A Psychiatric
Case Study on Religious Fanaticism
Originally
published by:
The American Journal of Psychiatry
155:415-420, March 1998
© Copyright 1998 American Psychiatric
Association
---------------------------
Clinical Case Conference
Psychiatric
Evaluation of a "Monk" Requesting Castration
- A Patient's Fable, With Morals -
by Laura Weiss Roberts, M.D., Michael
Hollifield, M.D. and Teresita McCarty, M.D.
AN
INTRODUCTION by The M+G+R Foundation
NOTE
Added on January 9, 2002:
Now that the
Raelian Sect and their clones have become front page news... should you
meet one, please do ask of them, on our behalf, the following question:
"If aliens, not
God, created (cloned) humans, who created those aliens?"
With the authorization of the American Journal of Psychiatry we are
republishing the Case Study of "Brother David" [not his real name]. We
believe that Brother David's story, most of which was never published
by any of the nation's key newspapers, will give the serious reader a
better understanding of the fragile and fine line separating sanity
with insanity in matters of faith.
We have written of the errors of fanaticism
and of radical asceticism. In this fine
study by Dr. Laura Weiss Roberts, et al, the reader will achieve a
better grasp of the dangers of faith-related extremisms.
Brother David's story may initially bring memories of the ancient
ascetic of Biblical times, until the reader realizes that he was a
member of the Heaven's Gate cult who committed suicide in Rancho Santa
Fe, California, in March 1997.
But what if the faith-related extremism is expressed in the form of
believing that the group one is a part of will save, say, the Roman
Catholic Church from its arch-enemies? Or another that instead believes
that the Roman Catholic Church is evil? Or yet another group bent on
the destruction of the "infidels". To what extent will they go to
achieve what they believe is their well
justified mission?
In any case, this fine Case Study may be considered as a home-study
crash-course on the radical faith-related mentality and logic that we
must avoid at all times, regardless of the faith we may profess.
CASE
PRESENTATION
History of the Presenting Problem
An Anglo man who introduced himself as "Brother David," a "monk" from
"Ascension Monastery," was referred by a urologist in private practice
for a psychiatric evaluation at the University of New Mexico Health
Sciences Center during the summer of 1995. The consultation was
prompted by concern about the patient's request for an elective
bilateral orchiectomy. The patient could not explain the urgency behind
the request, and he denied a recent or specific precipitant for it. He
was willing to comply with the psychiatric evaluation simply because he
thought that the urologist would "help" him if the psychiatrist said it
was "OK."
Over the course of five evaluative sessions with one of us (M.H.), the
patient stated that he wished to undergo an orchiectomy because he felt
that his sexual impulses interfered with his spirituality. He described
his sexuality as a stumbling block and a barrier between himself and
"the Creator." He had worked hard for many years to minimize and master
his sexual feelings and felt that he had achieved good success.
Nonetheless, he felt that castration was the final and best option to
ablate his sexuality. His body, he said, was merely a tool of the mind
and spirit. He described his testicles as obsolete, useless, and
harmful to his purpose in life. He likened his genitalia to "a pest, a
fly you swat away that keeps coming back." He also described guilt,
shame, and conflict surrounding his sexual impulses. However, this was
not the case for his nocturnal erections ("when the vehicle wants to
stimulate itself"), which he saw as normal physiology. He reported that
a past trial of finasteride had not been helpful. He stated that he had
been considering the orchiectomy procedure for 10 years and thinking
seriously about it for the preceding 2 years.
In describing the beliefs behind his castration request, Brother David
talked about other "monks" he knew who felt that castration had been
helpful to them in diminishing or eliminating their sexual impulses. In
this context, he lamented his male hormones as "a lot of chemistry that
I don't need.stimulating areas I have been trying to ignore, or move on
from." He felt that his refractory sexual nature was a feature of
"lower existence." He repeatedly suggested that his hormones might, in
fact, be partially responsible for his rebelliousness with respect to
following rules in the monastery. In explaining his wishes, Brother
David referred to two scripture passages: "If your right hand offends
you, cut it off" and "there be eunuchs, which have made themselves
eunuchs for the Kingdom of Heaven's sake. He that is able to receive
it, let him receive it." When asked whether it might, in some way, be a
spiritual failure to need an orchiectomy to deal with his sexuality, he
replied, "[God] cares about overcoming, not how you overcomeIs it a
failure for a cripple to be given crutches?" He expressed chagrin over
the difficulties he had experienced in complying with the restrictions
of his religious life, but he felt that overall he had gained much more
than he had lost by joining the monastery.
Psychiatric Evaluation
Brief background.
Brother David was the second of three children. He described his family
upbringing as "laid back" but punctuated by occasional chaotic
emotional responses from his homemaker mother. While this was difficult
and resulted in distance between family members, the patient said that
he always felt cared for. During childhood he felt closest emotionally
to his grandfather. He discussed his early life as otherwise
uneventful, and he denied physical and sexual abuse. He was raised as a
Catholic. He related that during his young adulthood he became
disillusioned with the Church ("it talked the talk, but didn't walk the
walk"), and he abandoned his early thoughts of becoming a priest.
The patient's first sexual interaction occurred at age 8 and involved
another boy of similar age. He stated that this "homosexual" experience
was pleasurable. From early adolescence he recognized that he was
aroused by males and not by females. He became openly gay during
college, and he briefly underwent supportive psychotherapy, which he
described as very helpful overall. Brother David described his behavior
over the next few years as promiscuous; he reported numerous homosexual
partners, daily masturbation, and brief experimentation with
transvestitism and sadomasochistic sexual practices, which he did not
like. He received frequent treatment for sexually transmitted
infections ("that was before AIDS"). In retrospect, the patient
described feeling never satisfied, experiencing life and sex as if he
were "marking time."
In his mid-20s, Brother David "realized that there's more to life than
sex.than reproducing," although he had not had heterosexual experiences
and had not fathered children. He felt that he wanted to change in
order to "learn the truth" and returned to reading the Bible. Around
that time he found out about a monastery from two "monks" whom he met
one evening at an advertised public gathering. He joined the religious
community shortly thereafter.
Brother David stated that he had been celibate over the ensuing years,
had frequently moved with the others at the monastery, and had little
contact with his family. Nevertheless, he reported that his commitment
to "rising to a higher level" was not as strong as he would have liked
it to be. He engaged in frequent masturbation and felt considerable
remorse. He had left the monastery for a time as recently as 3 years
before the psychiatric evaluation. At that time he had obtained an
outside job. This foray was short-lived, though, as he quickly
"realized that there was nothing in the outside world" for him. He felt
that his religious dedication had been intermittently undermined by his
rebellious nature but that he belonged within the monastery's spiritual
community.
Brother David gave the impression that the monastery was a branch of
the Catholic Church, but not so "rote" in its teachings. He did not
give further information about the monastery, except to refer to his
"bishop" and the other "monks" and to indicate that he could not be
reached by telephone or mail.
Brother David agreed to ask one of the other "monks" if he would come
in to discuss his positive personal experience with castration. At the
fifth meeting, Brother David was accompanied by Brother Thomas, a
middle-aged heterosexual man who had also been involved with the
monastery for more than two decades. Brother Thomas had undergone
bilateral orchiectomy in 1994 elsewhere in the United States. Since
that time he noted a "75% decrease" in sexual interest and attention
toward women. He reported that this change pleased him and that the
procedure had helped him with his spirituality.
Psychiatric review
of symptoms. Brother David stated that other than the counseling
he had received in college, he had not previously received psychiatric
treatment or psychotropic medications. He reported having symptoms of
mood disturbance in the past, such as anhedonia, sleep disturbance,
appetite changes, mild suicidal ideation, and dysphoria connected to
the feeling that at times he "didn't belong." Once during college he
had taken a handful of aspirin when feeling confused, depressed, and
impulsive, but he could not identify a specific precipitant. He had not
attempted suicide again. He currently felt that suicide was not an
option, stating that one "cannot gain anything from it." His most
recent period of significant depressive symptoms had occurred 3 or 4
months before the evaluation and was short-lived. He reported that
since he had entered the monastery his dysphoria had been less
pronounced, his sense of sexual conflict had diminished, and his
depressive episodes had become less frequent. He denied mania, panic
attacks, auditory, visual, and olfactory hallucinations, paranoia,
self-mutilation, obsessions, and compulsions. He denied having physical
health problems, including head injuries or seizures. He had not used
alcohol, tobacco, or drugs in 20 years. He further denied a family
history of psychiatric illnesses.
Mental status
examination. Brother David presented as a healthy man of medium
build, wearing dark, casual clothing. He was punctual, polite,
pleasant, and engaging, and his manner was consistent over the course
of the five interviews. His speech had regular tone and rhythm but was
often slow, as he appeared to be very deliberate in his choice of
words. He used humor sparsely. He had difficulty describing his mood;
he said it was in general "OK." His affect was somewhat restricted,
with a normal range; it varied in accordance with the content of the
dialogue. His thought process was linear and clear. He revealed no
extreme or unusual beliefs (outside of his desire for an orchiectomy),
and there was no evidence of psychotic symptoms. The patient did not
appear impulsive. He acknowledged past suicidal tendencies but denied
suicidal or homicidal ideation at the time of the evaluation. He denied
the desire to hurt or mutilate himself. His capacity for
self-reflection, his insight, and his judgment were adequate and
appropriate to the context of the consultation. In general, his
thinking about a number of topics appeared to be flexible throughout
the interviews, yet he was concrete and fixed—even to the point of
lacking language—regarding his options for spiritual growth.
Clinical
impression and recommendations. The consulting psychiatrist
concluded that Brother David's wish for castration was authentic,
long-standing, and nonpsychotic in nature. Although the request was
thought to be unrelated to delusional beliefs, his overvalued ideas
regarding the relationship between sexuality and spirituality seemed
unusual, rigid, and intractable. No symptoms of a current, full
psychiatric syndrome were observed. However, it was noted that his past
history was suggestive of a recurrent depressive disorder and of ego
dystonia surrounding sexual desire and purposeful sexual behaviors.
Thus, it was concluded that no strictly psychiatric contraindications
to an orchiectomy were evident in this patient. Still, the consultant
recommended that other approaches to his suffering (e.g.,
pharmacological therapy) be considered, as the effectiveness and the
long-term medical and psychological implications of the surgical
procedure were unknown.
The private practice urologist chose not to perform the surgery. The
patient was then seen by a second urologist at the university hospital
who conducted his own evaluation. Subsequently, an ethics committee
meeting was requested jointly by the consulting psychiatrist and the
urologist at the university hospital. The committee's discussion
focused on the ethical aspects of such an elective procedure; no formal
clinical recommendation was sought or offered. The urologist also spoke
with officials of the Archdiocese in Santa Fe; it was unambiguously
stated that Catholic doctrine fundamentally opposes the performance of
castration for spiritual purity.
Ultimately, the second urologist also chose not to perform the
bilateral orchiectomy. He did, however, prescribe a
gonadotropin-releasing hormone analogue, leuprolide, for 6 months. The
patient complied with treatment and was pleased by the results of this
intervention. He also agreed to follow-up with psychiatric care but
stated that the monks were going to travel for a while so that he could
not commit to another appointment.
Consent
After the psychiatric assessment was completed and clinical
recommendations were reviewed fully with Brother David, he was
approached regarding possible publication of his case history in the
medical literature. He was receptive to this idea, suggesting that it
might help clinicians to understand better the sexual issues faced by
their patients. It was explicitly and accurately discussed that his
decision would in no way influence his clinical care at the University
of New Mexico Health Sciences Center. The patient gave his permission;
his consent was informed and voluntary.
Epilogue
Brother David and Brother Thomas were two of 39 members of the Heaven's
Gate cult who, apparently believing that they would evolve into a
supernatural life form, committed suicide in Rancho Santa Fe, Calif.,
in March 1997. Eight of the men who died were reportedly found to have
been castrated (1);
we do not know whether Brother David was one of them.
We were distressed to learn of the tragic and unanticipated end to this
patient's life. It is only after careful study, thought, and
consultation that we have chosen to publish this case report because of
the many morals to its story. To protect confidentiality, we have
disguised critical features of this patient's history and clinical
presentation, in keeping with the literature on ethical case reporting (2–5).
DISCUSSION
Spirit and matter in man are not two natures united,
But rather their union forms a single nature.
—Catechism of the Catholic Church
Half the truth is often a great lie.
— Benjamin Franklin
Truth is stranger than fiction.
— Unknown
This patient's story is like a fable. It is instructive. It involves
beliefs in supernatural persons or incidents. And in its fabric are
woven both truth and deception. While this case raises many issues, for
the purposes of this discussion we will briefly explore how the morals
of the story relate to cultism and to the complex clinical ethical
issues in the physician-patient relationship.
Cultism
Careful observation of cult activities and extensive clinical work with
cult survivors have dispelled the early belief that cults exclusively
attract only psychologically damaged or psychiatrically disordered
individuals (6–15).
Indeed, it is estimated that 2,000 cults exist in this country and that
between 5 and 10 million people in the United States have had
substantial involvement in cults during their lives (9, 14). Of these, nearly
one-half are thought to be healthy, normally maturing individuals who
are recruited into cult membership during a period of exceptional but
temporary vulnerability, such as after a divorce or the death of a
loved one or during another difficult life transition such as
adolescence (7–12).
The remaining half may have had preexisting psychiatric illnesses that
might have influenced their participation in cult activities (9, 10). Importantly, the
prevalence of distress and clinically significant psychiatric symptoms
is dramatically increased among those who leave cults, irrespective of
prior history (9–12, 14–18).
Brother David joined the cult during a young adulthood transition when
he felt that his sexual behaviors were excessive and would not provide
satisfaction or fulfillment in his life. By adopting the lifestyle of
the cult and no longer engaging in sexual activity, he reportedly felt
less anxious and dysphoric. In this sense, the cult's sexual beliefs
and expectations apparently helped him to defend against his conflict
over his sexual identity and behaviors. Like many defenses, however,
this psychological "solution" was inflexible and limiting within the
context of the patient's entire life.
Although cults vary widely with respect to their beliefs (sexual,
religious, apocalyptic, UFO-related, psychotherapeutic, Satanic, and
others), destructive cults differ from formal religions in that they
are characterized by the common themes of "deception, dependency, and
dread" (14).
Formal religions generally are committed to disclosing theological
doctrine truthfully, supporting personal inquiry, and promoting
autonomous choice or acceptance of religious principles. In contrast, a
destructive cult possesses four defining attributes. First, cult
involvement entails the eradication of the individual self or the
subordination of the self to the cult leader and the broader cult
community. Second, a primary goal of the cult usually is the
perpetuation and extension of exploitation (e.g., financial, sexual,
physical) of cult members. Third, the cult leader is typically a highly
authoritarian, determined, and charismatic individual who is alive and
whose unusual life experiences (e.g., visions, trauma, dreams) become
integrated into the cultic belief structure. Finally and most
importantly, the cult uses power unethically to ensure the compliance
of its members.
This last feature of destructive cults, the use of "unethically
manipulative techniques of persuasion and control," has been described
by Robert Lifton (6, 7)
and others (8–15).
These techniques include eight elements.
1. There is totalistic control of the everyday life of the cult members
(milieu control), such as physical isolation, censorship, and
restricted communication; highly narrowed work activities and social
interactions; limited clothing and few possessions; and deprivation of
food. In the Unification Church of Rev. Sun Myung Moon and in the
Heaven's Gate cult, for example, recruits were required to travel in
groups of two, to dress alike, to renounce their former lives and sell
their possessions, and to relinquish their driver's licenses (8, 19, 20).
2. Cult leaders practice purposeful deception in order to appear to
have special powers (mystical manipulation). For instance, before the
1978 mass suicide and homicide claiming 914 lives in Guyana, the leader
of The People's Temple, Rev. Jim Jones, appeared to "cure" cult members
miraculously of systematically fabricated medical illnesses (13).
3. Absolute and unquestioning loyalty to the cult organization and
beliefs is present (demand for purity). This is seen in the rules of
Heaven's Gate: offenses included deceit toward cult members or leaders,
intentional disobedience, sensuality, and finding fault with cult
leaders (19).
Individuals who left the Heaven's Gate cult reported that while they
were within the cult they were required to live for long periods in
severe poverty and to drink "cleansing" liquids while forgoing solid
foods (20).
4. Shame and harsh judgment are used to ensure the psychological
vulnerability of cult members (cult of confession). In EST (Erhard
Seminars Training) and other psychotherapy cults, for example, the use
of "hot seat" confession rituals has been commonly reported (13).
5. Seemingly scientific, comprehensive, and distorted explanations are
advanced in order to give cult beliefs the appearance of greater
credibility (sacred science). This is well-documented in materials
published on the Internet by the Heaven's Gate group and is also seen
in other futuristic and UFO cults (19, 20).
6. A ritualized, narrow repertoire of phrases is used to limit
independent thinking around cult beliefs and may facilitate
dissociative experiences (loading of the language). In contrast to
beliefs of the Catholic church, by referring to the person's body
merely as a vehicle, the Heaven's Gate language presupposed a split
between the mind and body, between the spirit and the material nature (19, 20). This language
preempted reflection about the self and the body together forming one
whole.
7. Persistent invalidation of the cult member's perceptions and
feelings takes place in order to advance cult ideals or goals (doctrine
over person). In the Heaven's Gate group, putting oneself first, taking
independent action, having private thoughts, having likes or dislikes,
being distracted, having inappropriate curiosity, and trusting one's
own judgment were offenses against cult rules (19).
8. Those outside the cult, including friends, families, and entire
nations of people, are redefined as evil, unworthy, dehumanized, and
perhaps deserving of retribution (dispensing with ordinary existence).
A dramatic recent example of this feature of destructive cults is the
Japanese cult that released poisonous gas in a subway in 1996 in an
attempt to start a world war, there~by "saving" cult members and
annihilating all others.
These manipulative measures accompany cult indoctrination, exhaust an
individual's strengths, promote fragmentation, and lead to repudiation
of the self and unquestioning acceptance of cult beliefs and practices (7–15). For these and other
reasons, the destructive cult experience is one of devastating trauma
and has been described as the "impermissible human experiment" (9, 14).
In retrospect, phenomena related to destructive cultism may be
identified in Brother David's clinical presentation. Milieu control was
evident in the fact that Brother David could never be reached directly
by letter or telephone. He appeared to be nearly alexithymic, since he
was typically unable to characterize and articulate his internal
emotional state. It was as if he experienced dissonant internal or
affective milieu control in this respect. Demand for purity was present
in the rule for total celibacy, both mental and physical. The issue of
sexuality was likely one around which Brother David felt the most shame
and guilt; this suggests a possible role of cultic confession. Loading
of language and doctrine over person were evident in his narrow and
concrete reasoning about options other than an orchiectomy for enhanced
spirituality. Impressively, these features existed in an otherwise
flexible, likable, and bright person. The connection of Heaven's Gate
to Star Trek and UFOs and to Internet computer technology suggests the
element of sacred science. Finally, Brother David had become highly
dependent on the cult to find meaning in his life. He described being
unable to tolerate life away from the monastery. In addition, it was
clear that those outside the cult were thought of as incapable of
reaching the higher plane of spirituality. It is uncertain whether he
was uncomfortable with his homosexual orientation or his core gender
identity. Nevertheless, gender itself was felt to not exist at the
"next level," and Brother David's castration request may have
represented a first step in departing from earth and earthliness. This
way of thinking, conceptualized as dispensing with ordinary existence,
relates directly to the stated motivation behind the group suicide of
Heaven's Gate members.
Ethical Issues in the
Physician-Patient Relationship
The most salient ethical dimensions of Brother David's case relate
primarily to the fundamental principles of respect, clinical
competence, autonomy, beneficence, and nonmaleficence in the
physician-patient relationship. If given equal weight, these principles
commonly come into conflict. In this particular case, respect for the
patient's beliefs and preferences placed the urological surgeon in a
tremendous clinical ethical bind: to perform a bilateral
orchiectomy—electively and without clear or traditional medical
imperatives—seemed neither certain to promote good (beneficence) nor to
prevent harm (nonmaleficence) in the care of this patient. The
psychiatric evaluation itself, though extensive, did not reveal
possible indications for the procedure (e.g., repeated, perpetration of
sexual violence upon others) or absolute contraindications (e.g.,
psychotically driven beliefs). Moreover, in addition to the usual
surgical risks, the desired benefit of the requested procedure was
questionable, because testosterone would continue to be produced by
nongonadal endocrine sources such as the adrenal glands. Although it
has yet to receive adequate study, early experience with surgical
castration of sex offenders suggests that this continued hormone
production is clinically meaningful, since sexual impulses, erections,
and performance ability may persist in up to 25% of those who have been
forced to undergo the procedure (21).
In sum, despite the patient's request and clear statement of suffering,
bilateral orchiectomy was not felt to be clinically indicated in this
case. For these reasons, acting respectfully, competently,
beneficently, and nonmaleficently toward Brother David entailed not
respecting his apparently autonomous wishes for castration. It appears
that this clinical conclusion was not unique to our institution; it has
been reported that Do, the leader of Heaven's Gate, also had difficulty
obtaining an orchiectomy and that other members of the cult had had to
seek the procedure in Mexico (19).
Psychiatrists are commonly asked by colleagues to assist in the care of
patients who present complex moral issues (22). Indeed, the scope of
psychiatric practice includes patients who are decisionally
compromised, noncompliant, resistant, uncommunicative, erratic,
terminally ill, institutionalized, traumatized, unlikable, or simply
"hateful" (22–24).
This was noted many years ago by Perl and Shelp (22), who felt that
psychiatrists fill this niche in medical settings because they are
perceived "as having added training in dealing with conflict, including
moral conflict, as being more reflective, and as having more time to
assess" patient situations. The two authors cautioned, however, that
psychiatrists should not assume the role of moral guide when their
primary tasks are to support autonomous decision making and to create a
nonjudgmental context in which to explore complex problems and
feelings. To this, we add that consultation psychiatrists also should
seek to help identify wide-ranging, clinically relevant factors
underlying apparent moral dilemmas. For example, noncompliance with
treatment recommendations may actually be prompted by a patient's
inability to read medication instructions or to pay for clinic
appointments; by cultural beliefs, undiagnosed neurologic problems, or
mistrust in the therapeutic relationship; or by misconceptions about
the illness and the need for care (24).
Consultation-liaison psychiatrists and urologists together encounter
particularly knotty clinical ethical problems when caring for patients
with suspected past trauma and abuse (25). Recurrent urogenital
pain and injury, genital self-mutilation, impaired sexual function,
sexual impulsivity, sexual dysphoria, and odd, eroticized, or
self-destructive behaviors all may arise in traumatized patients who
present for urological care (25).
The relentless, severe, and mysterious nature of these complaints may
lead to multiple diagnostic procedures and surgeries. Patients may not
fully reveal or recall previous trauma, and patients and physicians
alike may not always understand the relationship of traumatic events to
the current clinical situation. In such cases the urologist is placed
in the position of unwittingly adding to the abusive experiences in
patients' lives—of perpetrating new, but very "old" or "recapitulated"
trauma. For these reasons, nonmaleficence is an especially critical
ethical imperative for sound urological care and is a factor that
consultation psychiatrists must watch for in their collaborative work
with urological surgeons (25).
The potential contribution of trauma to Brother David's case, including
psychological trauma associated with cult involvement, is unclear and
remains an untested clinical hypothesis.
In light of these issues, it is important to note that the university
urological surgeon sought to preserve the doctor-patient relationship
while providing optimal clinical care for Brother David. In no way did
he abandon this patient or refuse to serve as his physician, despite
the patient's problematic request. The urologist worked carefully to
understand his patient well and to have his patient's capacity for
decision making fully assessed. He astutely expressed concern about the
accuracy of Brother David's report of his religious affiliation. He
took time. He offered and proceeded with alternative care. He sought
expert consultation and guidance from medical, ethical, and religious
sources before making his final clinical judgment. He did not perform
the bilateral orchiectomy.
Brother David's case also poses interesting ethical issues surrounding
truthfulness in the physician-patient relationship. In essence, Brother
David kept much of his life secret during the process of his surgical
and psychiatric evaluations. The ethical questions related to the
patient's incomplete or misleading statements are complicated in this
instance, however, by his perceived need to protect his personal
autonomy, to shield the cultic group, to preserve his belief system,
and to safeguard his confidentiality. Ford (26) recently identified a
number of other factors that may influence patients' lying, such as
lying to manipulate the behavior of others, to assist in
self-deception, to accommodate others' self-deception, and to avoid
punishment. These issues may have been present in Brother David's case
in varying degrees. For instance, he clearly did not disclose the whole
truth when attempting to persuade his doctors of his need for the
orchiectomy. Moreover, the extent to which Brother David was motivated,
or perhaps coerced, to shield his cultic group remains uncertain but
must be considered.
Brother David's religious tale may also be understood within the
context of the cultures of New Mexico. Roman Catholicism is the most
common religion in this state, but relatively dramatic variations in
Catholic religious practices developed in the 1800s when there was
little contact with European clergy (27). The Penitentes,
referred to as Los Hermanos de Luz—The Brothers of Light—still engage
in flagellation and self-punishment during reenactments of the
crucifixion of Christ, practices which place them in uneasy association
with the official church (28).
The dynamic history of religious differentiation and tolerance together
with the sparsely populated, austere landscape of New Mexico continue
to attract many religious sects, some of which live in monastic
isolation. In addition, Roswell, N.Mex., is the site of a supposed
alien spaceship crash in 1947. It is a source of tremendous curiosity,
and it is the destination of ritualized pilgrimages by many individuals
each year. However, by neglecting to disclose his beliefs in
extraterrestrials and suggesting his connection to the
long-established, slowly changing Catholic church, Brother David
deliberately deceived his caregivers.
Finally, during early discussions connected to this case, three other
kinds of ethics questions were raised. In the ethics committee
deliberation, for example, controversy arose around issues that were
framed as rights—the patient's right to insist upon an elective
procedure, the physician's right to provide care that he or she deems
appropriate and do it in a competent manner, and society's right not to
pay for unnecessary or questionable procedures. Second, concerns about
the role of gender in the clinical care of this patient were also
explored because of a question raised by Brother David. He expressed
puzzlement that physicians in the past have performed elective
oophorectomies for women's subjective and persistent symptoms. He
suggested that his own analogous symptoms would be cured by the
orchiectomy, and yet the procedure was, he felt, more difficult for him
to obtain as a man. A third area of controversy triggered by this case
relates to the greater acceptance of medical interventions that address
genital or reproductive pathology and/or appear to enhance nature or
natural sexuality (e.g., breast or penile implants, in vitro
fertilization) than of those that diminish or seem to distort natural
sexuality (e.g., orchiectomy, transsexual surgeries). While
conscientious differences of opinion persist around such topics, this
case is valuable in terms of making explicit the values that are
operative within and throughout ethics-laden clinical decision making.
CONCLUSIONS
The morals of this patient's story are many and intertwined. Foremost
is the observation that unusual requests from patients merit careful
and prolonged clinical evaluation. Such requests often reveal unusual
motivations in unusual individuals, requiring thoroughness, multiple
sources of information, time, and other forms of clinical conservatism
to understand well. While not all sources of distress in patients will
result in a definitive diagnosis or a clinically effective, ethically
acceptable treatment, it is nevertheless the tradition of medicine to
inquire, investigate, and accompany the patient in the face of poorly
understood suffering. The consulting psychiatrist may play a critical
role in supporting troubled patients and in helping to clarify these
complex issues, which may be camouflaged or obscured and otherwise may
cause physicians to do harm unwittingly.
A second moral relates to psychiatry's incomplete understanding of the
ties among psychopathology, coercion, sexuality, and cultism. Our
field's diagnostic nosology does not yet adequately capture
psychological aspects of cultic phenomena, nor does it offer an
explanatory model to help understand the impact of sexual issues,
conflicts, and behavioral expectations experienced by individuals
affiliated with cults. Few empirical data in such areas exist. Does
this inattention, as some have claimed, reveal a naive and mistaken
belief among mental health professionals that cults provide a benign
psychological home for societal misfits (13)? Further inquiry and
self-reflection are imperative if we are to recognize and respond in
clinically and ethically astute ways to patients whose lives may be
affected by destructive cult experiences.
A third moral of Brother David's fable-like story—complete with its
lessons, supernatural events, and untruths—is the value of recognizing
patients' immense need for personal meaning in their lives. Brother
David was a very likable, bright man who felt that his search for
spirituality through the monastery had helped him. We can see how it
also destroyed him, and, for this reason, we may be tempted to dismiss
the nature and magnitude of his everyday cult experience over two
decades. Brother David's life history nevertheless reminds us that
spirituality is an important domain of psychological health that should
be respected but not overlooked for its clinical implications.
FOOTNOTES
Received June 19, 1997; revision received Nov. 4, 1997; accepted Nov.
11, 1997. From the Department of Psychiatry, University of New Mexico
School of Medicine. Address reprint requests to Dr. Roberts, Department
of Psychiatry, University of New Mexico Health Sciences Center, 2400
Tucker N.E., Albuquerque, NM 87131-5326. The authors thank Drs. Carol
Fryer, Sally K. Severino, Zachary Solomon, and Joel Yager and Brother
Mary Aquinas Woodworth for their comments on this paper.
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Originally published by The
American Journal of Psychiatry 155:415-420, March 1998
© Copyright 1998 American Psychiatric
Association
Published in this domain (The M+G+R Foundation) in 2000
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