETERSON D.R., The Clinical Study of So- American Psychologist, 1992, 46, 1278-1286. Universitaires de France, 1972, V-XV. cial Behavior, New York: Appleton Century VITZ P.C., Psychology and Religion. 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EUGENE WOLPERT

Psychological Therapies

The theme that I was asked to happened worldwide as a conse- community-oriented care? I will speak about can hardly be exactly quence of these proposals. Up to present a meta-analysis of the defined. The questions as to what now the programmes of renewing most reliable outcome studies on belongs to psychosocial therapies, psychiatry and mental health care this question, performed by Häfn- what has to be excluded, and are concentrated on reducing beds er and co-workers (1989) of the where there are larger overlap- and replacing them by community Central Institute of Mental Health pings with other themes like pre- care, as far as possible. But what in Mannheim, where I worked for vention and rehabilitation cannot happens in detail with the patients about 10 years before moving to be answered properly. Too many in the communities and how ef- Darmstadt and continuing modern versions of defining “psychoso- fective is the so-called extramural community-oriented psychiatry. cial” are used. I restrict my subject to two different core areas of TABLE 1 “psychosocial”: 1) I will concentrate on psychosocial treatment Study Effect of extramural (community) care and care by extramural communi- positive no negative ty facilities and 2) on therapies with families and couples (part- An der Heiden et al. (1989) X ners) as very useful and effective Antohony e Buell (1973) X in many aspects, mainly for schiz- Beard et al. (1963) X ophrenic patients and their fami- Beard et al. (1978) X lies. 3) I will not describe thera- Bosch e Pietzker (1975) X pies in detail but try to show how Byers et al. (1979) X far the psycho-social therapeutic Christensen (1974) X approaches are confirmed by Claghorn e modern scientific evaluation of Kinross-Wright (1971) X their outcomes. Cottman e Mezey (1976) X Community-centered care as Dincin e Witheridge (1982) X the alternative to traditional hos- Franklin et al. (1975) X pital-centered treatment of men- Hornstra e McPartland (1963) X tally ill was postulated by differ- Kirk (1976) (X) (X) ent professionals and political authorities, by the Joint Commission Mayer et al. (1973) (X) (X) on Mental Illness and Health in MaCranie e Mizell (1978) X the USA (1961), the Royal Com- McNees et al. (1977) X mission on Mental Health Law in Nuehring et al. (1980) X Great Britain (1977) and the so- Orlinski e d’Elia (1964) X called German Psychiatry En- Purvis e Miskimis (1970) X quete from 1975, along with law Sheldon (1964) X 180 that laid the ground for the Solomon et al. (1984) (X) (X) Italian Mental Health revolution. Tessler e Mason (1979) X All these steps demanded that, Vitale e Steinbach (1965) X wherever possible, hospital treat- Winston et al. X ment should be replaced by extra- ——————————————————————————————- mural or community-centered Meta-analysis of 24 evaluative studies on the effectiveness of extramural treatment, and that authorities (community-centered) care of mentally ill. should provide facilities for such alternatives to hospital treatment. Source: An der Heiden, W., Krumm, B., Häfner, H., 1989 (modified). Much could be said about what 194 DOLENTIUM HOMINUM

Most of the studies showed that TABLE 2 - RELAPSE RATES OF PROSPECTIVE OUTCOME STUDIES community care can reduce the ON THE INFLUENCE OF THE FAMILY CLIMATE; TWO-YEAR FOLLOW- hospital admission frequency by UPS allowing patients to stay longer Source: Wiedenmann et al. 1996 (modified) outside the hospital than with traditional care by general praction- ers or psychiatrists in private practice. This is the case mainly for schizophrenic patients but also for numerous other conditions of mental illness, whose outcome is not yet clearly evaluated.

The effectiveness is highly dependent on the variety and quality of the extramural facilities. I regret that I cannot point out in detail this important aspect.

Now I will come to the second part of my presentation. This picture shows that high This figure may convince you As you heard from Dr. expressed emotion in families of that a fairly simple, pragmatic ap- Bertolote yesterday, about 25% schizophrenics, when the latter proach, partly consisting of infor- of the world population suffers have a certain amount of contact mation about the nature of the ill- from psychologically prompted with their families, enhance the ness and the need for continuous behavior disturbances that need relapse rate significantly, com- treatment, partly of educational ele- treatment. When, as Dr. Bertolote pared to patients of families that ments, partly of behavioral and pointed out, one takes into ac- reveal a low rate of expressed cognitive therapeutic elements, is count that the families or related emotion. “Expressed emotion” is highly effective, when linked with persons have to share with them measured in these studies gener- appropriate medication. the burden of mental illness, ally by the Comberwell Family In a further study of Bebbington about 75% of the World popula- Interview of Vaughn and Leff and Kuipers (1994), re-evaluating tion is in some way influenced by and is predictive for high EE 24 EE-studies and the basis of the mental illness or handicap. This when critical comments, hostility original data, it was shown that fre- gives us the right to see family- and over-involvement are high. quent contact of patients with low oriented interventions as a need- Therapeutic interventions on the EE families can have a protective ed and effective therapeutic ap- basis of the EE-concept try, in effect in the sense of relapse pre- proach. family settings, to reduce the vention and that there is no gender harmfully high level of expressed difference, either in the EE level, or In the early 60s, beginning emotion. in frequency of occurrence. with the investigations of Wing, Brown, Burley, Castairs and oth- TABLE 3 - RELAPSE RATES OF SCHIZOPHRENIC PATIENTS: ers in the United Kingdom and of Family care (each left column) vs. individual care (each right column); Zubin and others in the United one- and two-year follow-up data from patients out of high-EE-families. States, the hypothesis got evi- Wiedemann et al. 1996 (modified) dence, that schizophrenics are highly susceptible to emotional stress and that the reduction of stressful living conditions, mainly within the patients’ families, can prevent relapses and hospital admissions. What I briefly want to show you is how far this hypothesis has stood the test of evaluative outcome studies up to now, and second, how far family- oriented therapies in similar forms and settings can be helpful to other mental illnesses in addition to schizophrenia. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 195

Family intervention approach- Minuchin, Selvini-Palazzoli and eties with different conditions? es, either including the patient in others) and the psychoanalytical What does “family”, “partner- the therapeutic sessions, or work- approach (Stierlin, Singer and ship” or “career” mean in African, ing with the families alone or others) the more structured, be- Indian, or Asian societies? What putting family members together havioural and cognitive, ap- does “Expressed Emotion” look in groups for counselling and proaches seem to be superior, not like there? By which interventions therapy, effective in reducing the only for schizophrenics (Massi can it be reduced? What I want to illness of the patient and reducing and bells, 1972, Gurman et al. stress at the end of my comments the burden for the family in other 1986). is that we have to be cautious with mental illnesses such as affective Almost all the studies men- generalization and uncritical disorders, eating disorders, chron- tioned above have been per- transfer of therapeutic measures ic pain, anxiety states, personality formed and the related therapies from one society to another before disorders, diseases of the elderly have been developed in the Unit- having investigated how far this is and of children. Most of these ap- ed States or Western European useful and appropriate—and eco- proaches have been shown as ef- Countries, mainly in big cities nomically realistic. fective, but still need further eval- with their special socioeconomic uation (Wiedemann et al., 1996). conditions. How far are the pro- Professor EUGENE WOLPERT Compared to similar family and posals, valid for these societies on Director of the Evangelisches group approaches, mainly the sys- the basis of the reported evalua- Elisabethenstift Institute for Psychiatry temic approach (according to tive studies, transferable to soci- in Darmstadt (Germany) 196 DOLENTIUM HOMINUM

DRISS MOUSSAOUI

Rehabilitative Therapies in Psychiatry

Civilization can only exist when gravated by mental disorders which dard forms of health care. They the weak, suffering or sick person in their turn act to aggravate the im- have to be taken care of by health is seen as a human being in the full pact of chronic poverty. By such a care workers and must be the ob- sense of that term and when he is route is a devilish vicious circle is jects of an understanding attitude perceived as an individual who re- established. on the part of their employers. The quires and deserves special atten- The treatment of every sick indi- seriously mentally ill need far tion and care. In other words, civi- vidual, and even more of every per- greater levels of family and social lization can only exist when there is son who suffers from mental ill- support but luckily enough they are real human solidarity expressed to- ness, has a triangular base which is: only a small proportion of all those wards those people who are most —biological in character, (in par- who are afflicted by mental disor- afflicted by fragility and vulnera- ticular involving medicines); der. About 10-15% of schizophren- bility. For centuries the mentally ill —psychological in character, ics are cured of their illness, at least were excluded, marginalized or (involving a good relationship beat a social level. But about 15% of even suppressed—that is, physical- tween the sick person and his med- this category develop their patholo- ly eliminated. This shameful reali- ical doctor and the practice of psy- gy along very serious lines. It is ex- ty—which has burnt the mark of chotherapy); actly such people who deteriorate Cain into the forehead of humani- —social in character (basing it- both mentally and socially, who are ty—is not something which be- self upon the social rehabilitation repeatedly admitted to hospital, and longs to remote antiquity. Only of the individual). who often become violent. It is fifty years ago the Nazis engaged in The principal concept of social these people who furnish the mass the systematic execution of the rehabilitation is expressed in the media with their negative image of mentally ill and in this undertaking phrase “the human dignity of the the mentally ill and of the disci- they were helped and supported by patient.” The reintegration of the pline of psychiatry—something a significant number of psychia- mentally ill person into the com- which lies behind the contempo- trists who in reality were not wor- munity does not only involve the rary “condemnation” and the mar- thy of such a name. maintenance of his social rights and ginalisation of the mentally ill. Like every other sick person, the making sure that he is given a job. In order to achieve and promote mentally ill person has the right to It amounts first and foremost to the social “reinsertion” of such be treated—not only in his own in- guaranteeing that he is given and people contributions are required terest but also in that of his family attributed esteem and dignity with- on a broad front—that is, from and of the community at large. In- in his social environment. This lat- health care workers active in the deed, mental suffering afflicts at ter process takes many forms sphere of mental illness, from the one and the same time the sick per- which are heavily determined in families of these patients, from so- son himself, his economic produc- their character by the cultural con- ciety at large, and from employers. tivity and the life of his family. At text of the patient. one stroke it impedes the develop- This whole question is intimately 1. It is obvious that responsibility ment and/or the productivity of all bound up with the cultural percep- in the first instance falls upon the members of his family. It has tion of mental illness and the preju- health care workers active in the been demonstrated, for example, dices (something which is very field of mental illness. Indeed, it is that children in the shanty towns of characteristic of English-speaking of fundamental importance that third world countries who suffer experts) which are applied to pa- psychiatrists, psychologists and so- from malnutrition are more likely tients who suffer from mental dis- cial workers bestow the fullest pos- to have mothers suffering from order. It should be remembered that sible dignity upon psychiatry and mental disorders than their counter- the vast majority of mentally ill thus upon the people which this parts in the same places who do not people suffer from depression and discipline sets out to cure. In this suffer from malnutrition. In this anxiety disorders of light or mid- undertaking they should employ to way chronic poverty and its physi- dling intensity. In essential terms the full their human and profession- cal and social consequences are ag- they are treated by basic and stan- al qualities and skills. This is the “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 197 route by which it is possible to cre- patient is impeded and obstructed are especially strong, as indeed is ate a climate of trust which in turn when there are extrapyramidal ef- well borne out by the experience of allows the mentally ill and their fects involving delayed dyskinesia Japan. When public opinion comes families to ask for help without be- or acathexia caused by an exces- to realize that unemployment is not ing afraid to do so and in addition sive prescription of neuroleptics a question of a mere aggregate of to maintain their relationship with which in turn is promoted by an in- individuals and that there will nev- health care workers over a sus- appropriate use of synthetic drugs er be enough work for everyone, tained period of time. In contrary to treat Parkinson’s disease or by perhaps there will be a move to- fashion, the mentally ill themselves the prescription of neuroleptics wards a stance of greater solidarity often break off the treatment that which are not really suited to the towards the most vulnerable, and they are receiving, undergo a re- condition of the patient. It is also of this latter category includes those lapse as a consequence, and there- fundamental importance that pa- who suffer from mental illness. It by destroy the bonds which link tients are taught how to get dressed should be observed at this point them to their families and society. and to dress, how to look after their that in Great Britain more than a The people who really benefit from personal appearance, how to man- third of psychiatric patients admit- these kinds of situations are charla- age their personal hygiene, and in- ted to hospital never receive a visit tans of every kind and color. structed in how to behave towards from members of their families. Health care workers in the field other members of society. Furthermore, we are now begin- of mental illness should also strive ning to see examples in developing to convince health care workers 2. It is also very evident that the countries of children who want to more generally to adopt a more hu- family has a very important role to abandon parents who are suffering man approach towards all sick peo- play in this area. We have before us from Alzheimer’s disease and wish ple but in particular towards the a process which is undermining the to consign them to medical institu- mentally ill. It would be superflu- industrialized world and having tions. ous to remember that about a third very serious social and psychologi- In industrialized countries there of sick people who consult a gener- cal consequences for the whole of is a clear move in the direction of al practitioner or a specialist in ar- mankind. The progressive dissolu- creating ever more structures and eas other than psychiatry suffer tion of the family, and thus of social facilities which deal with the prob- from psychological or psychiatric solidarity as well, is corroding the lems caused by the absence of the forms of disturbance. This is true industrialized countries and gradu- family. This is true at many levels both of industrialized countries and ally contaminating third world and involves clubs, trade unions, of developing countries. It is cer- countries at the same time. All this associations and so forth. This well tainly true that information alone is has very destructive results for all confirms the old adage that “friends not enough to change people’s atti- members of society and in particu- are the family you choose.” In the tudes. The remedy lies in training lar for those who are most vulnera- same way we are also witnessing in the field of theory and practice of ble. Indeed, in some northern coun- various forms of alteration in fami- a more intense and specialized kind tries divorce afflicts more than a ly organization caused by divorce, for all those health care workers half of married couples. Thus, for new marriages, and the practice of who work and practice in the area example, one town in the United living together. The various protag- of mental health. States of America of 16,000 inhab- onists of these new configurations The correct and sound treatment itants has over four hundred people are involved in ever more intricate of the sick is equally imperative. sleeping rough. It comes to be and complex kinds of relationships. Indeed, hospitals or facilities dedi- thought that each individual must It is more than evident that the cated to mental health which be- rely upon his own efforts and his families of mentally ill people are come morally and/or materially own work. When something very themselves in need of help in order damaged cause great harm to pa- harsh occurs, when there are social to allow them look after their men- tients and to the discipline of psy- or professional difficulties, and in tally ill member. For this reason chiatry itself. The problem is not particular when mental illness they need the constant aid and sup- one solely of economic and finan- breaks out, the individual has be- port of a medical and support team cial resources. The sick person and fore him only begging or suicide. which should supply them with the his family must feel that the doctor The very deep socioeconomic information required to help them or other kind of health care worker transformations which the world is during the various stages of treat- who is taking care of the case is ful- now undergoing—and this is espe- ment that the mentally ill person ly involved in, and concerned cially true of the industrialized has to undergo. about, their suffering and their fu- countries—are perhaps tipping the ture. scales towards the side of reason. 3. Society itself has many duties We need to provide the best pos- Indeed, economic developments in towards the mentally ill person. sible forms of treatment and care to the direction of a extreme free mar- Wherever possible the mentally ill the sick person. In order to achieve ket methods and policies, in addi- should be able to work both in a this the latest discoveries at a clini- tion to important developments in protected place of work and within cal and therapeutic level must be the sphere of technology, have the community at large. This is es- followed and understood. For ex- turned unemployment into a struc- pecially the case in industrialized ample, it is more than clear that the tural feature of all societies. This is societies where work is a kind of social integration of the psychotic also true of those economies which “religion.” Indeed, in many devel- 198 DOLENTIUM HOMINUM oping countries and nations of the essary the employee should be people. If we become aware and third world those people who do helped to overcome difficult mo- conscious of their suffering we can not work are not condemned by so- ments in his life in order to ensure establish an approach towards them ciety. This is because there are so that he can return to his work at a which is based upon help and sup- many unemployed people in these later date. This is important both port rather than upon condemna- countries that unemployment actu- from the point of view of the health tion and sanction. This in turn will ally represents the norm. At the of the worker and in terms of the allow them to obtain treatment and present time there are more than a well-being of the company where to regain their peace of mind, thousand million unemployed peo- he works. An anxious or depressed achieving thereby a state of normal ple in the world—that is, a third of worker demotivates his colleagues levels of work performance. the active potential workforce on and gives rise to lower levels of To conclude this paper, it should the earth. However, in developing personal productivity. be observed that the integration of and third world countries small A recent study on the origins and mentally ill people into society is jobs which do not involve great re- patterns of illness in the national the concern and responsibility of sponsibilities or duties are available French electricity and gas company everybody. It involves solidarity to- to all those who want to make a shows that a half of those employ- wards the most vulnerable of the contribution to their society. On the ees suffering from depression were vulnerable—those afflicted by whole, it is possible to observe that not treated as such. The conse- mental disorder and disturbance. the mentally ill are not excluded quences at the level of behavior of This is not only something which from this reality. the condition of depression can should take place for ethical rea- have a notable social and profes- sons. It involves great savings on a 4. Employers also have a great sional impact (repeated late arrival broad front, both in terms of indi- deal to do in this field. They have at work, lower levels of productivi- vidual suffering and in relation to the duty to defend both the mental ty, threats of resignation, divorce economic performance. Here, more health and the physical health of and so forth). The adjectives which than in other spheres, ethics pay. their employees. In the same way as are stuck on these people like labels every year vaccinations are insisted (lazy, moody, difficult) are totally Professor DRISS MOUSSAOUL upon in order to avoid influenza, so unrelated to their actual personality Director of the Center for Psychiatry, preventive action should be taken and to how they behave normally in Ibn Rushd University, in the field of mental health. If nec- their usual relationships with other Casablanca, Morocco

“IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 199

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The Image of the Mentally Ill in the Mass Media

The mass media of the present age will discuss the possible reasons for quently. are in love with the mentally ill. This this later on in this paper. What Here we encounter an important has been going on for some time—in- should be emphasized here is that the aspect of how things evolve in the deed since the beginning of the 1940s. discovery of the mentally ill person mass media—the image of the men- The comparative hemerographic by the mass media is something tally ill person is dynamic—it studies into the question show first of which is of rather recent date. changes and in a few years can all that there has been great interest on This fact is rather mysterious. change radically. If we were led by an the part of the mass media in a very Whatever its origins, it cannot be at- interest in how the mass media por- broad range of psychiatric illnesses; tributed merely to the developments tray the mentally ill to study what has secondly that this interest is now of diagnostic or semiological tech- happened in this area over the last growing; and thirdly—and this is niques within the discipline of con- hundred years, we would find that even more significant—that this inter- temporary psychiatry. In the same these attitudes have moved back and est goes beyond the usual space that way it does not seem to be a result of forth in pendular form and that this these different forms of mass commu- the importance and influence of some process is still in full swing. nication—the television, the daily epistemological framework. The way At the outset, the image of the press, reviews, etc.—devote to health in which the mass media approach the mentally ill person was what we and health care. The mentally ill per- mentally ill person—and this is not might term “mute”—he was por- son—and this is a fact which in itself something which should surprise trayed as being alone with his illness. is relevant—is not in the mass media us—is not strictly scientific in charac- Mental illness was in a very literal just one more sick person. The mass ter. The mass media deal with this sense seen as a kind of “work of fate” media place him outside the general subject more in terms of “meaning” with which dialogue was not possible. areas dedicated to human illness and than with reference to description or It brought no ray of light into the his- emphasize his anthropological singu- treatment. It is not unusual for the tory and experience of man. In more larity. mentally ill person—and this is some- specific terms, it was thought to be an At the outset, a word about the thing especially true of the American accident to be located on the outer methodology employed in this analy- cinema of the 1940s and of the Euro- margins of anthropological meaning sis. When in this paper reference is pean Press of the 1950s—to be pre- and significance. made to the image of the mentally ill sented as though he were a key by In the space of a few years, how- person in the mass media, in funda- which to understand contemporary ever, this image gave way to another mental terms reference is being made man: a sort of hermeneutic parameter by which the mass media approached to the dominant image of such a per- with which to approach mankind. mental illness as being something of son. This is something rather different The mentally ill person for a large human interest. The mentally ill per- from the more elaborate and subordi- part of our century has been portrayed son appeared as a being to be valued, nate images which arise from the by the mass media not so much as the explored, and interpreted. At a specif- dominant model which is found in carrier of an illness but as the bearer ic level he could express the meaning most of the European and American of a message. He is seen as somebody of his illness in his own life-history. examples of mass media which have who has something to say. One need On by no means rare occasions, films been subjected to study. only study the image of the mentally portrayed the mentally ill person as ill person—which in fact is almost ab- having a relationship with his illness sent, or, rather, deliberately absent— which was akin to the experience of The Mass Media Discover in the mass media seventy years ago falling in love. In this way, the men- the Mentally Ill Person to realize that this new perspective is tally ill person became a subject for not the outcome of changes which cinema, a source of information. Although the mentally ill person is have been brought about within the What changes can explain this a long-standing figure of nonscientif- world of the media alone. In reality, shift in the public—rather than scien- ic literature, his frequent presence in we are dealing far more with a change tific—image of the mentally ill per- the mass media is a relatively recent in collective sensitivity and sensibili- son? phenomenon. It is certainly true that ty; with a change in social appraisal when the mass media acquired the vi- and approach. tality they now possess, the mentally At the present time—as will be Three Changes ill person was not a special, or even a shown later in this paper—this image Which Explain This Change suitable, object of attention. His pres- is undergoing a development along ence was therefore markedly rare. We lines which will be discussed subse- In the second half of this century 200 DOLENTIUM HOMINUM the public image of the mentally ill ill came about at the same time as the cluded a new dimension which was person has changed as a result of the popularization of theories which ad- not strictly connected to the two cate- impact of three factors: the develop- dressed themselves to the question of gories which preceded it and which ment of scientific medicine, changes the etiology of mental illness. Out- are discussed above. This new image in social awareness and concern with side the field of academic psychiatry, of the mentally ill projected by the the subject, and changes in anthropo- none of these theories had as much mass media involves certain new pa- logical models of the human condi- impact as psychoanalysis in shaping rameters which are in fundamental tion. These three factors have under- and determining the image of the terms more social than etiological in gone a very great change during the mentally ill person. Its impact on the character. Mental illness is defined present century and have had a great mass media and in particular on the with reference to its frequency, its influence on the way in which the press was enormous. Naturally ability to be treated in therapeutic mass media have portrayed—and still enough, this process of populariza- terms, and its lack of biographical portray—the image of the mentally ill tion took place at the cost of the vul- background. In other words, the person. garization of Freudian insight. How- mentally ill person is often to be At the beginning of the century the ever, the result in terms of the cre- found and at all levels of society can first image which the press presented ation of a new image of the mentally be cured through the use of drugs and of the mentally ill person was that of ill was of decisive importance. medicines, and because of this last an alienated being described with the Psychoanalysis—or, rather, its possibility—or in proportion to its popular term “mad.” His image was popular version—provided the mass feasibility—biographical research disquieting because it contained more media with the illusion that they were into the origins of his illness acquires than one element of threat for the portraying clinical symptoms from less importance. community. The mentally ill person an “overall” perspective even though In this popular image of the men- was portrayed as being at the summit this was done by people who were tally ill person we can see that the re- of a deplorable human condition not specialists in the field. Its claims ductionist etiological models which which in most instances required a to “interpret” both normal and abnor- characterized the period from the policy of isolation on the part of the mal mental processes conferred on 1940s to the 1970s in America and community. For this reason such a the world of the mass media for the the war years in Europe are much less person very rarely constituted an item first time an ability to focus on the important and influential. With the of news for the mass media unless mentally ill person as somebody of decreased popular adherence to there was a question of him being—or extraordinary “human interest.” Freudian psychoanalysis and its ac- allegedly being—a danger for society. With the spread of psychoanaly- companying theories, there was a Unlike any other illness of our centu- sis the image of the mentally ill per- fall-off in medical circles in the illu- ry, mental illness bore a stigma which son as projected by the mass media sory belief that it was possible to find society imposed in order to isolate changed. This change took two an overall and complete answer to those who suffered from it and which forms. On the one hand, the mentally psychiatric problems and conditions meant that the mass media remained ill person abandoned his lifestyle of and to understand the mentally ill largely silent on the whole subject. isolation and became a being whose person with reference to a single In this image the mass media gave illness could be grasped, interpreted, causal-theoretical framework of in- a paradigmatic form to the idea pro- appraised, and understood. On the terpretation. Indeed, at the present moted by one school of psychiatry in other hand, the mass media discov- time, it is not unusual to find the mass particular that “every mental illness is ered that the range of mental illness media laying stress upon the inability a cerebral illness.” As such, it was as had expanded in extraordinary fash- of psychoanalysis to provide valid lacking in anthropological meaning as ion and had opened up spaces for the explanatory hypotheses which can be any other episode which had physical great pathology of “neurosis”—med- verified by empirical evidence. origins. icine now covered areas which hith- At the same time, the mass media It is more than evident that this erto popular opinion has excluded have spread the idea of the wide- image was the outcome of an ex- from the category of “mental illness.” spread presence of the mentally ill tremely reductionist approach to psy- In the first stage the mass media person. This has probably been chiatric illness. For the mass media adopted the general etiological idea achieved through the systematic use the “mentally ill person” of those days that “every mental illness is a cere- of the statistics and techniques of so- was almost exclusively a schizo- bral illness.” In the second stage the cial research. The very large space phrenic, a patient with physically- etiological approach was much more which the mass media now give to rooted mental disorders and the most dynamic—indeed, psychodynam- the mentally ill seems to go beyond severe examples of bipolar distur- ic—and was expressed in the slogan the approach of scientific psychiatry. bances of mood. Most of what now “every mental illness is the expres- Above all, what we encounter here is goes to make up clinical psychiatry sion of an unconscious conflict.” In the same problem which occurs in was excluded from that image by sta- the world of the mass media there other areas where the popularization tistical elimination—namely, patho- was a shift from the concept of cere- of science employs statistical meth- logical conditions involving anxiety bral disturbance to the notion of a ods in the wrong way: the wide- disturbance, mood disturbance, sleep category of disorders of the spirit. spread presence of mental illness is disorders, and disorders caused by the considered the norm, and the next use of psychoactive substances, and logical step in this process is to try to so forth. An Orphan Image distinguish between what is “normal” and what is “abnormal,” or to During the next stage—and here understand health with reference to The “Human Interest” we come to the present-day situa- illness. This attempt is what was of the Mentally Ill Person tion—the image of the mentally ill meant in this paper when reference person underwent another develop- was made to the mentally ill person The great change in the attitude of ment. Although it maintained many becoming a hermeneutic parameter the mass media towards the mentally of its previous characteristics, it in- by which to understand human be- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 201 ings. Whatever the truth of the mat- expectations, and so forth. The mass facts or with the past or life history of ter, at the present time the mass me- media in their descriptions assert that the person concerned. dia describe the “extreme” behavior mental illness is a situation and not a In the case of other physical ill- and the character features of the men- place which is frequently reached nesses such as contagious or neoplas- tally ill in such a way that the bound- from certain starting points such as tic pathologies, the mass media tell aries which clinical psychiatry em- habits, behavior at risk, etc.—ele- people about the preventive and ploys to define mental illness become ments which are all very instructive health measures which can be taken blurred. from the point of view of clinical to avoid falling ill. In the case of In the world of practical medicine psychiatry. mental illness they very rarely give the development of the treatment of Over and over again we en- information about behavior at risk, mental illness has been understood counter disturbances caused by the about elements of lifestyle which are first of all in terms of the evolution of use of psychoactive substances being factors which predispose people to- psychopharmaceuticals. This reality discussed without reference to the so- wards such illness, bring it on, or per- has radically changed the image of cial context of these disorders, the so- petuate it. In this way, the mentally ill the mentally ill person as portrayed in cial factors behind their develop- person is portrayed not only as being the mass media. At the beginning of ment, the role of social and cultural beyond the parameters of an anthro- the century, this image involved the forces, the attitudes of the individuals pological framework, but the patient picture of a person who was alone concerned, the previous beliefs and himself is deprived of knowledge and isolated and was based upon the expectations of the mentally ill per- about those elements which could be notion that “every mental illness is a son, the stability or instability of the utilized to achieve a suitable life hy- cerebral illness.” Subsequently, the family background, and so forth. giene in relation to his illness. diffusion of psychodynamic theories Without a discussion and awareness To conclude this paper, we can transformed this image into one of the human context of the mentally now ask questions about the relation- which involved an enigmatic being ill person—a context which is clini- ship between this image of the men- who was nonetheless full of “human cally relevant—the drug-addict who tally ill person which is conveyed by interest.” Here the notion was that is also mentally ill ends up by being the modern mass media and the way “mental illness is an illness of the constantly consigned to the “crime” in which he is currently considered spirit.” Today we have the image of a pages of newspapers. In addition, his by scientific psychiatry. mentally ill person whose condition image is very often linked to the con- There can be no doubt that the im- can be cured by pharmacology with- cept of “criminality.” age of the mentally ill person held by out there necessarily being a need to A reductionism of this kind is of- the mass media and its evolution dur- consider the biographical back- ten present when the organs of mass ing the course of this century have ground to his illness. The modern- information deal with other psychi- followed—at least in general day dominant image of the mentally atric pathologies. The image of the terms—the various conceptual con- ill person involves the idea that the depressive mentally ill person—for figurations of mental illness adopted fundamental treatment of his condi- example, in films, television, or the by academic psychiatry. Here we are tion—and at times the only treatment press—is often effective from a de- dealing with diagnosis, classifica- for his illness—lies in the application scriptive point of view. But the lack tion, and treatment. Psychiatry is one of drugs and medicines. As a result of of discussion of the causes of the of those areas of medicine which this line of thought, inquiry into the condition places the illness on a level have always had good popularizers. biography of the clinical syndrome of total discontinuity with the past But the osmosis between scientific becomes of secondary importance life-history of the mentally ill person. psychiatry and the mass media still and at times is even seen as being Nothing can be more deceptive than fails to produce the results we would useless. the image of a depressed person like. This is probably the new element which is detached from his biogra- Certain forms of reductionism which is to be found nowadays in the phy. Without reference to his usual which are present in the image of the ascendant popular image of the men- way of reacting to stress; without a mentally ill person conveyed by the tally ill person. The tendency is to knowledge of his habits or the risk mass media were already latent in portray illness as an orphan without a situations which are present in his certain ideas of psychiatry itself. Oth- biography and without a past. The life; and at a more specific level, er such forms—and indeed most of image is one of a chance visitor without a suitable light which can il- them—were introduced and promot- whose arrival is not in the least fore- luminate the general configurations ed by the mass media themselves, seen from the past life of the patient. of his life, the depressed person can- and this is something which brings The supposed ability to treat the ill- not be understood and is not even out the extent to which the process of ness with drugs and medicines and recognizable as a figure from real popularization was flawed. the lack of interest in etiological life. The most notable of these forms models which at one time provided The biographical amputation of of reductionism, in my opinion, is of the mass media with a fictitious and the mentally ill person is perhaps the a deterministic character and its most facile conviction that they could uncommon evil and probably the most evident expression involves the men- derstand mental illness have both regular feature of the way in which tally ill person being divorced from given rise to this approach. the mass media transmit his image in his own biography. Its greatest limi- At the present time the mentally today’s world. This is what we tation and its greatest risk is a deper- ill person seems to be the bearer of an should term an orphan illness—with- sonalization of the mentally ill per- illness which has no roots in the past. out genealogy, without paternity, and son through a separating of his psy- The interest in describing his condi- without biography. It is assumed— chiatric syndrome from its anthropo- tion and his behavior excludes in- and this is something which is not al- logical roots. quiry into the possible influence of ways the case—that mental illness is the life experience of the mentally ill a mere question of fate, a chance oc- Dr. JOAQUIN NAVARRO-VALLS person on his condition—his prefer- currence which arises without any Director of the Press Office ences, upbringing, systems of values, connection with anthropological of the Holy See 202 DOLENTIUM HOMINUM

MICHELE SCHIAVONE

Ethics and Psychiatry

Interest in moral problems and tween clinical psychiatry and from the level of principle to that questions has always been keenly bioethics but (and above all else) of individual sets of approaches of felt in the discipline of psychiatry we come to realize the benefits practical implementation is not in not only with reference to the sub- which bioethics brings to psychia- actual fact valid. This is so for two ject matter of medical deontol- try through its ability to move eth- reasons: ogy—which goes back to Greek ical requirements from their origi- 1) In the first place because medicine and Hippocrates and nal location in the spaces of ideo- ethics is not a science in the strict Galen—but also in relation to the logical beliefs or the intuitions of sense of the term because moral special characteristics which dis- moral common sense to an organ- reasoning is chiefly, if not exclu- tinguish mental illness from phys- ic system of principles which in sively, characterized—in relation ical illness. In recent times, it turn gives rise to individual rules to comprehension and interpreta- should be observed, a special im- of conduct, and this through the tion—by a tradition which began petus to this concern has been sup- employment of an intricate and with the Aristotelian concept of plied by a phenomenological ori- rigorous system of lines of argu- phronesis with its idea of a practi- entation first and foremost but also ment. From this point of view it cal wisdom. This bears a line of ar- by a sociogenetic impetus—both becomes clear that bioethics is the gument based upon a rationality can be described with good reason fundamental basis of psychiatric which is different from scientific as being the precursors of contem- deontology. rationality and which does not in- porary bioethics. But in reality one Before outlining the cardinal volve processes of causal explana- cannot relate ethical problems to principles of bioethics and estab- tion. single theoretical models unless, lishing their individual effects and 2) In the second place because that is, there is not in addition an meaning for the world of practical there is a structural difficulty when employment of great emphasis on, psychiatry, it is useful to observe we try to apply a universal princi- or an examination of, underlying at the outset that the search for a ple to a specific case. There philosophical principles. Such rigid and guaranteed system of de- emerges an essential divergence concern with ethical questions, in duction by which one can move between the irreducible specific fact, is present in all schools and features of the single example and directions of thought when applied the universality of principles, and to real clinical practice. this divergence means that there However, there can be no doubt can not be a mechanical and uni- that research of the last twenty form application at the practical years has created a new discipline level of actual conduct. This does which takes the moral aspects of not in the least mean that a rela- the biomedical sciences as its sub- tivistic lapse is at work because ject matter. Such research, in turn, the universality and the objectivity has had important consequences in of the law is not called into ques- the narrower and more confined tion. It merely means that the law field of psychiatry. itself should be adapted to each in- According to the classic defini- dividual case and studied in its tion offered by the Encyclopedia complex situational context so as of Bioethics, bioethics is “the sys- to avoid the promotion of arbitrary tematic study of human behavior abstractions and devastating ex- in the field of the sciences of life amples of reductionism. and of the care of health where After this epistemological pre- such behavior is examined in the miss, it should be observed that the light of moral values and princi- severe criticism made by Jaspers ples.” For this reason not only can of the reduction of a mentally sick we grasp the close connection be- person to a mere clinical case with “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 203 a consequent compromising and level which rises above the merely philosophical in orientation. loss of subjectivity—something biological. To put it differently, the In this sense the defence of the which constitutes a real and au- illness should not only be diag- subjectivity of the mentally dis- thentic break with the organicist nosed and addressed at a clinical turbed person which refuses to see orientation of Griesinger, level but should also be interpreted him as a clinical case or an object, Kahlbaum, Wernicke, and on to within the context of the individ- and this in order to stress the fact Kraeplin—can and must be revis- ual’s personal history, of the inner that he is a person, has an essential ited and reconsidered today in eth- history of the patient (to cite the ethical meaning. This is because, ical terms. This should be done in definition of Binswanger and following on from the Kantian such a way as to complete and ex- Zutt), and of the world of the life postulate that the human person is tend the significant contributions and the experiences of the individ- an end in himself, it belongs to the of an anthropological-existential ual in an overall sense and not on- category of values. And this is so and phenomenological-existential ly in psychological terms. both in a negative sense as a moral character made by Binswanger, There is thus a dialectic interac- obligation on the part of the psy- Minkowski, Gebsattel, Straus, tion between nature and existence chiatrist to respect the dignity of Schneider, Blenkenburg, Tellen- (I refer here to the famous distinc- another person (one thinks here of bach, Zutt, Wyrsch, Rumke etc. In tion made by Jaspers and Bin- the ideas of Cargnello, derived particular it is my belief that the swanger) according to which the from Binswanger, of altered states question must also be tackled from psychotic experience has its own and alienated states) and in a posi- the point of view of the principles meaning which should be under- tive sense as a condition of moral of benefit and autonomy which are stood, a meaning which although progress of the clinical experience. the mainsprings of contemporary it is present in the furthest reaches By this means one achieves a solu- bioethics—without, however, of the existential level (which, tion to the dichotomies present in abandoning the psychopathologi- however, is neither transcendence the recognition of the unity of the cal approach. nor dualistic division) when com- person and the interpersonal rela- A first reading of the relevant pared to the biological and biopsy- tionship which from a philosophi- evidence is of an ethical-deonto- chological level, exists in a rela- cal point of view is awareness of logical character and constitutes tionship of unity and circularity totality—that sense of one/all an appeal to respect the personal with this latter level where the which in lyrical form is expressed dignity of the sick person, who is function of the bestowal of mean- in sublime fashion in the quartets firstly and always a man and as ing is in turn correlated to the op. 132 and 135 by Beethoven and such has an absolute value, the physio-pathological processes. which is both a poetic moment and recognition of which is absolutely When we see and interpret mental ethical-mystic feeling as ex- obligatory. But one would remain illness from this point of view as pressed in the Amor Intellectualis fatally vague and general, or one an event rooted in the existential in Deum by Spinoza. would even fall into the rhetoric of singularity and totality of the per- The defence of the subjectivity an uplifting speech, if one did not son of the sick individual, we of the psychotic person aims at the really face up to the meaning of thereby understand and recognize return of the communication the concept of the guardianship of the mind-brain structural unity which has been compromised or subjectivity. And here especial at- which is the final limit but also the interrupted by the psychosis and tention should be paid to the defin- point of arrival of every form of which thus renders listening possi- itive decline of faith in the possi- anthropology whether scientific or ble. Beyond the diagnostic-clini- bility of a scientific nosography cal approaches to the case history, involving a substitution of the listening and knowing how to lis- awareness of the practical-eco- ten also have a very high ethical nomic need for the relevant classi- value because they involve the fication of theoretical questions perception and recognition of the and hypotheses. sick person not as somebody dif- We thus come to a psychopatho- ferent from me but as another who logical consequence from which gives meaning to my relationship one can and one must draw ethical with him and thus with myself. conclusions. What I mean by this The ethical value of listening thus is that a mental illness of whatever lies in a choice of self-limitation kind, but, above all, if it is chronic which the psychiatrist makes by or long-term, afflicts the sick per- abandoning the recurrent tempta- son in his entirety and creates a tion to narcissism and to a feeling complex dynamic not only in a of omnipotence and by placing pathological sense but also in an himself in contrary fashion in the existential sense. Indeed, we dimension of encounter and love. should not proceed to an abstract Without abandoning his own role isolation of the syndrome and its as leader in the therapeutic reac- symptoms from the sick person tion or the deontological responsi- who not only is involved in that bilities which come from his own syndrome but responds to it at a scientific-professional expertise, 204 DOLENTIUM HOMINUM the psychiatrist dedicates himself the subjectivity of the sick person ill person and of his life and to the conventions of humility— does not involve the belief that he health, and in so doing he should if that humility which is also truth is free (which is against the evi- necessary take unilateral decisions (St John the Evangelist)—and dence of the pathological influ- in the case of exceptional circum- thereby creates a parity of a moral ences of his cognitive or affective stances. This, of course, should character without however in any nature) but involves, rather, help- take place when that mentally-ill way denying the disparity of func- ing him to become free. And if person is not able to make coher- tions and knowledge which is also freedom—and here I adopt the de- ent and rational decisions. present in the relationship. finition offered by Jaspers—lies in The defence of subjectivity, The defence of the subjectivity the need to be free then the psychi- therefore, does not involve letting of the sick person also and above atrist who is loyal to the principle the patient do what he wants or all else acquires an ethical signifi- of autonomy will make such a what he thinks he wants but rather cance because it is the pre-condi- need emerge where it is absent or in leading him to acquire the abili- tion to freedom. It is certainly very will actually strengthen it. He will ty to choose in a way which con- difficult to speak about freedom. It also integrate it into the personal forms to the values and real inter- is, indeed, evident that the improb- dynamics of the disturbed and ests of his own personal life. We able hypothesis of a faculty for mentally ill person. should therefore rediscover a rela- self-determination of the finite is We should however abandon tionship of harmony between the obscure from a philosophical point easily-held illusions because the principle of autonomy and that of of view and at the very boundaries daily experience of encounter with benefit by going beyond possible of the unproposable, and in a sim- the sick man is in reality a chal- immediate situations of conflict ilar fashion the qualitative and lenge to widely-held theories and and embracing the principle of re- quantitative importance of the bio- is a source of unceasing perplexi- spect for the priority of benefit logical, psychological, social, and ty. This requires if not the revision within the hierarchical order of cultural influences of human beat least the questioning of the bioethical principles. Freedom, in havior is also more than evident methods and ways by which prin- fact, is not an easy process within from the point of view of scientif- ciples are applied, including that the reach of everyone in indiscrim- ic anthropology. But if we aban- of the bioethical principle of au- inate fashion. It is, rather, a diffi- don the unsafe terrain of meta- tonomy. A rejection of the objecti- cult conquest which requires ma- physics and the ambitions of a sci- fying model by which the patient turity and knowledge. Freedom, ence which is unaware of its own is approached is certainly ab- therefore, is not a point of depar- limits, the problem can be solved solutely binding but it should not ture, a fact—it is a point of arrival. through the bestowal of an exclu- involve an abdication on the part In other words, freedom is essen- sively ethical connotation and by of the psychiatrist of his own de- tially a process of liberation based acting from the starting point of ontological, ethical and profes- upon an ethical need which is fun- the human awareness of feeling sional responsibilities. One should damental to the human person. free which is the precondition and not therefore give a sense of myth The defence of the subjectivity meaning of moral life. Jaspers has to the freedom of the sick person of the mentally-ill individual thus observed with great prescience and thereby debase the concept of has an ethical connotation because that: “the question of whether free- freedom. There is in fact an au- it is an encouragement and an ori- dom exists has its origins in my- thentic freedom and there is a false entation to feeling free and to self for I want it to exist.” In this or degraded freedom. wanting to feel free. It is, there- sense because it is a “fact of con- The first form of freedom is fore, the promotion of authentic sciousness like the passing of chosen from alternatives which freedom (one thinks here of the time” (Bergson) freedom has an are rationally understandable greater libertas of St.Augustine). essential and exclusive ethical val- within the context of an underly- Freedom, for this reason, should ue in the sense outlined by Kant— ing rationality. False freedom, on be placed between an objectifica- it is a pure formalism without ob- the other hand, is an uncontrolled tion which exasperates and absol- jective contents which is a practi- and indiscriminate choice which utizes the relationship of depen- cal principle of will when faced takes place beyond all ties and dency on the one hand, and an an- with duty. limits; it is therefore an arbitrary archic self-abandonment to a Furthermore, freedom is an es- decision, a whim, a foolish option. spontaneity polluted by pathologi- sential attribute of the individual To prevent the bioethical principle cal factors on the other. And it is in and for this reason the defence of of autonomy—which is the deon- this way that the clinical-therapeu- subjectivity is the defence of free- tological norm of psychiatric in- tic relationship becomes in essen- dom. Such a concept of freedom is tervention—from degenerating tial terms an active recognition strictly bound up with the bioethi- and to stop the defence of the val- and a construction of the dignity of cal principle of autonomy to the ue of the person from falling into the human person of the sick pa- point of being actually identified dehumanizing systems of practical tient. with it. This principle refers to ab- implementation the following solute respect for the human per- must take place. The psychiatrist Professor MICHELE SCHIAVONE Ordinary Professor of the History son. But in order to avoid danger- should defend with the utmost vig- of Philosophy ous misunderstandings it should or the defence of the interests and Professor of Bioethics be pointed out that the defence of the primary rights of the mentally- at the University of Genoa, Italy “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 205

PIERLUIGI MARCHESI

The Role of the Church in the Treatment of the Mentally Ill

Introduction Health Care Workers to launch a Ursulines of Saint Pelagia, and the campaign of information gather- Penitents for the women. The religious orders which ing on the different forms of The work of the “Fatebene- form a part of the Church and are health care provided in this sphere fratelli” was a practical mission dedicated to serving humanity in by male and female members of inspired by the action of St. John various ways have in the past dis- religious orders and by the very of God who through personal trial tinguished themselves for their large number of Catholic volun- had to undergo those forms of ability to attend to the needs of tary organizations throughout the treatment which at the time were men in all historical contexts. world. A census of these initia- applied to the mentally ill or those They now look at the present in an tives could also act as an appeal to who were thought to be such. attempt to render the richness of those who wish to dedicate their Roundabout the year 1700 we the charisms of their foundation lives totally to serving the most encounter the rise of the scientific ever more contemporary. In so forgotten of the sick and ill. belief, which was itself the work doing they defend and promote of the hospitallers, that madness their own special traditions but of- could be the organic outcome of ten have to fight against legal-ad- 1. A Look at the Past brain malfunction or damage. It ministrative systems which are was for this reason that it began to very distant in their character Drawing upon my own person- be thought that the mentally ill from the Christian sensibility. The al experience as a member of the could be treated. There was an most worthy initiatives which Hospitaller Order of St. John of abandonment of the idea that they engage in are those directed God, I would like to speak about madness in some way was con- towards helping the incurable, care for the mentally ill. Long ago nected to diabolical possession. I sick people drawn from the ranks the “Fatebenefratelli” made their would like to lay great stress upon of the poor, the afflicted and the decision in favor of the method of this point because although based diseased, and defenseless children tenderness in the treatment of the upon different premises it is the who are judged abnormal or are mentally ill. A large number of same belief as that which now un- not wanted. important figures stand out as ex- derlies the modern neuropsychi- Today, amongst those who are amples of this approach who atric approach. most in need, members of reli- should be taken as models to fol- St. John of God, like St. Camil- gious orders, with the help of low. lus De Lellis and St. Vincent De many volunteer workers, take By 1632 St. Vincent De Paul Paul after him, sought to human- care of those people who are ter- had already founded the House of ize health care by restoring the ap- minally ill, those who have AIDS St. Lazarus in Paris—hence the propriate respect that was due to or are drug-addicts, and people name “Lazzarists.” This was an sick people drawn from the ranks who suffer from mental illness. I authentic model of charity, even of the poor and the abandoned. must observe, with great regret, of tenderness and love, towards As the Italian historian Cos- that I have not been able to gather those mentally ill people who macini has observed, hospital as- data on the many-faceted pres- resided in that compassionate asy- sistance was seen in the sixteenth ence of the Church in these fields lum. century in Europe as an ambigu- of health care. I sent a letter last In France by 1600 there were ous practice caught between zeal May to a large number of reli- ten homes where the “Fatebene- and detachment. The doctors and gious institutions on the question fratelli” offered a refuge to the nurses often saw a sick person as but I have not received even one abandoned and desolate mentally something alien. Different from reply. ill. Engaged in the same activity the normal and from themselves. I would like to take this oppor- there were also Franciscans, Hence the forms of behavior tunity to invite the various episco- Brothers of the Christian Schools marked by absenteeism and indif- pal conferences and the Pontifical and Marists for the males; and ference which gave rise to a lack Council for Pastoral Assistance to Sisters of the Good Shepherd, the of care and even violence—ele- 206 DOLENTIUM HOMINUM ments which served to add suffer- 2. The New Frontiers of Care based upon four central principles: ing to the existing illness. for the Mentally Ill A. Utilizing the human poten- St. John of God emerged tial of every mentally disabled against this kind of background in Like many other members of re- person. relation to hospital care. He want- ligious orders, the “Fatebene- B. Teaching the sick person ed a hospital where the sick could fratelli” have directed institutions how to develop his own capacities be looked after as he wanted, that for the mentally ill which for and his own sense of self-determi- is to say without obscurantism many years occupied an auxiliary nation. and with the belief that the sick role in relation to the field of ac- C. Humanizing treatment pro- person was a neighbor and not an tivity of the state. With the passing grams through a continual training alien. of time they recognized, and often and updating of health care work- Through him there was estab- well before the public authorities, ers. lished an anthropological model at least in Italy, the need to reduce D. Changing the life environ- for interpersonal relationships the number of those kept within ment and changing it in a way whereby a neighbor cared for his an asylum and to place the psychi- suitable to human needs. neighbor, a nurse looked after atric patient at the center of a mul- We have seen rehabilitation, those to be nursed, and a man did tidisciplinary system of care. therefore, as something involving the same for another man who But I could say the same about a new vision of mental distur- was sick or less fortunate than Portugal, Spain, Ireland, or Co- bance and as an expression of the himself. lumbia. The Hospitaller Order of “demedicalization” of the thera- The madness of St. John of God St. John of God has produced a se- peutic context. thereby acquired a symbolic value ries of studies and programs of re- The various contemporary of enormous spiritual interest be- search to draw the attention of schools of rehabilitation should be cause it set in motion a process by those who are concerned with this praised for having discovered a which the mad who were poor field to the need to pool their large number of ways by which to were reclaimed in a way which knowledge and expertise not only help the so-called mad person to saw them as human beings in the for reasons of approach and return to so-called normality. But full sense of the term. method but also on humanitarian an evident danger remains. As The movement of care and con- grounds. An authentic cultural members of religious orders and cern for the mentally ill which the battle has taken place both outside as believers, we must feel called “Fatebenefratelli” began gave rise and within the Order to under- to avoid the loss or suffocation of to a system of hospital service stand how mental illness can be the individuality of the mentally which was to guide Catholic prevented, how its lapsing into a ill person. Following the theoreti- health care institutions for cen- chronic state can be impeded, and cal precepts of models of rehabili- turies to come. This system in- how more flexible methods of re- tation, we must strive to avoid volved the following key princi- habilitation can be developed. placing all patients in the same ples: One son and follower of St. kinds of category. We must, 1. Service to the sick is some- John of God, Padre Benedetto rather, follow individual varia- thing which comes directly from Menni, who was recently pro- tions as opposed to our own scien- such principles of the faith as the claimed blessed by the present tific and professional nostrums universal love of the Father and Supreme Pontiff, established a fe- and prejudices. the dignity of man. male religious congregation A man, even a madman, is 2. Service is thus a right and a which carried on in his footsteps made in the image of God and duty of the Church with full rein a special and heroic fashion in should be respected precisely be- spect for different cultural reali- caring for the mentally ill. Padre cause of his extreme weakness— ties; and this approach involves Menni himself, in his restoration something which constitutes his the announcement of salvation in of the Order in Spain, laid especial vulnerable origins. Man is always the face of illness. emphasis on psychiatric care and made in the image of God, and 3. Each hospital mission is a to this end created a large number above all when he is denied those work of evangelization and thus of psychiatric institutes. physical and spiritual traces of involves the bearing of witness to Basing ourselves upon that ther- that sublime intelligence which the loving mercy of Christ. apeutic model which has been has created us ad imaginem et From the French Revolution termed the “method of tender- simulitudinem suam. until the present day many pro- ness” by historians, we have I would even go so far as to say found changes have transformed sought to see rehabilitation as a that if this faith in the weak and the various health care systems of tool of authentic humanization wounded God who is capable of the world. But the members of the and not merely a technical process suffering within his creatures is religious orders, although much of the carrying out of dry conven- lacking, then the very principle of reduced in numbers, have never tions. We have run the risk—and equality and solidarity among ceased to serve the sick in a spirit this is something which we have men is also absent. of denial and with their faces fully been pointing out for ten years— If I may, I would like to make a directed towards their evangeliz- of believing in the possibility of final appeal to the men of science ing mission. passing from internment to psy- and to those public leaders who chiatric rehabilitation in a process are interested in this subject and “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 207 this whole field. I would like to pation in the lowering of his son, provocative fashion invokes the say that the mentally ill person of the Christ, who makes himself remedy of euthanasia rather than today’s world has need first and suffering man. the abandonment of their dear foremost of this recognition of the That God is fragile because he ones to the streets. wounded God who walks among is love is the only metaphor which All Christians, and health care us and within us. protects him from the accusations workers in particular, are called Let us train people who are able of insensitivity or injustice, as in- upon to create points of reference to hear his cry and understand his deed is pointed out by Paul Ri- and support groups for these fam- movements. God is among us coeur, one of the most important ilies. We must provide room for within those who are mad, the dis- of today’s Christian philosophers. voluntary work and initiative inherited poor, in the suffering, which can perform an educational just as he is present within the mission greatly infused with achievements of science and the Conclusion Christian civilization and which joy of living. can also constitute a major and ac- Suffering reveals to men in cru- The whole of society and, tive enterprise of social solidarity. el fashion the very limits of the above all, ecclesial society is The mentally ill person, in work of God, the open wounds of called upon to engage in a great whom there shines in a particular a missing alliance between nature qualitative advance in the exercise way the lamp of the Spirit of the and God, the sign of a contradic- of the health care professions, the Creator, should be protected in all tion between the love of the cre- provision of services to people, possible ways against the winds of ator and the impenetrable hard- and the construction of small resi- fear and wickedness if we want to ness of the creation. dential facilities which can sup- be able to speak today of charity. Here we perceive the weakness port the efforts and initiatives of of our God, who loves us so much the families of the mentally ill. Br. PIERLUIGI MARCHESI, O.H. as to suffer with us. God should From these families, precisely Director of the Studies Office not be the subject of our com- at the moment when from so of the Lombard-Venetian Province of the Order of St. John of God (Italy) plaints and laments because He many directions we hear the call Member of the Pontifical Council Himself suffers, and the alliance to close the lunatic asylums, we for Pastoral Assistance with man culminates in a partici- hear a desperate cry which in to Health Care Workers 208 DOLENTIUM HOMINUM

HERVÉ ITOUA

Pastoral Care and the Spirituality of the Mentally Ill

Introduction the mentally ill. This paper, there- only emerges when one becomes fore, is not the work of a specialist, aware of the complexity of the sit- I have been asked to speak on but of a man of experience who uation, of the relationship that this the subject of pastoral care and the constantly comes up against the situation has to the reality of social spirituality of the mentally ill. I difference between what is actual- sin, and of the attitude which Jesus would not like to begin this paper ly done and what could or should adopted towards illness in general. without thanking those who have be done. I would like to empha- organized this international con- size, above all, that my paper is A.The Mentally Ill Person: ference, not least because this is an “framed” by certain realities and An Attempt at a Definition event which enables us to remem- marked by the experience of my ber once again that care and con- local or regional Church. But be- Who is a mentally ill person and cern for the mentally ill forms a cause what takes place within this what distinguishes a mentally ill part—as we can well understand ground-level framework can help person from other kinds of sick from the ministry of Jesus him- to strengthen the communion of people? On the whole, a mentally self—of the Good News, on the the universal Church, I would not ill person is seen as someone who one hand, and that thought and re- hesitate for a moment to seek to is afflicted by mental illness. But flection on how to improve the share our experience with others the term “mental illness” is very communication of this Good News and to do this in a spirit of humili- general in character and, as a re- is a pastoral necessity, on the other. ty. Your questions and your obser- sult, very broad in meaning. With- I will seek to deal with this subject vations will be most willingly ac- out seeking to offer a definition by answering the following ques- cepted—so that what we have to which a specialist in the field tion: What kind of pastoral care say to each other can become en- would provide, we can perhaps and what kind of spirituality must riched and so that new vitality can confine ourselves to observing that the Church bring into being today be given to our pastoral work. the term covers a whole range of in order to provide a better service I would like to deal with the sub- neurological, psychiatric, or neu- to the mentally ill, those suffering ject of this paper by dividing it in- ropsychiatric disorders which of- limbs of the Body of Christ? I to three parts. First of all, I will ten express themselves in mental must confess that this is a difficult dwell upon the character and na- problems or a lack of structuring undertaking, and this is especially ture of mentally-ill persons and il- of the personality—something the case because there is a general lustrate the challenge that they which occurs in cases of mental belief that at the level of local constitute for today’s Church. I deficiency. These kinds of illness- Churches real action in this sphere will then discuss the great ques- es can have—depending on the has yet to be taken. But even tions relating to pastoral care for case—genetic origins (trisomy 21 though it is difficult, this undertak- the mentally ill and their spirituali- syndrome, autism, etc.); physio- ing can also be very exciting be- ty, and the policies which should logical causes (traumas caused by cause it involves—above all—the be adopted in this whole sphere— cerebral injuries or car accidents); making of proposals and the shar- without, however, ever seeking to psychological causes (serious neu- ing of ideas within the Church in conceal the problems which will roses); or social roots (deviant order to achieve the provision of a have to be faced up to and tackled. forms of behavior such as drug-ad- better service to those “wounded diction or alcoholism). An obser- by life” in our time. vation of contemporary social- It is perhaps a good idea to re- 1. The Mentally-Ill Person: medical realities demonstrates that member that I am speaking here as A Challenge these mental illnesses usually give a priest who wants to dream when for Today’s Church rise to different approaches which he thinks about the form and the range from clinical treatment to quality of the service that the I believe that the mentally-ill social care or which involve a Church should provide to the suf- person is a challenge for today’s combination of different ap- fering limbs of the body of Christ, Church. This challenge, however, proaches at the same time. Al- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 209 though some of these forms of or a dialectic between personal sin The struggle against illness cannot mental illness can be cured or alle- and social sin. Indeed, “sin makes be separated from the announce- viated through the use of medi- men accomplices of one another ment of the Kingdom of God—a cines or rehabilitative methods in- and causes concupiscence, vio- kingdom which is also to be volving the reawakening or stimu- lence, and injustice to reign among achieved through the healing of lation of the impaired functions, it them. Sins give rise to social situa- the sick. Every time, therefore, that has to be recognized that some tions and institutions that are con- Jesus heals and fights illness he never respond to treatment. trary to divine goodness. ‘Struc- proclaims the Kingdom of God. From this it follows that a men- tures of sin’ are the expression and Over recent years a large num- tally ill person is, first and fore- the effect of personal sins. They ber of theologians have demon- most, like every other sick individ- lead their victims, in turn, to do strated in very important works on ual, a person “wounded by life” evil. In an analogous sense, they Christology that the Kingdom of and a being who suffers. He is a constitute a ‘social sin.’”2 God and the special love for the wounded person because he is a poor which this kingdom involves person whose spirit, or whose B.Jesus and the Sick: occupy a central position in the emotional, intellectual, relational, The Struggle Against Illness apostolic preaching of Christ. But and psychological balance, have and the Proclamation it should also be pointed out that not been able to endure the impact of the Kingdom the proclaiming of the Good News of a number of factors over which of the Kingdom of God in Galilee he was not able to exercise a total Even a brief look at the Gospels (Mt 4:23; 9:35) is accompanied by control. He appears to us, in essen- shows us two things. We see, a certain number of miracle-signs. tial terms, as a handicapped per- above all, that at the time of Jesus These are not just demonstrations son. His suffering is caused not on- a specific number of illnesses and of the achievement and the pres- ly by this handicap but also by the neurotic or psychic disturbances ence of this kingdom—they also feeling that he is useless, a burden, whose origins are now better bring out and reveal its meaning. and a nuisance. He believes that known were very easily attributed The apostles were informed that without his presence everything to the devil. We thus see a Jesus their mission was to proclaim the would be more simple. This feel- who meets and heals sick people Good News of this Kingdom of ing can lead him to fall into a dis- throughout his public ministry. God, and this communication was tinctive form of loneliness. But de- Even though he rejected the tradi- made when Jesus was still alive spite all this, his handicap does not tional link between illness, suffer- (Mt 10:7). After the death and the deprive him of his dignity as a man ing, and personal sin which was resurrection of Jesus and after the created in the image of God. perceived by the Jews of that peri- Pentecost the proclaiming of this In discussing the causes of men- od,3 one thing really mattered to kingdom was the ultimate and de- tal illness, I referred to those which him: to comfort those who were finitive purpose of the evangelical are social in character, such as suffering. Jesus seemed to under- preaching—as is more than evi- drug-addiction and alcoholism. stand their suffering and strove to dent from the Acts of the Apostles Certain studies have shown that alleviate it. However, he did not (Acts 19:8; 20:25; 28:23-31).5 there is a link between these judge those who were sick but al- The gospels do not refer specifi- pathologies and certain factors be- ways expressed compassion and cally to the mentally ill, but every- longing to the social environment. tenderness towards them. But Je- thing they say about the fight If the causes of the suffering of the sus did not confine himself to be- against illness also relates to this mentally ill can at times be traced ing tender of heart and compas- category of sick people. To fight to the social environment, it be- sionate—he also fought against ill- against mental illness and every- comes possible to consider such ness. For Jesus illness was something which causes it is a way of people as victims of certain social thing to be met and challenged. continuing the work of Jesus—the conditions which we could well Thus it was that “he saw in ill- proclaiming of the Kingdom of deem “structures of sin” or “social ness an evil which men suffer God. sin.” There can be no doubt that from..., a sign of the power of Sa- sin is first and foremost a personal tan over men (Lk 13:16). He feels C.The Church at the Service act, but this does not mean that we compassion (Mt 20:34) and this of the Mission of Christ should not be held responsible for compassion informs his action”.4 sins committed by other people or His actions in favor of these sick The Church does not serve if she for what harms them. We and soci- people take the form of healing. does not proclaim. She is the ser- ety are responsible when we coop- The healing which he achieves vant of the mission of Christ—the erate in these sins “by participating means at one and the same time mission to proclaim the Kingdom. directly and voluntarily in them; triumph over Satan and the estab- She must be faithful to the mission by ordering, advising, praising, or lishment hic et nunc of the King- which Christ entrusted to her, and approving them; by not disclosing dom of God of the Scriptures (Mt she must do this in relation to ill- or not hindering them when we 11:5). It is from this point of depar- ness, employing as she does so the have an obligation to do so; by ture that one perceives the link tender and compassionate, but also protecting evildoers.”1 within his ministry between the real and effective, love of God. It should be immediately em- healing of the sick and the estab- As has already been pointed out, phasized that there is always a link lishment of the Kingdom of God. the acts of healing which were the 210 DOLENTIUM HOMINUM sign of the presence and expression. Sick people were once the our country of a tradition in this sion on earth of the Kingdom of objects of the special love of Jesus most important of spheres. Indeed, God were not linked solely to the and today they are the “object of a although the Congo Church has re- preaching of Jesus. Indeed, Christ preferential love on the part of the habilitation centers for the victims associated the apostles with his Church, who, from her very begin- of polio and training centers for power to heal illness and sickness nings, and despite the faithlessness the blind and the dumb, she has from the very outset of their mis- of many of her members, has nev- never been concerned directly sion (Mt 10:1). The promise of the er stopped trying to comfort, to de- with the plight of the mentally ill. constant achievement of these fend, and to free. She has done this How many of our dioceses have signs to give credibility to their through innumerable works of chaplains for the mentally ill and proclamation of the Gospel mes- charity and help which remain al- how many lay apostolic groups are sage is made to the apostles at the ways and everywhere indispens- dedicated to looking after people moment of the bestowal of this able.”9 who suffer from mental illness? mission (Mk 16:17ss). The life of The Church, therefore, at all Our pastoral activity in relation the apostolic Church involved a times, has paid especial attention to the mentally ill is still too much large number of healings which to the plight of the sick. As the concerned with providing spiritual bore witness to the presence of Holy Father recently observed, help to the terminally ill and to Christ within the community of “pastoral care in the health field giving material aid to those who believers (Acts 3:1ss; 8:7; 9:32ss; continues to occupy a prominent are afflicted by AIDS. Hitherto, 14:8ss; 28:8ss). place in the apostolic action of the for example, our Church has nei- The presbyters of the early Church: she is responsible for ther understood the complexity of Church were also much concerned many institutions which provide the situation we have before us nor with the health of the sick (Jm help and care; and she works understood the link between men- 5:14ss). Although the Church of among the very poor with effective tal illness and social sin. This ab- the first centuries perceived illness concern for health care through the sence can be explained, on the one as being an evil to be fought, she generous commitment and in- hand, with reference to the fears also taught both that illness was a volvement of many brothers in the which these sick people gener- difficult trial whose mystery had to episcopate, priests, members of ate—given that they have a reputa- be accepted by man on this earth male and female religious orders, tion for being violent and danger- and that it was something which and many of the lay faithful. These ous—and, on the other, with refer- united man to the suffering Christ people have developed a marked ence to the lack of qualified pas- (2 Co 4:10). From this comes that sensitivity towards those who are toral workers and the absence of duty to exercise charity towards in paino.”10 well-organized pastoral activity. the sick which from the very earli- In the Congo, after the first peri- Today, therefore, the situation of est days of the Church was im- od of evangelization, the Church the mentally ill constitutes a chal- posed upon Christians and that displayed special concern and care lenge for our local Church because obligation to perceive Christ as be- for the well-being of the sick. Al- it requires the invention of an ap- ing within the sick. The Christian though the Church was deprived propriate approach and the devel- must serve the sick and help them of her health care facilities by the opment of suitable pastoral strate- to bear their trials by visiting them Marxist-Leninist regime from gies. The current pastoral gap can and alleviating their suffering. To 1965 to 1990, she never aban- no longer continue and needs to be serve the sick means to serve Jesus doned her duty towards the suffer- filled—at a time when everybody himself in the suffering limbs of ing limbs of the Body of Christ is talking about a new evangeliza- his Body (Mt 25:36).6 This vision and she always maintained a pres- tion. of things explains why the Church ence in the world of health policy sees the image of her suffering and and care. In addition to the phar- poor founder in the poor and why macies, the mobile, or parish- 2. What Kind of Pastoral Care she strives to diminish their an- based clinics, the rehabilitation for the Mentally Ill? guish and pain.7 centers for all kinds of handi- The sick as well are the poor of capped people, and the involve- The task of helping and alleviat- our time. “The love of the Church ment of many of her members at ing the trials of the mentally ill and for the poor...belongs to her con- public health facilities, the Church serving Christ in the suffering stant tradition.”8 This love draws today completes this presence limbs of his body which such peo- inspiration from the care and con- through the action of those lay ple represent is something which cern Jesus himself felt and ex- people who belong to the Gospel should be carried out both by each pressed towards the poor (Mk Groups for Health.11 baptized Christian and by the 12:41-44). Mental and physical in- But if the Church in the Congo Christian community as a whole. firmities form part of that more has, on the one hand, always cared This is a mandatory requirement of general human misery which is it- for the sick, it is also true that, on the Christian faith and cannot be self a sign of man’s need for salva- the other, there has been almost an limited to a mere supportive role tion. They also create those vic- absence of pastoral care or a or to spiritual and material help tims among the poor with whom poverty of pastoral care in relation and assistance. It is essential to the Jesus often identified and who to the mentally ill. One could even proclamation of the Kingdom of were the objects of his compas- speak of the nonexistence within God and must flow over into a re- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 211 newal of the structures of the A.Pastoral Care of, what is said or spoken. This world. In order to avoid the risks and Evangelization means that “every evangelization of oblivion and ineffectiveness, it requires signs which are connect- must be organized in the form of a It is clear that “the mission ened to the spoken word.”17 Such clear, global, relevant, and cultur- trusted by Christ to his Church is signs are necessary because “for ally suitable pastoral initiative. that of preparing for the eschato- believers the sign is within the Such an initiative is necessary to logical reign through the promo- new life of faith. For non-believ- evangelization,12 and the drawing tion of the growth of the Body of ers the sign must be external and up and implementation of such a Christ within humanity during the should emphasize the realism of pastoral project is the principal re- course of history. Considered in the proclamation by showing the sponsibility of the bishops, who these terms, this mission takes on- fruits of the Gospel in the world of must bring it into being with the ly one form. But in every believer empirical demonstration. One help of those among their advisers, the Body of Christ only forms pro- goes here from the more sensitive priests, members of religious or- gressively. For this reason the to the more spiritual, from the sign ders, and lay people who are in- Church—in order to perform her of the Gospel to the very heart of volved every day in the field of unique mission—must be in- the Gospel, which gives meaning service to the mentally ill. volved in different kinds of medi- to the sign. And at the same time it The pastoral gap which I re- ation which conform to this organ- is through the spoken word and ferred to above can be filled only ic future.”14 The Church performs through the sign that the power of by a deep-rooted commitment to this mission through evangeliza- the Gospel in the Holy Spirit pastoral action. And by pastoral tion because “the first task of [her] touches welcoming hearts. The action we mean “organized action mission..., without which her oth- signs also bear witness”.18 The by the Church which is promoted er tasks would be in vain and evangelizing mission of the by the clergy or by the lay faith- would not really build up the Body Church has a collective goal: the ful.”13 Such action has no other of Christ, is evangelization. The building up of the Body of Christ. purpose but that of responding to Church must carry out this mis- This objective means that the the mission Christ has entrusted to sionary task wherever the Gospel Church should also employ col- his Church. The question which has not yet been preached whether lective signs. forms the title of this paper links in a geographical or a sociological two concepts which involve a sense.”15 The mentally ill are not a B.In Search of dilemma—should we aim for as- geographical element but a socio- a New Pastoral Initiative sistance or pastoral care? Are we logical reality in relation to whom dealing here with an assistance the Church must carry out her mis- From these reflections on the which must be pastoral or pastoral sionary task. The proclamation of mission of the Church in the world activity which takes the form of the Gospel message is at the center and the means by which it can be assistance? It is my view that we of the mission of the Church and carried out in order to achieve pas- are referring here to assistance “in essential terms involves seeing toral care for the mentally ill, we which becomes pastoral action. the event of Jesus Christ as a pre- can draw the following conclu- But I also know that in relation to sent-day mystery. Not a mere sions. Pastoral care for the mental- the mentally ill our pastoral activi- statement about God nor a simple ly ill must take two directions: that ty does indeed often take the form fact belonging to the past, but the of the proclamation of the spoken of assistance. Furthermore, why contemporary coming of God into word and that of its proclamation should we not speak directly about history in order to christify histo- through individual and collective pastoral care for the mentally ill ry.”16 signs. and commit ourselves to speaking The work of evangelization The proclamation of the word is about assistance which has a pas- which the Church carries out in directed towards ensuring the wel- toral dimension? the world is the principal means coming of Jesus Christ into the life It is clear that not all these ques- by which the Word of God—who of every person. This welcoming tions and problems can be faced up is Jesus Christ—enters into human usually occurs through conversion to and tackled if one seeks to dis- lives. Indeed, it is through the and then entrance into the Christ- cuss the action of the Church in re- Word that the Good News— ian community. The proclamation lation to the mentally ill only in which the Word brings in the Holy of the word must be carried out terms of pastoral assistance. To an- Spirit—comes to be expressed for within the framework of small swer the question posed by this pa- the benefit of those who receive it. groups or through a one-to-one re- per in a more or less relevant Each act of evangelization presup- lationship. It should seek to wake way—a question which I express poses the presence of the spoken men from their torpor and slum- in the following manner: What word, the normal channel by ber—without, however, ever vio- kind of pastoral care is of use for which the Word of God is propa- lating their liberty of conscience. It the mentally ill of today’s gated. This follows the example must be suitable to the condition of world?—we must first of all an- and the mission of Christ himself. those to whom it is addressed, peo- swer two other questions: what do But the history of salvation also ple to whom the mercy of God we mean by pastoral care and what shows us that God has always spo- must also be shown.19 It must take is its purpose? ken through facts which render the form of a catechesis which is visible, and attest to the veracity culturally suited to the real situa- 212 DOLENTIUM HOMINUM tion and condition of mentally ill thenic, to a neurotic, or to a de- should lay great stress both upon people. The question of a cultural- pressive—to list only the more ob- the need for orthodoxy (sound ly suitable catechesis brings us to vious. The clinical and medical- doctrine) and upon the need for or- the problem of “inculturation.” By social treatment of these very dif- thopraxis (Christian practice this term is meant “the embodi- ferent situations and conditions re- which conforms to the message of ment of the Christian life and mes- quires methods and techniques Jesus). It may be observed that up sage in a specific cultural area so which are varied and different. A to the present time our pastoral as- that not only is this experience ex- proclamation of the word of God sistance to the mentally ill has in- pressed through the elements of which is to reach the victims of volved the development, above the culture in question (if things mental illness should also be suit- all, of the dual dimension of char- were left merely at this level one able and appropriate to the special itable assistance (material help would be dealing with an eminent- characteristics of each individual and visits) and sacramental help at ly superficial adaptation), but it al- situation. But pastoral workers of- the moment of death. This is the so becomes a source of inspiration ten do not have the training and pastoral work exemplified by the which is at one and the same time the grounding to achieve this end. behavior of the Good Samaritan, a both a guideline and a unifying For this reason the Church should proclamation of the word of God force which transforms and creates often take advantage of the help of through signs of fraternal help and anew this culture, indeed promot- people who are qualified in this care. Such pastoral activity along ing thereby a new ‘creation.’”20 field. these lines is necessary not only The deep insertion of the Chris- The proclamation of the word of because it is required by Christian tian faith and life into a specific God through individual and col- faith but also because it imparts culture is the fundamental princi- lective signs bears witness to the credibility to the proclamation of ple of inculturation. A successful power of Jesus Christ’s being wel- the word of God. process of inculturation can give comed by every baptized person Pastoral action which takes the rise to three essential features. and every community of believ- form of charitable help towards First of all, there is the presenta- ers. It further attests to the fruitful- mentally ill people who are very tion of the message and the values ness of the Gospel within the poor and spiritual assistance (of a of the Gospel in the forms and Christian community. These signs sacramental character) to those terms specific to a given culture. are at the service of evangelization who are about to meet death is Then there is the new cultural de- because they can lead lives which necessary, but it is also markedly velopment which springs from the are lost in drowsiness to listen to limited. It is limited because those sowing of the Gospel within a cul- the spoken word of God. The wel- who practice it confine themselves ture. Finally, there is the new ex- coming of Jesus Christ should not to assistance. They do not pay suf- pression which the members of a close Christians within them- ficient attention to all the aspects specific culture who have received selves but—on the contrary— of the individual condition and sit- Christian faith proceed to give to open them to others and in partic- uation of the mentally ill person. the Gospel.21 A culturally adapted ular to the poorest and most af- For example, what is his social catechesis must be the product of flicted in whom indeed they rec- and family environment and what this process, and this process must ognize the presence of Christ. is the real level of his indepen- be within the reach of a Church Such signs can take the form of dence? The giving of help to a such as ours, which has been en- practical works of faith and chari- mentally ill person often means gaged in evangelization for over a ty in relation to people who suffer. helping him deal with something century. Such a catechesis is re- Practical works of charity, for ex- he lacks; it means fighting against quired, above all, in a situation ample, may take the form of indi- everything which injures his con- where most mentally ill people ex- vidual or organized visits of the dition. In certain cases, the assis- perience socialization only in their faithful to sick people in order to tance supplied by the Church can- families or their villages—reali- express their fraternity or their sol- not go beyond material help and ties where the weight of local cul- idarity. There can also be material support. This is what the Church ture is still very important. help to reduce the suffering or the already does in relation to those When we refer to a catechesis burdens of those who suffer or who have no autonomy of action suitable to the real situation of the spiritual help through the sacra- and suffer from intense levels of mentally ill we mean simply that ments at very difficult moments in poverty. In other cases the Church we should be fully aware of the se- the lives of sick people. could help those people whose riousness of the handicaps and the All this is already done in our health could improve as a result of ability to be independent of these local Church so as to provide help treatment or suitable rehabilitative mentally ill people. The word of to the mentally ill even though— aid. In this way, such people could God cannot be offered in the same and this is something which has to be helped to regain their dignity way and with the same approach be recognized—few of the lay by enabling them to support them- to a person suffering from a tri- faithful or lay apostolic groups are selves from a material point of somy syndrome, a person suffer- really involved in such activity. view, or at least in part. Medical- ing from Alzheimer’s disease, a We have to ensure that Christians social centers engaged in such ac- psychotic (schizophrenic or autis- perceive this duty as being an im- tivity have still to be brought into tic person), to an individual suffer- pelling part of their faith. This being in our country. Although our ing from aphasia, to a psychas- means that our catechumenate Church may lack the means by “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 213 which to create such centers, it re- ethical problems which surround ways escapes us. It lives by the mains true that public authorities and/or accompany mental illness tension between this project and could be encouraged by the caused by the use of drugs or con- this mission and it is, by nature, Church to establish such centers nected with the condition of tri- open.”22 It is for this reason that and to support their day-to-day somy 21—to give just two exam- pastoral care can be born only running and administration. ples—if she does not cooperate within the contours of a debate In yet other cases the Church with the public authorities, with which is continually in progress. could pave the way in the fight legislators, and with the various against certain traditional ways of medical and associated bodies? treating and understanding mental This kind of cooperation could 3. The Search for illness. Our pastoral activity in re- help and foster the search for solu- a Suitable Spirituality lation to the mentally ill would tions on a very broad front. What gain from an integration of the di- we need, therefore, is pastoral ac- As I have already pointed out in mension of liberation—that is, a tivity based upon openness and this paper, it is my opinion that campaign against social sin which cooperation. It is most important, this international conference con- in the Congo takes the form of however, that such an initiative is stitutes a helpful framework by families abandoning their mental- not programmed and put into which to improve the quality of ly ill members, on the one hand, practice outside communion with our commitment and approach to and through a rejection of inhu- the Holy Father and the bishops— the sick. When we address our- man living conditionsw which are with those, that is, who are respon- selves to the question of the spiri- often imposed upon the mentally sible for the evangelizing mission tual lives of the mentally ill, we ill by traditional forms of treat- of the Church. necessarily set in motion a search ment which pay little attention to Pastoral care for the mentally ill for a spirituality which is suitable the dignity of the individual, on has not yet become a challenge in- and appropriate to their condition. the other. All this should be done, volving a proclamation of the But can we look for such a spiritu- however, without forgetting the evangelical word which is both ality without first of all establish- social causes of mental illness, culturally suitable, on the one ing what we actually mean by this where these really exist. We are hand, and a proclamation of the concept? referring here to a collective strug- same word through individual and In a general fashion—and with- gle to achieve a transformation of collective signs which at the same out getting lost in technical de- social structures—this fight time integrate the dimension of as- tails—we can define “spirituality” against social sin forms an integral sistance and liberation, on the as a set of ideas, principles, meth- part of evangelization. Such an other, within the range of activities ods, and techniques which enable initiative would also help to open of our local Church in the Congo. man to draw near to God. Spiritu- the human contexts where it oper- We have for long been dedicated ality is concerned first and fore- ates to the proclamation of the to care and help, and this is some- most with the personal relation- word of God. We should therefore thing which must never be lost ship between man and God—that go beyond the logic of assistance. from view because it involves exis, man’s attempt to reach God in Aliis verbis: what is needed is a pressing the face of the Good order to be transformed by Him pastoral initiative in relation to the Samaritan to many of those who and to live in communion with mentally ill fully suited to the new are “wounded by life”—some- Him. Where this is achieved we evangelization which, to be com- thing, it may be pointed out, which can speak about a spiritual life. plete and fully appropriate, must is an imperative of our faith. But But this term can also refer to an not be confined to mere assis- today we should also strive to be organized body which has its own tance. concerned with how we can trans- nature and its own special spiritu- This pastoral action must be at mit the Gospel message and fight al tradition. This is because “spiri- the same time both assistance and against the different forms of so- tuality is like efflorescence, the liberation. We must therefore find cial sin in order to ensure that our spontaneous and personal expres- new ways by which to deal with pastoral activity in relation to the sion of spiritual life—that is, its the problems involved in the indi- mentally ill involves a complete invitation to share in it.”23 Thus it vidual condition of mental illness. and integral evangelization. is that we talk about an Ignatian, Such pastoral activity would However, “pastoral care can on- Franciscan, or Benedictine form clearly rise above the efforts of the ly be a reality which is in perpetu- of spirituality. Spirituality, there- apostolic workers who are cur- al evolution. It should always re- fore, can take the form of elements rently involved in helping the define itself in line with the ways which give rise to an authentic mentally ill. In order to achieve in which the advance of history re- spiritual life or to communicable the Church’s goals of evangeliza- veals new aspects of the divine factors which reflect a specific tion, those who are responsible for work which itself is to be fol- spiritual tradition designed to pro- pastoral care in the field of health lowed. It must express itself in the mote and sustain spirituality. must accept the idea of acting in form of a functioning human pro- These two dimensions to spiritual- cooperation with other ecclesiasti- ject, but it must never cease to take ity will now be discussed in the cal elements and with the public place because it is rooted in a di- last part of this paper. In the light authorities. How can the Church vine mission which rises above it of these considerations we must address herself to the social and and whose breadth and size al- now reformulate our question in 214 DOLENTIUM HOMINUM the following way: in being near without the achievement of a co- both personally and with others, to the mentally ill person what presence of other believers, with great emphasis should be placed kind of spirituality should we Christ and us, in the Church. And upon taking part in liturgical as- choose for him and upon which this is necessary not only because semblies. “The liturgical assembly aspect of Christian mystery should it is an essential means but also be- of the Church is the assembly of we place emphasis? cause it involves the very purpose the people of God, summoned by itself of spiritual life.”25 For this God himself principally to hear A.The Spiritual Life reason we should be fully aware his word.”27 Suffering members of of the Mentally Ill Person that the spiritual life of a mentally the Church, but members of the ill person will become more Church in the full sense of the Spiritual life can only be that Catholic the more he develops his term, mentally ill people should life engendered by the Spirit given personal relationship with God take part in her prayer and be the by Christ. Nourished by faith, it within the Church. This is “be- subjects of her prayer. They will becomes defined through a rela- cause the Word of God is spoken feel accepted and welcomed as tionship with God made possible to us within the Church and it is in- brothers and sisters whose pres- by his Spirit and flourishes in the separable from the Church to such ence completes the body of Christ. presence of God. It is the relation- an extent that we can only really They will remind other limbs of ship with God which is of preemi- accept it in the way that it is com- the Body of Christ of the duty to nent importance in spiritual life, municated to us by the Church.”26 pray for them. and this life is the reply of the The poverty of the mentally ill The culminating point in shared Christian to the call for commu- person leads him to pray—that is, liturgical celebrations must be the nion which God makes to him. to turn towards the Other, towards celebration of the Eucharist. Like every other Christian—and God. His prayer, therefore, must Christ’s work of salvation centers despite the handicap which afflicts be nourished by biblical faith and around the celebration of the last his rational faculties—the mental- by the tradition of the Church. supper. The Eucharist is the proto- ly ill person is called to take part in Like every other Christian, he type of every shared prayer in the this communion. When the “spo- should look for and find the prin- Church and reminds us of the cross ken word” is proclaimed in such a cipal source of his life of prayer in of Christ. It invites us to contem- way as to enable him to receive it, the Old and New Testaments. But plate the cross within the suffering he also experiences the need to the Bible should be presented to limbs of his body—that is, in this fight the spiritual fight and to open him in a way which takes his lim- case, the mentally ill. The liturgi- himself to the grace of God its fully into account. Since he is cal assemblies are certainly the through faith. Those who have ex- handicapped in relation to his ra- places where the word of God is perienced the growth and develop- tional faculties, it will be almost proclaimed, but they should also ment of faith in the mentally ill impossible for him to engage in be the place where there is a sacra- know all about this process. But to such forms of prayer as meditation mental manifestation of salvation. ensure that the response of these and contemplation, both of which “The word of God which is illumi- mentally ill people to the call of require a major employment of the nated by the ecclesiastical tradition God becomes ever more authentic mind. However, it will be relative- is captured to the utmost in a mys- it must be sustained and supported ly easy for him to pray personally tery—Christ and his cross. But in by a life of personal and communi- with his own body and his the Church the mystery is not ty prayer and by a suitable ap- rosary—to give just two exam- merely proclaimed. With the au- proach and attitude to the sacra- ples. These two forms of prayer thority itself of God, it is pro- ments. can be easily used by mentally ill claimed as being present. It is Although, obviously enough, it people at an individual level but therefore represented and made should be adapted to their real con- they can be even more easily prac- present for us in us. The sacra- dition and situation, the spiritual ticed within a group context. ments have the role of supplying life of the mentally ill which the Prayer groups based upon charis- us with this presence and commu- pastoral work of the Church is matic renewal, where great impor- nicating to us the permanent actual called upon to promote should first tance is given to the word and the reality of this mystery. This ex- of all be Christian and Catholic. body can be of very great help in plains the close links between the These characteristics will be dis- developing the prayer life of the divine Word proclaimed by the played in proportion to the estab- mentally ill person. Praying the Church and the sacraments which lishment within that life of an ex- rosary can involve its mysteries the Church celebrates and admin- perience of a personal relationship being explained by gestures and isters to us.”28 The sacraments ex- with God. This means that the spir- images. These are two forms of press the redemptive love of God. itual life of the mentally ill should prayer which should be encour- Through the sacraments the be based upon the Word of God aged. In becoming familiar with Church represents the salvation and upon faith—the Word by them mentally ill people can see brought by Jesus and promotes the which God calls man to Him and their relationship with God grow spiritual lives of mentally ill peo- the faith by which man recognizes deeper and flower in the context of ple. The sacraments are important and accepts this call.24 In the the practical expressions of faith. because they render such people Catholic Church there cannot be a In addition to these forms of more holy and help them to live spiritual life which is “authentic prayer, which can be experienced out their communion with the “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 215 mystery of the cross of Christ. In Human Dignity God. He beatifies them (Mk order to benefit to the full from all Despite their handicaps, mental- 10:16) and thereby reveals their the graces of the sacraments, men- ly ill people retain their whole dig- predisposition to enter into his tally ill people must be helped to nity—something which is re- kingdom. Each and every Christ- welcome and receive them in faith. ceived not only from the fact that ian is invited to welcome the they are created “in the image and Kingdom of God like a child (Mk B.Certain Key Features likeness” of God (Gen 1:26) but 10:15) and to agree to become a of a Spirituality also from their vocation to live in child once again (Mt 18:3) in or- for the Mentally Ill communion with Him. This is der to enter the Kingdom of God. what Vatican II made clear when it To be or to become a child means Spirituality is also a kind of doc- declared “the highest reason for to become humble. This spiritual trinal corpus which has been the dignity of man lies in his voca- childhood leads to total trust in drawn up to support and accompa- tion to communion with God. God. Taught by the Gospel and ny the efforts Christians make in From the moment of his birth man constantly inspired by St. Thérèse their search for authentic commu- is invited to a dialogue with God. of the Child Jesus, for mentally ill nion with God. Indeed, he exists only because he people this childhood can consti- Because it has this characteris- is created by the love of God and tute a path to finding peace of tic, it can be transmitted and com- he is always protected by God’s heart. municated. In order to facilitate its love. In the same way man does transmission or communication, it not live fully in conformity to Sharing in the Cross of Christ must be presented in the form of truth if he does not recognize God The Cross of Christ evokes the certain key aspects. Mentally ill freely and he does not place him- sufferings of Christ. St. Paul often people, in one way or another, are self in the hands of his Creator.”29 observes that the Christian is handicapped in relation to their ra- Indeed, man is the only creature called upon to make Christ live tional faculties. This kind of hand- on earth whom God wanted for his within him. Suffering is a path of icap often makes them incapable own sake. If emphasis is placed communion with the mystery of of intellectual activity and elabo- upon this dignity of the mentally the Cross of Christ. “The Christian ration. The key aspects of the kind ill in helping and supporting them, lives in a state where ‘it is no of spirituality which are being pro- this can help them to accept their longer he who lives, but Christ posed in this paper are not directed handicap and to see their handicap who lives in him’ (Ga 2:20), and principally to the mentally ill, but not as a divine punishment but as a as a result the sufferings of the to pastoral workers—whether feature of beings who are unique Christian are the ‘sufferings of members of the clergy or the lay in the eyes of God and have their Christ’ (2 Co 1:5). The Christian faithful—who should discover the own place in the creation. They belongs to Christ through his own best means by which to transmit can thus also be opened to the body and suffering makes him like this spirituality and ensure that it mystery of the love of God. Christ (Phil 3:10).”30 If emphasis is marked by vitality. A perception is placed upon this reality, mental- of these key aspects which is high- The Special Love of God ly ill people can be helped to bear ly systematic in character forms a for the Weak their suffering more easily and to part of helping the mentally ill to The teaching of the prophets bestow upon it a mystical signifi- live out their spiritual lives in a and of Jesus shows that the weak cance. positive fashion. It is therefore a and the poor are the object of a necessary feature of pastoral work special love on the part of God and Hope in the Resurrection and activity. that they are the privileged heirs to The reality of hope demon- But these key elements cannot his kingdom. For them this love is strates the future of happiness to be offered without reference to the the expression of God’s intention which all men are called in their condition and lives of the individ- to honor his promises. An aware- lives as Christians. Trust in God uals who are called upon to re- ness of this love on the part of and in his intention to honor his ceive them. Pastoral workers must mentally ill people—something promises nourish this hope. The pay especial attention to each indi- which is in contrast to the attitude resurrection of Christ bears wit- vidual mentally ill person whom of a society which often finds no ness to God’s honoring of his they help and support and should better solution to their condition promises and is thus at the center base their action upon these vital than that of excluding them—can of the hope of the Christian. The aspects. These key elements are help them to rediscover faith in dead and risen Jesus Christ is the rooted in the Word of God and ec- their own lives. The feeling of be- future of man. He calls upon his clesiastical tradition. They are hu- ing loved, notwithstanding every- disciples to follow him and thus to man dignity, the special love thing and above everything else, accept suffering and death to take which God feels for the weak, can in turn be of help in the pro- part in his glory (Mt 16:24ss). spiritual childhood, sharing in the motion and development of their Each and every Christian who is in cross of Christ, and hope in the spiritual childhood. communion with Christ’s suffer- resurrection. Why these elements ing can hope to achieve commu- in particular and in what ways can Spiritual Childhood nion with his glory. Reference to they help the spiritual lives of Jesus engages in the same be- this aspect of the Christian experimentally ill people? havior towards children as that of ence—an aspect upon which a 216 DOLENTIUM HOMINUM large number of spiritual teachers modernize the knowledge of those sial presence in the world of health (Ignatius of Loyola, St. John of the who are already working in this policy and care and contribute to a Cross) have laid great emphasis— field. Our local Churches must common search for pastoral care can also be useful in helping and take advantage of the modern which meets to the full the re- supporting people who are men- methods and techniques which are quirements and aspirations of the tally ill. In particular, it can help employed to help and advise men- new evangelization. them to keep their hope alive tally ill people and to establish when they are engaged in treading communication with them. These Most Rev. HERVÉ ITOUA their path of the cross. pastoral workers must cooperate Bishop of Ouessa, Real and authentic pastoral care with the structures of their local President of the Bishops’ Commission for the mentally ill cannot omit Churches or within the broader for Pastoral Care in Health, these key elements which should framework of the wider Church. The Congo be communicated within the In addition, the special character framework of catechesis, liturgi- of the condition of mentally ill cal celebrations, and the individ- people opens up new fields of re- ual spiritual support and advice search and study for our theolo- which are promoted. Spiritual gians. help to the mentally ill based upon In order to achieve greater ef- Notes these simple, clear, and profound- fectiveness and fruitfulness in her ly evangelical ideas can help our evangelizing mission, the 1 Catechism of the Catholic Church, no. 1868. brothers and sisters to accept their Church’s pastoral role in relation 2 Ibid., no. 1869. condition. It can also help them to to the mentally ill must not be- 3 See the healing of the man born blind in transform it into a means by which come separate from her overall Jn 9:1ss. 4 XAVIER LEON-DUFOUR, Vocabulaire de to engage in real praise of God and pastoral purpose. Priests must be- Théologie Biblique (Paris, Cerf, 1981), p. to achieve a real encounter with come used to bearing in mind and 700. Him. These are all insights which, perceiving the social and individ- 5 Ibid. p. 1146. 6 Ibid., p. 702. if judged to be of worth by spe- ual dimension to sin, to the spiritu- 7 See the address of John Paul II to mark cialists in the field of spiritual the- al struggle, and to the building of the Fourth World Day of the Sick, 11 Febru- ology, could be subjected to a the Kingdom. Such a path can inary 1996. 8 See the Encyclical by John Paul II, Cen- more rigorous process of elabora- creasingly lead every baptized tesimus Annus, no. 57. tion and development. Christian to honor the implica- 9 See the instruction issued by the Congre- tions of his duty to charity towards gation for the Doctrine of the Faith: Libertatis Conscientia, no. 68. those “wounded by life” and the 10 See note 7. Conclusion suffering limbs of the Body of 11 The reference here is to movements of Christ—that is, our brothers and lay apostolate of which Christian health care workers form a part. If we recognize the complexity sisters. 12 Indeed, as the Holy Father often ob- of his situation and condition and May these simple words which serves, pastoral care in the health field which the problems which they involve, spring from the experience and the is perfectly organized is rooted in evangeliza- tiono. the mentally ill person clearly con- dream of a priest who shares a 13 See “Pastorale” in Catholicisme, X, p. stitutes at the present time a real commitment with the many peo- 766, col. 2. challenge for the pastoral work of ple who help him—whether 14 See “Evangélisation” in Catholicisme, IV, p. 755, col. 2. the Church—a challenge at the priests, members of religious or- 15 Ibid., p. 757. level of the training of pastoral ders, or lay people—to an eccle- 16 Ibid., p. 758. workers, the work of our theolo- 17 Ibidem. 18 Ibid., p. 760. gians, and our global pastoral ini- 19 Ibid., pp. 759-760. tiative. Today the Church should 20 P.ARRUPEE, “Lettera sull’Inculturazione” involve herself with courage in , Acta Romana XVII, 1978, p. 283. 21. Théoneste Nkeramihigo, “Préalables pour new experiences but at the same une Conception Inculturée de la Formation time she should not turn her back Jésuite en Afrique et Madagscar,” unpub- on her past experience. This is our lished text, p. 3. 21 THÉONESTE NKERAMIHIGO, Préalables most deepest feeling. pour une conception inculturée de la forma- Indeed, through what I have just tion jésuite en Afrique et Madagacar, Inédit, said we can already see that the p 3. 22 Ibid., p. 768, col. 1-2. pastoral activity and the spirituali- 23 See the contribution by MICHEL DUPUIS ty that we are all seeking to to the article on spirituality in the Dictionary achieve with full respect for the of Spirituality, p. 1164. 24 L.BOUYER, Introduction à la Vie Spir- special local conditions of our ituelle: Précis de Théologie Ascétique et Mys- Churches—which we hope will tique (Paris/Tournai, Desclée & Cie, 1960), p. help such Churches to carry out 27. 25 Ibid., p. 13. their evangelizing mission to- 26 Ibid., p. 27. wards the mentally ill—must 27 Ibid., p. 30. oblige us to reflect upon the ques- 28 Ibid., p. 107. 29 Gaudium et Spes, no. 19, 1. tion of the training and formation 30 See the article on suffering in X. LEON- of future pastoral workers and to DUFOUR, op. cit., p. 1524. Round Table

Legislation on Mental Illness 218 DOLENTIUM HOMINUM

PHILIPP JENNINGER Legislation on the Mentally Handicapped in Germany

1. Introduction we live. In the same way, real e- Article 20 of the Constitution quality of opportunity between dis- guarantees the individual the right The Constitution of the Federal abled people and nondisabled peo- to enjoy the security offered by the Republic of Germany guarantees ple has not yet been reached in all welfare state. all citizens respect for their human sections and fields of our national Article 103 guarantees every- dignity, the right to life and the right life. body the right to be heard by a to physical integrity, the free devel- They thus remain a task and a judge. opment of their personalities, treat- permanent challenge in a country ment on an equal footing by gov- which wishes to consider itself civ- 2. The Capacity to Act of the ernment authorities, and the up- ilized and to create a climate in Mentally Disabled Person holding of the fundamental princi- which the disabled do not feel dis- Not all people who have a juridi- ples of the welfare state. criminated against in the way they cal capacity can achieve the up- These rights and all the other fun- live their lives, in which, wherever holding of their rights or the perfor- damental rights are also bestowed possible, equality of opportunity is mance of their duties. We should in Germany upon the mentally ensured, and where the disadvan- therefore distinguish between gen- handicapped, whatever the cause, tages which still remain are greatly eral juridical capacity and the ca- the character or the seriousness of reduced. pacity to act. The capacity to act is their handicap. All other juridical the capacity to generate juridical ef- laws and regulations apply in the 2. The Juridical Position of the fects through one’s own behavior same way to handicapped people Mentally Disabled Person and to be able to engage in the inde- whatever the level of their disabili- pendent exercise of one’s rights— ty, and for this reason acts of dis- 1. Juridical Capacity for example, to sign contracts, take crimination in relation to the dis- The first part of our civil code part in a trial, and so forth. But it al- abled in Germany are not allowed lays down that every individual ac- so means being able to undertake an according to our national law. This quires juridical capacity from the obligation such as being held re- expresses an interpretation of basic moment of his birth, regardless of sponsible for damages. principles laid down by the state. his sex or his physical or mental The capacity to act includes legal However, a mutual readiness on condition. This juridical capacity is responsibility relating to agree- the part of the sick and the healthy inalienable and irremovable. Each ments and criminal acts. Such a ca- to accept each other—a mutual individual thus has a large number pacity is in part determined by the process which should be imple- of rights such as the right to welfare age of the person but in part also by mented as such—remains of funda- support and the right to be the own- his mental state. According to Ger- mental importance if the mentally er of goods or to inherit them. man law, the “person who has disabled are to play a full part in the The second article of the Consti- reached the age of eighteen is held social life of our country. The con- tution guarantees to the mentally to be completely responsible for cept of the human being expressed disabled person, as to others, the what he does except in the case of in our national Constitution re- right to the free development of his the person who is in a pathological quires integration, cooperation, and or her personality as long as this state of mental infirmity at such a participation. Everybody must co- does not come into conflict with the level as to exclude the free exercise operate in the achievement of this rights of other people or with the of personal will, except where this goal, whether ordinary citizens, provisions of the Constitution. The state is of a transitory nature” (sec- members of the Church hierarchy, mentally disabled person, like other tion 104 of the civil code). Patho- or professional or voluntary health people, has the right to life and logical disturbance of mental activ- care workers. Unfortunately, in our physical integrity. The freedom of ity takes place when an individual is country solidarity towards disabled his person is inviolable. The same incapable of the rational and inde- people and respect for their human may be said in relation to liberty of pendent management of his will. dignity in daily life cannot as yet be thought and of religious faith and This is always the case when an in- considered real features of the way practice. dividual does not have the neces- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 219 sary faculties of criticism or judg- licit acts require the payment of instrument which envisages differ- ment, when he is not able to reflect damages only when the author of ent kinds of personal care and assis- upon his own decisions in a reason- those acts is culpably aware of what tance which are to be established by able way, and when he is unable to he is doing. The person who causes the judge according to the case in form a suitable idea of what the damage in a malicious or culpable hand. By this instrument it is possi- possible consequences of his ac- fashion is said to have acted with ble to achieve suitable solutions to tions might be. In other words, culpability. the problems and difficulties pre- when the individual is incapable of It is believed that acts are carried sented by different kinds and de- acting. In such cases the will of the out with culpability only when the grees of illness or handicap. To help person has no juridical relevance at author of the violation of the juridi- disabled people in their daily lives all and any acts of will are null and cal good does so with wrongfully- assistance can be provided only void. A person of adult age who is intentioned will. It is assumed that where there is a real need because in reality unable to consent cannot the author could have avoided that of mental illness or mental and sign a contract. This form of effec- act of will which gave rise to the physical handicap. Such help is not tive incapacity is very important in damage. The question of whether allowed when other forms of action the daily work of the mentally dis- culpability is involved therefore de- are deemed to be possible. abled because it is in a certain sense pends first of all on the assumption The aim of this law is to improve a corrective by which contracts are of the presence of the freedom to the care and assistance provided to annulled which have been signed make decisions and autonomy of individuals—that is, this law seeks by a person who is not capable of will on the part of the person who to increase the personal rights of the judgment and who is not aware of carries out the act. Section 827 of subject and to take into account— their significance and implications. the civil code lays down that a per- where this is possible—the well-be- It is not, however, true that this son in a condition of pathological ing of those receiving care, and rule defines or establishes the inca- disturbance of mental activity their wishes and needs. Help and pacity to consent in matters of civil which rules out the free formation assistance in rehabilitation should agreement of an adult person with a of will or brings about a condition be directed towards regaining au- mental handicap in overall terms. of unawareness is not responsible tonomy and freedom of action. The invalidity of a juridical act of for damage caused to a third party. According to these principles: consent involving a mentally hand- The presence of such forms of dis- Ð the provision of care and assis- icapped person is only established turbance is assumed to be operative tance to individuals does not have when the disabled person himself, in cases of serious mental handicap. any bearing on their capacity to act; or the other party, asserts or even But the presence of less serious Ð the search for well-being, like demonstrates that at the moment of mental disability does not necessar- an attempt to meet the wishes of the the conclusion of the contract there ily lead to the supposition that there assisted person, are the main guid- was an incapacity to consent. The is an incapacity to commit illicit ing principles in helping those who circumstances of each individual works. Here, also, each case must receive care; case are then examined in a judicial be examined on its merits. Ð with regard to their own re- context. The person who claims In general terms, therefore, peo- sponsibilities, those who receive that there is juridical incapacity to ple with mental handicaps can also help must themselves act to exploit consent must prove that this is so be required to pay damages. The all the opportunities available to e- because for those of adult age the person who invokes an incapacity liminate the illness and reduce their law presumes the presence of a ca- to commit illicit acts is called upon handicap or mitigate their conse- pacity to consent. to demonstrate the validity of his quences; assertion. Only a medical examina- Ð major measures regarding ju- 3. The Civil Responsibility of tion can establish in each case ridical goods can only be applied Mentally Disabled People whether the mental disability is with very severe conditions at- The questions of responsibility such as to justify the exclusion of tached to them, and their sole pur- which can arise in relation to care responsibility. The mentally dis- pose must be to act in the interests for the mentally disabled for the abled person is held to be responsi- of the person receiving assistance; most part concern the payment of ble where it is not possible to prove Ð the selection of properly damages in a civil court or tribunal his incapacity to commit illicit acts. trained assistants and health care and are largely a matter of the re- workers is of particular importance; payment of debts. 4. The Law on Social Security Ð all judicial decisions must be In our civil law offenses are illic- The law on social security which reconsidered every five years. it acts carried out against certain ju- came into effect on January 1, 1996 This new law greatly improves ridical goods such as health, free- has greatly improved the juridical s- the juridical status of mentally sick dom, and property. The perfor- tatus of adult mentally disabled per- and disabled people. mance of an illicit act in the civil sons. In Germany this law has elim- law sphere produces the right to inated the discriminatory practice compensation for the damage to the of interdiction and has replaced the 3. Help Envisaged by the Law person who has been wronged. obsolete juridical norms for the defor the Social Integration Anybody can commit an illicit fence of adults and the custody of of Mentally Disabled Persons act, including children and the men- the mentally or physically infirm tally disabled. But, on the whole, il- with a new and flexible legislative For those people who are mental- 220 DOLENTIUM HOMINUM ly disabled from birth, the so-called ment and help for children which 4. The Provisions of the Law “assistance for integration” envis- have still not reached school age are in Relation to aged by the Law on Social Security seen as instruments of rehabilita- Residential Centers must be seen as the most important tion. The risk of illness is a suffi- for the Mentally Disabled instrument for rehabilitation. Sec- cient cause for such action in an in- The person who lives in a resi- tion ten of this law declares that, re- dividual case. On the whole, pedia- dential center depends in a special gardless of the causes of his or her tricians diagnose those forms of way upon those who organize and handicap, each mentally or physi- handicap when they carry out their manage that center. The law upon cally disabled person and every per- preventive medical examinations. residential centers seeks to defend son who is likely to undergo such a After the birth of a child, doctors the rights, the interests and the handicap has the social right to sign a certificate which lays down needs of those who live within those forms of help and assistance which measures of early assistance them and of those who would like which are needed to: can be given to that young person. to enter them. The definition of the Ð prevent, eliminate, mitigate, or Care supplied within the family by contract in relation to these resi- impede the worsening of a distur- professional practitioners forms the dential centers is the central con- bance or to reduce the conse- most important part of early assis- cern of these provisions. The sign- quences of handicap; tance. ing of a contract between those Ð and to ensure a place in the Each child with a mental handi- who finance the residences and community for that person, and in cap has the right to a place in nurs- those who live in them is obligato- particular in the world of work, ery school and where possible with ry. The following principles must which corresponds to his or her in- children who are not handicapped. be respected when the contract is terests and capacities. Disabled and nondisabled children signed by the two parties: This “social right” is not only should be able to have the opportu- a) The obligation to describe recognized in a general sense as a nity to do tasks and act and behave each service. Those provided by juridical principle in the interpreta- in a way which is natural to their the organizers must be listed clear- tion and application of German so- age. The Law on Social Security ally and precisely in the contract and cial law, but it is also seen as the pri- so provides for a right to a suitable a distinction must be made be- mary guideline in the policy of re- school education. This right in- tween normal services and special habilitation and of help to the dis- cludes, among other things, access services. abled. I would like to draw attention to all those therapeutic measures b) The centers must provide ade- to, and emphasize, the following designed to help disabled children quate space for long-term resi- principles which arise from this and adolescents. These provisions dence. right. They are as follows: have had a decisive role in expand- c) In the contract the constraints Ð the principle that the objective ing the system of “differential on freedom of action must be re- is the integration of disabled people schools” (Sonderschulen) in Ger- duced to an absolute minimum and into society; many. They have also facilitated the intrusions into the private sphere of Ð the principle of ultimate pur- creation of experimental schools the tenants must be treated in the pose—this lays down that the forms which are state-aided. These same way (in full respect for the of help and assistance which are schools have shown that it is possi- rights of the liberty of each individ- provided must be given to all those ble to provide an education to chil- ual as laid down by the Constitu- with a handicap or who risk a hand- dren with a mental handicap. As a tion). icap without reference to the cause result, the local Landers in recent d) The inhabitants must have the of the handicap; years have created an elaborate net- greatest degree of freedom possible Ð the principle of rapid action work of special “differential with regard to the decorating and which is directed towards contain- schools.” furnishing of their rooms with their ing to the greatest extent the seri- own furniture and personal objects. ousness or the consequences of dis- 2. Help in Transport e) There must be no constraints ability; As a rule, free transport to the on the right to choose their own Ð the principle that individual centers for disabled people has medical doctor. help and care must be supplied with formed a part of the policy of reha- f) As a general rule, the contract reference to the practical needs of bilitation. must be open-ended. each individual handicapped person g) The conventional right to ter- and that this must be supplied in 3. Housing Assistance minate the contract is exclusively suitable form and with appropriate Help in finding and maintaining a in the hands of the person who methods. residence suitable to the needs of a lives in the residential center. disabled person also forms part of h) Wherever this is possible, the the policy of promoting social inte- financing authority must take into 4. The Chief Forms of Assistance gration. It includes both modifying account the improvement or wors- Directed at Social Integration a flat to meet the needs of handi- ening of the condition of health of capped people and in placing the the tenant and adapt its services ac- 1. Help for Children disabled in special residential cen- cordingly. and Adolescents ters or family homes for which a s- The above-mentioned provisions With regard to so-called early as- tate grant is available. relating to the signing of the con- sistance, all the measures of treat- tract are an implicit right in that “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 221 they constitute rules by which to the same rights and the same duties Concluding Observations protect the tenant. as those laid down by general labor All residential centers for dis- law. The serious invalids who have It is our opinion that the task of abled people are under the control worked for at least six months for a ensuring that the mentally disabled and supervision of suitable govern- company or other kind of employer take part in the “most normal way ment agencies which have the duty also enjoy the protection of the spe- possible in social life” is not only an to make sure that the law is correct- cial law on serious invalids. This obligation on the part of the state but ly and well applied. Where there means that every termination of a also a responsibility of society as a are instances of transgression they relationship of work involving a whole. It has always been natural can intervene and take suitable serious invalid by the employer can for the family, for friends and for measures, and may even, where only take place with the consent of neighbors to be especially caring to- necessary, close the residence. a government social security of- wards the mentally disabled, to try fice. to integrate them into family life 5. Workshops for Disabled People The period of notice can not be and to guarantee them to the best of Those mentally disabled people less than four weeks. their ability the daily support and who because of the nature or seri- In relation to the actual validity necessary assistance that they need. ousness of their handicap are not of the dismissal the invalid worker Today this task is accepted by pub- able to take advantage of those pro- has the same—indeed, more— lic institutions and it is performed visions of the law designed to en- rights than other workers to present ever increasingly in the various sec- sure their participation in the gen- the dismissal to a labor tribunal for tors of private, social and public eral labor market must be given the judgement. life—for example, in the spheres of opportunity to work in a way In all those companies where education, transport, work, or free which is suited to their kind of dis- more than five serious invalids are time. This takes place with the full ability. This is envisaged in the so- employed—that is, people with an recognition that disabled people are called “workshops for the dis- invalidity higher than 70%—a spe- important in the construction of so- abled” clause. The workshop for cial representative committee for ciety as a whole because they show the handicapped is an institution such invalids must be established us that the completely healthy and which seeks to insert the handi- in addition to the normal system of perfect person does not exist. They capped person into the world of workers’ committees. This com- allow the “normal” individual to un- work. It offers a job or the opportu- mittee must ensure that within the derstand that from certain points of nity to engage in work which is place of work all the laws, regula- view he himself is fragile or handi- suitable to them when the kind or tions and contracts relating to the capped and this promotes a socially seriousness of disability from disabled must be enforced and up- positive form of behavior which ex- which they suffer is such as to pre- held. presses Christian charity. vent them from being inserted or Juridical laws and orders, institu- re-inserted into the general labor 7. Assistance for the Elderly and tions and services of social assis- market. The workshop must allow Seriously Mentally Disabled tance cannot but represent means the disabled people to develop, in- The Law on Social Assistance and opportunities by which to crease, and reacquire their capaci- lays down that the defence of the achieve social integration. But such ties and give them the opportunity disabled person is to last for the w- goals and aims can be achieved on- to receive a suitable wage. The hole of his or her life. For example, ly if the disabled person is himself workshop should also be able to of- there should be no age limit applied motivated. For this reason consulta- fer a wide range of jobs and work to the provision of social care and tion and help to promote such inte- activity and be equipped with an support. Elderly mentally disabled gration must be linked to the practi- in-depth and far-ranging system by people should be able to decide cal motivations of those concerned, which to provide assistance and whether the assistance given to developing them to the full and un- support. them in the workshops is still of derstanding and appreciating all the The system by which the dis- help to them. For this reason they opportunities for rehabilitation abled are paid in these workshops can decide upon how long they which exist in each individual case. is still totally inadequate. In the want to remain as workers within The adoption of measures of reha- Federal Republic of Germany the these workshops for the disabled. bilitation can only take place with people who work in a workshop The law for the provision of assis- the consent of the disabled person. earn on average 220 marks a tance of 1994 lays down that an el- And because from many points of month. There is thus an urgent derly mentally disabled person view it is difficult to develop the need for new forms of labor law in who is need of constant help can personality of mentally handi- this area. avail himself of free assistance sup- capped people, we must strengthen plied by specially qualified staff. and promote—wherever this is pos- 6. The Special Defense of Disabled Here what is of great importance is sible—their personal initiative and People who Work within that in addition to grants for daily self-determination, that is to say, the Normal Labor Market assistance the positive help in en- their ability to help themselves. In the free market all workers suring insertion into the world of and office workers with a mental work is not suspended—indeed, it Dr.Philipp JENNINGER handicap are considered as should continue to be provided. German Ambassador providers of labor. They thus enjoy to the Holy See, Rome 222 DOLENTIUM HOMINUM

RAYMOND R.M. TAI

Mental Health Law and Mental Health Services in the Republic of China

Foreword paign earlier this year, President Health Law in August 1987. A Lee stressed long and hard the new version of the Mental Health The transformation of the Re- need for a kinder, more caring so- Law was drafted in collaboration public of China on Taiwan from a ciety, and a return to the past Chi- with various government agen- sleepy, impoverished, war-torn nese virtues of community self- cies related to mental health. That backwater to become one of the reliance and family-based wel- draft was passed in 1990 by the most vibrant industrial economies fare. Legislative Yuan, the central gov- in a short forty years has earned Under the stewardship of Lee’s ernment’s law-making body. It the Chinese island dynamo world Administration, the DOH has tak- was promulgated into law by renown. But with this success en steps to integrate policies of President Lee on December 7, came some of the common ills of improvement of mental health in- 1990. The Law provides the legal modern societies—including to the National Health Insurance basis for the prevention and treat- maladjustment caused by rapid (NHI) programs.* ment of mental illness. For Presi- change, drastic upheavals in the dent Lee, it was a watershed event social structure, erosion of the in his pursuit of ensuring the family as the basic building block Mental Health Legislation rights and dignity of all citizens. of society, and more, all of which Not unlike the laws regarding have led to a rise in mental illness. The first Mental Health Law mental health in other mature In the nineties, issues of mental commission in the Republic of democracies, the Mental Health health have gained increasing im- China on Taiwan was established Law of the Republic of China on portance as governments and in December 1981. A first draft of Taiwan is comprehensive, includ- community organizations at all the Law was written by the Men- ing fifty-two articles in six chap- levels strive to get mental illness tal Health Association under the ters. The Law provides compre- under control. So as to meet head auspices of DOH in July 1983. hensive provisions for a wide on the growing problems associ- But controversy over its potential range of mental health system fa- ated with mental illness, the Cen- implementation arose over issues cilities, treatment of patients, and tral Government’s Department of such as a shortage of psychiatric the rights of patients. Its real pur- Health (DOH) has placed higher professionals, and serious lack of pose is to promote, protect and priority on mental health policies. an infrastructure in existing hos- otherwise guarantee the rights This represents a major change, pitals to handle the expected in- and welfare of patients, and to en- and an important recognition of flux of patients with “new rights”. hance the overall mental health of this modern-day problem. Thus, the Law was postponed. the country, specially in these try- Much of the impetus for the Following this failure, DOH set ing times of great social and eco- greater priority of mental health out to prepare for the eventual im- nomic adjustment to rapid and e- comes from the basic ideals of the plementation of a Mental Health pochal change on Taiwan. president of the Republic of Chi- Law by setting up Regional Psy- na, Dr. Lee Tenghui. Since taking chiatric Care Networks round the the reins of office in 1988, Presi- island, as well as related support Content of the dent Lee has emphasized the need programs for improving mental Mental Health Law for greater respect for human dig- health care. With the joint efforts nity, regardless of the economic, of psyichiatrists, psychologists, physical and mental status of the lawyers, social workers, con- 1. Definition of Mental Illness individual. sumers and families of patients, Mental illness is defined as one His pursuit of equality and op- DOH has organized numerous fo- involving abnormalities of mental portunity for all has helped place rums to help promulgation of the state with respect to thinking, or the calamity of mentally ill per- Law. of an emotional, sensory or cog- sons at the forefront of public pol- These efforts led to the creation nitive nature, which, giving rise icy concerns. In his election cam- of a special task force on Mental to hindrances in the capacity to “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 223 adjust to daily life activities, re- Such hospitalization is to be ef- teaching hospital or psychiatric quire medical treatment and care. fected when, upon initial and con- institution, written consent of the The term includes psychosis and forming diagnoses by two spe- mentally ill person shall first be neurosis, as well as alcohol and cialist physicians respectively, a obtained. (Article 31 & 32) drug addiction. (Article 3) severely ill person is “clearly likely to injure” others or self, or 6. Medical expenditures 2. Mental Health System who has already acted injuriously, and Facilities is deemed to require full-time 1) Governments of each level shall subsidize impoverished mentally ill persons. (Article 33) Establish units with special 2) The expenses of sending a responsibilities in central and severe mentally ill person for municipal (city) health authorities compulsory evaluation and impa- Administrative organizations ¥ tient treatment shall be borne by (Article 9) Appoints specialists in the central government. (Article county (city) and villages 34) Mental Illness (towships, cities or districts) Prevention ¥ Deliberation 7. Rights of Mentally Ill Persons Committee Community mental health centers (Article 11) (Article 10) 1) The personal dignity and legal rights and interests of mental- Mental health counselling ly ill persons shall be respected institutions and protected. (Article 36) Facilities ¥ (Article 12) Psychiatric institutions 2) There shall be no audio (Health Act) recording, filming or photograph- ing of a mentally ill person with- Psychiatric rehabilitation institution out the prior consent of the mentally ill person and his Caretaker or the mentally ill person and his 3.Protection of hospitalization. Compulsory hos- family members. (Article 37) Mentally Ill Persons pitalization for purposes of evalu- 3) Mentally ill persons who are ation may not exceed seven days. hospitalized shall enjoy personal 1) “Severe mentally ill persons Determinations as to the necessi- privacy, the right to freely com- should be diagnosed by a special- ty for continued compusory hos- municate, and to meet visitors. ist physician. (Article 5 [2]) pitalization is to be effected (Article 38) 2) For a severe mentally ill per- through reexamination by two 4) When rights and interests set son, a “Caretaker” shall be as- specialist physicians using the forth in the law of the mentally ill signed. (Article 14 and 15) same criteria, after the first thirty person are violated, he or his 3) A Caretaker shall assist the days and at six-month intervals Caretaker or family members mentally ill person to receive thereafter. (Article 21 & 23) may appeal to the health authori- medical treatment. (Article 18) ties concerned. (Article 39) Otherwise, the Caretaker shall 5. Scope of Psychiatric Care 5) Mentally ill persons who bear, together with the mentally have recovered may receive oc- ill person, the responsibility of 1) Psychiatric institutions shall cupational training and guidance. compensation for the harm. (Arti- provide mentally ill persons with (Article 40) cle 19 [1]) affirmative and appropriate med- 6) In accordance with the law, 4) The institutions or settings ical treatment without unreason- an appropriate reduction or waiv- having the purpose of detention, able delay or detainment. (Article er of taxes may be granted to the correction, or social welfare shall 26) mentally ill person or one who assist ill persons who have been 2) A psychiatric institution provides for him. (Article 41) detained for long periods to re- shall explain the nature of the ill- ceive medical attention. When a ness, the plan of treatment, the mentally ill person has left an in- prognosis, the reason for hospital- Actions for the stitution or setting, the institution ization, as well as the rights of the Mental Health Programs or setting concerned shall imme- patient to the mentally ill person diately inform the local health au- and his Caretaker or family mem- Since the promulgation of the thorities to provide follow-up bers. (Article 27) Mental Health Law, the Depart- protection. (Article 20) 3) Psychiatric institutions may ment of Health has taken the fol- not confine the ill person, impose lowing actions: 4. Compulsory Hospitalization bodily restraint, or restrict a mentally ill person’s freedom of The Law expressly deals only movement. (Article 29) 1. Establishing a mental health with one form of hospital admis- 4) When a special treatment is administration system: sion, compulsory hospitalization. needed to be carried out by a According to the Mental Health 224 DOLENTIUM HOMINUM

Law, DOH at the central level TABLE 2 should establish a direct route of PSYCHIATRIC CARE FACILITIES IN TAIWAN administration from local health Means No. of Beds No. of Patients No. of No. of Patients No. of departments to the central health Means in Day Hospital Provincial and in Community Family authority. Thus, one unit each is Municipal Psychiatric Residence created in the national, provincial Hospitals Rehabilitation Beds and municipal health authorities; with Services Centers and at the country (city) level, 1985 79 11,066 179 5 0 18 there are specifically assigned 1991 112 11,935 559 22 461 71 personnel for the administration 1996 160 14,045 1895 28 945 359 of mental health programs; (Arti- Percent 103% 27% 958% 460% 945% 1900% cle 9) increased

2. Strengthening mental health services and reinforcing 4.Promoting the Rehabilitation 6. Prevention and Treatment manpower: of Psychiatric Patients of Drug Addiction: in the Community: Psychiatric care requires team With the increase in drug abuse work involving physicians, nurs- Beginning 1989, action has al- in recent years, DOH is taking es, clinical psychologists, social so been taken to promote the re- various preventive measures and workers and occupational thera- habilitation of patients in commu- medical care measures for addicts pists. Psychiatric educational pro- nities by sponsoring public and and to prevent drug abuse prob- grams were initiated in 1986 to private hospitals to set up com- lems from becoming worse. To provide continuos and systematic munity rehabilitation centers, enable drug addicts to receive ad- training for all levels of mental shelter workshops and half-way equate medical care, DOH has care workers. Mental health per- houses to assist discharged pa- designated 132 hospitals and clin- sonnel has increased considerably tients in adjusting to the realities ics to provide adequate medical from 1985 to 1996 (Table 1). of social life and to promote care to help drug addicts quit. In addition, DOH has also estab- TABLE 1 lished a drug-cessation system in PROFESSIONAL PSYCHIATRIC MANPOWER IN TAIWAN, R.O.C. the psychiatric care network.

Professional Physicians Nurses Clinical Social Occupational Manpower Psychologists Workers Therapists 7. Reinforcing public education 1985 202 832 48 35 79 of mental health at all levels 1991 454 1292 103 112 111 to ascertain the correct 1996 629 1832 170 187 204 knowledge of mental health and understanding of mental Percent 211% 119% 245% 434% 158% illness increased To summarize, the Mental Health Law reflects our basic 3.Integrating and increasing home care in order to avoid recur- mental health policies, which are: mental care facilities: rence. 1) Emphasizing both psychi- In the Republic of China on atric care and mental health; 2) Promoting positive cure and Taiwan, there are roughly 14,000 5. Assisting local governments psychiatric care beds. The goal rehabilitation, reducing negative to establish community confinement and segregation; for the next five years is to in- mental health centers. crease the number of beds to 3) Combining psychiatry with 20,000. Several concrete mea- Health authorities in national c- social welfare; and sures are being implemented, ities and in counties may establish 4) Emphasizing both patients’ namely: community mental health centers rights and social security. 1) Add a total of 1,000 beds to responsible for activities related Based upon those basic poli- public general hospitals. to the promotion of public mental cies, DOH has taken some posi- 2) Encourage private organiza- health. Kaohsiung City - a special tive steps in the work of preven- tions to invest in psychiatric care municipality under the central tion and treatment of mental ill- units that will add 4,000 more government, together with Taipei ness. In the future, our mental beds. Country, Taichung County and health work should be based on 3) Build a new psychiatric cen- Chiayi County of the Taiwan the Mental Health Law and the ter in the southern area that will province, each has been assisted conception of community psychi- accommodate 500 beds. to set up a community mental atry to reduce confinement and 4) Use the 1,500 beds that are health centre to provide mental segregation of patients, to provide currently not in use in some psy- health services to the people and more efficient and accessible chiatric care institutions (Table to promote mental health educa- mental health services and to im- 2). tion in the community. prove the state of mental health. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 225

Conclusion cy to Taiwan, Pescadores, Que- Those tenets, which still carry moy, Matsu and other islets under much weight in the modern Chi- The emphasis placed on pre- the sovereign control of the Re- nese society in the Republic of serving human dignity for all citi- public of China. China on Taiwan, coupled with zens by President Lee Teng-hui, a President Lee’s course and President Lee’s respect for human devoted Christian, will figure ideals mirror closely the tenets of dignity for all, signal the impor- prominently in the mental health human equality and world unity e- tance attached to issues of mental policies pursued by DOH. Dignity spoused by Confucius (551 - 479 health. for al regardless of one’s econom- B.C.). That sage left no human be- ic, physical or mental status is one ing unaccounted for when outlin- His Excellency RAYMOND of the cornerstones of President ing his famous relationships be- R.M. TAI Lee’s drive to bring full democra- tween people and among nations. Chinese Ambassador to the Holy See 226 DOLENTIUM HOMINUM

FRANCISCO EDUARDO TRUSSO

Legislation and Mental Health in Argentina

In Argentinean law, and I be- such people can perform this role. ers a “state of violent emotion” as a lieve this is the case in most coun- Who are the people that the law mitigating circumstance in decid- tries, a specific set of legislation re- defines as being “incapable being what the punishment for a lating to mental illness does not ex- cause of a state of dementia”? The criminal act should be. This state ist. The legislature has dealt with answer is straightforward: “Those of violence is placed on a par with mental illness through the instru- people who because of mental ill- alterations in mental faculties. For ments of the civil code where that ness are not able to govern them- this reason this subject requires code addresses itself to the legal selves or to manage their own special consideration and analysis capacity and responsibility of indi- property” (art. 141 C.C.A). In such in this paper. viduals and the legal validity or a context the law has to step in and The Italian penal code does not otherwise of their actions. In the take suitable measures. see this condition as a mitigating penal code, on the other hand, the Such people are not allowed to circumstance. Article 90 of that mentally ill are covered by the leg- operate in a legal sense on their code declares that “states of emo- islation relating to impunity or mit- own and wherever it is feared that tion or passion neither exclude nor igating and attenuating circum- they could cause injury to them- reduce imputability.” stances. selves or to other people they are At the same time in increasing or Mental infirmity is dealt with in deprived of their liberty and admit- reducing the punishment attention this way by the Argentinean civil ted to a special institution for the must be paid to the various circum- code to protect those who suffer mentally ill. stances which led the individual to from it, the society in which they Chronic alcoholics and drug-ad- commit his criminal act. Thus “the live, and the third parties with dicts are included within this cate- poverty or the difficulties of ob- whom they come into contact. gory of people who are to be taining a living for himself or his The civil code lays down that the placed within special institutions. family” acts as an attenuating fac- legal responsibility of an individ- The penal code declares that no tor, and in cases of “violence or ual is a pre-requisite for the acts of prosecution can be made in rela- rape” or “the abandonment of peo- that person to be considered real tion to those people who at the mo- ple” where the victim of the crimi- and valid. ment of the crime suffered: nal act “lacks his or her rational This responsibility is always as- 1) “from an inadequacy of their faculties” the punishment must be sumed to be present because inca- faculties”; 2) “from illness-in- increased. pacity must be expressly declared duced alterations in such facul- (art. 52 of the Argentinean civil ties”; and 3) “from mental alien- code). The “demented” are the ation.” In the case of the third con- Marriage Law most conspicuous members of the dition the judge can order the indi- category of those who are defined vidual to be placed within a lunatic The Argentinean civil code lays as being not legally responsible. asylum. In the other two circum- down that the “permanent or tran- The Argentinean civil code follows stances he can order the person to sitory loss of reason, irrespective other precedents and stresses with be admitted to a “suitable institu- of the causes,” is an impediment to very great emphasis that it “pro- tion.” contracting marriage and, when p- tects the incapable” and seeks to The aim of these clauses is to resent at the moment of marriage, “remove the impediments to their protect those who suffer from de- leads to the annulment of the valid- responsibility.” It therefore gives mentia or from alterations in their ity of that marriage. them special “representatives” faculties, and to protect third par- The Code of Canon Law, which who act on their behalf and whose ties to whom they are linked in a operates on a broader front than its task it is to protect them and their juridical sense. At the same time, civil counterpart in this area of interests. These representatives can naturally enough, the intention of contracting marriage, lays down in either be private individuals (in this these provisions is to protect soci- canon 1095: “The following are in- case they are called guardians) or ety as whole. capable of contracting marriage: 1) the public ministry responsible for Argentinean legislation consid- those who have an inadequate lev- “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 227 el of reason; 2) those who are seri- cognitive ability of the individual that power of judgement which is a ously lacking in their capacity to or his powers of intellectual per- prerequisite for marriage. This is judge in relation to the essential ception as to the level of personal seen as the only proof of the valid- rights and duties of marriage, in- maturity he has reached. Such ma- ity of consent to marriage in the volving, as they do, mutual giving turity enables the individual to un- case of every individual, including and receiving; and 3) those who derstand and perceive the essential those suffering from mental illness. cannot assume the essential obliga- rights and duties of marriage. The Debate among legal experts as to tions of marriage because of psy- expression “serious lack” is con- the specific and precise limits to chic factors.” nected to the notion of “powers of this power of judgment has led to a The marriage partner who at the judgment,” which is a legal con- reliable conclusion: “Reference to moment of marriage is not of cept. As a result, it is not the seri- similar criteria which are applied sound mind or does not possess the ousness of the psychic anomaly, to penal responsibility in the con- powers of judgement which enable but the seriousness of the lack of text of those of the same age en- him or her to perceive, understand powers of judgment which gives gaged in marriage” (cf Sent. C. Fe- or accept the essential rights and rise to the inability to consent and lici, 3.12.1957). duties of the mutual giving and re- to the invalidity of the act. What is At the present time the concept ceiving of marriage, or is impeded decisive is not so much the illness of powers of judgment is very dis- from assuming the essential oblig- or the mental disorder which has tinct from the concept of the use of ations of marriage, does not have created the serious lack but the fact reason and involves a speculative- the capacity which is necessary to that this lack is really produced and practical—and at the same time engage in that special act of will that it deprives the individual of his very profound—concept of mar- which is pivotal to the consent to powers of judgment. The serious- riage. The concept of “powers of marriage. ness of the defect is seen in the judgment” adds another faculty to light of an objective criterion that of the (abstract) faculty of cog- which the same code of canon law nition—the faculty of criticism— Lack of a Sufficient itself supplies—that is, “the essen- that is, the ability to perceive, think Use of Reason tial rights and duties of marriage about, assess, and weigh the impli- which must be mutually assumed cations of the marriage to which Lack of a sufficient use of reason and accepted.” one gives one’s consent, the oblig- is deemed to exist in those people This is a factor which is distinct ations which that marriage in- who suffer from a mental illness and separate from the question of volves, and the personal motives and at the moment of consent are the insufficient use of reason. From behind the choice of such a life deprived of the use of their own the first decades of this century condition. Modern psychology faculties of understanding and vo- canon law, when approaching the holds that this critical way of per- lition—elements which are consid- subject of mental illness, has as- ceiving matters, or this critical fac- ered essential to the validity of a serted that the only incapacitating ulty, appears later than the faculty human act. This definition also ap- criterion is that of a reduced level of cognition and is by no means the plies to those people who, at the in the use of reason. In cases of same thing. This last faculty is held moment of expressing their con- marriage between people under the to emerge at the age of about sev- sent to marriage, suffer from a age of puberty, St Thomas (IV en, whereas the faculty of criticism mental disturbance (such as states Sent. d. 34q. 1 to 4; d.27 q.2 to 2 appears at about the age of twelve. of disorder, drug-addiction, alco- and Suppl.q.43 ad.2; q.58 a.5 ad.1) The need to recognize the pres- holism, drunkenness, sleep-walk- and Sánchez (De Sancto Matri- ence of both forms of faculty—that ing, hypnosis, etc.) which— monii Sacramento, I disp. 8 n.5; is, the one involving speculation, whether or not they constitute an disp.16 n.16; VII disp. 104 nos. which is abstract in character, and actual mental illness from a med- 5,21,22, and 27), like all the fol- the one involving the power to as- ical point of view—cause a lack of lowing authorities and the system sess, which implies an ability to self-government and of the use of of jurisprudence itself, always re- weigh matters up and apply the their faculties of understanding and quired (in addition to the use of conclusions of such reflection at a volition. In law, such a state is reason and the suitability of the practical level—appears in the de- placed on the same level as the lack marriage partners) a sufficient lev- liberations of the Sacred Rota for of a sufficient use of reason and el of powers of judgment to allow the first time in the Wynen sen- means that the acts which are car- “the assumption of obligations or tence of 25.2.1941. ried out while this state is operative the understanding of the nature of In order to render a person inca- and present cannot be considered consent to marriage.” pable of consent and thus to define as being full and responsible hu- The jurisprudence practiced by a person as having a “serious lack man acts. the Sacra Rota (Sent C.Sabbatani of powers of judgment,” both ju- 24/2/1961) involves reducing the risprudence and the law do not re- importance of the very static crite- fer to a total lack or an absolute A Serious Lack ria of the use of reason and the de- lack of such powers. Equally, they of Powers of Judgment liberative capacity, which have to do not refer to any kind or nature of be present for a mortal sin to be lack. Instead, for such a lack a very The expression “powers of judg- committed, in favor of a more dy- serious cause is required. In the ment” does not so much refer to the namic criterion—the presence of case of forms of mental illness 228 DOLENTIUM HOMINUM which are evident and manifest volving symptoms which affect be- himself so much to understanding such causes are those belonging to havior, even though they cannot be the illness as to determining the the following list: placed within the category of men- level of incapacity and of maturity. a) Psychosis. A mental disorder tal illness. When they influence the In doing this he must investigate where the decline of the mental personality or character, they are and explore all aspects of the indi- functions has reached such a level termed “characterpathic,” and vidual’s personality (cf. L. Vela, as to interfere in marked fashion when they affect behavior, they are Marriage Law, class notes with the individual’s processes of called “sociopathic.” 1985/1986, P U Comillas). introspection and the ability to de- Here we encounter three princi- From a detailed and extensive cide or to deal with certain ordi- pal groups with their own internal- jurisprudence of the Sacred Rota nary questions of his life or to ly mixed sub-groups: on psychological immaturity we maintain suitable forms of contact —Sexual pathologies: homosex- may cite as illustrative examples: with reality. uality, erotomania, perversions, C. Mattioli 6.11.1956: SSRD 48, p. b) Neurosis or neurotic forms of and immaturity; 873; C. Ferraro 6.2.1973: SSRD 65 disturbance. Although the patient —Emotional pathologies: the p. 56; C. De Jorio 11.3.1973: SS- may have marked capacities for in- schizoid personality, the cycloid RD 65 p. 656, and in more moder- trospection and an assessment or personality, the paranoid personali- ate terms: “matrimonii nullitas appraisal of reality which has not ty, and emotional instability. tuno tantun declarari potest, si in- undergone alteration, and despite —Asocial-amoral pathologies: victe probetur immaturitatem psy- the fact that he is not confused in anti-social personalities, vaga- chologicam alterutius vel utrius his perception of his individual bonds, morally deficient individu- que contrahensteis causam fuisse personal experiences and does not als, misanthropes, and mythomani- gravis defectus descretionis judicii mix his fantasies with external re- acs. corca jura et officia matrimonialis ality, his behavior nonetheless is In terms of symptoms all these essentialia, quia non quaelibet psy- influenced by his neurosis or neu- forms of disturbance are character- chica inmaturitas matrimonii nulli- rotic condition in extreme fashion. ized by interference with the emo- tatem gignit, sed la tantummodo in However, this disturbance remains tional and volitional cohesion and qua difectus descretionis judicci within socially acceptable limits balance of the individual. They verificetur” (C. Pinto 14/12/1984, and his personality is not directly give rise to unsuitable behavior no.3). affected. This condition finds ex- and to maladjusted behavior which pression in excessive anxiety, differ markedly in character, how- symptoms of hysteria, phobias, ever, from the symptoms of psy- The Impossibility of Assuming and frequent obsessive-coercive or chosis or of neurosis. They are per- the Essential Obligations of depressive symptoms. manent and appear during youth or Marriage for a Psychic Reason c) Borderline state or limit state. even during adolescence or child- This condition exists between neu- hood. Here one is dealing with a The psychic cause lays down rosis and psychosis and involves failure of integration of the emo- that individuals cannot assume they disturbance of the patient’s emotional life, anachronistic forms of lack the self-government or self- tional life, pan-anxiety and pan- behavior which are regressive—all dominion which are necessary to neurosis, and easily provoked reac- of which are elements connected to them to take on and discharge the tions of anger and aggression infantile ways and methods of liv- essential obligations of marriage. which are often caused by stress, ing and experiencing the world. As one authority has well ex- the use of drugs, and acute psy- The judge must not dedicate pressed it, “it is supposed here that chotic episodes of a paranoid char- the individual has a sufficient use acter. We may also note as belong- of his reason and a sufficient pow- ing to this condition such phenom- er of judgment. But, beyond these ena as hypochondria and ideas factors, it can happen that an indi- connected with the experience of vidual who embraces marriage depersonalization. through a consent which is ex- In his commentary on canon pressed conscientiously, by his 1095, Luis Vela, S.J. includes per- own free will, and with maturity, sonality disorders which manifest may have problems in relation to themselves in the stage of the e- the question of his obligations.” mergence of the abstract faculty. The incapacity to which the They are to be approached and an- canon refers must come not from a alyzed with reference to the practi- somatic or purely psychological cal responsibility of the individual cause, but from a cause of a psychic as regards the fulfillment of the nature (psychosis, neurosis, a char- purpose of consent and are not to acterpathic condition, and so forth). be placed solely within the framework of mental illnesses. His Excellency FRANCISCO One is dealing here with a cate- EDUARDO TRUSSO gory of abnormalities of the per- Ambassador of the Republic of Argentina sonality and of the character in- to the Holy See “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 229

MICHEL MBOUSSOU

Mental Health Law in the Gabon

French legislation relating to tal treatment tends to be that most teen days, which both declare that mental illness was based for a widely practiced and as result the the above-mentioned conditions long time upon a law more than a law of January 1968 provided for are present. hundred years old—that of 30 the protection of the goods and 2. Before admitting the patient June 1838. After the general ap- property of the mentally ill person the director of the institution must proval provoked by its enactment, which are left outside the institu- verify that the documents are in this legislation—which was imi- tion. order, check the identity of the tated in many countries—came to person who requests the admis- receive intense criticism, espe- A.The Hospital Structures sion and of the patient, and must cially as regards the whole ques- and Procedures Governed then send these documents as tion of arbitrary arrest and the lack by the Law of 27 June 1990 soon as possible to the local pre- or ineffectiveness of guarantees fect and the departmental com- by which to protect individual In order to hospitalize a patient mission for psychiatric hospital- freedom. After 1860, and for without his consent three condi- ization. these reasons, the reform of this tions must prevail (art. L333): 3. In cases where the health of law was constantly on the public —the mental disorder of the pa- the patient is in danger, an excep- agenda. tient makes his consent impossi- tional procedure can allow the In this paper I will dwell in ble to obtain; sick person to be admitted when overall and brief terms upon the —the state of the patient re- there is only one certificate. general legislation concerning the quires immediate care and treat- 4. A psychiatrist of the institu- mentally ill in so much as it con- ment; tion to which the patient is admit- cerns imposed confinement and —one of the following proce- ted (but not the person who has civil and penal responsibilities. dures is adopted after a constant drawn up the second certificate) As a citizen of a developing monitoring of the patient in a hos- must draw up a new certificate country I would like to draw at- pital environment and in line with within twenty-four hours which tention to the limits to a real and his requirements: admits the necessity or otherwise proper legislation on mental ill- of admission to the hospital as re- ness caused by the fact that psy- A.1. Hospitalization quested by a third party. chiatry is not possible without in- on the Request of a 5. After a period of time which stitutions—in general, in black Third Person (HDT) goes from twelve to fifteen days a French-speaking Africa, the insti- This procedure has taken the psychiatrist of the institution tutions are themselves sick. place of the old voluntary admis- which has admitted the patient (in sion (PV). principle the same person as that 1. For this admission into hos- stipulated in paragraph 4) must 1. The Confinement pital to take place the following draw up a new certificate (the so- of the Mentally Ill documents are required: called “fifteen-day certificate”) a) A handwritten request for ad- which lays down that the condi- The placing of people in psy- mission drawn up by: tions still exist for the hospitaliza- chiatric hospitals can take place in —a member of the patient’s tion of the patient and makes clear two ways: family; as to whether there is a need to —in line with the provisions of —a person acting in the interest prolong the so-called HDT. the law of 27 June 1990 where of the patient. This person can be In such a situation the hospital- such confinement takes place the patient’s doctor, as long, that ization of the patient can be con- without the consent of the patient. is, as he does not practice within tinued for periods of a month —without reference to this the institution to which the patient which are renewed every month law—a process which involves is to be admitted. in the same way. the patient going to hospital of his b) Two medical certificates, 6. The hospitalization of the pa- own free will. This kind of hospi- drawn up within the previous fif- tient finishes: 230 DOLENTIUM HOMINUM

a) if the certificates are not B.2. Psychiatric Hospitalization sures—the safeguarding of justice, drawn up and signed; in General Hospitals the tutorship of the patient, and his b) when the HDT conditions no At the present time most of the guardianship—each involve differ- longer prevail, that is to say: general hospitals—both CHU and ent kinds of possible application. —if a psychiatrist who works in CHR—offer specialized service in the institution produces a certifi- psychiatry where patients are sent A. The Safeguarding of Justice cate which states that this is the from other wards and sections of case; the hospital when they display The safeguarding of justice is —if a prefect gives an order to symptoms of psychological or the simplest and least intrusive of this effect; mental disturbance. But these hos- these measures. In principle it as- —on the request of the medical pitals also receive patients from sumes that the civil capacity of the doctor who treats the patient, or of outside for a period of hospitaliza- patient remains. It allows the an- a member of the patient’s family, tion which usually lasts for short nulment or modification of acts or by grandparents and parents or by or medium terms. undertakings only when these children and grandchildren, or by have been carried out in an ill- the departmental commission. B.3. Private Psychiatric Clinics judged fashion during the period These private institutions are of- of protection. This measure is put A.2 Official Hospitalization (HO) ficially recognized by the Ministry into practice on the recommenda- When the mental disorder of the of Health as being psychiatric clin- tion of the judge or when a med- patient threatens public order or ics and at the level of treatment ical declaration is presented to an the security of other people, the their worth is commensurate with attorney of the Republic (here one prefect can order an official hospi- that of the skill and expertise of the is dealing with the declaration of a talization which at one time was medical staff. These specialized general medical practitioner ac- called official admission (PO). He clinics are numerous and usually companied by a similar judgement does this when he has a medical crowded. The waiting time for ad- by a specialist or the declaration of certificate available and acts mission lasts from a day or two to a specialist on its own). through a precise and justified or- a week or two. The system of safeguarding is der. In the case of imminent dan- provisional. It lasts for two months gers he can also use special emer- after the entry in the register of the gency procedures. 2. Civil Responsibility state attorney’s office and can be The director of the psychiatric renewed on the application of the institution has the same obliga- Civil responsibility is defined as medical doctor for a period of six tions and duties as those laid being the “legal role of an individ- months. down in the case of HDT. The ual in the enjoyment and exercise medical certificates must be of his rights.” B. The Tutorship of the Patient drawn up in line with the same Here measures are employed conditions as those involved in which involve the protection of the Such tutorship is the system of HDT (twenty-four hours, fifteen property and goods of the individ- protection which is the most im- days, a month). ual where his mental faculties are portant. In principle the individual damaged by illness, infirmity, or concerned is freed from his legal B.Hospital Structures and by old-age, or when a simple “al- capacity and is represented over a Procedures not Governed teration of the physical faculties” constant period of time by a “legal by the Law of June 27, 1990 prevent the expression of his will. representative” in the various acts This new system has separated of his civil life. In this instance the mentally ill the actions of hospitalization from The tutorship judge is informed people are treated on their own re- civil protection. In this way an of- by a request accompanied by a cer- quest or by the family but always ficially hospitalized patient can tificate signed by a specialist. The with their agreement and co-oper- manage his own property and request can be made by the pa- ation. Here one is dealing with goods. In the same way patients in tient’s doctor who is asked only to open services. a free service, or even when they give his opinion on the question are not hospitalized, can enjoy a without having to provide a diag- B.1. The free services offered measure of such protection. Fur- nosis. The certificate must be by psychiatric hospitals thermore, the law of 1968 softened drawn up by a specialist chosen On the whole these are small-s- and simplified the procedures in- from a list drawn up by the state at- cale facilities which have twenty volved and sought to confer torney. One is dealing here with to forty beds. They are located in greater responsibilities upon the cases where there is an alteration the surroundings of a psychiatric individual’s medical doctor. In- in the mental or physical faculties hospital, but do not have the ad- deed, the judge responsible for the of the patient and not of a psychi- ministrative regime of forced con- case is required to ask for a med- atric diagnosis or assessment. The finement. They usually receive ical opinion on the patient. judge decides on such an assess- seriously ill people who cooperate Finally, the diversification of the ment only when there are doubts in their treatment and do not reforms of protection is one of the about what kind of alteration in the quire close supervision. principle intentions of this new patient’s mental faculties are in- law. Three different kinds of mea- volved. “IN THE IMAGE AND LIKENESS OF GOD: ALWAYS?” DISTURBANCES OF THE HUMAN MIND 231

The tutorship depends upon a C. Guardianship individual is in a state of madness. judgement. An adult who is under The French penal code de- such defense is represented by the This system of protection, clares: “A crime or illegal action following. which is less complete and intense does not take place when the ac- —A tutor. This is the usual form than tutorship, is applied to those cused was in a state of dementia at that such tutorship takes. The people who need to be advised or the moment of the action.” The mentally ill person who is not de- controlled in the acts of their civil idea of dementia is interpreted in fended cannot make a will. He los- lives. But such guardianship does the widest sense possible and in- es his right to vote and cannot be not involve the possibility of im- cludes mental illness belonging to elected. When he is married his posing certain acts. The procedure every nosological category with- wife becomes the tutor except in here is similar to that to be found out any etiological or clinical dis- cases where the judge believes that in the regime of tutorship. The ca- tinction. The shared feature of all this choice is not in the interests of pacity is decided upon and deter- these forms of mental illness, the sick person. The judge also ap- mined by the judge after he has however, is that they damage the points a substitute tutor and a fam- consulted the medical doctor in responsibility of the individual ily council. If the patient is unmar- charge of the case. In this way cer- concerned. This damage must be ried the family council appoints tain acts can be performed without total and must have existed at the the tutor. The patient’s doctor can the guardian. Others, however, exact time of the action. This of participate in a consultative capac- need his presence (on the whole course excludes mental illnesses ity in this council but he cannot be- those acts which require the au- prior to the illegal act and those come the patient’s tutor or the sub- thorization of the family council which emerge after it. Also ex- stitute-tutor; in the system of tutorship). The cluded are partial alterations in re- —A legal administrator. Ap- right to make a will and testament, sponsibility caused by the inter- pointed by the judge, the adminis- however, is maintained. The pres- ference of mental illness or by a trator (a near relative or relative- ence of the guardian is required in personality disorder subsequently in-law) acts as a tutor under judi- the case of marriage. In situations revealed by a crime or an illegal cial control (in this case there is of divorce the presence and role of act. neither a substitute tutor nor a fam- the guardian is usual. The identification and ascer- ily council); tainment of this state of dementia —A defense guardian. This lies exclusively in the hands of the takes place only in the case of 3. Penal Capacity investigating judge, who must en- adults without a family or who are gage in a highly private decision. very poor. The defense guardian’s Like normal individuals, the In this procedure he makes special powers are relatively limited and mentally ill commit criminal or il- use of an examination of the ac- he may be appointed from within legal acts. For this reason they cused by a specialist, in this case a the psychiatric institution or may come up against judicial systems psychiatrist. But the opinion and be a special administrator. which try them for their actions at judgment of this figure is by no These different approaches en- a penal level. In such situations means decisive as regards the able the patient’s incapacity to be there is the question of the penal judge’s decreeing whether or not dealt with and managed. At any sanctions that they might en- the illegal or criminal act was car- moment the judge, after consulting counter and the matter of their re- ried out during a state of demen- the doctor in charge of the case, sponsibility for such actions. Ca- tia. can give—or restore—to the pa- pacity is understood as the ability tient a partial responsibility, listing an individual has to exercise penal A. The Role of the Expert as he does so the various acts responsibility when a wrongful which the patient can carry out on act has been committed. Penal The judicial authorities who his own or with his tutor. sanction implies two preliminary consult a psychiatrist in order to The acts carried out under this requirements: the ability to exer- ascertain the presence of a state of defense regime are rendered “null cise responsibility and the im- dementia set out what his tasks and void” at the request of the tu- putability involved in a crime are. The questions he is asked are tor, the patient himself, or his which has been really committed the following. heirs. Marriage is authorized only and then proved to have been —Does the psychiatric exami- with the consent of the family committed. nation of the individual reveal council except where the parents In French penal law the percep- mental or psychic anomalies? give their consent (in such a case tion of a criminal fact implies a —Is the transgression of which the opinion of the doctor in charge moral element which in turn in- is accused linked in some way to of the case is also taken into con- volves notions of guilt, being such anomalies? sideration). guilty, responsibility, and the ap- —Is the individual in a danger- This defense finishes when the plication of a penal sanction. In ous state? causes which have brought it order for a person to be accused —Can penal sanctions be ap- about also finish. The procedures and tried for an action he has com- plied to the individual? for ending it are the same as those mitted, his actual responsibility —Can the individual be treated for bringing it into being. has to be demonstrated, and of or rehabilitated? course this is not the case when an 232 DOLENTIUM HOMINUM

B. Conclusions Despite certain adaptations and one place than in seeking to cure changes, the governing principles them. Law no. 75-1093 of Octo- If at the end of the psychiatric remain the same. The application ber 23, 1975, which created a spe- examination it is ascertained that of the legislation in relation to cialized closed institution at at the moment of the action a com- mental illness involves two very Thiaroye after a specific judicial plete state of dementia which de- great problems: the experience of decision, reinforced this role of prived the individual of evaluating the mentally ill person and the being a place of confinement or the meaning and consequences of psychiatric institution. prison, a place where the mentally his actions was present, then no ill or the homeless were dumped. case for imputability in relation to A. The Experience of After more than thirty years of in- the act exists, on the grounds of Mental Illness dependence the situation is Africa the presence of dementia. has become worse: various health If the case is only at the prelim- Black people have never sought care systems have collapsed and inary stage of investigation, the to deny illness, but have known psychiatric hospitals are reverting investigating judge can immedi- how to employ the best and most to what they were at the outset— ately issue an order of “no trial” subtle instruments and means by places of confinement. which thereby puts an end to the which to defeat it; they have never judicial process. accepted it as a natural phenome- If the case is at the trial stage, non. It is nearly always seen as a 5. Conclusion the individual is absolved if he is supernatural force which disturbs being tried by a county court. He the peace and serenity of the liv- Real psychiatry cannot exist is ordered to be released from ing. without institutions. Legislation prison if a correctional court is in- When faced with mental illness, relating to the mentally ill cannot volved. the community (and this is espe- be applied without competent and If at the end of the psychiatric cially true of the rural areas) ap- skilled psychiatric institutions examination it is observed that the plies the traditional methods of whose fundamental role is to treat elements do not exist for the dec- healing (sacrifices, rites, initia- and to cure those who suffer from laration of a state of dementia, tions, and so forth). The increas- mental illness. then: ing ineffectiveness of traditional Although it is certainly true that —the individual is deemed free forms of treatment in “reconcil- such legislation in the industrial- from any form of mental illness ing” the patient with society is ized countries has been supported and the judicial process is allowed now commonly observed, and this by suitable facilities and institu- to carry on its path; is especially the case in the urban tions, in developing countries— —or the individual is deemed to environment. There are many rea- and especially in Africa—legisla- have mental anomalies, an intel- sons for this failure, but they are tion dealing with mental illness is lectual handicap, or a mental ill- probably linked to a progressive still not implemented in the right ness with no bearing, however, on lack of commitment to traditional way. the acts of which he is accused, or methods of social control. The authorities in African coun- are of such a character as not to re- Even today, more than a half of tries must look again at the con- move the responsibility of the in- those suffering from mental ill- cept of psychiatric institutions and dividual in relation to the act ness are first subjected to tradi- bring them into being with refer- which has been committed. The tional forms of treatment. ence to our realities so that a truly same occurs if the illness is human application of legislation deemed to have been merely a B. Psychiatric Institutions relating to mental suffering can be concomitant factor, a facilitating achieved. factor, or a modifying factor in re- All over French-speaking lation to the transgression without Africa on the eve of independence Dr. MICHEL MBOUSSOU having been of determining im- institutions were created which Embassy of the Gabon portance in the illegal or criminal were largely run by general doc- to the Republic of Italy act. The investigating judge in- tors and only rarely by psychia- quires into the case, and the indi- trists. These institutions were con- vidual is then placed within cus- ceived along lines of the model of tody. confinement and involved exclusion or entrance rather than treatment. The example of the psychi- 4. Legislation in Relation atric hospital of Thiaroye (in Bibliography to Mental Illness Senegal), which was created in J. D. GUELFI ET AL., Psychiatrie (PUF, and African Realities 1960, brings out the delicate mis- 1987). sion of the psychiatric institutions H. N. BARTHE and OSTAPTZEFF, “Législa- The countries of French-speak- in Africa. Reserved for the chron- tion Psychiatrique Française,” in Encycl. Méd. Chir., Paris—Psychiatrie, 37901.A10, ing Africa, which are former ically ill, the dangerous, and the 10—1981. colonies of France, have for the marginalized, Thiaroye was much M.MBOUSSOU, “L’Institution Psychia- most part adopted the penal code more interested in their confine- trique en Afrique Noire Francophone,” in L’Information Psychiatrique, no. 5, 1991, pp. of the colonizing country. ment and their concentration in 441-448.