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wrgs-book-sLater, the whole field of psychiatry and religion became indebted to David Roberts for an understanding of forgiveness as the antidote for the sense of guilt. Roberts described a theistic faith as being in "the language of drama and personal relation—struggle and triumph, anxiety and fellowship, guilt and forgiveness." (David Roberts, Psychotherapy and a Christian View of Man, p. 87; Charles Scribner's Sons, 1950.) Such release from guilt through forgiveness can result in a transformation of the self. This happens in psychotherapy when one faces and grasps "the deeply hidden causes of inner dividedness." (Ibid., p. 135.) One receives acceptance (i.e., forgiveness).

      More recently, E. Mansell Pattison, M.D., has elucidated the problem of guilt and forgiveness by distinguishing between ego morality and superego morality. On the one hand, superego morality is more childish, more compulsive, and more determined by one's previous history; on the other hand, ego morality is more responsible, more related to present reality, and more free in its power of personal decision. Pattison says that psychoanalysts such as Hartmann, Rapaport, and Erikson have "systematically elaborated the role of so-called autonomous ego function." (E. Mansell Pattison, "Morality, Guilt, and Forgiveness," International Psychiatry Clinic, Vol. 5, No. 4, p. 100; Little, Brown and Company, 1969.) In another place he states the recent developments among ego psychologists as follows:

     Although couched in various terms, there is a growing consensus that personality development reflects not only physiological needs, but also value needs. Such needs to "make sense out of the world" have been termed the "quasi-needs" of the ego (von Bertalanffy), the will to meaning (Frankl), ego efficacy (White), and cognitive coherence (Festinger)....

      These autonomous ego functions assume the function of "ego drives" in contradistinction to "instinctual drives," These ego drives are dependent upon the beliefs and values of the culture and these drives become important if indeed not the overriding determinants of behavior. Thus it can be seen that belief systems or value systems are the data that the ego uses to organize individual behavior. The lack of such cultural value data results in the failure to develop an effective coherent ego structure; or the cultural value system may result in significant distortions in the formation of ego structure. Belief systems, whether they be religious or otherwise, then are both necessary and influential in the development of personality. (E. Mansell Pattison, The Effects of a Religious Culture's Values on Personality Psychodynamics; American Association for the Advancement of Science, Berkeley, California, 1965.)

     In the course of his formulations, Pattison classifies four kinds of guilt that provide the "stuff" of forgiveness and unforgivingness. He speaks, first, of an arbitrary and impersonal guilt, which he calls "civil guilt" or the breaking of specific laws. Then he describes, second, psychological, subjective guilt feelings, or the internal effect of self-condemnation. Existential guilt is the third kind that springs from the interaction between man and man. People are estranged from each other, as in the case of divorce. Some guilt attends this estrangement in most instances. Finally, Pattison speaks of ontological guilt and says that this, theologically speaking, is original sin. It is that "fatal flaw of human character that leads man to damn himself." (Clinical Psychiatry and Religion, p. 105.) Pattison observes:

     In terms of ego morality, the question is not one of guilt but rather of the assessment of what one is and how one behaves in order that one may modify one's behavior in terms of one's conscious moral commitments. (Ibid., p. 107.)

     Pattison rejects the "punitive model" for forgiveness such as a superego or narcissistic model of forgiveness would demand in terms of "appeasement, restitution, paying back or making up" for wrongdoing, Rather, he proposes a "reconciliation model of forgiveness." (E. Mansell Pattison, "On the Failure to Forgive or to Be Forgiven," American Journal of Psychotherapy, Vol. 19, 1965, p. 106.) By this he means that one is "learning to accept oneself when one realizes that one is unacceptable; and seeking reconciliation from the estrangement one's behavior has brought." Pattison defines forgiveness by saying that the need for forgiveness is filled with "anxiety." "The anxiety is not over punishment but estrangement; the driving force for the resolution of guilt is the deprivation of love.... Here the process of forgiveness is that of reconciliation in the I-Thou of love." (Ibid., p. 107.)

      Pattison's model of forgiveness is the ideal one of which Paul Tillich speaks in describing faith as the "courage to be," i.e., of accepting that one is accepted by God even though one is unacceptable to one's self.

      Therefore, my hypothesis in this chapter is that religion becomes sick when a person is unwilling and/or unable to appropriate the forgiveness of God and his fellowman or is unwilling and/or unable to forgive those from whom he is estranged. He erects a wall of unforgivingness around himself that isolates him from his "significant others," with whom he must live. The publican is an example of the self-condemnatory model of forgiveness as appeasement, atonement rituals, and repetition compulsions. The elder brother who was "angry, and would not go in" to celebrate the return of the prodigal is an example of the unforgiving person who withdraws into a persecutory shell and continues to do so even when no real damage has been done him at all. The kind of sick religion involved in both such instances is apparent as a garden variety of ambulatory sick people who never get to physicians for treatment or to pastors for the ministry of confession and absolution. Yet the symptoms on top of the unresolved guilt consist of reaction formations such as exceptional religious zealotry that "breathes threatenings and slaughters" against the "heretic," the repetition of confessions of small infractions of cultural taboos around them, and exceptional preoccupation with abstract philosophical doctrines to the detriment of those around them. Another example of these garden varieties of sick religion is found in the compulsive church worker who spends the majority of his waking hours in activistic church "doing." It is as if he does and does and does in orderto be accepted and approved in spite of the fact that he does not accept himself.

      Recently the Group for the Advancement of Psychiatry published a monograph entitled The Psychic Function of Religion in Mental Illness and Health. In the tradition of a kind of psychoanalysis that puts much stress on the development and defense of the ego, the authors publish an intriguing case history of a "Methodical Methodist," which reflects a ropelike braiding of both unforgiveness and unforgivingness in the themes of the man's life. I quote by permission the case and its interpretation in its entirety as follows:

     On the eve of his appointment to a professorship in an American university, a highly moral 40-year-old college teacher, then engaged in scholarly pursuits at Oxford University, impulsively picked up a prostitute on the streets of London. No sooner had he left her than he developed a consuming, paralyzing, guilt-laden fear of syphilis and insanity. Later he became afraid of murdering someone in his family, and got rid of an ax out of the fear that he might use it involuntarily. Feeling like an unworthy sinner, he became agitated and depressed, unable either to sleep or to carry on his work. He wished to be hospitalized and wondered whether castration might alleviate his symptoms.

      The patient was a solemn scholar, a professor of history who specialized in l8th-century England. His considerable energies were almost completely devoted to his work, and his pleasures were in the main derived from it. The English accent of his deep, stentorian voice was sometimes broken—but only during times of acute stress—by a weak Southern drawl. The gestures of his hands were those of an orator. Hard work was the keynote of his life. He had published many learned articles and books and edited others, and was a bibliographer of note. At intervals, he took count of the number of pages in his oeuvres. He made meticulous use of his time, rising at 5 a.m. daily and thereafter going through his routine chores according to a prescribed formula. Activities that took him away from his work provoked anxiety on his part. He was frugal, far more so than his financial position demanded. He felt it immoral to squander money, but he also feared being left penniless if he did so. The exception to his frugality was the purchase of books, and he was proud of his extensive, well-ordered library.

      He was scrupulously proper, not only as a scholar and teacher, but also in his daily dealings with family, friend, and stranger alike. He was a popular teacher; his courses were organized with precision and presented dramatically and articulately. A sense of humor, usually absent from his activities in other areas, sometimes came to light in his classes. He was strict, however, in adhering to the rules and demanded high standards both from his pupils and from colleagues of lesser rank. In spite of severe anxieties, he enjoyed addressing large classes and remained composed under classroom stress. His hobby was the study of foreign languages, and he was fluent in several. He greatly enjoyed travel and study in foreign countries. In contrast to his punctuality, punctiliousness, and propriety, he dressed carelessly; his clothes tended to be unpressed, unclean, or unbuttoned.

      He was envious and critical of older colleagues although invariably polite in their presence. On the other hand, he was gracious and helpful in his dealings with students. He was ambitious not only as a teacher and scholar, but also as an administrator. This split loyalty occasioned much distress on his part. While he sought to be with distinguished, intelligent, famous, and wealthy people, he was uncomfortable in their presence.

      He was concerned with the underdog and voiced liberal views on such issues as race discrimination and security for the poor and sick. Yet he was conservative in regard to the loosening of social and sexual restrictions on youth, or the modernization of educational rules. He resented passionately those who, he felt, exploited him or others; physicians in private practice who milked the sick and the poor led the list. It was typical for him to react to stress or disappointment by working harder than ever; success in work helped alleviate the discomfort.

      He had married prudently. To him, his wife's chief characteristic was the fact that she was from a family that was distinguished by its intellect, in addition to being wealthy. The relationship with her, although generally friendly, had little warmth or intimacy. Sexual relations were routine, and lacked spontaneity; during them, he frequently fantasied himself in an orgy with a "promiscuous slut." Fantasies of this sort often stressed the buttocks.

      Both as boy and man, he did not utter obscene words and felt uncomfortable when others did so. His rich, though disturbing inner life included the fantasy of being a distinguished Englishman, such as a statesman, a duke, or a Lord Admiral. His dreams frequently had to do with the toilet, soiling, and bowel movements. He also had "snob dreams," set in plush surroundings where he consorted with royalty or presidents. Though he had not attained the peak of his fantasies, he considered himself to be extraordinarily lucky and feared that it would all disappear in an instant.

Early Life and Development

     The professor was born in Georgia. Early in life he developed an intense shame about himself, his parents, and his Southern origin. His mother he described as crippled, uneducated, and shrewish; her family had more than its share of mental instability and insanity. He suspected that she had Negro blood and that he himself was "contaminated" with it. This fear was intensified by the fact that his dark complexion and black hair resembled hers. He was less ashamed of his father, although ill at ease with his vulgarity and his drawl; he was pleased, however, that some of his father's ancestors had come from England. He became suspicious of his parents at an early age, probably five, when they did not celebrate their wedding anniversary; he feared that he, the firstborn, had been conceived out of wedlock. When he was 11, he confirmed this suspicion.

      He described himself as a "very unsuccessful little boy." He had been expected to die during an attack of measles at the age of 18 months; thereafter, he was treated as a frail, sickly child. He was frightened by fellow students, from whose physical abuse his younger sister sometimes protected him. From the age of six on, he had attacks in which he feared dying of a horrible disease.

      His suspicions about his mother's premarital pregnancy and supposed Negro blood seemed to have fanned the flames of his sexual lust for her at an early age. Fear, however, caused him to turn his back upon this temptation and instead he identified himself with her. The identification was encouraged by the fact that they shared the same dark features and were both "sick people." It was further encouraged when he was eight years old, at which time he injured his penis and went to her for consolation. Strange as it may seem, she advised him to watch out for enlargement of his breasts!

      The identification with his mother did not completely repress competitive, murderous feelings toward his father. These feelings were, however, displaced onto superiors, whom he often found reason to hate. He dreamed frequently of murder; murderous impulses, as we have seen, returned during his adult illness.

      Self-images included being a "sissy," a "nigger," and a "bastard." He considered both his head and penis to be abnormally small, but he often gazed with pride at the size of his bowel movement. He felt stupid, and from the beginning did poorly in school. His first-grade teacher warned him that he was incapable of learning.

      Intense anal-erotic and anal-sadistic impulses, in part a regressive defense against genital impulses, added to his feelings of shame and guilt. He had been thoroughly toilet-trained at an early age, and was regarded as an eager-to-please, sweet boy. Erotic feelings centered around his anus; he often dreamed of soiling, toilets, and large piles of refuse, which symbolized feces. His earliest erotic memories concerned his uncle's buttocks, cut off from the body. In childhood, his sexual interest concerned itself more with a girl's buttocks than with her genitals. Anal messiness spread to other functions; his school-papers were criticized as untidy and his thinking as muddled. Later on, he developed reaction-formations to this messiness; he recorded data and assembled information with great care, and his thinking became meticulous. This combination of anal impulse and reaction-formation contributed to his amassing of a large bibliography, which contributed to his success.

      In part out of the need to assuage oedipal guilt, and in part in order to regain an imagined infancy in which he had come to be loved through being ill and dying, he was already a masochistic hypochondriac at the age of six. At the same time, he developed masochistic fantasies, in one of which he was mortally ill, and his grieving mother was sitting at his side. Before dying, he turned black, as if to remind her what her imagined Negro ancestry had visited on him. In another, he was a servant, imprisoned in the stall of a public toilet, being tortured in order to entertain a princess.

      When the boy was ten, the father became exasperated with his weakness and hypochondriasis and commanded him to "be a man." In response, he began to exercise regularly, forced himself out of isolation, and experimented with his voice, which soon deepened. He thought of outdoing his father's wishes for him: not only would he "be a man," but he would be a great one at that. Every night he prayed, "May I be a truly great man." The shame he felt toward himself and family spread to his house and neighborhood. He yearned for the life of a Southern gentleman, full of dignity.

Religious Background

     The members of his family were devout Southern Methodists. His maternal grandfather was an itinerant preacher. The future scholar faithfully attended the church, its Sunday school, and its other functions. It was the one unifying influence of childhood. Therehe felt accepted, and the emotional atmosphere of its revival meetings stirred him deeply.

      The repeated warnings against sin and about the need to prepare for death, however, frightened him. Guilt and masochism, the latter derived in part from the childhood bout with death, made Hell seem fearfully close. But the solution to the problems that his churchgoing underscored for him was also provided by the church: hard work. Life was represented as a testing period for the beyond, and work was the key to acceptance in Heaven. Further, working one's fingers to the bone satisfied some masochistic needs. His Methodist teaching led him to regard the Bible as a library of great literature, the nucleus out of which his religion had grown. This attitude contributed toward an intense desire to read the Bible and understand it. This interest soon spread to other literature, thus laying the foundation for his evolution into a scholar. The warm, emotional atmosphere of a revivalist church gave some outlet to his erotic feelings, in addition to the promise that high morals and hard work would guarantee the satisfaction of his dependent wishes, whether on earth or in Heaven.

      Latency—Elijah and Christ.During latency, he was especially impressed by the Bible stories about Elijah and Christ. Partial identification with each of them helped lighten some conflicts. He consciously fantasied himself as Elijah, who had outlawed the worship of Ba'al, with its vulgar and licentious orgies, and had encouraged instead the return to a more austere religion. He had literally thrown the immoral Jezebel to the dogs. In identifying himself with Elijah, the boy sought to eliminate his own wicked desires and to find a key character defense—austerity. At the same time, the wicked Jezebel, whom he equated with his mother, was to be removed as an object of temptation. Elijah's miracles inspired him, especially the one in which Elijah raised the widow's son from the dead, for he too had been miraculously snatched from death! Elijah's final dramatic departure to Heaven in a chariot of fire swept by a whirlwind was a proud exit indeed for a "dirty nigger bastard," who might otherwise have been expected to drop straight into Hell. Both miracles helped fan omnipotent feelings that relieved him of his shame.

      He viewed Christ as a New Testament reincarnation of Elijah: Christ too brought the dead back to life. Christ also helped him see that sins can be forgiven and showed him how to work out masochistic fantasies in a socially acceptable way. It is not certain whether the Pietàfantasy of dying in the presence of a grieving mother facilitated the identification with Christ or resulted from it. He became a Christ who took on the sins of the world—a neat way of rationalizing his feelings of being a sinner. If a classmate erred, he confessed and took the punishment. Literary inclinations, already fanned by an interest in the Bible, centered on the fantasy of writing a book about a boy's suffering. This book would bring him fame.

      Adolescence and John Wesley. As he entered adolescence, these identity components became less satisfying. The emotional atmosphere and the magical ideas brought him too close to the loss of control he feared. The shame that he felt for himself and his family contaminated his attitude toward the local church. But there was someone in the church to whom he could turn—John Wesley. He had long been acquainted with Wesley, the l8th-century founder of Methodism. When he was 11 years old, his grandmother had given him a book of Wesley's sermons. Wesley was venerated in the church, and the growing boy put him above Jesus. Wesley proved to be a more practical source for finding solutions to his adolescent dilemmas than did the Biblical figures. His interest in Wesley continued even after he left the church: he wrote a term paper about Wesley in high school, and would probably have made Wesley the topic of his Ph.D. thesis, had he not been afraid that this would mark him as a Southern Methodist.

      Wesley, who shared his initials, had preached in Georgia for several years, and it was easy for the adolescent to imagine himself following in the great man's footsteps. Wesley, like him, had been a sickly child but had blossomed into a vigorous and successful man, perhaps the most energetic of his day; to be like him would more than fill the father's demand that he "be a man." Wesley was an English gentleman who traced his pedigree back to a 10th-century nobleman. His father was the Anglican rector of Epworth and a man of letters; his mother, the daughter of a vicar and related to an earl. Her training is said to have formed the foundation of Wesley's character. The adolescent boy felt that his own mother, by contrast, was largely responsible for the shame he felt about himself. To be Wesley and to have such a mother, even in fantasy, would be to undo his destiny. To a boy who regarded himself as a low Southerner, in being a Wesley he would surpass even the hitherto envied Southern gentleman. Indeed he would be a distinguished English gentleman, accent included.

      Wesley had given up a social life at Oxford in order to become an ascetic preacher. As a preacher, he was a spellbinder, imperturbable in front of a crowd. He was rigid in belief and action, and lived by hard work. Methodism originated in the methodical conduct for which Wesley was himself the model. He was precise and punctilious, both in worship and in the practice of life. He rose every morning at 4:00 a.m., and carefully noted his activities in a daily journal; he was frugal and led a simple life. The boy was thus given leave to give up the social life that had been forced upon him by his father. Once having decided to follow directly in Wesley's footsteps by becoming a minister, he isolated himself from his peers and ascended in fantasy to a preacher's pulpit, from which he could look down on the crowd, instead of feeling looked down upon by them. Erotic and hostile feelings were partially controlled by this fantasy, although hostility could continue to be expressed in righteous indignation against sinners. In his later identity as a professor, he simply converted the pulpit into a podium and carried Wesley's composure as a preacher into the classroom. The whining weakling became an effective, full-voiced orator. Like Wesley, he arose early in the morning (although not until 5:00 a.m.), maintained punctilious study habits, and kept a journal. The shame-laden frugality and simple life that had been forced on him in childhood by his economic and social status had now become the admirable attributes of a moral and genteel man.

      To the future professor, as well as in reality, Wesley had been much more than the founder of Methodism. He was a scholar, a literary man, a teacher, and an expert in foreign languages, as well as a writer, translator, editor, and traveler. From college on, the professor gradually managed to include all these interests in his own identity. The boy who had been told in the primary grades that he could not learn and who had struggled through high school became an honor student in college and was graduating magna cum laude. Wesley had encouraged the publication of inexpensive books in order to create a popular taste for good reading, and the professor associated this with the large accumulation of paperbacks in his library.

      Wesley's preaching had been directed toward "the unclean beasts"; he ministered to the humble and the poor, exorcising the greedy clergy who were interested only in parishioners with wealth and position. Hence his mission to Georgia. He fought against slavery and was one of the first in England to promote medical clinics for the poor. In contrast to these activities, he was also a high churchman and a Tory. At first, the humble Southern boy felt protected by Wesley, the venerated churchman; later, however, he identified himself with Wesley's humanitarianism and promoted human rights. His hatred for the South's treatment of Negroes, while a part of this humanistic attitude, was also a means of expressing anger about his own feared origin. Wesley severely criticized the physicians of his time and opened medical clinics for the poor. The professor's contempt for the greedy doctors who prospered on the suffering of others barely repressed his wish to be a greedy patient himself, who would be forever entitled to care and protection. In this respect, Wesley became for him a protecting parent rather than an object for identification. Without any financial need to do so, he often considered transferring from private care to a public clinic. Wesley was an outstanding administrator of his flock, as well as a scholar and teacher; the professor's administrative ambitions, by contrast, while partially successful, caused him anguish, for he did not have enough time for all of these activities. Further, his serious, rigid temperament was not acceptable to a liberal faculty, which was intent on maintaining its academic freedom.

      He also unconsciously imitated Wesley's less successful aspects. Wesley did not offer the youth a satisfying model for relating to women, for his own love life had been far from happy. He had been forced to break off an imprudent relationship with a woman in Georgia. Love had been lacking in his marriage; ultimately, his wife had left him. The professor was more fortunate than Wesley in his marriage partner; but to him the marriage was essentially a prudent alliance, and lacked warmth and intimacy.

Adult Identity

     The identity of the professor was not a mere composite of the identity elements he took on from the Methodist Church and his successive identifications with the religious figures attached to it. The partial identifications with Elijah and Christ helped tide him through the latency period, but they were barely discernible in his adult identity; except for Elijah's austerity, which had been reinforced by Wesley's austerity, they existed mainly in omnipotent and masochistic fantasy. Wesley, however, played a leading role in it, especially in its ego-syntonic aspects. Yet the professor was no Wesley: he could not cope with the problem of being a real preacher, for to do so would have tied him to the Southern Methodist Church and to his Southern origins, a tie that was too painful for him to continue. Also the magical ideas that are inherent in religious myths threatened his cherished reason, which was so important in shielding him from the fear of insanity. In specializing in the 18th century, the professor's fantasy life had been focused on Wesley's era; yet this had also been the Age of Reason. While being a preacher did not solve the dilemma, his identity as an English scholar and teacher—an important segment of Wesley's identity—had enabled him to carry on the Wesley identification in a practical and satisfying fashion. In finding his way, he had formed partial identifications with a succession of literary and historical figures, as well as with his own college professors. This had enabled him to scale himself down to the proportions that his own talents and environment would permit him actually to achieve, instead of blindly attempting to mimic the never-to-be-achieved ideal of his adored god, Wesley.

Failure of Identity and Symptom Formation

     The integration of talents, drives, defenses, identifications, and environment did not result in a fully satisfying whole. Much of his shame and guilt remained unbound, and not enough of his hope and pride was able to become bound, in the identity of the professor. The low Southerner and the compensatory Great Man both lingered in the background, while the wished-for ideal of the professor came closer and closer to being realized. In the scholarly Oxonian England that he loved and that he shared in fantasy with John Wesley, at the moment when he was preparing to enter into a professorship to which he had long aspired, he was threatened with the possibility of success. The unbound shame and guilt, on the other hand, led to a fear of failure. The idea that dream and reality were so close together caused his latent fear of insanity to burst into the open. For him, to become insane meant that his anal sadistic and murderous oedipal thoughts would come into consciousness and be acted upon; on the other hand, there was the danger that the delusion of being a Wesley or one of the other Great Men after whom he had patterned himself might emerge full-blown. These fears drove him to act out two more or less repressed identity components: that of the sexual reprobate and that of the helpless patient. The tremendous control over his instincts that had led him to the brink now gave way to reenactment of oedipal fantasies with the London prostitute, who reminded him of the image of his mother—low and sexually promiscuous. But as a helpless patient, he returned to a protecting, preoedipal cradle, thereby avoiding the possibility of adult failure. For failure meant that he would be forced to return, Cinderella-like, to his ignoble origins.

     The case presented above illustrates the fact that characterological derivatives of church affiliation relate only in part to religious doctrines themselves, or to the "religious" qualities of its leaders or prophets. Factors that are more or less irrelevant to the religious message may play an equally significant role. Psychoanalytic studies cannot draw clear lines between doctrinal aspects and seemingly incidental aspects—a reflection of the fact that the unconscious cannot do so either. The particular aspects of religion that are utilized by one individual, as well as the particular uses that he makes of them in character formation, depend on what he brings to religion from previous development and present conflict, and from the ensemble of his liabilities, assets, and needs.

      As this case study shows, the religious material in psychoanalysis may not be manifestly religious. On the other hand, manifest religious content may have little to do with the influence of religion. A particular gesture or tone of voice may have originated in a significant religious experience, whereas a long discussion of church activities may have little significance. Knowledge of latent content is as essential here as it is in the study of dreams.

      Religious figures and religious myths are sometimes said to be projections. The individual may perceive them, not as they exist in the mind of the theologian nor as they are described in the Bible or by the pastor, but as extensions of his own private world. From this point of view, he makes his own religion. Are we then to conclude that such religious ideation, psychologically speaking, is merely adapted to carry on one's previous relationships and identifications, along with the conflicts associated with them? That happens, but, as we can see in the case of the professor, something else happens too. The individual may perceive qualities that are not projections, but that nonetheless fill specific needs or answer specific problems for him at a particular time. These qualities may then add a new essence to living. (The Psychic Function of Religion in Mental Illness and Health, Vol. VI, No. 67, pp. 690-702; Group for the Advancement of Psychiatry, 1968. Used by permission of the publisher.)

     My own interpretation of this case points up my hypothesis about sick religion. In the first place, the "Methodical Methodist" could not feel accepted as who he was in fact. He focused most of his self-rejection upon his birthplace and parents, facts and persons who permit of no substitution. Erik Erikson says that maturity can be said to consist of accepting one's parents and origins as nonnegotiable and permitting of no substitution.

      The only alternative to this kind of forgiveness extended to one's own heritage is a life of repetitious undoingof the facts and persons of one's heritage. This kind of "Out, damned spot!" behavior consistently appeared in the life of the Methodical Methodist. In his inability to forgive and be reconciled with his parents, he remained estranged, alienated, and alone. His symptom formation revealed his kinship with the "low and sexually promiscuous" life he attributed—rightly or not—to his mother. It was a kind of private ritual of confession, an attempt to communicate with conscious intention the ambivalent lack of forgiveness and search for punishment of which neurosis is made. In one and the same act, he both confessed his inability to forgive and received punishment for atonement in his role as a sick patient. He, as the authors of the case suggest, got the status of a sick person and the exemption from any responsibility for his own acts.

      In the second place, the case materials show vividly the usesto which religion is put in the individual's struggle for survival as an independent self. The man rebelled against what he considered to be a sordid and ignorant background. The case material is weakly presented in that the details of the religious instruction of the man are not known or not given. We do not know the data about the religious ideas, behavior, and emotions of the parents. Familiarity with the kind of culture in which the man grew up prompts one to hazard a guess that the parents were not religious at all or were extremely religious. I prefer to assume that the disdain the man expresses indicates that the parents were irreligious and uneducated skilled laborers at best. They probably wanted their son to have what they were deprived of—an education. The education, in turn, alienated him from them and was rationalized through the intellectualisms of his education, his use of language in writing, and his moral superiority feelings about himself in contradistinction from them. The alienation itself produced a burden of unresolved guilt, which in turn manifested itself in his sick behavior and religion. His fastidiousness belied his heritage of uncouthness.

      In the third place, the case history shows that the man's awareness that he was born out of wedlock was a primordial source of feelings of being unwanted. These feelings seem to reflect, in addition to unforgivingness toward his parents, a feeling of being unforgiven and unblessed by his parents. They did not celebrate their wedding anniversary. Apparently, they would have been even less likely to celebrate his birthday. He, in a sense, was a blot on the family escutcheon. He entered life disfranchised.

      Neither do we find any data about his siblings in the history. If he, as the firstborn, did not have the welcoming blessing of his parents, was there another sibling upon whom their approval was lavished to the exclusion of the patient? As long as Biblical figures of identification are being used in the interpretation, one asks about the siblings to see if there is a Cain and an Abel, a Jacob and an Esau, a Joseph and his elder brothers, or a prodigal son and an elder brother. I have noticed how quick analysts are to use father-child and mother-child symbols from the Scriptures and how sibling rivalry and religious-educational motivation are a part of each other. In short, was there, in addition to a "black-mother" image that haunted the patient, a "black sheep" of a sibling that followed him as well. Could he dareto be as profligate as his brother, for instance, without losing the approval of his parents?

      Finally, the illness of the man represents an invasion of his territory by the reenactment of his memories of his heritage apart from his own personal control. Here is how ontological guilt can be the fatal flaw of human character whereby the sins of the fathers are visited on the children unto the third and fourth generations. The purpose of effective religion is not to reenforce the reaction formations of an utterly discontinuous and completely different life in the young as opposed to that of their parents. Rather, effective religion enables the ego functions of the growing youth to reappraise the strengths as well as the weaknesses of his heritage and to lower the emotional importance of one's earthly family to realistic levels. Thus the new territory established by the young "scribe," as the Methodical Methodist was in fact, will include things both old and new. This, as has been said before, is the interpretation Freud himself gave of the psychic function of religion in mental illness and health. Freud's comment in essence was that the function of religion in the mental health of a person, ideally, was to lower the importance of the earthly family, to give the individual's instinctive strivings a safe ethical mooring place, and to enable him to have access to the larger family of mankind. If the above patient's religion could have been such as to have lowered the intensity of his involvement with his earthly parents, then it could be said to have been a well and not a sick religion. As it was it was sick. This idea of Freud's, regretfully, does not appear in the report of the Group for the Advancement of Psychiatry. (For further reference read Sigmund Freud, Collected Papers, Vol. III, 2d ed., p. 597.) Lowering "the importance of one's earthly family," however, does not mean the denying of one's family as having any importance. In Christ and Selfhood, I pointed out that in the life of Jesus the paradoxical process went on as he freed himself of his family—both parents and siblings—and as he unabashedly proclaimed his new identity in his hometown of Nazareth. This paradox, in one way or another, produces either a creative or destructive tension in the religious and intellectual pilgrimage of men and women who in fact do grow and achieve a place or a territory in life that is uniquely their own.

      

Therapy and Unforgiveness

     One of the real gaps in the presentation of the case of the Methodical Methodist is the absence of any discussion of the therapeutic process of caring for the patient. One leaves the case material wishing for this. In order to focus well upon this dimension of the present discussion, I am presenting a second case prepared by Theodore Bonstedt, M.D. The emphasis of this case is upon the positive role of religion in the treatment of a psychiatric patient in that patient's movement toward recovery. I present it as is and will then make some pastoral observations. The aim of this chapter is to understand what the "private hell" of the patient is like. Techniques of the confessional ministry can be found elsewhere (Max Thurian, Confession; London: SCM Press, Ltd., 1959. Wayne E. Oates, Protestant Pastoral Counseling, pp. 89-91, 184-185; The Westminster Press, 1964). The concern here is with counselor insight, which is always a tedious process to develop. The following case report makes specific the positive values of confession and confrontation in the recovery of a psychiatric patient:

     Against this historical background, let us consider the situation of a white, Protestant, 31-year-old married man who was referred to us for psychiatric treatment in the summer of 1960. He was very anxious, almost panicky, as he could not stop himself from vivid sexual fantasies and actions. He was spending long periods of time walking the streets of his city, following a particular "pair of shapely feminine legs"; he would follow up this activity by much masturbation and abuse of his wife, whom he would openly accuse of not being well-built enough to satisfy his sexual needs. Then again there were recurrent moments of despair, a realization that he was immoral and sinning, but many confessions and discussions with his minister would not break this cycle. His worry and anxiety had increased to the point where for much of the time it was no longer possible to concentrate upon his work as an accountant.

      The background of this man was unusually traumatic. His mother had been known as a manic-depressive psychotic patient even prior to the birth of our patient. The father was described by the professional people who knew the family as "nearly psychotic," a strict disciplinarian. Although the patient's older sister tried to serve as a "substitute mother," there was often little she could do when the mother was violent, banging her head against the wall, running and screaming around the house for hours at a time, in fact trying to kill the patient by choking him on at least two well-documented occasions. As the sister became older, she tried to protect our patient from the parental outbursts by taking him into bed with her whenever she heard him stir at night. When the patient was 12, his father died after an operation for a malignant growth, and shortly afterward his mother was committed to a nearby State Hospital for long-term care. The mother died in the State Hospital some years later, but while she stayed there she continued to have various bizarre ideas, and so she told the patient's older sister that her son wanted to abuse her (the mother) sexually.

      The patient was first referred to a psychiatrist at the age of 18 after a fight with his mother. As usual, he threatened that he would "go out with bad women," which seemed to be the only way that he could really get back at his mother. He was then hospitalized for six months because of what his hospital record describes as "a psychotic illness with catatonic agitation." He was treated with deep sleep and psychotherapy, then was followed for three years on an outpatient basis, after which (1951) he was seen only once or twice a year. Meanwhile his performance improved to the point where he was employed steadily and efficiently at a local corporation. He married a shy, reticent young woman, and soon started many arguments over how inadequate she was as a sexual partner, not having enough size to her bust or any sufficient proportions otherwise. In spite of this, he remained very attached to his children, was a good provider, and was regularly practicing his Protestant religion.

      In 1959 (at the age of 28) our patient was asked to leave town on a business trip, as part of a promotion on his job, There followed much anxiety, insomnia, anorexia; outpatient treatment by the previous doctor proved insufficient and he was rehospitalized. He was treated with phenothiazines and psychotherapy. Although he seemed to improve and was discharged in two weeks, he had to be readmitted because of an increase in the previous symptoms five days after discharge. He was described by his doctor as "feeling unwanted, with a feminine identification, with much sibling rivalry toward his younger brother." On this third psychiatric hospitalization (which was actually a continuation of the second), since even rather high doses of Trilafon (8 mg. q.i.d.) would not make him more comfortable, a course of ten electro-convulsive treatments was undertaken. His anxiety diminished and he was followed as an outpatient with tranquilizing medication and psychotherapy by a psychologist. The diagnosis during the second and third hospitalizations was psychoneurosis, anxiety reaction.

      The patient's therapist left the city early in 1960, and it was felt that the patient probably would not need further psychotherapy. However, a few weeks prior to our evaluation of him in the summer of 1960, the above mentioned obsession with not getting enough sexual pleasure returned; once more he was very anxious, almost panicky, pleading for help to prevent another psychiatric hospitalization. At this time we were impressed with the extent of the traumata suffered by this man, and by the 12-year history of a successively psychotic and then neurotic disorder. Under the circumstances it did not appear that further application of a conventional psychoanalytically oriented psychotherapy would offer much hope. We felt that some sort of "synthetical" approach was indicated instead, based upon some asset or strength already present within this man. Since his social history and his own verbal production in the interview were replete with references to an apparently genuine religious faith, decision was made to use this religious conviction as a lever or pivot from which to start a new chapter in the man's rehabilitation at this critical time. Accordingly, after he stated that some of his previous doctors were permissive toward the idea of his trying out a prostitute, he was somewhat surprised when, instead, we posed the question (in the very first hour of psychotherapy) whether or not he wished to remain a man whose utmost goal is that of greatest sexual pleasure.

      We explained to the patient that apparently he had never questioned this point, taking for granted the feeling that he had to be sure of maximum obtainable comfort and pleasure the rest of his days, and that it was an unbearable thought to him that perhaps sometime in the future his wife might not look even as pleasant to him as she did then, and he might indeed feel that he had missed a great deal of sexual experience in the course of his life. The patient at first looked baffled and stunned by this question, then rather impetuously assured me that he wanted to change, but he shifted the topic of conversation. In the next therapy session he reported that he had managed to have a few more relaxed moments when looking at a girl who tempted him by her appearance, as he thought about our discussion and his inclination to surrender the sexual goal. However, it became apparent that his reasoning was that "he did not desire to go out with her because religion says so," and the more he thought in this way, the more the old upsetting thoughts came back. Accordingly, we impressed upon him again the issue of his own decision, his own personal "gamble," rather than what he was told to do. Was his sexual play the most important goal for him by his own decision, or was it not? He momentarily said that it was. We then suggested that in line with this goal it would be only expected that he would drop his wife. He retorted that this was impossible, and we asked what stopped him. With tears in his eyes he confessed that it was the belief in God and also the love for his wife and children.

      An interpretation was made that he had been keeping together within his heart two goals which were quite contrary to each other, as if it were possible to keep these two goals at the same time; he was now finding out the hard way that it was quite impossible, that it "was tearing him apart" and that it brought on all the terrible nervous problems. The suggestion was made that, even if the nervous problems had not arisen at all, he surely would have wanted to straighten out such a mess in his life when he found out about it. During the next several hours in psychotherapy, the working-through of this issue was continued, with the patient somewhat undecided. Meanwhile there was more information concerning the very troubled relationship with his wife.

      In the fourth hour the patient announced that he had decided he was going to live for the sake of his children and not for the sake of sexual pleasure above all. Curiously enough, the patient tried to place partial blame upon two psychiatrists and one psychologist previously involved with him, who reportedly encouraged him to practice extramarital sex "to help himself," since otherwise "suppression is going to take revenge on him." His preoccupation with obtaining pleasure was interpreted as having to do partly with his traumatic background, where on so many occasions it seemed he had been "cheated out of something" which other children obtained naturally.

      With the patient's permission, we started seeing his wife on some occasions, jointly as well as separately, as many episodes of his panic appeared to have a direct connection with interaction in marriage. As the wife herself confirmed, the patient, for the first time in his life, became really concerned about her as a person, being now motivated to make up for some of his previous neglect of her and the children.

      Throughout this time the patient made frequent references to his group meetings in "Recovery" and his counseling sessions with his minister, the latter being placed within the framework of a strictly spiritual counseling (both of these activities had been going on for years).  The patient made spontaneous comments on how the approach taken by us was particularly helpful in that there was no disagreement or conflict with his religious teaching. Thus he found himself able to apply his religious teaching more consciously and more consistently. Although throughout the first year of psychotherapy there were many brief returns of panic during which rehospitalization seemed imminent, he was in fact hospitalized only once for a month in the fall of 1961, following a particularly stressful situation in his job. The intensity of psychotherapy and the approach used continued unchanged after hospitalization; at this time the issue of his excessive dependence upon a doctor (most openly shown in demand for more tranquilizers and sleeping pills) was finally faced with the assistance of genetic interpretations and joint sessions with the wife. Since early 1962 there has been a marked and steady improvement in his psychiatric symptoms, coinciding with his spontaneous verbalization of his chosen values: trying to be a good father and husband rather than getting the utmost in sexual pleasure, trying to do his best rather than fulfilling some absolute standard of achievement, trying to do his best today rather than anticipating all the future to follow.

      As the sexual and aggressive content of the behavior largely disappeared from the waking life of this man, it began to appear in his dreams. While during 1962 he was seen only once a month, in the last three and a half years he has been seen only two or three times a year, and these visits coincided with promotions on the job in the course of which he has successfully traveled as far as a thousand miles away from home. On such stressful occasions the old sexual thought may reappear briefly, but there is no more panic, and a brief psychotherapeutic session is sufficient to tackle the real increased responsibilities. (Theodore Bonstedt, M.D., "Religion as an Asset in a Psychiatric Patient: An Historical and Clinical Comment," The Journal of Pastoral Care, Vol. XXII, June, 1968, pp. 84-88. Used by permission.)

      

Pastoral Observations

     This patient was suffering not only from the symptoms or temptations (if one wishes to think theologically and existentially) that caused him to ask for help in the first place. He defined his problems as sickness and not as in any sense involving his identity as a religious person. He added to the temptation of the sexual fantasies a secondary layer of temptation to make the process of psychiatric treatment a way of life. One wonders if he did not expect the psychiatrists to exorcise his plaguing thoughts with no responsible action on his part at all. Accepting personal responsibility for his acts and thoughts was required of him instead. This realistic confrontation asked that he recognize his behavior, not as something for which he should be punished, but as signs of his alienation from those around him, from himself, and from God. Overcoming this estrangement became the objective of the therapy. Accepting personal responsibility would require that he confess that to some extent he himself had chosen this alienation. If he could make a decision about it once, this gave hope that he could make a different decision about it again.

      In a sense, psychiatric treatment apart from the assets that religion could offer had produced some side effects of its own. The patient was, as I have said, being tempted to make psychiatric treatment a way of life. To the extent that this had happened, the secondary side effects could be called iatrogenic symptoms. This means that the illness originally called for treatment; then new symptoms appeared as a secondary side effect of the treatment process itself. A simple but clear analogy would be the case of an orthopedic patient suffering multiple fractures from an automobile accident getting bed sores from lying in bed. In this case, Dr. Bonstedt refused to let such an accumulation of problems take place. He focused the patient's sense of guilt upon his responsible relationship to God. This transformed his guilt into a realistic sense of having become alienated from God, i.e., having sinned. Now he was both responsible and being treated as responsible to God for his thinking, saying, and doing. The therapist refused to let the man use the "psychiatric out" from under his sense of responsibility. The therapist did not do this punitively, but in a mood of reconciliation of the two different value systems that were "tearing him apart." The side effect of this was that, inasmuch as he was being treated as a responsible "Thou," he could now place a higher value upon himself. When seen as a responsible "Thou" and not as a petrified collection of symptoms, the man began to act like a responsible human being in his own right.

Ethical Perspective and Sick Religion

     The ethical issue at stake in the life of this patient was that of the restoration of the man's personal right and responsibility for decision. The power to decide is a blessing, an affirmation of our humanity, and when it is taken from us we are less than our basic selves. When it is restored, this is acceptance, forgiveness amounting to the reinvestment of trust in us. Yet, this challenges our ambivalence toward either exercising or escaping from the freedom that attends our acceptance of responsibility for making our own decisions. An impressive part of the case report is where Dr. Bonstedt patiently took "several hours in psychotherapy" to work through a moral value issue. The patient was "somewhat undecided." This is the crux of the therapeutic problem—can the therapist "wait out" the forces of indecision and can the patient rise to the occasion of responsible decision on his own? Sherrill speaks of rebirth taking place in psychotherapy. Otto Rank suggests a setting of an end to the therapy by agreeing together with the patient upon a reasonable length of time for "coming through with" some decisions on the part of the patient as to what he intends to be and become. "When he [Otto Rank] did this, he states, he found that the patients began to have birth dreams. The thought of leaving the ... [therapist], he believed, brought out all the anxieties of birth." (Clara Thompson, M.D., Psychoanalysis: Evolution and Development,p. 175; Thomas Nelson & Sons.) Instead of using time to precipitate a decisiveness in this patient, Dr. Bonstedt challenged his relationship to God to become a reality in the processes of his thought.

      A reconciliation model for forgiveness is illustrated in this case also. The fantasies that plagued the man were symptomatic of the man's alienation from his wife. He was a religious man but the covenants he made as a husband and a parent stood alongside his behavior as a contradiction, "tearing him apart." The therapy challenged the patient about his estrangement from his wife. His inner territory was closed to his wife. She was, in the course of treatment, involved also. "Room" was made in both their lives for the other to be included. John Bunyan's classical story of the Christian life in The Pilgrim's Progressis followed by a less well known writing in which he "goes back" and gets his wife and children and enables them to share in his new life. In a less metaphorical way, psychotherapy was the means of grace whereby the man's wife was "caught up" and "brought into" reconciliation with the husband.

      Similarly, the patient as a young adult had not established an effective relationship with a group of his own peers. The "Recovery" group, and his pastor, began to overcome this estrangement, also. Symbolically, the pastor as a person represents the corporate life of the church as a fellowship. In private, he can convey both confrontation and comfort to those who disburden themselves of loads of guilt such as this person expressed. In this way people who would be asocial to the point of pain in the presence of groups of other persons can experience by proxy something of the mind of the group by talking with a pastor.

Paranoid Constructions and Unforgivingness

     The patient discussed in the case material above projected much of his problem onto his wife. He held her unforgiven for something about which neither she, himself, nor anyone else could do anything about—her physical form. This relieved him of the responsibility of being accepting of her. There was no chance for her to change the physiognomy of her breasts, etc. Underneath this projection of blame upon his wife was a subtle game going on that relieved him of the responsibility to be adequate as a man in relation to her. Eric Berne would call the game "If It Weren't for You." In rejecting his own humanity, the patient required perfection of others. If it were not forthcoming, he was freed of any responsibility for overcoming the distance between him and his wife.

      This, it seems to me, is the dynamic of much paranoid interaction in marriage. (See Wayne E. Oates, "Paranoid Interaction in Marriage," The Journal of Family Law, Vol. 4, No. 2, Fall, 1964, pp. 200-208.) The person builds a constellation of complaints against one or more individuals and preoccupation with these relieves him of the responsibility of personal change, understanding, and acceptance of the other person, and, worst of all, keeps a distance between him and other people that is guarded with his whole being.

      This, too, is a garden variety of mental illness, which resides at the heart of many church "splits," chronic division among church people, and running battles with a succession of pastors. At best, it is sick religion.

      

In Summary

     The main sources of sick religion rest in the feeling of being unforgiven and the inability to forgive. Various approaches to forgiveness are discussed and the reconciliation model suggested by E. M. Pattison is chosen. The case of the Methodical Methodist is used as illustrative of the dynamic understanding of guilt and shame. The clinical report of a physician on the role of religion as an asset in therapy aims at the matter of pastoral and medical approaches. The possibility of an undesirable set of side effects of a purely psychiatric pattern of treatment that ignores the assets of religion is discussed.

 

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