HENRY
ENOCH
KAGAN
God and the Psychiatrist in Psychotherapy Tar. ]POSTMASTEROf a New England village, on hearing an eminent clergyman addressed as "Doctor," asked the distinguished visitor what kind of doctor he was. The clergyman replied that he was a Doetor of Divinity. "Hmm," mused the postmaster, "I don't seem to recollect we ever had a ease of that here." When he praetiees psyehotherapy, the average medieal psychiatrist also does not think his eases involve the divine. This is no reflection on the psychiatrist's competence. Unfortunately, there are all too frequent instanees where a nareissistie, self-eentered approach by a clergyman or his congregants in the religious experiences of worship, ritual, and prayer also does not seem to include the divine. The possibility of the presenee of God in the art of psyehotherapy is just beginning to occupy the attention of the medical profession. The therapy of the divine has always been a eonvietion of the theologieal profession. In primitive times, the medicine man was both priest and physieian. Some of them had surprising successes in healing by using incantations to their gods to exorcise the demons they thought possessed a sick body and particularly a siek mind. A recent humorous eartoon showed in the baekground a patient lying on a couch and being eured by the incantations of a dancing Indian medicine man. In the foreground, one modern psychiatrist is saying to his colleague, "But, after all, we just can't dress up like that." The comparatively recent separation of medicine from religion is illustrated by the story of Dr. Oliver Wendell Holmes (father of the An address delivered at the Scholars Series, Washington Hebrew Congregation, Washington, D. C., February 26, x967. God and the Psychiatrist in Psycbotberapy 79
great American Supreme Court Justice). One day in a hospital in preCivil War Boston, a very agitated minister rushed up to him and said: "Dr. Holmes, I've just seen my parishioner, your patient, who is very seriously sick and as a matter of fact, Dr. Holmes, I think she is going to die." Dr. Holmes thought for a moment and said: "You may be right, pastor, and if she does, she'll go straight to hell." The minister was shocked and said: " W h y , Dr. Holmes, how can you say such a thing?" Dr. Holmes replied: "Well, I have as much right to a theological prognosis as you do to a medical one." Of course, Dr. Holmes and this Christian clergyman had no common meeting ground, even though both were Christians; or, more to the point, they could not get together because both were conditioned by a Paulinian-Greek ideology. This interpretation of Christianity separates the body from the soul as though they were independent of each other. W e know now, as that physician and pastor should have known, that the soul is so close to the body that they catch each other's diseases. Our ancient Hebrew ancestors assumed the inseparability of the soul from the body. They believed that since man was created in the image of God, man received even his body in trust from God and, therefore, should take care of it. Furthermore, because Judaism was the first religion to declare that there was only one God, it rejected the idea that there could be evil gods or demons who caused diseases. Therefore, the magic medical practices of witches and astrologers are denounced in the Bible. Health in the Bible is a blessing divinely conferred on those who live properly. "If thou wilt diligently hearken to the voice of the Lord, thy God, and wilt do that which is right in His eyes, and wilt give ear to his commandments and keep all His statutes, I will put none of the diseases upon thee, which I have put on the Egyptians: for I am the Lord who healeth thee." (Exodus, x5:26) This does not mean that the Jewish priests who were in charge of health waited around for God to cause a cure. They rather looked upon themselves as God's medical assistants, and a study of medicine as practiced in biblical times reveals that despite the picturesque, supernatural, and unscientific language of the Bible, the Hebrew priests diagnosed malaria, gastroenteritis, dysentery, bubonic plague, tuberculosis, and a variety of mental diseases. Elisha was famed as a diagnostician, for when a Syrian general came to Israel to be cured for what he supposed to be leprosy, Elisha knew it was only skin irritation caused by the general's uncleanliness and told 80
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him simply to wash in the Jordan River and he was cleansed. They knew a great deal about drugs--"the balm of Gilead"wand the use of poultices. Of course, some of their medicaments seem magical. Their use of that mysterious vegetable, the mandrake, as a sexual or fertility stimulant was as doubtful as the eating of the tomato in the East as a presumably effective love apple. Their concern for cleanliness is evident in the ceremonial laws for washing before meals. Their concern for public health is confirmed by their dietary laws, whatever be the origin of these laws. They even invented quarantine. The Levitical laws demanded that everyone who had been in contact with any infection must observe a forty-day period of ritual cleansing and isolation. When, in the fourteenth century, Italy was ravaged by an epidemic, it was noticed that the Jews suffered less because they were observing this biblical law of forty days of isolation. It made so much sense to the Italian authorities that they made the regulation mandatory for Christians as well as Jews. The Italian word for the Hebrew word "forty" is quaranta and, hence, the period of isolation came to be known as quarantine. Now I am not recommending that we replace modern medicine with the folk medicine of the Bible. I am only pointing out that the biblical Hebrews were advanced healers for their time because they viewed man as a whole, not as a fragmented person. In a limited sense, they anticipated what we today call psychosomatic medicine, which has demonstrated how many diseases originate in or are aggravated by unresolved emotions of anger, anxiety, loneliness, rejection, and unlovableness. Peptic ulcer, ulcerative colitis, migraine, asthma, hypertension, rheumatoid arthritis, even coronary thrombosis can be caused or at least precipitated by emotional stress. Therefore, it is sometimes more important for the modern physician "to know what kind of fellow has the germ than what kind of germ has the fellow." Illness may sometimes be the way a person unconsciously tries to resolve the frustrations in his life. To understand what a patient may actually be saying by his illness may be the first step toward his healing. This is exactly what the Bible implies when it says, "Hope deferred maketh the heart sick, but desire fulfilled is a tree of life;" and "A merry heart doeth good like medicine, but a depressed spirit" gives you arthritis or as the Bible describes that disease, "drieth up the bones." These ancient healers, of course, openly invoked the aid of God in their medical practice and, if I may also add, in their intuitive psychiGod and the Psycbiatrist in Psychotherapy
8x
attic practice. The word "psychiatry" comes from the Greek that literally means "healing souls." The concept of a partnership with God in a medical team-work continued long after biblical times, particularly by the Jewish physicians who were famed throughout Europe. Rabbi Dr. Ben Siraeh, in the 2nd century, said: "My son, in sickness be not negligent, pray unto God, for He will heal; and to the physician also give a place, for there is need of him likewise. For there is a time when in His hand is good success for the physician too will supplicate to God that God will prosper him in his treatment." (Hokmat ben Sirach. The Wisdom of Ben Siraeh) Rabbi Dr. Moses Maimonides, the renowned court physician to Sultan Saladin during the period of the Crusades, sounds quite modern in his saying: "Among a thousand people, only one dies a natural death--the rest suecumb to irrational modes of living." (Moreh Nebukim. The Guide to the Perplexed) This rabbi, who lived Boo years ago, was far in advance of certain present-day clergymen who seem to advocate what I would call unhealthy religion when they advise people to pray to get peace of mind. This may make of religion another temporary tranquilizer, but it removes the effect religion should have on changing evil conditions in society that disturb the peace. In contrast, Rabbi Dr. Maimonides said: "Not until one has peace of mind should one pray." (Mishneh Torah) In the thirteenth century, there was a mystic kabbalist physician, Rabbi Dr. Samuel Abulafia, who actually anticipated Freud's use of free association to get at the origin of neurosis. Abulafia called it "ke[itsa," the Hebrew for "skipping from one idea to another." Abulafia said this method would help "to unseal the soul, to untie the knots which bind it." In the fifteenth century, Rabbi Dr. Almoli wrote a book entitled The Interpretation of Dreams, in which he describes the sex symbols in dreams and also treats the dream as wish fulfillment. His ideas are strikingly parallel to the psychoanalytic theory of Freud. Indeed, Freud quotes Almoli in his own famous book, The Interpretation of Dreams. The rabbis who were the most expert in combining religion with psychotherapy were the seventeenth- and eighteenth-century Hassidic rabbis. They lifted their followers out of despair and guilt and gave them meaning and hope. They tried to help their followers recapture a confidence in the happiness of living. They emphasized a new, joyful prayer instead of the old orthodox, doleful prayer. They practiced a kind of group therapy in the communal dance they introduced into the syna-
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gogue. A century before Freud, the Hassidic rabbi even devised his own technique of a talking-out method to aid a person achieve a sense of his worth and confidence in life. Rabbi Simcha Bunam of Parshisha said: "It is highly necessary for every human being to have at least one sincere friend--one true companion. This friend must be so close to us that we are able to tell him even that of which we are ashamed." One of the most pious of the Hassidic rabbis once said: "Supposing some one comes to you and asks your help. You shall not turn him off with pious words, saying 'have faith and take your troubles to God.' You shall act as though there were no God; as though there was only one person in all the world who could help this man--only yourself!" Of course, this rabbi could risk making this astonishing and apparently sacrilegious assertion because he believed there is a God with whom man is in partnership. He was simply stating that man should uphold his end of that parmership, t One of the greatest concerns of the Hassidic rabbi was to eliminate from the Jew his neurotic guilt feeling that the Jews deserved being persecuted for their sins. Rather were they the victims of the neurotic aberrations of the Christian anti-Semites. A piquant example of the effort of these Hassidic rabbis to normalize guilt and distinguish between healthy, responsible guilt and unhealthy, self-hating guilt is the Hassidic explanation of why the listing of the sins recited on the Jewish Day of Atonement is arranged in alphabetical order. The ./1I Cbet, "for the sins" prayer, is arranged on the basis of A to Z (from the sin of adultery to the sin of xenophobia). If that prayer of penitence were not arranged alphabetically, they said, "we should not know when to stop beating our breasts, for there is no end to sin and no end to being aware of sin, but thank God, there is an end to the alphabet. ''z It is not accidental to note that a number of Freud's first disciples were Jewish physicians whose fathers were Hassidic rabbis. The founder of Habad Hassidism, Rabbi Schneuer Zalman, in the nineteenth century, wrote vigorously about the capacity of man's conscious free will to overcome subconscious evil instincts. His grandson, the late Joshua Schneirson, M.D., psychiatrist, founded the Mental Hygiene Institute for Children in Tel Aviv. He incorporated Jewish religious insight in his modern Hebrew works on child psychology. The philosophy about the "Thou and the I" of Martin Buber, which has had widespread influence on modern psychotherapy, was also derived from
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Buber's own great studies of these Hassidic rabbinical, intuitive therapists. Despite this long history of the use of a religious philosophy in the practice of medicine by Jewish physicians, the Jewish founder of psychoanalysis, Sigmund Freud, was the most powerful force for separating religion from medical psychotherapy, even though he spent a great deal of his own psychic energies theorizing about religion. There is as much popular confusion about what Freud said about religion as there is about what Marx said about communism, simply because both of these Jewish geniuses have been approached from the special prejudices of the person speaking. First, let us state what Freud said about religion; second, let us ask why he said it; and, third, did he mean that what he said was the absolute final word on the matter? Concerned that men should grow up and stop acting like infants, Freud said: "Immature men invented a God-father to defend them, since man cannot cope rationally with his own life's problems." W h e n an adult behaves like an infant and is obsessed by his dependence on a father, he is neurotic. Religion, then said Freud, "was the obsessional neurosis of humanity. ''a Freud was particularly opposed to what he justifiably thought religion had been doing to repress sexual fulfillment. So, while religion was a neurosis, anyone, he claimed, who could engage in a normal sex life could never suffer a neurosis. A mature person had no need for the illusion of a God, since he would be free from anxieties this religious delusion fails to remove. Freud's attack on religion cannot be put in the same category as other criticisms of the tyranny of those religious institutions that, throughout history, have repressed man in more ways than sex. His criticism of religion is more fundamental in that Freud had a mechanical view of the nature of man. He thought man's behavior could be reduced to scientific formulas horganie, inner psychic and outer social conditioning without any reference to man's spiritual dimensions. Did Freud think man would be healthier if he obeyed mechanical, rational laws of behavior freed from religion? It seems he did not, for Freud was a pessimist about life as a whole. He admitted that psychoanalysis was not a v:eltanschauuzeg, a life philosophy. While he attacked religion's worst aspects, he never was absolutely sure that religion had no place in mental healing, as his letters to the first clergyman he had analyzed, the Swiss pastor, the Reverend Oskar Pfister, reveals. In fact, Freud thought this clergyman84
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therapist had an advantage over himself in that Pfister could lead his patients to a mature concept of God that might even reduce neurosis. Freud was supremely honest and did not, himself, believe in God. He was even more honest about his pessimistic outlook on life. He was brave, but knowing that his sisters had been taken away by the Nazis, a fate from which he, himself, was barely rescued, and dying of cancer of the jaw could scarcely induce optimism. One can understand, then, this sentence in his book, Civilization and Its Discontents: "Only religion is able to answer the question of the purpose of life. One can hardly go wrong in concluding that the idea of a purpose in life stands and falls with the religious system." Since Freud found no meaningful purpose in man's existence, he repudiated religious systems. If he had lived after Hiroshima, his pessimism would have been even greater. In 1967, Freud would have found an even more profound pessimism among his fellow intellectuals about the absurdities of the human condition and existence. W e should realize that most of Freud's patients were intellectuals or among the upper luxury class who could afford his treatment. In fact, a psychiatrist today who practices classical Freudian analysis, with its prolonged involvement with transference for two years, five hours a week, can probably see only a few hundred patients in his entire career. In Freud's day, the major problem of such persons as his patients was thought to be their repression of sex. In our day, twenty-five years after Freud's death, I think the major problem of this select group is their repression of hope. One can now have a normal sex life and still be neurotic. The general cultural European atmosphere in Freud's time was optimistic, even though people were prudish and secretive about sex. Tennyson describes this Victorian hopefulness in his poem, "Loeksley Hall," in which we find the familiar line: "In the spring a young man's fancy lightly turns to thoughts of love." And farther on: "For I dipped into the future, far as human eye could see,/Saw the Vision of the world, and all the wonder that would be;/ . . . Till the war-drum throbbed no longer, and the battle-flags were f u r l e d / I n the Parliament of man, the Federation of the world." Despite this optimistic atmosphere, Freud was a pessimist and had very little to say about how a hopeful trust and the capacity to love go hand in hand. What he did say has become a much misunderstood household language. As our technological society has dehumanized, disorganized, and disoriented man,
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everyone today freely talks about the mechanics of sex, oedipus complexes, incest, and homosexuality. W e even witnessed a rash of amateur analysts all over our land in the Bridey Murphy craze; a person would suggest that his friend lie clown on a couch and go back in his memory as far as possible. A cartoon ridiculing this caricature of psychoanalysis showed a man going back so far in his subconscious that he retreated to the very beginning of time. The caption of this cartoon had him saying: "And after six days of creation, I rested on the seventh." Of course, one does not become a god through analysis, nor does an analyst pretend to be a god. Some neurotic patients may have an idea that their analyst is a god, and there seem to be a few analysts who do speak ex cathedra on all subjects. The fact is that the analyst can never be as impersonal as Freud thought he should be, sitting behind the couch so that his patients could not see his facial expressions. Since Freud's time, much study has been devoted to the relations between the analyst and the analysand. Objective though he try to be, the analyst is a human being, and his own theories and values come to be absorbed by his patients. Because a major cause of neuroticism is rejection, the patient wants to be accepted by the analyst. To win acceptance, patients may accommodate their Freudian analysts by dreaming Freudian dreams, while for the Jungian analyst, they dream Jungian dreams. The therapists can choose whether to take on a patient for therapy; they tend to choose those with whom they, themselves, have something in common--economically, socially, or intellectually. With these people, the psychoanalysts do have some successes. Since the analyst is as much involved as the analysand, expert teachers of psychotherapy, like the late Dr. Franz Alexander, are less interested in the technique a therapist has learned in his particular denominational school and are more interested in who the therapist is, what he believes, what his personality is, how much commitment he has, and what are his problems. Over a certain period, the patient internalizes the values and attitudes of his therapist. That the therapist's confidence in himself and positive convictions about his own healing methods is persuasive to the patient should not be surprising. A physician tried samples of a new drug received from a pharmaceutical house to treat a patient's long-term asthma. The asthma was dramatically relieved by the new drug, but the physician decided to be more scientific and, without the patient's knowledge, substituted a
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placebo--a harmless sugar pill. The asthma returned. Again, secredy, the physician substituted the sample drug with excellent relief. Now impressed with the sample drugs, the physician requested another supply. He was then informed that the drug company, having had some question about the new drug, had given him a placebo from the very beginning. As long as the physician believed in the value of the pill, it worked; but when he didn't, somehow his patient got the message and the drug failed. In his clinical experiments at Johns Hopkins, Dr. Jerome Frank demonstrated that those psychiatric patients who were simply told before therapy began that they had excellent prognosis of recovery did better and in quicker time than those who were not given this initial assurance by the psychiatrist. Shall we then accuse a physician who gives a placebo or a psychiatrist who holds out reassuring hope of being fakers? Not at all! This only demonstrates how much those sick in body or in mind need to relate to another person who will give them enough confidence in life to want to live and the responsibility of exerting the will to do so. This is why the old one-sided emphasis in Freudian psychoanalysis is being questioned because of its limited results for a limited number of people and is being replaced by a broader view that "neurosis comes not merely from repressing unsatisfied instincts, but also from repressing an uncomfortable conscience. The neurotic is not merely sinned against; he may also be a sinner. The emotionally ill may aggravate illness by irresponsibility. They would rather lie on a couch than put their shoulders to the wheel." Their recovery is as much related, then, to a healthy sense of their own ego and what they can do in life when they feel respected and loved as it is related to satisfying the sexual id. And now there are vigorous new explorations in new forms of therapymbehavioral therapy, operational therapy, conditioning therapy, reality therapy, group therapy, family therapy, existential therapy, and spiritual therapy. These newer methods are the result not merely of newer theories, but of public necessity. Every resource available must be used to meet the overwhelming challenge of mental illness, which troubles at least seventeen million Americans today. A report by the Senate a few months ago indicated that one out of every ten children in the U. S. will need some form of psychotherapeutic help. So, today, competent psychiatrists are exploring all kinds of ways to meet this problem, in-
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eluding even training sensitive laymen or laywomen in the art of listening as assistants in the mental hospitals. Compared to less than I5,ooo psychiatrists, there are 3oo,ooo clergymen in the United States, and, if properly oriented, they could make a considerable contribution in the over-all area of social or preventive psyehiatry. But where does God come in, in all these newer short-term, nonFreudian therapies? A therapy may deal less with the past and direct the person more to having goals, but it still need have nothing to do with God. A therapy may be less involved with origins of emotional disturbanees and more concerned with the patient's potential for health; it may be less based on examination of inner past conflicts and more concerned about developing the feeling of being loved but this may be done by a psychiatrist in psychotherapy without God. One may even employ successful group therapy in which a sense of belonging in a group of trusted confidants who have endured similar sufferings is developed and a new confidence in life effeeted. In Israel, the psychiatrist, Dr. Weinberg, studied the neurosis eaused by the horrible experienees in Nazi concentration camps. He found that because they suffered together, those caught were less neurotic than those who had escaped this camp experience. Those without the concentration camp experience felt more guilty because they were alive while their relatives were dead. From such a concentration eamp, where he had lost his entire family, one Jewish psychoanalyst, Dr. Viktor Frankl, was liberated in x945 and returned to Vienna, where Freud had started. "At that moment," he wrote, "there was little I knew of myself or of the world. I had but one sentence in mind, always the same--I called to the Lord from my narrow prison and He answered me in the freedom of spaee. TM Frankl calls his therapy logotherapyRlogos, the Greek for meaning, " . . . or a therapy that foeuses on helping a person find meaning to life." He eould have been more pessimistic than Freud, who once said to his patient, Princess Bonaparte: "The moment a man questions the meaning and values of life, he is sick. ''5 But Frankl believes the opposite. To overcome the sickness of being a nobody in the erowd, without any identity, alienated from yourself, controlled by our present-day collectivist madness, one must ask, says Frankl, "what is existence for me and my aim and my responsibility in life?" The time has eome to add height psychology to depth psychology. "Any attempt to produce goodness and love out of our deep animal in88
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stincts is as thinkable as a river building its own power plant," says Frankl. "Everyone has an altar where he finds his aspirations, and those who have not found the Absolute God absolutize some relative good, like money, status, women, nationalism, or what not, until all these prove to be only fragmented answers to life and, therefore, empty." And there are other analysts like Frankl whose values are religious. Without prayer and without even mentioning God, they convey to their patients this need for meaning in life. Martin Buber had this in mind when he became convinced that a dialogue between two persons in search for God's meaning relating the I to the Thou was itself the most sacred religious experience. Martin Buber did not suggest the word God be used like a placebo. It seems that Jung did not believe in the actuality of God, although he used religious language in his therapy. Buber meant actually the reality of God. No less than the national director of the National Institute of Mental Health, a medical psychiatrist, recently said that "Psychoanalysis and psychotherapy can often put the patient on the right track, but it is religion that can help him realize that the track leads somewhere. Although under normal conditions the difference between a deeply religious person and one who is not religious may be negligible, if both are pushed, the one who topples first is the one who has nothing to hold on to. I can testify to this as a psychiatrist who has observed both types under stress. ''6 As a religious psychotherapist, I, too, can testify to this phenomenon. In a world so destructive, depersonalized, dehumanized as ours has become, the drive for meaning--to achieve a sense of what one of m y patients calls a "me-ness"--has become more important than the sex drive. Without a sense of meaning and identity, sex is no more than sex without any of the elevation of love. Indeed, if life has no worth, even sex becomes disgusting, since sex reproduces life. To avoid reproducing life because it has become meaningless may be one of the more subtle reasons for the rapid rise of homosexuality in our times. Because the Victorian Age believed in life and progress, a Tennyson could write of love in a positive way. In our atomic age of nihilism, the proliferation of nuclear weapons, population explosion, hunger and poverty, annihilation of the human race itself dominates our thinking. In this totally pessimistic frame of mind, the Nobel prize winning poet, T. S. Eliot, logically ridiculed love in his most famous poem, Wasteland. The poet who represents the transition between these two ages--be-
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tween the age of hope with love and our age of hopelessness without love is Matthew Arnold. In his p o e m "Dover Beach," Arnold is standing on the cliffs of England, facing the Channel, and is speaking to his loved one. H e deseribes the waves as they draw back and forth in the moonlight and draws this analogue: The Sea of Faith Was once, too, at the full, and round earth's shore Lay like the folds of a bright girdle furled. But now I only hear Its melancholy, long, withdrawing roar, Retreating, to the breath Of the night-wind, down the vast edges drear And naked shingles of the world. Ah, love, let us be true To one another! for the world, which seems T o lie before us like a land of dreams, So various, so beautiful, so new, Hath really neither joy, nor love, nor light, Nor certitude, nor peace, nor help for pain; And we are here as on a darkling plain Swept with confused alarms of struggle and flight, Where ignorant armies clash by night. As long as there can be no hope for man, it is doubtful whether lovers can "be true to one another," and sex becomes only a masochistic or sadistic escape from life's ultimate frustrations and meaninglessness. In psychotherapy today, psychiatrists seem to be turning more and more to the existence of G o d as a source of hope and meaningfulness in life. Some are aware of it, but most do it without awareness. REFERENCES x. Buber, Martin, Tales of the Hasidim. New York, Shocken Books, 1947. 2. Ibid.
3. Freud, Sigmund, The Future of an Illusion. London, Hogarth Press, i928. 4. Frankl, V. E., The Doctor and the Soul. New York, Alfred A. Knopf, i965. 5. Jones, Ernest, The Life and Work of Sigmund Freud. New York, Basic Books, 196I. 6. Yolles, Stanley, "The Role of Religion in the Mental Health Program," Journal of Religion and Health. 1965, 4, 302-3~
9~
Journal of Religion and Health
ENOCH
KAGAN
God and the Psychiatrist in Psychotherapy Tar. ]POSTMASTEROf a New England village, on hearing an eminent clergyman addressed as "Doctor," asked the distinguished visitor what kind of doctor he was. The clergyman replied that he was a Doetor of Divinity. "Hmm," mused the postmaster, "I don't seem to recollect we ever had a ease of that here." When he praetiees psyehotherapy, the average medieal psychiatrist also does not think his eases involve the divine. This is no reflection on the psychiatrist's competence. Unfortunately, there are all too frequent instanees where a nareissistie, self-eentered approach by a clergyman or his congregants in the religious experiences of worship, ritual, and prayer also does not seem to include the divine. The possibility of the presenee of God in the art of psyehotherapy is just beginning to occupy the attention of the medical profession. The therapy of the divine has always been a eonvietion of the theologieal profession. In primitive times, the medicine man was both priest and physieian. Some of them had surprising successes in healing by using incantations to their gods to exorcise the demons they thought possessed a sick body and particularly a siek mind. A recent humorous eartoon showed in the baekground a patient lying on a couch and being eured by the incantations of a dancing Indian medicine man. In the foreground, one modern psychiatrist is saying to his colleague, "But, after all, we just can't dress up like that." The comparatively recent separation of medicine from religion is illustrated by the story of Dr. Oliver Wendell Holmes (father of the An address delivered at the Scholars Series, Washington Hebrew Congregation, Washington, D. C., February 26, x967. God and the Psychiatrist in Psycbotberapy 79
great American Supreme Court Justice). One day in a hospital in preCivil War Boston, a very agitated minister rushed up to him and said: "Dr. Holmes, I've just seen my parishioner, your patient, who is very seriously sick and as a matter of fact, Dr. Holmes, I think she is going to die." Dr. Holmes thought for a moment and said: "You may be right, pastor, and if she does, she'll go straight to hell." The minister was shocked and said: " W h y , Dr. Holmes, how can you say such a thing?" Dr. Holmes replied: "Well, I have as much right to a theological prognosis as you do to a medical one." Of course, Dr. Holmes and this Christian clergyman had no common meeting ground, even though both were Christians; or, more to the point, they could not get together because both were conditioned by a Paulinian-Greek ideology. This interpretation of Christianity separates the body from the soul as though they were independent of each other. W e know now, as that physician and pastor should have known, that the soul is so close to the body that they catch each other's diseases. Our ancient Hebrew ancestors assumed the inseparability of the soul from the body. They believed that since man was created in the image of God, man received even his body in trust from God and, therefore, should take care of it. Furthermore, because Judaism was the first religion to declare that there was only one God, it rejected the idea that there could be evil gods or demons who caused diseases. Therefore, the magic medical practices of witches and astrologers are denounced in the Bible. Health in the Bible is a blessing divinely conferred on those who live properly. "If thou wilt diligently hearken to the voice of the Lord, thy God, and wilt do that which is right in His eyes, and wilt give ear to his commandments and keep all His statutes, I will put none of the diseases upon thee, which I have put on the Egyptians: for I am the Lord who healeth thee." (Exodus, x5:26) This does not mean that the Jewish priests who were in charge of health waited around for God to cause a cure. They rather looked upon themselves as God's medical assistants, and a study of medicine as practiced in biblical times reveals that despite the picturesque, supernatural, and unscientific language of the Bible, the Hebrew priests diagnosed malaria, gastroenteritis, dysentery, bubonic plague, tuberculosis, and a variety of mental diseases. Elisha was famed as a diagnostician, for when a Syrian general came to Israel to be cured for what he supposed to be leprosy, Elisha knew it was only skin irritation caused by the general's uncleanliness and told 80
Journalof Religion and Health
him simply to wash in the Jordan River and he was cleansed. They knew a great deal about drugs--"the balm of Gilead"wand the use of poultices. Of course, some of their medicaments seem magical. Their use of that mysterious vegetable, the mandrake, as a sexual or fertility stimulant was as doubtful as the eating of the tomato in the East as a presumably effective love apple. Their concern for cleanliness is evident in the ceremonial laws for washing before meals. Their concern for public health is confirmed by their dietary laws, whatever be the origin of these laws. They even invented quarantine. The Levitical laws demanded that everyone who had been in contact with any infection must observe a forty-day period of ritual cleansing and isolation. When, in the fourteenth century, Italy was ravaged by an epidemic, it was noticed that the Jews suffered less because they were observing this biblical law of forty days of isolation. It made so much sense to the Italian authorities that they made the regulation mandatory for Christians as well as Jews. The Italian word for the Hebrew word "forty" is quaranta and, hence, the period of isolation came to be known as quarantine. Now I am not recommending that we replace modern medicine with the folk medicine of the Bible. I am only pointing out that the biblical Hebrews were advanced healers for their time because they viewed man as a whole, not as a fragmented person. In a limited sense, they anticipated what we today call psychosomatic medicine, which has demonstrated how many diseases originate in or are aggravated by unresolved emotions of anger, anxiety, loneliness, rejection, and unlovableness. Peptic ulcer, ulcerative colitis, migraine, asthma, hypertension, rheumatoid arthritis, even coronary thrombosis can be caused or at least precipitated by emotional stress. Therefore, it is sometimes more important for the modern physician "to know what kind of fellow has the germ than what kind of germ has the fellow." Illness may sometimes be the way a person unconsciously tries to resolve the frustrations in his life. To understand what a patient may actually be saying by his illness may be the first step toward his healing. This is exactly what the Bible implies when it says, "Hope deferred maketh the heart sick, but desire fulfilled is a tree of life;" and "A merry heart doeth good like medicine, but a depressed spirit" gives you arthritis or as the Bible describes that disease, "drieth up the bones." These ancient healers, of course, openly invoked the aid of God in their medical practice and, if I may also add, in their intuitive psychiGod and the Psycbiatrist in Psychotherapy
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attic practice. The word "psychiatry" comes from the Greek that literally means "healing souls." The concept of a partnership with God in a medical team-work continued long after biblical times, particularly by the Jewish physicians who were famed throughout Europe. Rabbi Dr. Ben Siraeh, in the 2nd century, said: "My son, in sickness be not negligent, pray unto God, for He will heal; and to the physician also give a place, for there is need of him likewise. For there is a time when in His hand is good success for the physician too will supplicate to God that God will prosper him in his treatment." (Hokmat ben Sirach. The Wisdom of Ben Siraeh) Rabbi Dr. Moses Maimonides, the renowned court physician to Sultan Saladin during the period of the Crusades, sounds quite modern in his saying: "Among a thousand people, only one dies a natural death--the rest suecumb to irrational modes of living." (Moreh Nebukim. The Guide to the Perplexed) This rabbi, who lived Boo years ago, was far in advance of certain present-day clergymen who seem to advocate what I would call unhealthy religion when they advise people to pray to get peace of mind. This may make of religion another temporary tranquilizer, but it removes the effect religion should have on changing evil conditions in society that disturb the peace. In contrast, Rabbi Dr. Maimonides said: "Not until one has peace of mind should one pray." (Mishneh Torah) In the thirteenth century, there was a mystic kabbalist physician, Rabbi Dr. Samuel Abulafia, who actually anticipated Freud's use of free association to get at the origin of neurosis. Abulafia called it "ke[itsa," the Hebrew for "skipping from one idea to another." Abulafia said this method would help "to unseal the soul, to untie the knots which bind it." In the fifteenth century, Rabbi Dr. Almoli wrote a book entitled The Interpretation of Dreams, in which he describes the sex symbols in dreams and also treats the dream as wish fulfillment. His ideas are strikingly parallel to the psychoanalytic theory of Freud. Indeed, Freud quotes Almoli in his own famous book, The Interpretation of Dreams. The rabbis who were the most expert in combining religion with psychotherapy were the seventeenth- and eighteenth-century Hassidic rabbis. They lifted their followers out of despair and guilt and gave them meaning and hope. They tried to help their followers recapture a confidence in the happiness of living. They emphasized a new, joyful prayer instead of the old orthodox, doleful prayer. They practiced a kind of group therapy in the communal dance they introduced into the syna-
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gogue. A century before Freud, the Hassidic rabbi even devised his own technique of a talking-out method to aid a person achieve a sense of his worth and confidence in life. Rabbi Simcha Bunam of Parshisha said: "It is highly necessary for every human being to have at least one sincere friend--one true companion. This friend must be so close to us that we are able to tell him even that of which we are ashamed." One of the most pious of the Hassidic rabbis once said: "Supposing some one comes to you and asks your help. You shall not turn him off with pious words, saying 'have faith and take your troubles to God.' You shall act as though there were no God; as though there was only one person in all the world who could help this man--only yourself!" Of course, this rabbi could risk making this astonishing and apparently sacrilegious assertion because he believed there is a God with whom man is in partnership. He was simply stating that man should uphold his end of that parmership, t One of the greatest concerns of the Hassidic rabbi was to eliminate from the Jew his neurotic guilt feeling that the Jews deserved being persecuted for their sins. Rather were they the victims of the neurotic aberrations of the Christian anti-Semites. A piquant example of the effort of these Hassidic rabbis to normalize guilt and distinguish between healthy, responsible guilt and unhealthy, self-hating guilt is the Hassidic explanation of why the listing of the sins recited on the Jewish Day of Atonement is arranged in alphabetical order. The ./1I Cbet, "for the sins" prayer, is arranged on the basis of A to Z (from the sin of adultery to the sin of xenophobia). If that prayer of penitence were not arranged alphabetically, they said, "we should not know when to stop beating our breasts, for there is no end to sin and no end to being aware of sin, but thank God, there is an end to the alphabet. ''z It is not accidental to note that a number of Freud's first disciples were Jewish physicians whose fathers were Hassidic rabbis. The founder of Habad Hassidism, Rabbi Schneuer Zalman, in the nineteenth century, wrote vigorously about the capacity of man's conscious free will to overcome subconscious evil instincts. His grandson, the late Joshua Schneirson, M.D., psychiatrist, founded the Mental Hygiene Institute for Children in Tel Aviv. He incorporated Jewish religious insight in his modern Hebrew works on child psychology. The philosophy about the "Thou and the I" of Martin Buber, which has had widespread influence on modern psychotherapy, was also derived from
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Buber's own great studies of these Hassidic rabbinical, intuitive therapists. Despite this long history of the use of a religious philosophy in the practice of medicine by Jewish physicians, the Jewish founder of psychoanalysis, Sigmund Freud, was the most powerful force for separating religion from medical psychotherapy, even though he spent a great deal of his own psychic energies theorizing about religion. There is as much popular confusion about what Freud said about religion as there is about what Marx said about communism, simply because both of these Jewish geniuses have been approached from the special prejudices of the person speaking. First, let us state what Freud said about religion; second, let us ask why he said it; and, third, did he mean that what he said was the absolute final word on the matter? Concerned that men should grow up and stop acting like infants, Freud said: "Immature men invented a God-father to defend them, since man cannot cope rationally with his own life's problems." W h e n an adult behaves like an infant and is obsessed by his dependence on a father, he is neurotic. Religion, then said Freud, "was the obsessional neurosis of humanity. ''a Freud was particularly opposed to what he justifiably thought religion had been doing to repress sexual fulfillment. So, while religion was a neurosis, anyone, he claimed, who could engage in a normal sex life could never suffer a neurosis. A mature person had no need for the illusion of a God, since he would be free from anxieties this religious delusion fails to remove. Freud's attack on religion cannot be put in the same category as other criticisms of the tyranny of those religious institutions that, throughout history, have repressed man in more ways than sex. His criticism of religion is more fundamental in that Freud had a mechanical view of the nature of man. He thought man's behavior could be reduced to scientific formulas horganie, inner psychic and outer social conditioning without any reference to man's spiritual dimensions. Did Freud think man would be healthier if he obeyed mechanical, rational laws of behavior freed from religion? It seems he did not, for Freud was a pessimist about life as a whole. He admitted that psychoanalysis was not a v:eltanschauuzeg, a life philosophy. While he attacked religion's worst aspects, he never was absolutely sure that religion had no place in mental healing, as his letters to the first clergyman he had analyzed, the Swiss pastor, the Reverend Oskar Pfister, reveals. In fact, Freud thought this clergyman84
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therapist had an advantage over himself in that Pfister could lead his patients to a mature concept of God that might even reduce neurosis. Freud was supremely honest and did not, himself, believe in God. He was even more honest about his pessimistic outlook on life. He was brave, but knowing that his sisters had been taken away by the Nazis, a fate from which he, himself, was barely rescued, and dying of cancer of the jaw could scarcely induce optimism. One can understand, then, this sentence in his book, Civilization and Its Discontents: "Only religion is able to answer the question of the purpose of life. One can hardly go wrong in concluding that the idea of a purpose in life stands and falls with the religious system." Since Freud found no meaningful purpose in man's existence, he repudiated religious systems. If he had lived after Hiroshima, his pessimism would have been even greater. In 1967, Freud would have found an even more profound pessimism among his fellow intellectuals about the absurdities of the human condition and existence. W e should realize that most of Freud's patients were intellectuals or among the upper luxury class who could afford his treatment. In fact, a psychiatrist today who practices classical Freudian analysis, with its prolonged involvement with transference for two years, five hours a week, can probably see only a few hundred patients in his entire career. In Freud's day, the major problem of such persons as his patients was thought to be their repression of sex. In our day, twenty-five years after Freud's death, I think the major problem of this select group is their repression of hope. One can now have a normal sex life and still be neurotic. The general cultural European atmosphere in Freud's time was optimistic, even though people were prudish and secretive about sex. Tennyson describes this Victorian hopefulness in his poem, "Loeksley Hall," in which we find the familiar line: "In the spring a young man's fancy lightly turns to thoughts of love." And farther on: "For I dipped into the future, far as human eye could see,/Saw the Vision of the world, and all the wonder that would be;/ . . . Till the war-drum throbbed no longer, and the battle-flags were f u r l e d / I n the Parliament of man, the Federation of the world." Despite this optimistic atmosphere, Freud was a pessimist and had very little to say about how a hopeful trust and the capacity to love go hand in hand. What he did say has become a much misunderstood household language. As our technological society has dehumanized, disorganized, and disoriented man,
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everyone today freely talks about the mechanics of sex, oedipus complexes, incest, and homosexuality. W e even witnessed a rash of amateur analysts all over our land in the Bridey Murphy craze; a person would suggest that his friend lie clown on a couch and go back in his memory as far as possible. A cartoon ridiculing this caricature of psychoanalysis showed a man going back so far in his subconscious that he retreated to the very beginning of time. The caption of this cartoon had him saying: "And after six days of creation, I rested on the seventh." Of course, one does not become a god through analysis, nor does an analyst pretend to be a god. Some neurotic patients may have an idea that their analyst is a god, and there seem to be a few analysts who do speak ex cathedra on all subjects. The fact is that the analyst can never be as impersonal as Freud thought he should be, sitting behind the couch so that his patients could not see his facial expressions. Since Freud's time, much study has been devoted to the relations between the analyst and the analysand. Objective though he try to be, the analyst is a human being, and his own theories and values come to be absorbed by his patients. Because a major cause of neuroticism is rejection, the patient wants to be accepted by the analyst. To win acceptance, patients may accommodate their Freudian analysts by dreaming Freudian dreams, while for the Jungian analyst, they dream Jungian dreams. The therapists can choose whether to take on a patient for therapy; they tend to choose those with whom they, themselves, have something in common--economically, socially, or intellectually. With these people, the psychoanalysts do have some successes. Since the analyst is as much involved as the analysand, expert teachers of psychotherapy, like the late Dr. Franz Alexander, are less interested in the technique a therapist has learned in his particular denominational school and are more interested in who the therapist is, what he believes, what his personality is, how much commitment he has, and what are his problems. Over a certain period, the patient internalizes the values and attitudes of his therapist. That the therapist's confidence in himself and positive convictions about his own healing methods is persuasive to the patient should not be surprising. A physician tried samples of a new drug received from a pharmaceutical house to treat a patient's long-term asthma. The asthma was dramatically relieved by the new drug, but the physician decided to be more scientific and, without the patient's knowledge, substituted a
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placebo--a harmless sugar pill. The asthma returned. Again, secredy, the physician substituted the sample drug with excellent relief. Now impressed with the sample drugs, the physician requested another supply. He was then informed that the drug company, having had some question about the new drug, had given him a placebo from the very beginning. As long as the physician believed in the value of the pill, it worked; but when he didn't, somehow his patient got the message and the drug failed. In his clinical experiments at Johns Hopkins, Dr. Jerome Frank demonstrated that those psychiatric patients who were simply told before therapy began that they had excellent prognosis of recovery did better and in quicker time than those who were not given this initial assurance by the psychiatrist. Shall we then accuse a physician who gives a placebo or a psychiatrist who holds out reassuring hope of being fakers? Not at all! This only demonstrates how much those sick in body or in mind need to relate to another person who will give them enough confidence in life to want to live and the responsibility of exerting the will to do so. This is why the old one-sided emphasis in Freudian psychoanalysis is being questioned because of its limited results for a limited number of people and is being replaced by a broader view that "neurosis comes not merely from repressing unsatisfied instincts, but also from repressing an uncomfortable conscience. The neurotic is not merely sinned against; he may also be a sinner. The emotionally ill may aggravate illness by irresponsibility. They would rather lie on a couch than put their shoulders to the wheel." Their recovery is as much related, then, to a healthy sense of their own ego and what they can do in life when they feel respected and loved as it is related to satisfying the sexual id. And now there are vigorous new explorations in new forms of therapymbehavioral therapy, operational therapy, conditioning therapy, reality therapy, group therapy, family therapy, existential therapy, and spiritual therapy. These newer methods are the result not merely of newer theories, but of public necessity. Every resource available must be used to meet the overwhelming challenge of mental illness, which troubles at least seventeen million Americans today. A report by the Senate a few months ago indicated that one out of every ten children in the U. S. will need some form of psychotherapeutic help. So, today, competent psychiatrists are exploring all kinds of ways to meet this problem, in-
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eluding even training sensitive laymen or laywomen in the art of listening as assistants in the mental hospitals. Compared to less than I5,ooo psychiatrists, there are 3oo,ooo clergymen in the United States, and, if properly oriented, they could make a considerable contribution in the over-all area of social or preventive psyehiatry. But where does God come in, in all these newer short-term, nonFreudian therapies? A therapy may deal less with the past and direct the person more to having goals, but it still need have nothing to do with God. A therapy may be less involved with origins of emotional disturbanees and more concerned with the patient's potential for health; it may be less based on examination of inner past conflicts and more concerned about developing the feeling of being loved but this may be done by a psychiatrist in psychotherapy without God. One may even employ successful group therapy in which a sense of belonging in a group of trusted confidants who have endured similar sufferings is developed and a new confidence in life effeeted. In Israel, the psychiatrist, Dr. Weinberg, studied the neurosis eaused by the horrible experienees in Nazi concentration camps. He found that because they suffered together, those caught were less neurotic than those who had escaped this camp experience. Those without the concentration camp experience felt more guilty because they were alive while their relatives were dead. From such a concentration eamp, where he had lost his entire family, one Jewish psychoanalyst, Dr. Viktor Frankl, was liberated in x945 and returned to Vienna, where Freud had started. "At that moment," he wrote, "there was little I knew of myself or of the world. I had but one sentence in mind, always the same--I called to the Lord from my narrow prison and He answered me in the freedom of spaee. TM Frankl calls his therapy logotherapyRlogos, the Greek for meaning, " . . . or a therapy that foeuses on helping a person find meaning to life." He eould have been more pessimistic than Freud, who once said to his patient, Princess Bonaparte: "The moment a man questions the meaning and values of life, he is sick. ''5 But Frankl believes the opposite. To overcome the sickness of being a nobody in the erowd, without any identity, alienated from yourself, controlled by our present-day collectivist madness, one must ask, says Frankl, "what is existence for me and my aim and my responsibility in life?" The time has eome to add height psychology to depth psychology. "Any attempt to produce goodness and love out of our deep animal in88
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stincts is as thinkable as a river building its own power plant," says Frankl. "Everyone has an altar where he finds his aspirations, and those who have not found the Absolute God absolutize some relative good, like money, status, women, nationalism, or what not, until all these prove to be only fragmented answers to life and, therefore, empty." And there are other analysts like Frankl whose values are religious. Without prayer and without even mentioning God, they convey to their patients this need for meaning in life. Martin Buber had this in mind when he became convinced that a dialogue between two persons in search for God's meaning relating the I to the Thou was itself the most sacred religious experience. Martin Buber did not suggest the word God be used like a placebo. It seems that Jung did not believe in the actuality of God, although he used religious language in his therapy. Buber meant actually the reality of God. No less than the national director of the National Institute of Mental Health, a medical psychiatrist, recently said that "Psychoanalysis and psychotherapy can often put the patient on the right track, but it is religion that can help him realize that the track leads somewhere. Although under normal conditions the difference between a deeply religious person and one who is not religious may be negligible, if both are pushed, the one who topples first is the one who has nothing to hold on to. I can testify to this as a psychiatrist who has observed both types under stress. ''6 As a religious psychotherapist, I, too, can testify to this phenomenon. In a world so destructive, depersonalized, dehumanized as ours has become, the drive for meaning--to achieve a sense of what one of m y patients calls a "me-ness"--has become more important than the sex drive. Without a sense of meaning and identity, sex is no more than sex without any of the elevation of love. Indeed, if life has no worth, even sex becomes disgusting, since sex reproduces life. To avoid reproducing life because it has become meaningless may be one of the more subtle reasons for the rapid rise of homosexuality in our times. Because the Victorian Age believed in life and progress, a Tennyson could write of love in a positive way. In our atomic age of nihilism, the proliferation of nuclear weapons, population explosion, hunger and poverty, annihilation of the human race itself dominates our thinking. In this totally pessimistic frame of mind, the Nobel prize winning poet, T. S. Eliot, logically ridiculed love in his most famous poem, Wasteland. The poet who represents the transition between these two ages--be-
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tween the age of hope with love and our age of hopelessness without love is Matthew Arnold. In his p o e m "Dover Beach," Arnold is standing on the cliffs of England, facing the Channel, and is speaking to his loved one. H e deseribes the waves as they draw back and forth in the moonlight and draws this analogue: The Sea of Faith Was once, too, at the full, and round earth's shore Lay like the folds of a bright girdle furled. But now I only hear Its melancholy, long, withdrawing roar, Retreating, to the breath Of the night-wind, down the vast edges drear And naked shingles of the world. Ah, love, let us be true To one another! for the world, which seems T o lie before us like a land of dreams, So various, so beautiful, so new, Hath really neither joy, nor love, nor light, Nor certitude, nor peace, nor help for pain; And we are here as on a darkling plain Swept with confused alarms of struggle and flight, Where ignorant armies clash by night. As long as there can be no hope for man, it is doubtful whether lovers can "be true to one another," and sex becomes only a masochistic or sadistic escape from life's ultimate frustrations and meaninglessness. In psychotherapy today, psychiatrists seem to be turning more and more to the existence of G o d as a source of hope and meaningfulness in life. Some are aware of it, but most do it without awareness. REFERENCES x. Buber, Martin, Tales of the Hasidim. New York, Shocken Books, 1947. 2. Ibid.
3. Freud, Sigmund, The Future of an Illusion. London, Hogarth Press, i928. 4. Frankl, V. E., The Doctor and the Soul. New York, Alfred A. Knopf, i965. 5. Jones, Ernest, The Life and Work of Sigmund Freud. New York, Basic Books, 196I. 6. Yolles, Stanley, "The Role of Religion in the Mental Health Program," Journal of Religion and Health. 1965, 4, 302-3~
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