The Church and Psychiatry

When I began to think about psychiatry as a medical specialty in 1963, I was vaguely aware of a tension between the church and psychiatry. Bishop Fulton J. Sheen suggested on his weekly television show that Catholics would not need a psychiatrist if they made a good confession. G. K. Chesterton had put it somewhat differently: Psychoanalysis is confession without absolution. This type of innuendo from prominent Catholics slowed down the acceptance of psychiatry as a valuable part of Catholic health care.

The history of the church and psychiatry or, in broader terms, the church and mental illness is a sub-chapter of the history of the church and science. Dava Sobel’s excellent book Galileo’s Daughter recounts the events leading to Galileo’s trial before the Holy Office in 1633. Galileo’s theory contradicted the literal interpretation of the Book of Ecclesiastes, in which The sun rises and the sun goes down; then it presses on to the place where it rises (Eccl. 1.5). A historical perspective is required to understand the evolving relationship between the Catholic Church and science. In 1992 a papal commission finally acknowledged the errors in the Galileo affair. At the time John Paul II remarked, A tragic mutual incomprehension has been interpreted as the reflection of a fundamental opposition between science and faith. There is a parallel between the church’s struggle with Copernican theory and its acceptance of psychiatry.

The Judeo-Christian tradition has had difficulty determining the boundary of religion and mental illness. As Michel Foucault wrote in Mental Illness and Psychology, It was at a relatively recent date that the West accorded madness the status of mental illness. Primitive cultures attributed mental illness to possession by demons. The role of priest and physician was combined in the witch doctor, shaman or faith healer. Babylonian priest-doctors expelled a demon named Idta from the mad patient by magic. In ancient Greece priests of the cult of Asclepius practiced at the temple of Delphi. Hippocrates was an enlightened exception when he taught that epilepsy, the sacred disease, was no more divine or sacred than any other disease.

This ancient thinking is reflected forward in the Old Testament. In Deuteronomy Moses speaks to the children of Israel in the wilderness and warns that if they do not keep all the commandments, The Lord will strike you with madness, blindness and panic (Dt. 28:28). Saul, as punishment for his disobedience to God, goes into a deep depression, stops eating and eventually commits suicide by falling on his sword (1 Sam. 31).

Belief in demonic possession of the mentally ill continues in the New Testament. Jesus cures the possessed along with lepers, the blind, the deaf and the lame. In Matthew, a man comes to Jesus beseeching him: Lord, have pity on my son, for he is a lunatic. And Jesus rebuked him, and the demon came out of him, and from that hour the boy was cured (Mt. 17:14-17). Casting out demons is almost always coupled with other miracles of healing. In Mark, the Twelve are sent out two by two: So they went off and preached repentance. They drove out many demons, and they anointed with oil many who were sick and cured them (Mk. 6:12-13). Even Luke, a physician, equates casting out devils with cure: And even those who were tormented by unclean spirits were cured (Lk 6:18). The juxtaposition of cure of physical and mental illnesses is again found in the Acts of the Apostles. The sick were brought into the streets so that when Peter came by, at least his shadow might fall on one or another of them. A large number of people from the towns in the vicinity of Jerusalem also gathered, bringing the sick and those disturbed by unclean spirits, and they were all cured (Acts 5:15-16).

Although there are few descriptions of specific symptoms, the demonically possessed appear to be a mixture of epileptics and the mentally ill. This is not surprising, considering that the classification of mental illnesses began to mature only in the late 19th century. We should not expect modern diagnostic nomenclature at the time of Christ.

This literal interpretation of Scripture continued to influence the church’s attitude toward mental illness through the Middle Ages. In The City of God Augustine clearly places the mind in the realm of the spiritual. Aquinas considered the soul the principle of intellectual operation. In the Summa Theologica he writes, Therefore the intellectual principle, which we call the mind or intellect, has essentially an operation in which the body does not share. If the soul is the locus of intellectual functions, it follows that madness is not the province of medicine but of the church. On the contrary, if madness has a physical cause, it belongs to the doctors. This brings us to the classical mind-body question. When the priest was also the physician, this was a theoretical question. As psychiatry became more scientific, the question became more relevant.

The church did not abandon the mentally ill. The Rule of St. Benedict prescribed that the care of the sick is to be placed above and before every duty. In the Middle Ages the mentally ill were cared for in monasteries along with the physically ill. During the Renaissance there were some advances in medicine but few if any in psychiatry. Psychological theories were based primarily on Aristotle and Plato.

The low point came during the Inquisition. In 1487 two German Dominicans, James Sprenger and Heinrich Kraemer, published Malleus Maleficarum (The Witches Hammer), a handbook for witch-hunting with meticulous and lurid instructions on how to identify, torture and burn a witch. Many of the victims were undoubtedly mentally ill. Malleus is an eye-opener upon the depths to which pious intentions dragged the church. In the 17th century the tide of the scientific revolution lifted many boats, but not psychiatry. Indeed, René Descartes cemented the mind-body split. In his Discourse on Method, he wrote that the soul was attached to the body as a pilot in a ship, specifically moored to the pineal body. The legacy of the Cartesian dichotomy is still very much with us. Psychiatrists are often asked the either-or question: is mental illness psychological or biological?

The 18th century saw what Foucault refers to as The Great Confinement. A royal decree in 1756 established the Hôpital Général in Paris. Thousands of poor, petty criminals and mentally ill were incarcerated under barbarous conditions. The decree included the following provisions: The directors having for these purposes stakes, irons, prison, and dungeons in the said Hôpital Général and the places thereto appertaining so much as they deem necessary. The administrative board of the hospital included the chief of police and the archbishop of Paris. There were similar institutions all over Europe, including the infamous Hospital of Saint Mary of Bethlehem in London (the source of the term bedlam).

The inhumane treatment of the mentally ill continued until the Enlightenment, with the beginning of what has been called the moral treatment of the insane. Philippe Pinel unchained the inmates in the Bicêtre in Paris in 1794. William Tuke, a Quaker, founded the York Retreat in England in 1813, and Benjamin Rush, a signer of the Declaration of Independence and founder of the American Psychiatric Association, reformed practices in Philadelphia. Moral treatment is associated more with the Quakers than with the Catholic Church.

The church’s relationship with psychiatry was further complicated in modern times. In The Future of an Illusion Sigmund Freud relegates religious beliefs to neurotic relics and concludes we may now argue that the time has probably come, as it does in analytic treatment, for replacing the effects of repression by the results of the rational operation of the intellect.

Two occurrences in the 20th century required the church to reevaluate its position on mental illness and psychiatry: World War II and scientific advances in the neurosciences. During the war thousands of soldiers developed psychiatric conditions under the stress of combat. These couldn’t be ascribed to transgressions or moral weakness. Symptoms were usually resolved when the soldier was sent back from the front lines. The introduction in the 1950’s and 60’s of drugs effective for treating mental disorders further diminished any reason to consider mental illness a moral weakness. Moral problems should not be susceptible to chemical treatment.

Pius XII took an initial step in 1953 to recognize modern psychology and psychoanalysis, albeit with caveats. In an address to the Fifth International Congress on Psychotherapy and Clinical Psychology, he noted that science affirms that recent observations have brought to light hidden layers of the psychic structure of man, and tries to understand the meaning of these discoveries, and to interpret them and render them capable of use.... But theoretical and practical psychology, the one as much as the other, should bear in mind that they cannot lose sight of the truths established by reason and by faith, nor the obligatory precepts of ethics.

A number of Catholic laymen in this country played important roles in changing the church’s response to psychiatry. Two were particularly influential. Francis J. Braceland, M.D., was the director of the Institute of Living in Hartford, Conn., editor of The American Journal of Psychiatry and president of the American Psychiatric Association and the American Board of Psychiatry and Neurology. Harvey J. Tompkins, M.D., also a president of the American Psychiatric Association, started the first major psychiatric service in a Catholic hospital at St. Vincent’s in New York. Cardinal Francis Spellman and Sister Loretto Bernard of the Sisters of Charity supported him in this effort. Both Braceland and Tompkins had experience as psychiatrists in World War II and brought the lessons learned back to civilian practice. Their standing as Catholics in the profession was influential in changing the church’s attitude toward psychiatry.

The church’s position on modern science was made clear in the Second Vatican Council’s Constitution on the Church in the Modern World (1995). Advances in biology, psychology and the social sciences were specifically recognized. If there was any remaining doubt, it ended on Jan. 4, 1993, when Pope John Paul II addressed an international delegation of psychiatrists led by Joseph T. English, M.D., then president of the American Psychiatric Association. The pope greeted the assembled psychiatrists: The meeting affords me a welcome opportunity to express the church’s esteem of the many physicians and health care professionals involved in the important and delicate area of psychiatric medicine.... By its very nature your work often brings you to the threshold of human mystery. It involves sensitivity to the tangled workings of the human mind and heart, and openness to the ultimate concerns that give meaning to people’s lives. These areas are of the utmost importance to the church, and they call to mind the urgent need for a constructive dialogue between science and religion for the sake of shedding greater light on the mystery of man in his fullness.

The past two decades have seen dramatic insights into the working of the brain. The 2000 Nobel Prize in Medicine or Physiology was shared by three scientists for their contributions to understanding the neurophysiology and molecular biology of emotional and intellectual functions. Psychiatry has also come to recognize the importance of religion in the patient’s life. Polls consistently show that the great majority of Americans believe in God and belong to some organized religion. Religion is an important social and cultural factor to be considered in assessing any patient. Religious beliefs and practices are often incorporated into symptoms of mental illness such as delusions or obsessions.

The Freudian dictum of religion as a neurotic relic is no longer credible. The World Psychiatric Association recently established a section on psychiatry and religion. Medical school curricula and residency training programs now include awareness of religious beliefs and practices as important for understanding the whole patient. A number of studies have shown a relationship between religious practice and improved health outcomes, including lower blood pressure, recovery from depression and healthier immune systems. These findings have to be replicated. It is likely that the health benefits of religion are not related to theology, but are the result of non-specific factors such as the structure and support derived from belonging to a religion.

The story of psychiatry and the church is not unique in the history of religion and science. As in the Galileo case, the science had to advance sufficiently to allow the church to view madness as illness rather than possession or moral weakness. However, there will always be a natural interface between religion and psychiatry. Descartes would agree: the soul is closer to the brain than to the foot. Questions about boundaries will always arise, questions of free will, immorality versus psychopathology or the ethical implications of treatments and research, which are, as John Paul II put it, at the threshold of the human mystery.