International conference "Church care for mentally ill people. Church and psychiatry: facets of cooperation"

Below are papers read at the International conference "Church care for mentally ill people. Church and psychiatry: facets of cooperation", November 26-27, 2021, Moscow (continuation)

Coping strategies in pastoral care for people, who have lost their loved ones (according to the writings of Metropolitan Anthony Blum)

Priest Ioann Melnik

Grief is defined as a reaction to the loss of an object or connection that is significant for the person. It is not necessarily about physical death, it can also be the loss of relationships, a strife, loss of significant things, disappointment in religion or worldview [1]. In this report, we will consider the reaction of grief in relation to the death of a loved one.

The state of grief is caused by information about the death of a loved one, which entails destruction of the vital relationships of the individual.

Mourning is a natural, rather long and multi-stage process that every person, who has suffered the loss of a loved one, lives through.

Among the natural manifestations of grief caused by the death of a loved one, physical suffering is in the first place; it comes in form of periodic crying jags with throat spasms, asthma attacks, shallow breathing and a constant need to fetch a deep sigh, loss of appetite, weakness. Along with the bodily manifestations, a person experiences emotional stress, mental pain. As a rule, there is a preoccupation with the image of the deceased loved person, a slight feeling of the unreality of what happened. Often a person in a state of grief feels guilty, tries to find his own mistakes and omissions, blames himself for what he did not do for the deceased. Often a person reacts to others with irritation and even anger, expressing a desire not to be disturbed, he cannot always control his outbursts of anger. The behavior of a person during a period of acute grief can change so that he becomes incapable of ordinary organized activities, temporarily loses the previous natural patterns of behavior. Over time, a person, as it were, learns to do everyday things again, overcoming the experience of loss and the lack of meaning of any action after what happened [2]. A normal acute grief reaction lasts about 4-6 months, going through a certain dynamic, which the German psychiatrist Lindemann called "grief work" [3]. The goal of grief work is to get over it, to become free of the loss, to adjust to a changed life, and to find new relationships with people and the world.

Psychologists distinguish, as a rule, 5 stages of grief and coping with loss [4]:

• Denial or the stage of shock and stupor, which manifest themselves in the refusal to believe that what happened is real (on average, 7-9 days, but can last up to several weeks).
• Anger / bitterness, or the search stage - is expressed in form of resentment, aggressiveness and hostility towards others. The grieving person unleashes his anger and aggression on many, alternating with denial and shock. He grieves that he is alone in his misfortune, that no one helps or sympathizes with him. He is angry at himself, swears at the Sky, and even at the loved one who died, whose death allegedly destroyed the rosy plans. The main task of this period is the transition from formal recognition to inner acceptance and humility before the fact of loss
• Bargaining /negotiation stage (the stage of acute grief according to Vasilyuk F.E.) [5] is an attempt to escape from mental pain. The grieving person contemplates various situations, often associated with an obsessive "if" ("if I do this and that, it will bring him back...", "if I were there...", etc.), and tries to answer his own questions. After all, this helps not only to realize that a loved one can no longer be returned, but also to survive what happened, to regain a sense of control over what is happening.
• Depression (the stage of "residual shocks" according to Vasilyuk F.E.) [5] follows the previous stages, is manifested by a feeling of sadness, emptiness, a person may lose confidence that he can return to normal life, he often avoids contacts alienating from others. The period of alienation is natural for the process of grief, but if this stage prolongs, a pathological state of depression may develop.
• Acceptance / adaptation ("completion", according to Vasilyuk F.E.) [5] - at this stage, the grieving person not only understands that the departed will not return, but also accepts the bereavement. Gradually, the feelings of loss that dominated a person are weakening, and destroyed social ties are being restored. F.E. Vasilyuk describes this period as a gradual transition of a grieving person from the psychological "staying in the past with the departed" to the state of the present. This period involves the search for a new meaning of relations with the image of the departed person, a new role for the departed in the present life [5].

The pathological reaction of grief differs from the natural reaction to loss by a longer duration (the acute stage can last more than 6 months, sometimes up to several years), the depth and severity of grief experiences that can develop into clinical depression, accompanied by persistent insomnia, self-negation and self-punishment. The feeling of guilt towards the deceased person because of with possible but not taken actions that could prevent the death is relentless and is accompanied by dominant (sometimes compulsive) thoughts and memories associated with the loss. Feelings of loneliness and abandonment, ideas about the meaninglessness of the future life, often with suicidal thoughts, are extremely persistent and painful. A long-term pathological grief reaction is often accompanied by somatic disorders in the grieving person, such as ulcers, rheumatoid arthritis, asthma, often dulled response, asthma attacks. Sometimes, a person with pathological grief reactions who has bereavement disorders, actually depression, may develop the symptoms that the deceased suffered from. Changes in social life are also a marker of pathology; a person can completely change his lifestyle, as well as disrupt relationships with friends and relatives. The grieving person may withdraw from social activities; strive for privacy. In some cases, he may talk about suicide to reunite with the deceased [6].

Various factors can contribute to the pathological grief reaction, for example, that the loss was sudden or unexpected; excessive dependence relationship with the deceased person, which gave rise to despair; multiple losses over a short period of time; lack of personal support, as well as personal and psycho-physical characteristics of a person who has experienced the loss.

It is important to note that many modern researchers deem it appropriate to consider each type of loss separately: the loss of a child, partner, parent, friend, etc. [7]. So, when children die, the reaction of parents to the loss can be especially severe and have a very destructive effect on the personality, accompanied by an all-consuming feeling of guilt and helplessness [8]. Manifestations of grief can last for the rest of the parent's life. Studies show that 50% of spouses who survive the death of a child divorce, unable to cope with the situation of loss.

The death of a loved one is a severe stress, especially for elderly and senile people, almost half develop a pathological grief reaction with severe depression, often accompanied by suicidal attempts, severe somatic distress [9]. The grief reaction in adolescents can be manifested by behavioral problems, learning problems, aggressive or even antisocial behavior.

In psychological and psychotherapeutic practice, coping strategies are an effective way out of a pathological state, which involve overcoming the crisis state of the individual and gradual adaptation to new living conditions. The word "coping" comes from the English "cope" (overcome). This term was first used by L. Murphy in 1962, later it was adopted by the scientific community dealing with stress issues. Now the term "coping" is used in the sense of adaptive coping behavior [10] in response to a stressful situation and the elimination of problems that prevent the continuation of a meaningful life of the individual.

The main tools of coping strategies are personality-specific features and environmental resources. Based on these features, the way of behavior is projected, which is directed to solving a crisis situation [11]. This is consistent with the person-centered principle of treatment, which implies analysis of the basic characteristics of the individual, such as worldview, religious experience, values, spiritual ideals, the state of ethical and moral awareness, etc. [12]. Although the forms of grief progression and its manifestations are very individual, the content of the grieving process is invariable, and this allows us to highlight those universal steps that a grieving person, and his doctor or psychologist, must take to return to normal life. The tasks of mourning do not change, because they are determined by the process itself, and the forms and methods of their solution are individual and depend on the personal and social characteristics of the grieving person (J.W. Worden, 2001).

Tasks one must accomplish in the process of grieving:

1) Accept the loss, overcome the denial of the loss and its significance;

2) Openly live through the feelings - feel and process the pain of loss. At the same time, it is important to overcome the obstacles that a person himself creates in order to avoid working through the pain of loss (keeping himself occupied with work, idealizing the deceased, escaping painful feelings through absorption by travels, etc.);

3) Develop skills to cope with those areas of life which were influenced by the deceased at most. Sometimes it is useful to reformulate the loss in a positive perspective: "What did I gain from the loss";

4) Create new emotionally rich connections. Withdraw emotional energy and reinvest it in other relationships (sometimes despite the feeling of guilt and the inner prohibition that the grieving person puts on himself (for example, not to remarry, etc.)). Often the task begins to be implemented only after a few years. The task four does not imply either oblivion or the absence of emotions. The attitude towards the departed needs to be rebuilt in such a way as to continue to live and enter into new, emotionally rich relationships [13].

Both in natural and pathological grief reactions after the loss of a loved one, turning to religious faith and spiritual life is essential and contributes to the effective development of coping behavior and the resolution of adaptation problems. According to V. Frankl, religious faith can give an individual peace and support, which are difficult to find in another area, and this, in turn, can bring about effective and psychotherapeutic results [14].

The famous Russian psychiatrist D.E. Melekhov, who gave particular importance to the issues of the spiritual sphere in the life of a healthy and sick person, pointed out that a holistic view of the patient cannot be reduced only to pathological symptoms and syndromes [15]. In his opinion, religious beliefs and experiences, especially in emotional and neurotic disorders, can help resist mental illness, adapt to it and compensate for its manifestations and consequences, help find a stronger life orientation based on the authority of God. The American researcher G. Allport, the author of the concept of internal and external religiosity, showed in his works that an internal, deep religious faith contributes to the preservation and strengthening of mental health and has great psychotherapeutic potential [16].

Assistance in situations of loss of a loved one is covered in great detail in the writings of Metropolitan Anthony (Bloom), in particular, in his well-known work "Life. Disease. Death" (record of conversations with Metropolitan Antony in the period 1993-1994 as part of the radio broadcasts series "Priest at the Bedside"). The pastoral approach to the loss of a loved one, presented by Metropolitan Anthony, largely corresponds to the modern understanding of religious coping strategies.

Metropolitan Anthony also raises the problem of overcoming the existential crisis after the loss of a loved one in his work "Death: those who leave and those who stay". It is worth noting that Metropolitan Anthony lived through the loss of all his loved ones and more than once faced the loss in his pastoral ministry. He shares with us his personal experience of losing a loved one and the experience of pastoral counseling, which is based in the Gospel.

Speaking about pastoral care, Metropolitan Anthony notes that a priest needs experience in pastoral ministry, as well as scientific knowledge in order to understand the manifestations and development of a mental illness. At the same time, it is important to take into account the fact that mental disorders, as well as the emotions of a person in a state of spiritual crisis and the loss of a loved one, affect the manifestations of religiosity and church life of a person. It is important to distinguish the symptoms of a pathology from religious experiences [17].

The examples of priest behavior as described by Metropolitan Anthony, though not systematized in terms of modern methods of coping with grief, are very close to religious coping strategies for overcoming grief and illness, which are currently described in professional literature. In particular, at the first stages of grieving, he pays special attention to tactile contact.

In times of acute grief, pastoral support should not be in the nature of rational persuasion, using verbal logical arguments. It is much more important to participate in the grieving, holding a person by the hand, as if saying: "I am with you" [18]. In such cases he advises not strive for heroism in restraining emotions. The following words express a very important spiritual aspect: "... pain is our love. Love expressed itself through joy, now it expresses itself through pain. This is love too, and there is nothing shameful in feeling it ...". The problem of not expressing emotions in a state of grief is that a person does not allow love to be realized, and the energy that was directed to parting with the deceased can come out in a different capacity, harming the person. Undoubtedly, it takes courage to be open in the face of death, and the lack of this action can provoke a person to turn to self-destructive behavior (aggression, suicide, alcohol and drug use).

According to Metropolitan, tears are a gift from God. Christ wept for his friend Lazarus, realizing that through the original sin death entered the world and contaminated the man with corruption. One can't prevent crying, but there is a difference between tears and hysterical crying, which means they affect a person in different ways. Metropolitan Anthony recalls the words of St. Theophan the Recluse at a funeral service: "Brothers and sisters, let's cry, because a loved one has left us, but let's cry like believers ...". The Christian weeps over the dead, because his vocation was not to die, but to have eternal life. Death entered our lives through human falling away from God, that is why death as such is a tragedy [19].

Metropolitan Antony believes that it is wrong for a person to artificially stir up a feeling of grief in himself. A person does this out of fear that if the grief for the deceased goes away, then this will mean that there was no true love. According to the Meropolitan, sorrow should be transformed into love, through the understanding that one himself has to go this way and in the end meet with his beloved [20].

After the shock and grieving, as Metropolitan Anthony writes, a person begins to look around and seek support, in particular in the church. At this stage of grief, meaningful church prayer for the deceased can bring relief. This is what Metropolitan writes: "…when we stand and pray for the deceased, we actually say: "Lord, this man did not live in vain. He left behind an example and love on earth; the example we will follow; love never dies"". Praying at the funeral service we thereby testify before God of love for the deceased and thereby affirm him in eternity [21].

Metropolitan Anthony points to guilt as an important symptom of grief. It is natural for a person to experience guilt associated with his actions in relation to the deceased. Especially often people regret the lack of love in their relationship with the deceased. According to Metropolitan, this is not the way to think, because God called each of us into the world out of His love and prepared eternal life for us. Therefore, our love does not die, and we should continue to love a person after death, erasing the border line of death. "We must always use the present tense to say: "I love him (her)", who has passed away from this life, because, as the Old Testament tells us: "Love is as strong as death" (Song of Solomon 8:6). Love is the only force that can resist death and not be defeated," says Metropolitan Anthony [22].

The mourning of a person is often exacerbated by resentment or unresolved conflict with the deceased. In this case, a person feels a particularly acute guilt and becomes unable to overcome this crisis, since in earthly life there is no longer an opportunity to talk and resolve the conflict. Here it is very important to address the departed in personal dialogue and in prayer.

Metropolitan Anthony describes such a case. A man during the war becomes an unwitting source of death of a loved one, a beloved woman with whom he planned to start a family. He was in a severe crisis and was unable to overcome this state due to a strong sense of guilt. Metropolitan advised him to address his beloved, share his pain, ask for forgiveness and for help in obtaining peace in his soul. After this conversation, the person was able to get rid of the oppressive feeling and cope with grieving that had lasted for so long in his life.

After the shock, grieving, search for support, the question arises, what to do next? The stage of restoring relations with the outside world begins. At the same time, a very important condition for living in new circumstances is the awareness of what kind of memory remains with us about the deceased. Metropolitan Anthony advises us to evaluate the role that the deceased person played in our life: his love, care, respect that he invested in us, and what we learned from him. And after that, "to continue his life" through the love that we received from him [19]. Thus, a person continues to live with us, in our love spreading in the world. Metropolitan Anthony refers to the words of the Gospel: "Unless a grain of wheat falls into the earth and dies, it remains alone; but if it dies, it bears much fruit" (John 12:24).

An analysis of Metropolitan Anthony's service in consoling people facing the loss of a loved one showed that in his pastoral ministry and work he followed principles of religious coping strategies for grieving, which are used by specialists in modern psychotherapeutic assistance. Metropolitan describes from personal experience those pastoral methods that he used in the process of consolation. Thus, the religious principles of spiritual pastoral support, described by Metropolitan Anthony, allow us to talk about the conceptual help of a pastor to people grieving about the loss of a loved one.

References:

1. Biktinina N.N., Workshop on post-traumatic stress psychology: a study guide. - Orenburg: FG BOU VPO OSU, 2011 - P. 37.
2. Burina E.A., Basic approaches to the study of loss. Interactive science. No. 6. - St. Petersburg: "Center for Scientific Cooperation" Interactive Plus "", 2016 - P. 54.
3. Lindemann E., Clinical picture of acute grief // Psychology of emotions: texts. - M.: Publishing House of Moscow University, 1984. - P. 247.
4. K?bler-Ross E., On Death and Dying, Corvette, 2016, 294 p.
5. Vasilyuk F.E., Psychology of distress. - M.: Iz-vo MGU, 1981. - P. 134.
6. Burina E.A., Basic approaches to the study of loss. Interactive science. No. 6. - St. Petersburg: "Center for Scientific Cooperation" Interactive Plus "", 2016 - P. 54.
7. Roos S., Chronic sorrow: a living loss. - New Haven and Londo: Yale University Press, 2000.
8. Smith H.I., ABC's of health grieving. A companion for everyday coping, - Indiana: Notre Dame, Ave Maria Press, 2007.
9. Kornilov VV, Adverse outcomes of pathological grief reaction in elderly people. - M.: autoref. cand. Dis., 2019. - P. 12.
10. Kolomeytsev Yu.A., Korzun S.A., Basic scientific approaches to coping behavior. - P. 3.
11. Yaltonsky V.M., Sokolova E.T., Sirota, N.A., Widerman, N.S., Relationship between coping behavior and self-concept in alcohol-addicted patients and apparently healthy men. Social and clinical psychiatry. No. 2 M.: Publ.House "Med practice-M", 2001. - P. 36-43.
12. Polishchuk Yu.I., Letnikova Z.V., Development of D.E. Melekhov's ideas on the role of the spiritual sphere of personality in mental disorders at a later age. Journal of Social and Clinical Psychiatry. T.30. No. 1. - M.: "Med practice-M", 2020. - P. 46.
13. Worden. J.W., Understanding the process of mourning. Journal of Practical Psychology and Psychoanalysis. No. 4. - M.: Institute of Practical Psychology and Psychoanalysis, 2015. - P. 7.
14. Frankl V., Fundamentals of logotherapy. Psychotherapy and religion. Transl. from German - St. Petersburg: Speech, 2000. - P. 125.
15. Melekhov D.E., Psychiatry and foundations of spiritual life, 1997.
16. Allport G.W., The individual and his religion. N.Y., 1971.
17. Anthony (Bloom) Met., Life. Disease. Death. - M.: Publishing House New Sky, 2018. - P. 38.
18. Anthony (Bloom) Met., Death: those who leave and those who stay. Transl. from English - M.: Foundation "Spiritual Heritage of Metropolitan Anthony of Surozh", 2016. - P. 13.
19. Anthony (Blum) Met., Life. Disease. Death. - M.: Publishing House New Sky, 2018. - P. 46.
20. Anthony (Blum) Met., Life. Disease. Death. - M.: New Sky Publishing House, 2018. - P. 48.
21. Anthony (Blum) Met., Death: those who leave and those who stay. Transl. from English. - M.: Foundation "Spiritual Heritage of Metropolitan Anthony of Surozh", 2016. - P. 18.
22. Anthony (Bloom) Met., Death: those who leave and those who stay. Transl. from English. - M.: Foundation "Spiritual heritage of Metropolitan Anthony of Surozh", 2016. - P. 15.

Why it is necessary to consider spirituality in mental health?

Wenceslao Vial Mena

Introduction

I would like to start by recalling the image of some flamingos in a lagoon in northern Chile. They are able to withstand the ice of the nights, which traps them as if it were cement... and the heat and radiation of the desert days. All this in order to mate and perpetuate the species, in a closed cycle of birth, procreation and death. They have no other objective or project, or dream: they are not free in their process of growing in maturity.

The human being develops, but in a process open to many possibilities. We make the process of growing in maturity our own, we possess it and little by little we know it. We are free and capable of loving. That is to say, we are spiritual beings.

The interest of spirituality in mental health is widespread. The American Psychiatric Association has a committee on religion, spirituality and psychiatry, and a specific agenda for it¹. Many scientific studies demonstrate a positive influence of spirituality on health.

However, in medical practice and medical education, spirituality is poorly understood and little considered. I have been teaching spirituality for four years to second year medical students². I asked several questions about the relationship between spirituality and medicine. I was surprised that when I asked if the physician should consider the patient's spirituality only 58% answered yes. But, when asked if the doctor should cure persons and not only pathologies, 100% answered yes. This is something of a paradox because the person is precisely the foundation of spirituality.

The World Health Organization defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease"³. In 1998 it was proposed to include the term "spiritual", but it has not been adopted. Several factors of a lack of well-being could be included in spiritual dimension. Incoherence, lack of meaning, activism and haste, that increase stress. Byung-Chul Han points out that one of the reasons of this activism is the fashion of thinking and acting as if everything were possible, in accordance with the slogan "yes we can"⁴.

We are in a society of fatigue in which there is no reaction to what is threatening. There is no immunological response: the defenses, the antibodies against the viruses of the spirit are not activated. What is different is accepted, whatever it is, without anything causing surprise or being considered bad. And sometimes it ends in heart attacks of the soul, in a spiritual illness.

1. Spirituality in its mystery

Spirituality is the dimension that differentiates us from animals, robots and plants or fruits. It makes us capable of asking ourselves about the meaning of life. It allows us to intuit good and evil unlike a robot. We are not determined by blind instinctive forces, like animals. We need others and education, unlike a fruit that requires only sun and time. And, also unlike a fruit, we can become unripe or immature again⁵.

So we have three dimensions: physical, psychic and spiritual. It is not possible to understand the person if only one dimension is considered. It would be, in an example of Viktor Frankl, like wanting to distinguish an object from the shadow it casts on a single plane. A cylinder, a cone or an ovoid can appear identical, like a sphere⁶.

The spirit is immaterial and cannot be directly observed or measured. It maintains the unity of the whole, penetrates or permeates the organic and the psychic. It is the center of the person, the seal and foundation of his dignity, which makes him unique and unrepeatable, the principle of self-knowledge and self-acceptance.

It does not have a place, it does not occupy a space, but to understand the spirit, it is necessary to reach the heart, the deepest part of our being and metaphor of the affective world. Like the center of a labyrinth. Pier Augusto Brescia was a heart surgeon at the Gemelli hospital in Rome. In the 1980s, he discovered that he was capable of painting and began to dedicate himself to it. When I met him, I liked a phrase of his: "I used to touch hearts with my hands, now I touch them with my works of art". A manifestation of spirituality is this heart capable of reacting or "letting itself be touched" by beauty, goodness and truth.

To reach the heart is to discover the "what is essential is invisible to the eye"⁷, as Antoine de Saint-Exupery wrote. Or the place where the person decides for or against God. We know that "the heart has its reasons that reason can't understand"⁸, as Pascal said, but it is worth trying to understand them.

The spirit also shows itself in the mind. Joseph LeDoux is one of the leading researchers of the cerebral amygdala, known since the beginning of the 19th century. He has studied the cerebral amygdala system, with its interactions and capacity to store emotional memories⁹. This system can act independently of the rational cortex and "decide" if we like something or not, if we are in danger or not: for example, it triggers the alarm before a viper, before the presence of the animal is noticed by the cortex and the person is aware of the danger.

But we are spiritual, that is free: this system is not blind. A famous phrase says: "Between a stimulus and the response there is a space. And in that space lies our freedom and the power to choose our response. In our response lies our growth and freedom"¹⁰.

To mature spiritually is to enter into that "mysterious space" and guide the responses. Walter Mischel's experiment, known as the marshmallow test, shows some of this mystery. In the late 1960s and early 1970s, they studied preschoolers¹¹. They were left alone with one marshmallow, promising them two if they waited for them to return. Some would eat the candy immediately, others would try a little bit..., or were able to wait for what was called delayed gratification.

They followed them until they finished school. It was found that those who had been able to wait as children were more socially competent, with better frustration and stress tolerance, more capable of challenges, projects and self-confidence, and were better students. The third part of the children, those who immediately ate the marshmallow seeking immediate gratification, had fewer of these qualities and a complex psychology. Lack of control was also the best predictor of delinquency and drug use in adulthood.

Twenty years later, M?nica Rodr?guez, a disciple of Mischel's, did a similar experiment in Chile, filmed with a hidden camera. She left 5-6 year old kids with a chocolate cookie, offering them more if they waited. One of the children, Roberto, when Monica left, separated the two parts of the cookie and ate the white part quickly, putting them back together. When the test was screened, this child was praised and at a university in the United States they said he deserved a scholarship.

But I wanted to look at another child in the experiment. Agnes, 6 years old, was not only able to wait for Monica to arrive and get more cookies, but when these cookies arrived, she put them in a bag to take them to her mother. This gesture goes beyond something conditioned by expectation. It shows a capacity of spirituality: self-transcendence.

Animals are also capable of waiting, although it is more difficult. If a dog sees a sausage, it will probably eat it, dominated by its instinct; although it may learn that, if it pounces on the sausage, the master will beat it up, and so it holds back. What a dog will not do is take the sausage to a friend he loves. It will not do what Agnes did. He cannot offer his own reward to another, selflessly, out of love, out of service. He does not have the capacity for self-transcendence.

To affirm spirituality is to affirm intelligence and will, which leads us to know something and to want it. Denial, on the other hand, considers the human being obliged to act as he acts, because of the way he is made and the materials of which he is composed, just like a boomerang, which comes back to the one who throws it because of how it is constructed, in the classic example of John Watson, who started the behaviorism¹².

I summarize this point with a quote from Kierkegaard: "What is the spirit? It is the self. Man is a synthesis of the infinite and the finite, of temporal and eternal, of freedom and necessity"¹³.

2. Mental health in harmony

One of Brescia's works is called The bay of innocence and shows a human being in balance walking on a rope, helped by a bar with two counterweights, representing his spiritual and material dimensions.

There are two psychological currents: those who point out as a health goal the balance or homeostasis of emotions, reasoning and desires, which causes peace and tranquility. And those who place the goal in harmony, highlighting the importance of effort or tension to reach ideals; to love with sacrifice, to give oneself. Balance points to the self and harmony to others.

The exclusive search for balance looks to oneself and is closed in the psyche. This is why it has been called "selfism"¹⁴. Behind it are the ideas of Maslow, for whom man realizes himself in an increasing process of satisfaction of needs, from the most basic, such as food or sex, to the highest, such as love and contemplation. Maslow transforms St. Augustine's phrase, "Love and do what you will", into: "Be healthy and you could be driven by impulse"¹⁵.

If the goal is harmony, on the other hand, one goes out of oneself in a movement of spiritual self-transcendence. This is Allport's line¹⁶. Harmony reminds us of what happens with a stringed instrument: each string has to have the right tension to hit the right note. Harmony makes us mature with and towards others, developing spiritual capacities.

At each stage of development, we see the relationship with others, the need to open up to a transcendent meaning. For Erikson¹⁷, the child grows in hope and strengthens his will. The adolescent and the young person discovers who he is, his identity and his intimacy, he becomes capable of fidelity and love. The adult grows in capacity for self-giving, wisdom, integrity and acceptance. The key lies in two binomials: identity/intimacy; fidelity/love.

Another sign of harmony is the capacity to convert instincts into tendencies: Advertising often points to the instincts in order to sell products, it mentions the need to "liberate instincts". But a healthy liberation would be to transform and guide them.

It is about moving from vice to virtue. To act according to the reality of our being, and to grow in freedom, as Aristotle explained. Vice puts evil in front of us, leads to lies and slavery. Virtue shows the good, the truth and makes free, which favors health.

For full harmony it is necessary to find the meaning of life. The human being is not only driven by instincts, impulses or the past. We have the capacity to look to the future and be attracted by something outside of us: meaning and values. Our main motivational force is not the will to pleasure or the will to power, but the will to meaning.

By this path there is a Copernican revolution in the inner world and of psychological aspirations. "Did not really matter what we expected from life, but rather what life expected from us"¹⁸, Frankl wrote. This search for meaning is the first step of religiosity as manifestation of spirituality: the desire to find an Absolute, God, and to deal with Him.

3. The doctor before the person

Medical science is not only technical, and let's hope that it will not be completely replaced by robots. Karl Yaspers said that technique and medical specialization cannot forget suffering, death, guilt, struggle, the life of the spirit. Only the lack of seriousness of modern man, who is carried away by comfort and lack of faith, can give rise to a "confusion between doctor and pastor of souls"¹⁹.

A health professional encounters people who suffer and wonder about the meaning of their pain, have shame, guilt, or have a hard time, or have to face death. And they always need hope. The physician who includes these concerns in his or her agenda humanizes medicine.

In the doctor-patient relationship we find two binomials. On the one hand, the need to objectify the patient: in order to cure him, he must be treated in a certain sense as an object. This is what the surgeon does when he isolates the operative field with drapes. This must go hand in hand with compassion, suffering with the other, sharing his pain, in moderation, so that this emotion does not impede the perhaps painful but necessary act. The second binomial is that of realism, to face the diagnosis and prognosis, and hope in making it known. Objectification-compassion and realism-hope are related.

The physician encounters unique and unrepeatable people, with a given temperament, which is worth knowing. There are tests that allow us to approach the initial way of being, to see it as a gift, discovering the defects and skills and virtues to be developed²⁰.

To know what is a healthy personality is a great challenge of mental health. It involves getting to those phenomena of war and peace, the personality disorders, from which many illnesses arise. At the bottom are often found somehow spiritual difficulties: egocentrism and existential emptiness.

Tolstoy, in War and Peace, describes Pierre's situation after separating from his wife and having fought a duel: "It was as if the main screw in his head, which held his whole life together, had become stripped"²¹.

That screw is the meaning of life, and it is possible to lose it or not find it with a disordered life. Existential emptiness is frequent, the apparent happiness of a faceless person, with a damaged personality. Frankl called this the pathology of the spirit of our time²², with its activism, massification and loneliness. And, as a consequence, a lack of identity.

We could talk about many diseases related to the spiritual substratum, or to the relationship between morality and health. I mention only one example: addictions, which try to fill the void with substances or behaviors. Some scientists say that they are not diseases, but a choice, because there are addicts who can say: no more alcohol, or no more gambling and stop being addicted, which is impossible in other diseases. The most common opinion is that the disease and the choice are related, as in many other pathologies. This is also why the physician must consider spiritual aspects in his patients.

Conclusions

I will conclude with another phrase from Kierkegaard that reflects the importance of spirituality and its openness: "The door to happiness does not open inward. It opens toward the outside"²³. Spiritual phenomena, including transcendence and religiosity, influence life, health and illness. That is why they must be considered in mental health.

Including spirituality is a challenge that we can summarize in a positive attitude, enjoying goodness, beauty and truth. This produces good feelings, which are related to acting well and thinking well, giving rise to positive and healthy affections, a healthy mind and a healthy heart²⁴.

Searching for the meaning of life is a deep need of the soul. It is well manifested by these verses of Neruda, with which I will end: "The world is a crystal sphere / man is lost if he does not fly: / he cannot understand transparency / That is why I profess / the clarity that never stopped / and I learned from the birds / the thirsty hope, / the certainty and truth of flight"²⁵.

¹Cf. John R, Peteet, Francis G. Lu, William E. Narrow, Religious and spiritual Issues in Psychiatric Diagnosis, American Psychiatric Publishing, 2010.

²This was a Medical Anthropology course at the Universidad de Los Andes, Chile, which included two hours of Medicine and Spirituality. Each year the responses were similar. The total number of students was about 480.

³The quotation comes from the Preamble of the WHO Constitution, which entered into force on April 7, 1948.

⁴Cf. Byung-Chul Han, The Burnout Society, Stanford University Press, 2015.

⁵You can see the website www.psychologicalmaturity.com; and Wenceslao Vial, Madurez psicol?gica y espiritual, Palabra, 2019 (4^a).

⁶Cf. Viktor Frankl, Der Wille zum Sinn. Ausgewahlte Vortrage uber Logotherapie, Hans Huber, Berna 1982. Frankl calls this phenomenon "dimensional ontology".

⁷Antoine de Saint-Exupery, The little Prince, Chapter XXI.

⁸Blaise Pascal, Pensees, n. 277.

⁹Cf. Joseph LeDoux, The Emotional Brain: The Mysterious Underpinnings of Emotional Life, Simon & Schuster, 1996.

¹⁰It has been attributed by some to Frankl, but I have not found it in Frankl's work.

¹¹The experiment was first published in Develomental Psychology in 1990. See Walter Mischel, The marshmallow test. Understanding self-control and how to master it, Penguin Random House, 2015.

¹²Cf. Behaviorism, Transaction publishers, New Brunswick, New Jersey 2009, p. 86

¹³Soren Kierkegaard, The Sickness unto Death: A Christian Psychological Exposition of Edification & Awakening by Anti-Climacus, Penguin Classics, 1989. Our translation is from Spanish edition, La enfermedad mortal, Sarpe, Madrid 1984, p. 35.

¹⁴Cf. Paul Viz, Psychology as Religion: The Cult of Self-Worship, Paternoster P., 1994.

¹⁵Abraham Maslow, Motivation and personality, Harpers, 1954. Our translation is from Spanish edition, Motivacion y personalidad, D?as de Santos, 1991, p. 76.

¹⁶Cf. Gordon W. Allport, Pattern and Growth in Personality, Holt, Rinehart and Winston, 1965.

¹⁷Cf. Erik Erikson, The life Cycle Completed: A review, W W Norton & Co, 1985.

¹⁸Viktor E. Frankl, Man's Search for Meaning, Beacon Press, 1992, p. 85.

¹⁹Cf. Karl Jaspers, Wahrheit und Bewahrung. Philosophieren fur die Praxis, R. Piper & Co. Verlag 1983 (article from 1947 to 1964). Our translation is from the Italian version Verita e verifica. Filosofare per la prassi, Morcelliana, 1986, p. 89.

²⁰Cf. Temperament Test: Russian: https://www.psychologicalmaturity.com/p/temperament-test-in-russian-alex-havard.html; English: https://www.psychologicalmaturity.com/2020/12/temperament-test-knowing-yourself.html.

²¹Leo Tolstoy, War and Peace, Oxford University Press, 1998, vol. II, part two, 1.

²²Cf. Viktor Frankl, Homo Patiens: versuch einer Pathodizee, Franz Deuticke, 1950.

²³Soren Kierkegaard, Enten - Eller (original in Danish, 1843); Our translation is from French edition, Ou bien... Ou bien..., Gallimard, 1984, p. 21.

²⁴For a deeper look at the personality, see: Wenceslao Vial (edited by), Be who you are. Developing your Christian personality, Scepter, New York 2018

²⁵Pablo Neruda, El vuelo, en Arte de pajaros, Editorial Sudamericana, Buenos Aires 2004, pp. 50-52. The translation is ours.