Sunday, November 9, 2014

Open Wide ... (Part 4)

Meantime I seek no sympathies, nor need;
The thorns which I have reap'd are of the tree
I planted, -- they have torn me  --  and bleed;
I should have known what fruit would spring from such a seed.
                                           ~  Lord Byron, "Childe Harold's Pilgrimage"

"It is not clear what methods modern psychiatry has for dealing with real guilt."
                                           ~ Dr. O. Hobart Mowrer, "The Crisis in Psychiatry and Religion"

The reader will recall the argument of Mowrer, a past president of the American Psychological Association (1954), that disorders of anxiety and mood arise from unacknowledged moral failings, which injure others and estrange the self's relationships to such.  The aim of psychotherapy, in his view, was to release or free the patient's conscience (Mowrer, p. 27), by facilitating an unbounded acceptance and admission of a heretofore publicly hidden (if not actively repressed) responsibility for the interpersonal rupture.  The anticipated result would be a gratifying, indeed grace-full, relief of the conscience and peace for the mind.   Interestingly, Mowrer was openly not adverse to the use of the word "sin," to describe the process of injury to either man or God (Mowrer, p. 48).   But he firmly rejected the insistence of Freud's disciples that a punitively harsh "super-ego"  ... a supposed derivative "structure" of the mind, introjected from and shaped by the external mandates of the (frequently) harsh parent and irrational society  ... was the root cause of neurosis and its crippling sense of a "false" or unnecessary guilt.  He also rejected any conclusion that this particular "structural" artifice somehow had to be made less rigid and less confining, in deference to the instinctual drives of survival which seek sexual and aggressive satisfaction.

Mowrer maintained that the prevailing Freudian stance (of his time) "in essence, holds that anxiety comes from evil wishes, from acts the individual would commit if he dared (Mowrer, p. 26)."  Today's insurance-favored cognitive-behavioral (CBT) and rational-emotive (RET) therapies, with their shared emphasis on problematic "core beliefs" and "automatic thoughts," are in reality not too far afield from classical psychodynamic theory, although being further dressed up with the finery of Stoic philosophy.   Mowrer's alternative scheme was that anxiety emerges from acts which the patient has committed, but wishes he had not.  Mowrer's proposal was a "guilt theory" of anxiety, rather than an "impulse theory."

Mowrer saw potential danger lurking in the Freudian metapsychology, in that impulses could be excused and condoned  in association with a loosening or even dismissal of group standards, especially in times where societal bonds come to weaken in their force.   Blame for the internal misery of the neurotic (or even the psychopath) could conveniently be externalized and the finger-pointing shifted.   Now, the patient could be seen as an innocent and helpless victim ... not of his own sin (if any such thing were recognized), but of the "sins of the fathers"  and patriarchal foofram.  Ann Russell's "Psychiatric Folksong," cited too by Mowrer (p. 49), prophetically sums up an entire age (one extending to our own) deliciously well:

At three I had a feeling of 
Ambivalence toward my brothers,
And so it follows naturally
I poisoned all my lovers.
But now I'm happy; I have learned
The lesson this has taught;
That everything I do that's wrong
Is someone else's fault.

It is left as an exercise for the good reader, to supply the appropriate "Selah."

As one might expect from the title of his book, Mowrer does not let the Church, especially its protestant manifestations, off the hook.  He theorized that the ministry to the Thessalonian creature composed of body, mind and spirit (1 Th 5:23) has been progressively enfeebled, by a "cheap grace" which de-emphasizes or completely avoids lancing the abscesses of anxiogenic sin (through specific and personalized confession of a named iniquity).

Examination of Roman Catholic and Evangelical Catholic practice in this regard (the Jesuits are on notice that the latter term refers to, well, to us ... the adherents of Augustana), and the benefits of such practice, will be reserved for a future post.  For now, we turn the eye on a still relevant case once formally presented years ago by Dr. Anton Theophilus Boisen, a hospital chaplain and clinical psychologist sympathetic to Mowrer's postulates, with whom he corresponded from time to time.               

Case summary (paraphrased and expanded from Boisen, 1958):
A thirty-eight year old man presented to the hospital in a severely agitated condition.  He maintained that he had committed "the unpardonable sin," and that "something was going to happen" to his wife and children.  He accordingly was exasperatingly adamant in his refusal to let them out of his sight.  He was certain that a world war was imminent, and when asked as to what role he was to play, if any, in this calamity, he replied with a fervent if not-so-cryptic conviction that "A little child will lead them."

What had triggered this paranoid and delusionally grandiose state of anxiety?     

The patient's record of  life, to this point,  was that of a well-meaning and conspicuously affable individual who had been sexually promiscuous both before and after marriage.  What seemed to trouble him most was an affair with a woman some ten years his senior.  She had undergone two abortions, which he had urged on her.  She had recently died of carcinoma, for which he also believed he held direct responsibility, in some way.  His emotional distress had taken root shortly after his lover's death.

The first disabling symptom to emerge was a resort to heavy drinking, which culminated in a loss of employment.   Following this setback, he somehow successfully managed to abstain from alcohol, but had unfortunately become increasingly depressed.  Now he began to agonize that his fraternal society, the Odd Fellows, was relentlessly "out to get him" because he had violated the lodge's solemn oath of civilitude.   This persecutory obsession became increasingly entrenched over the succeeding months; and eventually he sought a permit to carry a handgun, in order to thwart the murderous intent of his foes.   Finally, in great despair and panic, he felt compelled to confess to his wife his history of sexual transgressions.  This he did.

She responded with a generous and forgiving charity, but this did not alleviate his agitated fretting about her fate ...and the world's ... which things he was personally shouldering to extremis.  As mentioned earlier, he agreed to seek professional care and was admitted to an in-patient psychiatric facility.  His initial hospital course was noteworthy for the continuing marked intensity of anxiety, signs of de-realization, and a "deeply aroused religiosity."  By the end of approximately 2 months, however, he had achieved what physicians considered to be "an excellent recovery."   Dr. Boisen reported that there had been no comparable symptomatic relapse in the thirty years which followed this crisis; indeed, the gentleman was described as being "at present a successful contractor  and his family is happy and prosperous."

Observations of Boisen:
Boisen sees the "little child" of the patient's narrative as being "obviously" self-referential; the patient alone has provoked an inner war by his behavior, one with devastating and global consequences for his very constitution.  Boisen makes a further aside that his troubled patient's lover was "clearly a mother substitute."

A good deal of somewhat puzzled attention is paid to the post-confessional agitation of the patient, the intensity of which necessitated a locked-ward confinement.   Why was he not calmed and emotionally "cured" by a sharing of his transgression, with a remarkably sympathetic and forgiving ear?  Boisen argues (cited by Mowrer, p. 99) that the confession surely "brought about a certain socialization" to the patient.  But this restoration of healthy relationship and community was predicated on the discarding of "pretense and hypocrisy and put the suffer in position to be accepted for what he really was."  This is no easy task to achieve, this degree of psychological nudity; and it's one requiring a considerable store of psychic energy, mused Boisen. Such exhausting emotional turbulence, once stirred, could hardly be expected to subside immediately (especially in an everyday-setting) and required specialized care to tame.         

Observations of Mowrer:
Mowrer finds Boisen's analysis to be "eminently reasonable."  We won't belabor this point, to which we agree in good part.   Mowrer's genius goes on to insist that the hospitalization, however, was ... and this is startling in its implications ... "dynamically necessitated by the confession (Mowrer, p. 99) ."   He suggests that most human beings who have been ensnared in situations like that of Boisen's patient, feel uneasy with their emotional ledgers until "every last farthing is paid;" or rather, as Mowrer puts it, he or she has "taken her medicine and paid for ... past misdeeds."  This is on the order of common sense.  In legal circles of the Left Kingdom, the confessed murderer is not patted on the head, praised for taking a bold step in front of a jury of his peers, and released.  Instead, he serves his time and pays his debt to society (however that is determined), which may entail the surrendering of his life.   Mowrer makes an arresting aside, to the effect that we may not be perceiving the real function of the psychiatric ward ... that it may serve as a kind of expiation!

Comments of this writer:
1.  Some of Dr. Boisen's take is a necessary, professional bow to the Freudian interpretations dominating the '30's.   The patient's "little child" remark is less the disclosure of a lost waif, seeking a mommy of Oedipal fantasy ... a mommy only ten years his senior, by the way ... than a marker of someone likely familiar with conventional religious standards of the Law.  The "unpardonable sin" thing is not the verbiage of the typical worldling.   We are not provided much detail about the patient's childhood development, or his religious affiliation, which is unfortunate.  Perhaps the patient in crisis readily sees his promiscuity as infantile and ultimately unsatisfying and aimless and "leading to destruction"; or perhaps he does have a mother-fixation.  Who knows.  The apparent absence of any resort to clerical intervention, by what seems to be a religiously-versed fellow, is interesting; and, dare I say it, tragic.  It may have been a simple narrative omission on Boisen's part; but based on Boisen's vocational interests and his intense attitude, this possibility is not convincing.

2.   The insights of Dr. Mowrer are intriguing, and may help explain the repetitive pilfering of Dr. Meehl's adolescent girl (see part 3 of this series).  It seems she was not held to any significant restitution for her acts, certainly nothing comparable to that of, say, the forgiven tax collector Zaccheus.   The fascinating history of formal penance within the early Church has been examined by Lutheran theologian Werner Elert, in his Eucharistic studies.  While not consistent with the fresh breeze of Gospel forgiveness from the hands of God the merciful, penitential ritual appeared to have served a necessary juridical function, at a time when barbarian inroads had devastated civic authority, especially in the West of the fourth and fifth centuries (and beyond).  In the somewhat more secure East, it was deemed as a safeguard to the holiness of the communal Sacrament, culling away the "less sincere" and stubbornly impenitent from the altar; as being usefully instructive as to the seriousness of sin; and as "concern for inner healing (Heilung);" cf. for example Elert, p. 99.   This, in a sense, brings us full circle to Mowrer's cure ... if not for achieving the forgiveness of sins, and the attaining of life and salvation ... then for alleviating the agony of a "real guilt" neurosis.

3.  Whatever the merits of conceiving the "psych-ward" as means of penance, it is curious that both Boisen and Mowrer (no strangers, less enemies, to religion) address only the patient's "horizontal-axis" of confessional reconciliation; and that, with his wife alone.  The patient's anxious feelings engendered by the realities of two aborted children, and a deceased lover, are not in any way explicitly assuaged, unless such burdens were addressed and ameliorated in the course of a lengthy hospital stay. We are not directly informed about this, and in any event, those no longer living were not themselves witnesses to the patient's change of heart and subsequent recovery.  But the feelings of the patient  along these lines were certainly searing enough, to the point of a conviction that he was responsible for a carcinoma.  The "vertical-axis" of a confessional reconciliation with God would be of prime importance here, one thinks; one cannot help but recall the Davidic testimony of Ps 51:4  "Against You, You only, have I sinned and done what is evil in Your sight, so that You may be justified in Your words and blameless in Your judgment."  Given this abiding truth, the role of God's ordained representative, and his absolving role, is difficult to ignore.  But it was, in Mowrer's recapitulation of events.

4.  These days, in modern America,  a two-month or more stay in a psychiatric facility is exceedingly uncommon, even in instances of diagnosed psychotic anxio-depression.  I'm not convinced that this can be completely ascribed to the wonders and efficacy of contemporary medicines; economic pressures to "move things along" are that strong.  But this situation makes a return to that sacramental practice which the Lutheran fathers claimed was routine and not in any way abandoned by their parishes (AC XXV.1-5), all the more to be encouraged among us, in full service to the troubled neighbor.
Boisen A.T. :  Religious experience and psychological conflict.  Amer Psychol 13:568-570, 1958
Elert W. (trans. by N.E. Nagle) : "Eucharist and Church Fellowship in the First Four Centuries," Chap. 8 (Church Discipline and the Lord's Supper), Concordia Publishing House, St. Louis (MO), 1966; paperback
Mowrer O.H. : "The Crisis in Psychiatry and Religion," D. van Nostrand Co., Inc.,  Princeton (NJ), 1961; paperback

Nota bene:  The painting above illustrates the great 19th century French neuropsychiatrist Charcot at work, demonstrating to young physicians a clinical example of "conversion disorder."   As the DSM-IV emphasizes, the existence of the presenting motor or sensory deficits of the disorder invariably do not conform to known anatomical pathways or physiological functions.  But malingering is not an issue, here; the unfortunate sufferer is not "faking it." Traditionally, in psychiatry, the somatic symptoms were ascribed to a symbolic resolution of unconscious psychologic conflicts, often of a sexual character, and which solution served to keep the conflict out of awareness.

Next:  Forgiveness of sins, life and salvation, yes! But can the Sacrament of Absolution ("Private Confession") secondarily influence mental health in a positive way? --   Roman Catholic conniptions, and Lutheran lassitude cloud things.

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